{"id":3578,"date":"2025-03-07T07:32:58","date_gmt":"2025-03-07T07:32:58","guid":{"rendered":"https:\/\/baysidenurses.com.au\/?page_id=3578"},"modified":"2025-03-07T10:17:28","modified_gmt":"2025-03-07T10:17:28","slug":"ndis-referral","status":"publish","type":"page","link":"https:\/\/baysidenurses.com.au\/?page_id=3578","title":{"rendered":"NDIS Referral"},"content":{"rendered":"\t\t<div data-elementor-type=\"wp-page\" data-elementor-id=\"3578\" class=\"elementor elementor-3578\">\n\t\t\t\t\t\t<section class=\"elementor-section elementor-top-section elementor-element elementor-element-fb229c0 elementor-section-boxed elementor-section-height-default elementor-section-height-default wpr-particle-no wpr-jarallax-no wpr-parallax-no wpr-sticky-section-no\" data-id=\"fb229c0\" data-element_type=\"section\">\n\t\t\t\t\t\t<div class=\"elementor-container elementor-column-gap-default\">\n\t\t\t\t\t<div class=\"elementor-column elementor-col-100 elementor-top-column elementor-element elementor-element-fe05a89\" data-id=\"fe05a89\" data-element_type=\"column\">\n\t\t\t<div class=\"elementor-widget-wrap elementor-element-populated\">\n\t\t\t\t\t\t<div class=\"elementor-element elementor-element-e94f603 elementor-widget elementor-widget-heading\" data-id=\"e94f603\" data-element_type=\"widget\" data-widget_type=\"heading.default\">\n\t\t\t\t<div class=\"elementor-widget-container\">\n\t\t\t<style>\/*! elementor - v3.23.0 - 15-07-2024 *\/\n.elementor-heading-title{padding:0;margin:0;line-height:1}.elementor-widget-heading .elementor-heading-title[class*=elementor-size-]>a{color:inherit;font-size:inherit;line-height:inherit}.elementor-widget-heading .elementor-heading-title.elementor-size-small{font-size:15px}.elementor-widget-heading .elementor-heading-title.elementor-size-medium{font-size:19px}.elementor-widget-heading .elementor-heading-title.elementor-size-large{font-size:29px}.elementor-widget-heading .elementor-heading-title.elementor-size-xl{font-size:39px}.elementor-widget-heading .elementor-heading-title.elementor-size-xxl{font-size:59px}<\/style><h2 class=\"elementor-heading-title elementor-size-default\">NDIS Referral Form<\/h2>\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t\t<\/div>\n\t\t<\/div>\n\t\t\t\t\t<\/div>\n\t\t<\/section>\n\t\t\t\t<section class=\"elementor-section elementor-top-section elementor-element elementor-element-ba387f6 elementor-section-boxed elementor-section-height-default elementor-section-height-default wpr-particle-no wpr-jarallax-no wpr-parallax-no wpr-sticky-section-no\" data-id=\"ba387f6\" data-element_type=\"section\">\n\t\t\t\t\t\t<div class=\"elementor-container elementor-column-gap-default\">\n\t\t\t\t\t<div class=\"elementor-column elementor-col-100 elementor-top-column elementor-element elementor-element-2989454\" data-id=\"2989454\" data-element_type=\"column\">\n\t\t\t<div class=\"elementor-widget-wrap elementor-element-populated\">\n\t\t\t\t\t\t<div class=\"elementor-element elementor-element-4745d59 elementor-widget elementor-widget-shortcode\" data-id=\"4745d59\" data-element_type=\"widget\" data-widget_type=\"shortcode.default\">\n\t\t\t\t<div class=\"elementor-widget-container\">\n\t\t\t\t\t<div class=\"elementor-shortcode\"><div class=\"forminator-ui forminator-custom-form forminator-custom-form-3580 forminator-design--default forminator-custom forminator_ajax\" data-forminator-render=\"0\" data-form=\"forminator-module-3580\" data-uid=\"6a0a9ec3aeb4a\"><br\/><\/div><form\n\t\t\t\tid=\"forminator-module-3580\"\n\t\t\t\tclass=\"forminator-ui forminator-custom-form forminator-custom-form-3580 forminator-design--default forminator-custom forminator_ajax\"\n\t\t\t\tmethod=\"post\"\n\t\t\t\tdata-forminator-render=\"0\"\n\t\t\t\tdata-form-id=\"3580\"\n\t\t\t\t\n\t\t\t\tdata-design=\"default\"\n\t\t\t\t\n\t\t\t\t\n\t\t\t\t\n\t\t\t\tdata-grid=\"custom\"\n\t\t\t\tenctype=\"multipart\/form-data\"\n\t\t\t\t\n\t\t\t\tstyle=\"display: none;\"\n\t\t\t\t\n\t\t\t\tdata-uid=\"6a0a9ec3aeb4a\"\n\t\t\t><div role=\"alert\" aria-live=\"polite\" class=\"forminator-response-message forminator-error\" aria-hidden=\"true\"><\/div><div class=\"forminator-row\"><div id=\"section-1\" class=\"forminator-field-section forminator-col forminator-col-12 \"><div class=\"forminator-field\"><h2 class=\"forminator-title\">ABOUT YOU<\/h2><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"radio-2\" class=\"forminator-field-radio forminator-col forminator-col-12 \"><div role=\"radiogroup\" class=\"forminator-field\" aria-labelledby=\"forminator-radiogroup-6a0a9ec3aeb4a-label\"><span id=\"forminator-radiogroup-6a0a9ec3aeb4a-label\" class=\"forminator-label\">Please select what describes you best?