{"id":1211,"date":"2020-10-30T08:01:12","date_gmt":"2020-10-30T08:01:12","guid":{"rendered":"https:\/\/backon.karunahost.asia\/?page_id=1211"},"modified":"2021-05-21T13:03:47","modified_gmt":"2021-05-21T03:03:47","slug":"referral-form","status":"publish","type":"page","link":"https:\/\/backontrackpsych.com\/zh\/referral-form\/","title":{"rendered":"\u8f6c\u4ecb\u7533\u8bf7\u8868"},"content":{"rendered":"<div class=\"vc_row wpb_row vc_row-fluid\"><div class=\"wpb_column vc_column_container vc_col-sm-12 sc_layouts_column_icons_position_left\"><div class=\"vc_column-inner\"><div class=\"wpb_wrapper\"><div class=\"vc_empty_space\"   style=\"height: 50px\