<\/span><label id=\"forminator-field-radio-2-label-1\" for=\"forminator-field-radio-2-1-6a0a9ec3aeb4a\" class=\"forminator-radio\" title=\"Participant\"><input type=\"radio\" name=\"radio-2\" value=\"one\" id=\"forminator-field-radio-2-1-6a0a9ec3aeb4a\" aria-labelledby=\"forminator-field-radio-2-label-1\" data-calculation=\"0\"   data-hidden-behavior=\"zero\"\/><span class=\"forminator-radio-bullet\" aria-hidden=\"true\"><\/span><span class=\"forminator-radio-label\">Participant<\/span><\/label><label id=\"forminator-field-radio-2-label-2\" for=\"forminator-field-radio-2-2-6a0a9ec3aeb4a\" class=\"forminator-radio\" title=\"Family Member \/ Next of Kin\"><input type=\"radio\" name=\"radio-2\" value=\"two\" id=\"forminator-field-radio-2-2-6a0a9ec3aeb4a\" aria-labelledby=\"forminator-field-radio-2-label-2\" data-calculation=\"0\"   data-hidden-behavior=\"zero\"\/><span class=\"forminator-radio-bullet\" aria-hidden=\"true\"><\/span><span class=\"forminator-radio-label\">Family Member \/ Next of Kin<\/span><\/label><label id=\"forminator-field-radio-2-label-3\" for=\"forminator-field-radio-2-3-6a0a9ec3aeb4a\" class=\"forminator-radio\" title=\"Plan Manager\"><input type=\"radio\" name=\"radio-2\" value=\"Plan-Manager\" id=\"forminator-field-radio-2-3-6a0a9ec3aeb4a\" aria-labelledby=\"forminator-field-radio-2-label-3\" data-calculation=\"0\"   data-hidden-behavior=\"zero\"\/><span class=\"forminator-radio-bullet\" aria-hidden=\"true\"><\/span><span class=\"forminator-radio-label\">Plan Manager<\/span><\/label><label id=\"forminator-field-radio-2-label-4\" for=\"forminator-field-radio-2-4-6a0a9ec3aeb4a\" class=\"forminator-radio\" title=\"Early Intervention Partner\"><input type=\"radio\" name=\"radio-2\" value=\"Early-Intervention-Partner\" id=\"forminator-field-radio-2-4-6a0a9ec3aeb4a\" aria-labelledby=\"forminator-field-radio-2-label-4\" data-calculation=\"0\"   data-hidden-behavior=\"zero\"\/><span class=\"forminator-radio-bullet\" aria-hidden=\"true\"><\/span><span class=\"forminator-radio-label\">Early Intervention Partner<\/span><\/label><label id=\"forminator-field-radio-2-label-5\" for=\"forminator-field-radio-2-5-6a0a9ec3aeb4a\" class=\"forminator-radio\" title=\"Parent or Guardian\"><input type=\"radio\" name=\"radio-2\" value=\"Parent-or-Guardian\" id=\"forminator-field-radio-2-5-6a0a9ec3aeb4a\" aria-labelledby=\"forminator-field-radio-2-label-5\" data-calculation=\"0\"   data-hidden-behavior=\"zero\"\/><span class=\"forminator-radio-bullet\" aria-hidden=\"true\"><\/span><span class=\"forminator-radio-label\">Parent or Guardian<\/span><\/label><label id=\"forminator-field-radio-2-label-6\" for=\"forminator-field-radio-2-6-6a0a9ec3aeb4a\" class=\"forminator-radio\" title=\"Support Coordinator\"><input type=\"radio\" name=\"radio-2\" value=\"Support-Coordinator\" id=\"forminator-field-radio-2-6-6a0a9ec3aeb4a\" aria-labelledby=\"forminator-field-radio-2-label-6\" data-calculation=\"0\"   data-hidden-behavior=\"zero\"\/><span class=\"forminator-radio-bullet\" aria-hidden=\"true\"><\/span><span class=\"forminator-radio-label\">Support Coordinator<\/span><\/label><label id=\"forminator-field-radio-2-label-7\" for=\"forminator-field-radio-2-7-6a0a9ec3aeb4a\" class=\"forminator-radio\" title=\"Local Area Coordinator\"><input type=\"radio\" name=\"radio-2\" value=\"Local-Area-Coordinator\" id=\"forminator-field-radio-2-7-6a0a9ec3aeb4a\" aria-labelledby=\"forminator-field-radio-2-label-7\" data-calculation=\"0\"   data-hidden-behavior=\"zero\"\/><span class=\"forminator-radio-bullet\" aria-hidden=\"true\"><\/span><span class=\"forminator-radio-label\">Local Area Coordinator<\/span><\/label><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"name-1\" class=\"forminator-field-name forminator-col forminator-col-12 \"><div class=\"forminator-row forminator-no-margin\" data-multiple=\"true\"><div class=\"forminator-col forminator-col-md-6\"><div class=\"forminator-field\"><label for=\"forminator-field-first-name-1_6a0a9ec3aeb4a\" id=\"forminator-field-first-name-1_6a0a9ec3aeb4a-label\" class=\"forminator-label\">First Name <span class=\"forminator-required\">*<\/span><\/label><input type=\"text\" name=\"name-1-first-name\" placeholder=\"\" id=\"forminator-field-first-name-1_6a0a9ec3aeb4a\" class=\"forminator-input\" aria-required=\"true\" data-multi=\"1\" value=\"\" \/><\/div><\/div><div class=\"forminator-col forminator-col-md-6\"><div class=\"forminator-field\"><label for=\"forminator-field-last-name-1_6a0a9ec3aeb4a\" id=\"forminator-field-last-name-1_6a0a9ec3aeb4a-label\" class=\"forminator-label\">Last Name<\/label><input type=\"text\" name=\"name-1-last-name\" placeholder=\"\" id=\"forminator-field-last-name-1_6a0a9ec3aeb4a\" class=\"forminator-input\" aria-required=\"false\" data-multi=\"1\" value=\"\" \/><\/div><\/div><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"email-1\" class=\"forminator-field-email forminator-col forminator-col-12 \"><div class=\"forminator-field\"><label for=\"forminator-field-email-1_6a0a9ec3aeb4a\" id=\"forminator-field-email-1_6a0a9ec3aeb4a-label\" class=\"forminator-label\">Email <span class=\"forminator-required\">*<\/span><\/label><input type=\"email\" name=\"email-1\" value=\"\" placeholder=\"\" id=\"forminator-field-email-1_6a0a9ec3aeb4a\" class=\"forminator-input forminator-email--field\" data-required=\"1\" aria-required=\"true\" \/><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"phone-1\" class=\"forminator-field-phone forminator-col forminator-col-12 \"><div class=\"forminator-field\"><label for=\"forminator-field-phone-1_6a0a9ec3aeb4a\" id=\"forminator-field-phone-1_6a0a9ec3aeb4a-label\" class=\"forminator-label\">Phone <span class=\"forminator-required\">*<\/span><\/label><input type=\"text\" name=\"phone-1\" value=\"\" placeholder=\"\" id=\"forminator-field-phone-1_6a0a9ec3aeb4a\" class=\"forminator-input forminator-field--phone\" data-required=\"1\" aria-required=\"true\" autocomplete=\"off\" \/><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"section-2\" class=\"forminator-field-section forminator-col forminator-col-12 \"><div class=\"forminator-field\"><h2 class=\"forminator-title\">PARTICIPANT DETAILS<\/h2><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"name-2\" class=\"forminator-field-name forminator-col forminator-col-12 \"><div class=\"forminator-row forminator-no-margin\" data-multiple=\"true\"><div class=\"forminator-col forminator-col-md-6\"><div class=\"forminator-field\"><label for=\"forminator-field-first-name-2_6a0a9ec3aeb4a\" id=\"forminator-field-first-name-2_6a0a9ec3aeb4a-label\" class=\"forminator-label\">Participant Name <span class=\"forminator-required\">*<\/span><\/label><input type=\"text\" name=\"name-2-first-name\" placeholder=\"First Name\" id=\"forminator-field-first-name-2_6a0a9ec3aeb4a\" class=\"forminator-input\" aria-required=\"true\" data-multi=\"1\" value=\"\" \/><\/div><\/div><div class=\"forminator-col forminator-col-md-6\"><div class=\"forminator-field\"><label for=\"forminator-field-last-name-2_6a0a9ec3aeb4a\" id=\"forminator-field-last-name-2_6a0a9ec3aeb4a-label\" class=\"forminator-label\">Last Name<\/label><input type=\"text\" name=\"name-2-last-name\" placeholder=\"\" id=\"forminator-field-last-name-2_6a0a9ec3aeb4a\" class=\"forminator-input\" aria-required=\"false\" data-multi=\"1\" value=\"\" \/><\/div><\/div><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"date-1\" class=\"forminator-field-date forminator-col forminator-col-12 \"><div class=\"forminator-field\"><label for=\"forminator-field-date-1-picker_6a0a9ec3aeb4a\" id=\"forminator-field-date-1-picker_6a0a9ec3aeb4a-label\" class=\"forminator-label\">Date of Birth <span class=\"forminator-required\">*<\/span><\/label><div class=\"forminator-input-with-icon\"><label for=\"forminator-field-date-1-picker_6a0a9ec3aeb4a\"><span class=\"forminator-icon-calendar\" aria-hidden=\"true\"><\/span><\/label><input autocomplete=\"off\" type=\"text\" size=\"1\" name=\"date-1\" value=\"\" placeholder=\"\" id=\"forminator-field-date-1-picker_6a0a9ec3aeb4a\" class=\"forminator-input forminator-datepicker\" data-required=\"1\" data-format=\"dd-mm-yy\" data-restrict-type=\"\" data-restrict=\"\" data-start-year=\"1926\" data-end-year=\"2126\" data-past-dates=\"enable\" data-start-of-week=\"1\" data-start-date=\"\" data-end-date=\"\" data-start-field=\"\" data-end-field=\"\" data-start-offset=\"\" data-end-offset=\"\" data-disable-date=\"\" data-disable-range=\"\" \/><\/div><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"number-1\" class=\"forminator-field-number forminator-col forminator-col-12 \"><div class=\"forminator-field\"><label for=\"forminator-field-number-1_6a0a9ec3aeb4a\" id=\"forminator-field-number-1_6a0a9ec3aeb4a-label\" class=\"forminator-label\">NDIS Plan Number <span class=\"forminator-required\">*<\/span><\/label><input name=\"number-1\" value=\"\" placeholder=\"\" id=\"forminator-field-number-1_6a0a9ec3aeb4a\" class=\"forminator-input forminator-number--field\" inputmode=\"decimal\" data-required=\"1\" data-decimals=\"0\" aria-required=\"true\" data-inputmask=\"&#039;groupSeparator&#039;: &#039;&#039;, &#039;radixPoint&#039;: &#039;&#039;, &#039;digits&#039;: &#039;0&#039;\" data-hidden-behavior=\"zero\" type=\"number\" step=\"any\" min=\"1\" \/><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"date-2\" class=\"forminator-field-date forminator-col forminator-col-12 \"><div class=\"forminator-field\"><label for=\"forminator-field-date-2-picker_6a0a9ec3aeb4a\" id=\"forminator-field-date-2-picker_6a0a9ec3aeb4a-label\" class=\"forminator-label\">NDIS Plan Start Date <span class=\"forminator-required\">*<\/span><\/label><div class=\"forminator-input-with-icon\"><label for=\"forminator-field-date-2-picker_6a0a9ec3aeb4a\"><span class=\"forminator-icon-calendar\" aria-hidden=\"true\"><\/span><\/label><input autocomplete=\"off\" type=\"text\" size=\"1\" name=\"date-2\" value=\"\" placeholder=\"\" id=\"forminator-field-date-2-picker_6a0a9ec3aeb4a\" class=\"forminator-input forminator-datepicker\" data-required=\"1\" data-format=\"mm\/dd\/yy\" data-restrict-type=\"\" data-restrict=\"\" data-start-year=\"1926\" data-end-year=\"2126\" data-past-dates=\"enable\" data-start-of-week=\"1\" data-start-date=\"\" data-end-date=\"\" data-start-field=\"\" data-end-field=\"\" data-start-offset=\"\" data-end-offset=\"\" data-disable-date=\"\" data-disable-range=\"\" \/><\/div><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"date-3\" class=\"forminator-field-date forminator-col forminator-col-12 \"><div class=\"forminator-field\"><label for=\"forminator-field-date-3-picker_6a0a9ec3aeb4a\" id=\"forminator-field-date-3-picker_6a0a9ec3aeb4a-label\" class=\"forminator-label\">NDIS Plan End Date <span class=\"forminator-required\">*<\/span><\/label><div class=\"forminator-input-with-icon\"><label for=\"forminator-field-date-3-picker_6a0a9ec3aeb4a\"><span class=\"forminator-icon-calendar\" aria-hidden=\"true\"><\/span><\/label><input autocomplete=\"off\" type=\"text\" size=\"1\" name=\"date-3\" value=\"\" placeholder=\"\" id=\"forminator-field-date-3-picker_6a0a9ec3aeb4a\" class=\"forminator-input forminator-datepicker\" data-required=\"1\" data-format=\"mm\/dd\/yy\" data-restrict-type=\"\" data-restrict=\"\" data-start-year=\"1926\" data-end-year=\"2126\" data-past-dates=\"enable\" data-start-of-week=\"1\" data-start-date=\"\" data-end-date=\"\" data-start-field=\"\" data-end-field=\"\" data-start-offset=\"\" data-end-offset=\"\" data-disable-date=\"\" data-disable-range=\"\" \/><\/div><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"email-2\" class=\"forminator-field-email forminator-col forminator-col-12 \"><div class=\"forminator-field\"><label for=\"forminator-field-email-2_6a0a9ec3aeb4a\" id=\"forminator-field-email-2_6a0a9ec3aeb4a-label\" class=\"forminator-label\">Participant Email <span class=\"forminator-required\">*<\/span><\/label><input type=\"email\" name=\"email-2\" value=\"\" placeholder=\"\" id=\"forminator-field-email-2_6a0a9ec3aeb4a\" class=\"forminator-input forminator-email--field\" data-required=\"1\" aria-required=\"true\" \/><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"phone-2\" class=\"forminator-field-phone forminator-col forminator-col-12 \"><div class=\"forminator-field\"><label for=\"forminator-field-phone-2_6a0a9ec3aeb4a\" id=\"forminator-field-phone-2_6a0a9ec3aeb4a-label\" class=\"forminator-label\">Participant Phone Number <span class=\"forminator-required\">*<\/span><\/label><input type=\"text\" name=\"phone-2\" value=\"\" placeholder=\"\" id=\"forminator-field-phone-2_6a0a9ec3aeb4a\" class=\"forminator-input forminator-field--phone\" data-required=\"1\" aria-required=\"true\" autocomplete=\"off\" \/><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"address-1\" class=\"forminator-field-address forminator-col forminator-col-12 \"><div class=\"forminator-row\"><div id=\"address-1-street_address\" class=\"forminator-col\"><div class=\"forminator-field\"><label for=\"forminator-field-address-1-street_address_6a0a9ec3aeb4a\" id=\"forminator-field-address-1-street_address_6a0a9ec3aeb4a-label\" class=\"forminator-label\">Participant Address <span class=\"forminator-required\">*<\/span><\/label><input type=\"text\" name=\"address-1-street_address\" placeholder=\"\" id=\"forminator-field-address-1-street_address_6a0a9ec3aeb4a\" class=\"forminator-input\" data-required=\"1\" aria-required=\"true\" value=\"\" \/><\/div><\/div><\/div><div class=\"forminator-row\" data-multiple=\"false\"><div id=\"address-1-state\" class=\"forminator-col forminator-col-12\"><div class=\"forminator-field\"><label for=\"forminator-field-address-1-state_6a0a9ec3aeb4a\" id=\"forminator-field-address-1-state_6a0a9ec3aeb4a-label\" class=\"forminator-label\">Suburb<\/label><input type=\"text\" name=\"address-1-state\" placeholder=\"\" id=\"forminator-field-address-1-state_6a0a9ec3aeb4a\" class=\"forminator-input\" data-required=\"\" aria-required=\"false\" value=\"\" \/><\/div><\/div><\/div><div class=\"forminator-row\" data-multiple=\"false\"><div id=\"address-1-zip\" class=\"forminator-col forminator-col-12\"><div class=\"forminator-field\"><label for=\"forminator-field-address-1-zip_6a0a9ec3aeb4a\" id=\"forminator-field-address-1-zip_6a0a9ec3aeb4a-label\" class=\"forminator-label\">ZIP \/ Postal Code<\/label><input type=\"text\" name=\"address-1-zip\" placeholder=\"\" id=\"forminator-field-address-1-zip_6a0a9ec3aeb4a\" class=\"forminator-input\" value=\"\" \/><\/div><\/div><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"select-1\" class=\"forminator-field-select forminator-col forminator-col-12 \"><div class=\"forminator-field\"><label for=\"forminator-form-3580__field--select-1_6a0a9ec3aeb4a\" id=\"forminator-form-3580__field--select-1_6a0a9ec3aeb4a-label\" class=\"forminator-label\">Participant Address - State <span class=\"forminator-required\">*<\/span><\/label><select  id=\"forminator-form-3580__field--select-1_6a0a9ec3aeb4a\" class=\"forminator-select--field forminator-select2 forminator-select2-multiple\" data-required=\"1\" name=\"select-1\" data-default-value=\"\" data-hidden-behavior=\"zero\" data-placeholder=\"Select\" data-search=\"false\" data-search-placeholder=\"Select\" data-checkbox=\"false\" data-allow-clear=\"false\" aria-labelledby=\"forminator-form-3580__field--select-1_6a0a9ec3aeb4a-label\"><option value=\"\"  >Select<\/option><option value=\"Select\"  data-calculation=\"0\">Select<\/option><option value=\"one\"  data-calculation=\"0\">QLD<\/option><option value=\"two\"  data-calculation=\"0\">VIC<\/option><option value=\"NSW\"  data-calculation=\"0\">NSW<\/option><option value=\"SA\"  data-calculation=\"0\">SA<\/option><option value=\"WA\"  data-calculation=\"0\">WA<\/option><option value=\"TAS\"  data-calculation=\"0\">TAS<\/option><option value=\"ACT\"  data-calculation=\"0\">ACT<\/option><option value=\"NT\"  data-calculation=\"0\">NT<\/option><\/select><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"radio-4\" class=\"forminator-field-radio forminator-col forminator-col-12 \"><div role=\"radiogroup\" class=\"forminator-field\" aria-labelledby=\"forminator-radiogroup-6a0a9ec3aeb4a-label\"><span id=\"forminator-radiogroup-6a0a9ec3aeb4a-label\" class=\"forminator-label\">Participant Gender<\/span><label id=\"forminator-field-radio-4-label-1\" for=\"forminator-field-radio-4-1-6a0a9ec3aeb4a\" class=\"forminator-radio\" title=\"Female: she - her\"><input type=\"radio\" name=\"radio-4\" value=\"one\" id=\"forminator-field-radio-4-1-6a0a9ec3aeb4a\" aria-labelledby=\"forminator-field-radio-4-label-1\" data-calculation=\"0\"   data-hidden-behavior=\"zero\"\/><span class=\"forminator-radio-bullet\" aria-hidden=\"true\"><\/span><span class=\"forminator-radio-label\">Female: she - her<\/span><\/label><label id=\"forminator-field-radio-4-label-2\" for=\"forminator-field-radio-4-2-6a0a9ec3aeb4a\" class=\"forminator-radio\" title=\"Male: he - him\"><input type=\"radio\" name=\"radio-4\" value=\"two\" id=\"forminator-field-radio-4-2-6a0a9ec3aeb4a\" aria-labelledby=\"forminator-field-radio-4-label-2\" data-calculation=\"0\"   data-hidden-behavior=\"zero\"\/><span class=\"forminator-radio-bullet\" aria-hidden=\"true\"><\/span><span class=\"forminator-radio-label\">Male: he - him<\/span><\/label><label id=\"forminator-field-radio-4-label-3\" for=\"forminator-field-radio-4-3-6a0a9ec3aeb4a\" class=\"forminator-radio\" title=\"Non-binary: they - them\"><input type=\"radio\" name=\"radio-4\" value=\"Non-binary:-they---them\" id=\"forminator-field-radio-4-3-6a0a9ec3aeb4a\" aria-labelledby=\"forminator-field-radio-4-label-3\" data-calculation=\"0\"   data-hidden-behavior=\"zero\"\/><span class=\"forminator-radio-bullet\" aria-hidden=\"true\"><\/span><span class=\"forminator-radio-label\">Non-binary: they - them<\/span><\/label><label id=\"forminator-field-radio-4-label-4\" for=\"forminator-field-radio-4-4-6a0a9ec3aeb4a\" class=\"forminator-radio\" title=\"Prefer not to say\"><input type=\"radio\" name=\"radio-4\" value=\"Prefer-not-to-say\" id=\"forminator-field-radio-4-4-6a0a9ec3aeb4a\" aria-labelledby=\"forminator-field-radio-4-label-4\" data-calculation=\"0\"   data-hidden-behavior=\"zero\"\/><span class=\"forminator-radio-bullet\" aria-hidden=\"true\"><\/span><span class=\"forminator-radio-label\">Prefer not to say<\/span><\/label><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"section-3\" class=\"forminator-field-section forminator-col forminator-col-12 \"><div class=\"forminator-field\"><h2 class=\"forminator-title\">PRIMARY DISABILITY \/ HEALTH BACKGROUND<\/h2><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"text-1\" class=\"forminator-field-text forminator-col forminator-col-12 \"><div class=\"forminator-field\"><label for=\"forminator-field-text-1_6a0a9ec3aeb4a\" id=\"forminator-field-text-1_6a0a9ec3aeb4a-label\" class=\"forminator-label\">Please provide detail of the Participant&#039;s primary disability. <span class=\"forminator-required\">*<\/span><\/label><input type=\"text\" name=\"text-1\" value=\"\" placeholder=\"\" id=\"forminator-field-text-1_6a0a9ec3aeb4a\" class=\"forminator-input forminator-name--field\" data-required=\"1\" \/><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"section-4\" class=\"forminator-field-section forminator-col forminator-col-12 \"><div class=\"forminator-field\"><h2 class=\"forminator-title\">SERVICES<\/h2><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"select-2\" class=\"forminator-field-select forminator-col forminator-col-12 \"><div class=\"forminator-field\"><label for=\"forminator-form-3580__field--select-2_6a0a9ec3aeb4a\" id=\"forminator-form-3580__field--select-2_6a0a9ec3aeb4a-label\" class=\"forminator-label\">Allied Health Service Required<\/label><select  id=\"forminator-form-3580__field--select-2_6a0a9ec3aeb4a\" class=\"forminator-select--field forminator-select2 forminator-select2-multiple\" data-required=\"\" name=\"select-2\" data-default-value=\"\" data-hidden-behavior=\"zero\" data-placeholder=\"\" data-search=\"false\" data-search-placeholder=\"\" data-checkbox=\"false\" data-allow-clear=\"false\" aria-labelledby=\"forminator-form-3580__field--select-2_6a0a9ec3aeb4a-label\"><option value=\"Select\"  data-calculation=\"0\">Select<\/option><option value=\"one\"  data-calculation=\"0\">Occupational Therapy<\/option><option value=\"two\"  data-calculation=\"0\">Speech Pathology<\/option><option value=\"Early-Childhood-Intervention\"  data-calculation=\"0\">Early Childhood Intervention<\/option><option value=\"Psychologist\"  data-calculation=\"0\">Psychologist<\/option><\/select><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"section-5\" class=\"forminator-field-section forminator-col forminator-col-12 \"><div class=\"forminator-field\"><h2 class=\"forminator-title\">GOALS<\/h2><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"text-2\" class=\"forminator-field-text forminator-col forminator-col-12 \"><div class=\"forminator-field\"><label for=\"forminator-field-text-2_6a0a9ec3aeb4a\" id=\"forminator-field-text-2_6a0a9ec3aeb4a-label\" class=\"forminator-label\">What are the desired Outcomes\/Goals for the Participant ? <span class=\"forminator-required\">*<\/span><\/label><input type=\"text\" name=\"text-2\" value=\"\" placeholder=\"\" id=\"forminator-field-text-2_6a0a9ec3aeb4a\" class=\"forminator-input forminator-name--field\" data-required=\"1\" \/><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"upload-1\" class=\"forminator-field-upload forminator-col forminator-col-12 \"><div class=\"forminator-field\"><label for=\"forminator-field-upload-1_6a0a9ec3aeb4a\" id=\"forminator-field-upload-1_6a0a9ec3aeb4a-label\" class=\"forminator-label\">Please upload your NDIS plan here <span class=\"forminator-required\">*<\/span><\/label><div class=\"forminator-file-upload \" data-element=\"upload-1_6a0a9ec3aeb4a\"><input type=\"file\" name=\"upload-1\" id=\"forminator-field-upload-1_6a0a9ec3aeb4a\" class=\"forminator-input-file-required do-validate\" accept=\".jpg,.jpeg,.jpe,.gif,.png,.bmp,.tiff,.tif,.webp,.avif,.ico,.heic,.asf,.asx,.wmv,.wmx,.wm,.avi,.divx,.flv,.mov,.qt,.mpeg,.mpg,.mpe,.mp4,.m4v,.ogv,.webm,.mkv,.3gp,.3gpp,.3g2,.3gp2,.txt,.asc,.c,.cc,.h,.srt,.csv,.tsv,.ics,.rtx,.css,.htm,.html,.vtt,.dfxp,.mp3,.m4a,.m4b,.aac,.ra,.ram,.wav,.ogg,.oga,.flac,.mid,.midi,.wma,.wax,.mka,.rtf,.js,.pdf,.class,.tar,.zip,.gz,.gzip,.rar,.7z,.psd,.xcf,.doc,.pot,.pps,.ppt,.wri,.xla,.xls,.xlt,.xlw,.mdb,.mpp,.docx,.docm,.dotx,.dotm,.xlsx,.xlsm,.xlsb,.xltx,.xltm,.xlam,.pptx,.pptm,.ppsx,.ppsm,.potx,.potm,.ppam,.sldx,.sldm,.onetoc,.onetoc2,.onetmp,.onepkg,.oxps,.xps,.odt,.odp,.ods,.odg,.odc,.odb,.odf,.wp,.wpd,.key,.numbers,.pages,.svg,.json,.svgz,.xml\"><button id=\"forminator-field-upload-1_6a0a9ec3aeb4a_button\" class=\"forminator-button forminator-button-upload\" data-id=\"forminator-field-upload-1_6a0a9ec3aeb4a\">Choose File<\/button><span data-empty-text=\"No file chosen\">No file chosen<\/span><button class=\"forminator-button-delete\" style=\"display: none;\"><i class=\"forminator-icon-close\" aria-hidden=\"true\"><\/i><span class=\"forminator-screen-reader-only\">Delete uploaded file<\/span><\/button><\/div><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"text-3\" class=\"forminator-field-text forminator-col forminator-col-12 \"><div class=\"forminator-field\"><label for=\"forminator-field-text-3_6a0a9ec3aeb4a\" id=\"forminator-field-text-3_6a0a9ec3aeb4a-label\" class=\"forminator-label\">Preferred Appointment Time, day of the week and time ? <span class=\"forminator-required\">*<\/span><\/label><input type=\"text\" name=\"text-3\" value=\"\" placeholder=\"\" id=\"forminator-field-text-3_6a0a9ec3aeb4a\" class=\"forminator-input forminator-name--field\" data-required=\"1\" \/><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"section-6\" class=\"forminator-field-section forminator-col forminator-col-12 \"><div class=\"forminator-field\"><h2 class=\"forminator-title\">BILLING<\/h2><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"radio-3\" class=\"forminator-field-radio forminator-col forminator-col-12 \"><div role=\"radiogroup\" class=\"forminator-field\" aria-labelledby=\"forminator-radiogroup-6a0a9ec3aeb4a-label\"><span id=\"forminator-radiogroup-6a0a9ec3aeb4a-label\" class=\"forminator-label\">How is the plan funding managed ?<\/span><label id=\"forminator-field-radio-3-label-1\" for=\"forminator-field-radio-3-1-6a0a9ec3aeb4a\" class=\"forminator-radio\" title=\"NDIA \/ Agency Managed\"><input type=\"radio\" name=\"radio-3\" value=\"one\" id=\"forminator-field-radio-3-1-6a0a9ec3aeb4a\" aria-labelledby=\"forminator-field-radio-3-label-1\" data-calculation=\"0\"   data-hidden-behavior=\"zero\"\/><span class=\"forminator-radio-bullet\" aria-hidden=\"true\"><\/span><span class=\"forminator-radio-label\">NDIA \/ Agency Managed<\/span><\/label><label id=\"forminator-field-radio-3-label-2\" for=\"forminator-field-radio-3-2-6a0a9ec3aeb4a\" class=\"forminator-radio\" title=\"Self Managed\"><input type=\"radio\" name=\"radio-3\" value=\"two\" id=\"forminator-field-radio-3-2-6a0a9ec3aeb4a\" aria-labelledby=\"forminator-field-radio-3-label-2\" data-calculation=\"0\"   data-hidden-behavior=\"zero\"\/><span class=\"forminator-radio-bullet\" aria-hidden=\"true\"><\/span><span class=\"forminator-radio-label\">Self Managed<\/span><\/label><label id=\"forminator-field-radio-3-label-3\" for=\"forminator-field-radio-3-3-6a0a9ec3aeb4a\" class=\"forminator-radio\" title=\"Plan Managed\"><input type=\"radio\" name=\"radio-3\" value=\"Plan-Managed\" id=\"forminator-field-radio-3-3-6a0a9ec3aeb4a\" aria-labelledby=\"forminator-field-radio-3-label-3\" data-calculation=\"0\"   data-hidden-behavior=\"zero\"\/><span class=\"forminator-radio-bullet\" aria-hidden=\"true\"><\/span><span class=\"forminator-radio-label\">Plan Managed<\/span><\/label><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"section-7\" class=\"forminator-field-section forminator-col forminator-col-12 \"><div class=\"forminator-field\"><h2 class=\"forminator-title\">SAFTEY &amp; SUBMIT<\/h2><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"html-1\" class=\"forminator-field-html forminator-col forminator-col-12 \"><div class=\"forminator-field forminator-merge-tags\" data-field=\"html-1\"><label class=\"forminator-label\">Are there any Saftey Risks we should be aware of ?<\/label><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"checkbox-3\" class=\"forminator-field-checkbox forminator-col forminator-col-12 \"><div role=\"group\" class=\"forminator-field required\" aria-labelledby=\"forminator-checkbox-group-6a0a9ec3aeb4a-label\"><span id=\"forminator-checkbox-group-6a0a9ec3aeb4a-label\" class=\"forminator-label\">Behaviours of concern being demonstrated by Participant ? <span class=\"forminator-required\">*<\/span><\/span><label id=\"forminator-field-checkbox-3-1-6a0a9ec3aeb4a-label\" for=\"forminator-field-checkbox-3-1-6a0a9ec3aeb4a\" class=\"forminator-checkbox\" title=\"Sexualised behaviours\"><input type=\"checkbox\" name=\"checkbox-3[]\" value=\"one\" id=\"forminator-field-checkbox-3-1-6a0a9ec3aeb4a\" aria-labelledby=\"forminator-field-checkbox-3-1-6a0a9ec3aeb4a-label\" data-calculation=\"0\"   data-hidden-behavior=\"zero\"\/><span class=\"forminator-checkbox-box\" aria-hidden=\"true\"><\/span><span class=\"forminator-checkbox-label\">Sexualised behaviours<\/span><\/label><label id=\"forminator-field-checkbox-3-2-6a0a9ec3aeb4a-label\" for=\"forminator-field-checkbox-3-2-6a0a9ec3aeb4a\" class=\"forminator-checkbox\" title=\"Verbal aggression\"><input type=\"checkbox\" name=\"checkbox-3[]\" value=\"two\" id=\"forminator-field-checkbox-3-2-6a0a9ec3aeb4a\" aria-labelledby=\"forminator-field-checkbox-3-2-6a0a9ec3aeb4a-label\" data-calculation=\"0\"   data-hidden-behavior=\"zero\"\/><span class=\"forminator-checkbox-box\" aria-hidden=\"true\"><\/span><span class=\"forminator-checkbox-label\">Verbal aggression<\/span><\/label><label id=\"forminator-field-checkbox-3-3-6a0a9ec3aeb4a-label\" for=\"forminator-field-checkbox-3-3-6a0a9ec3aeb4a\" class=\"forminator-checkbox\" title=\"Absconding or running away\"><input type=\"checkbox\" name=\"checkbox-3[]\" value=\"Absconding-or-running-away\" id=\"forminator-field-checkbox-3-3-6a0a9ec3aeb4a\" aria-labelledby=\"forminator-field-checkbox-3-3-6a0a9ec3aeb4a-label\" data-calculation=\"0\"   data-hidden-behavior=\"zero\"\/><span class=\"forminator-checkbox-box\" aria-hidden=\"true\"><\/span><span class=\"forminator-checkbox-label\">Absconding or running away<\/span><\/label><label id=\"forminator-field-checkbox-3-4-6a0a9ec3aeb4a-label\" for=\"forminator-field-checkbox-3-4-6a0a9ec3aeb4a\" class=\"forminator-checkbox\" title=\"Repetitive or persistent behaviours causing harm\"><input type=\"checkbox\" name=\"checkbox-3[]\" value=\"Repetitive-or-persistent-behaviours-causing-harm\" id=\"forminator-field-checkbox-3-4-6a0a9ec3aeb4a\" aria-labelledby=\"forminator-field-checkbox-3-4-6a0a9ec3aeb4a-label\" data-calculation=\"0\"   data-hidden-behavior=\"zero\"\/><span class=\"forminator-checkbox-box\" aria-hidden=\"true\"><\/span><span class=\"forminator-checkbox-label\">Repetitive or persistent behaviours causing harm<\/span><\/label><label id=\"forminator-field-checkbox-3-5-6a0a9ec3aeb4a-label\" for=\"forminator-field-checkbox-3-5-6a0a9ec3aeb4a\" class=\"forminator-checkbox\" title=\"Physical aggression towards others\"><input type=\"checkbox\" name=\"checkbox-3[]\" value=\"Physical-aggression-towards-others\" id=\"forminator-field-checkbox-3-5-6a0a9ec3aeb4a\" aria-labelledby=\"forminator-field-checkbox-3-5-6a0a9ec3aeb4a-label\" data-calculation=\"0\"   data-hidden-behavior=\"zero\"\/><span class=\"forminator-checkbox-box\" aria-hidden=\"true\"><\/span><span class=\"forminator-checkbox-label\">Physical aggression towards others<\/span><\/label><label id=\"forminator-field-checkbox-3-6-6a0a9ec3aeb4a-label\" for=\"forminator-field-checkbox-3-6-6a0a9ec3aeb4a\" class=\"forminator-checkbox\" title=\"Self injurious behaviour\"><input type=\"checkbox\" name=\"checkbox-3[]\" value=\"Self-injurious-behaviour\" id=\"forminator-field-checkbox-3-6-6a0a9ec3aeb4a\" aria-labelledby=\"forminator-field-checkbox-3-6-6a0a9ec3aeb4a-label\" data-calculation=\"0\"   data-hidden-behavior=\"zero\"\/><span class=\"forminator-checkbox-box\" aria-hidden=\"true\"><\/span><span class=\"forminator-checkbox-label\">Self injurious behaviour<\/span><\/label><label id=\"forminator-field-checkbox-3-7-6a0a9ec3aeb4a-label\" for=\"forminator-field-checkbox-3-7-6a0a9ec3aeb4a\" class=\"forminator-checkbox\" title=\"Property damage\"><input type=\"checkbox\" name=\"checkbox-3[]\" value=\"Property-damage\" id=\"forminator-field-checkbox-3-7-6a0a9ec3aeb4a\" aria-labelledby=\"forminator-field-checkbox-3-7-6a0a9ec3aeb4a-label\" data-calculation=\"0\"   data-hidden-behavior=\"zero\"\/><span class=\"forminator-checkbox-box\" aria-hidden=\"true\"><\/span><span class=\"forminator-checkbox-label\">Property damage<\/span><\/label><label id=\"forminator-field-checkbox-3-8-6a0a9ec3aeb4a-label\" for=\"forminator-field-checkbox-3-8-6a0a9ec3aeb4a\" class=\"forminator-checkbox\" title=\"None\"><input type=\"checkbox\" name=\"checkbox-3[]\" value=\"None\" id=\"forminator-field-checkbox-3-8-6a0a9ec3aeb4a\" aria-labelledby=\"forminator-field-checkbox-3-8-6a0a9ec3aeb4a-label\" data-calculation=\"0\"   data-hidden-behavior=\"zero\"\/><span class=\"forminator-checkbox-box\" aria-hidden=\"true\"><\/span><span class=\"forminator-checkbox-label\">None<\/span><\/label><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"checkbox-4\" class=\"forminator-field-checkbox forminator-col forminator-col-12 \"><div role=\"group\" class=\"forminator-field required\" aria-labelledby=\"forminator-checkbox-group-6a0a9ec3aeb4a-label\"><span id=\"forminator-checkbox-group-6a0a9ec3aeb4a-label\" class=\"forminator-label\">Does the participant demonstrate any of these risks ? <span class=\"forminator-required\">*<\/span><\/span><label id=\"forminator-field-checkbox-4-1-6a0a9ec3aeb4a-label\" for=\"forminator-field-checkbox-4-1-6a0a9ec3aeb4a\" class=\"forminator-checkbox\" title=\"Risk of injury or harm to their person or others\"><input type=\"checkbox\" name=\"checkbox-4[]\" value=\"Risk-of-injury-or-harm-to-their-person-or-others\" id=\"forminator-field-checkbox-4-1-6a0a9ec3aeb4a\" aria-labelledby=\"forminator-field-checkbox-4-1-6a0a9ec3aeb4a-label\" data-calculation=\"0\"   data-hidden-behavior=\"zero\"\/><span class=\"forminator-checkbox-box\" aria-hidden=\"true\"><\/span><span class=\"forminator-checkbox-label\">Risk of injury or harm to their person or others<\/span><\/label><label id=\"forminator-field-checkbox-4-2-6a0a9ec3aeb4a-label\" for=\"forminator-field-checkbox-4-2-6a0a9ec3aeb4a\" class=\"forminator-checkbox\" title=\"Substance abuse\"><input type=\"checkbox\" name=\"checkbox-4[]\" value=\"two\" id=\"forminator-field-checkbox-4-2-6a0a9ec3aeb4a\" aria-labelledby=\"forminator-field-checkbox-4-2-6a0a9ec3aeb4a-label\" data-calculation=\"0\"   data-hidden-behavior=\"zero\"\/><span class=\"forminator-checkbox-box\" aria-hidden=\"true\"><\/span><span class=\"forminator-checkbox-label\">Substance abuse<\/span><\/label><label id=\"forminator-field-checkbox-4-3-6a0a9ec3aeb4a-label\" for=\"forminator-field-checkbox-4-3-6a0a9ec3aeb4a\" class=\"forminator-checkbox\" title=\"School or Service placement interruption temporary\"><input type=\"checkbox\" name=\"checkbox-4[]\" value=\"Absconding-or-running-away\" id=\"forminator-field-checkbox-4-3-6a0a9ec3aeb4a\" aria-labelledby=\"forminator-field-checkbox-4-3-6a0a9ec3aeb4a-label\" data-calculation=\"0\"   data-hidden-behavior=\"zero\"\/><span class=\"forminator-checkbox-box\" aria-hidden=\"true\"><\/span><span class=\"forminator-checkbox-label\">School or Service placement interruption temporary<\/span><\/label><label id=\"forminator-field-checkbox-4-4-6a0a9ec3aeb4a-label\" for=\"forminator-field-checkbox-4-4-6a0a9ec3aeb4a\" class=\"forminator-checkbox\" title=\"Sexual\"><input type=\"checkbox\" name=\"checkbox-4[]\" value=\"Repetitive-or-persistent-behaviours-causing-harm\" id=\"forminator-field-checkbox-4-4-6a0a9ec3aeb4a\" aria-labelledby=\"forminator-field-checkbox-4-4-6a0a9ec3aeb4a-label\" data-calculation=\"0\"   data-hidden-behavior=\"zero\"\/><span class=\"forminator-checkbox-box\" aria-hidden=\"true\"><\/span><span class=\"forminator-checkbox-label\">Sexual<\/span><\/label><label id=\"forminator-field-checkbox-4-5-6a0a9ec3aeb4a-label\" for=\"forminator-field-checkbox-4-5-6a0a9ec3aeb4a\" class=\"forminator-checkbox\" title=\"Homelessness\"><input type=\"checkbox\" name=\"checkbox-4[]\" value=\"Physical-aggression-towards-others\" id=\"forminator-field-checkbox-4-5-6a0a9ec3aeb4a\" aria-labelledby=\"forminator-field-checkbox-4-5-6a0a9ec3aeb4a-label\" data-calculation=\"0\"   data-hidden-behavior=\"zero\"\/><span class=\"forminator-checkbox-box\" aria-hidden=\"true\"><\/span><span class=\"forminator-checkbox-label\">Homelessness<\/span><\/label><label id=\"forminator-field-checkbox-4-6-6a0a9ec3aeb4a-label\" for=\"forminator-field-checkbox-4-6-6a0a9ec3aeb4a\" class=\"forminator-checkbox\" title=\"Loss of placement e.g. school accommodation day service\"><input type=\"checkbox\" name=\"checkbox-4[]\" value=\"Self-injurious-behaviour\" id=\"forminator-field-checkbox-4-6-6a0a9ec3aeb4a\" aria-labelledby=\"forminator-field-checkbox-4-6-6a0a9ec3aeb4a-label\" data-calculation=\"0\"   data-hidden-behavior=\"zero\"\/><span class=\"forminator-checkbox-box\" aria-hidden=\"true\"><\/span><span class=\"forminator-checkbox-label\">Loss of placement e.g. school accommodation day service<\/span><\/label><label id=\"forminator-field-checkbox-4-7-6a0a9ec3aeb4a-label\" for=\"forminator-field-checkbox-4-7-6a0a9ec3aeb4a\" class=\"forminator-checkbox\" title=\"Criminal history\"><input type=\"checkbox\" name=\"checkbox-4[]\" value=\"Property-damage\" id=\"forminator-field-checkbox-4-7-6a0a9ec3aeb4a\" aria-labelledby=\"forminator-field-checkbox-4-7-6a0a9ec3aeb4a-label\" data-calculation=\"0\"   data-hidden-behavior=\"zero\"\/><span class=\"forminator-checkbox-box\" aria-hidden=\"true\"><\/span><span class=\"forminator-checkbox-label\">Criminal history<\/span><\/label><label id=\"forminator-field-checkbox-4-8-6a0a9ec3aeb4a-label\" for=\"forminator-field-checkbox-4-8-6a0a9ec3aeb4a\" class=\"forminator-checkbox\" title=\"None\"><input type=\"checkbox\" name=\"checkbox-4[]\" value=\"None\" id=\"forminator-field-checkbox-4-8-6a0a9ec3aeb4a\" aria-labelledby=\"forminator-field-checkbox-4-8-6a0a9ec3aeb4a-label\" data-calculation=\"0\"   data-hidden-behavior=\"zero\"\/><span class=\"forminator-checkbox-box\" aria-hidden=\"true\"><\/span><span class=\"forminator-checkbox-label\">None<\/span><\/label><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"text-4\" class=\"forminator-field-text forminator-col forminator-col-12 \"><div class=\"forminator-field\"><label for=\"forminator-field-text-4_6a0a9ec3aeb4a\" id=\"forminator-field-text-4_6a0a9ec3aeb4a-label\" class=\"forminator-label\">Other behaviours and risks that we need to be made aware of ? <span class=\"forminator-required\">*<\/span><\/label><input type=\"text\" name=\"text-4\" value=\"\" placeholder=\"\" id=\"forminator-field-text-4_6a0a9ec3aeb4a\" class=\"forminator-input forminator-name--field\" data-required=\"1\" \/><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"checkbox-5\" class=\"forminator-field-checkbox forminator-col forminator-col-12 \"><div role=\"group\" class=\"forminator-field required\" aria-labelledby=\"forminator-checkbox-group-6a0a9ec3aeb4a-label\"><label id=\"forminator-field-checkbox-5-1-6a0a9ec3aeb4a-label\" for=\"forminator-field-checkbox-5-1-6a0a9ec3aeb4a\" class=\"forminator-checkbox\" title=\"Please acknowledge that you believe the information entered on this form is, to the best of your awareness, truthful and accurate. *\"><input type=\"checkbox\" name=\"checkbox-5[]\" value=\"one\" id=\"forminator-field-checkbox-5-1-6a0a9ec3aeb4a\" aria-labelledby=\"forminator-field-checkbox-5-1-6a0a9ec3aeb4a-label\" data-calculation=\"0\"   data-hidden-behavior=\"zero\"\/><span class=\"forminator-checkbox-box\" aria-hidden=\"true\"><\/span><span class=\"forminator-checkbox-label\">Please acknowledge that you believe the information entered on this form is, to the best of your awareness, truthful and accurate. *<\/span><\/label><\/div><\/div><\/div><input type=\"hidden\" name=\"referer_url\" value=\"\" \/><div class=\"forminator-row forminator-row-last\"><div class=\"forminator-col\"><div class=\"forminator-field\"><button 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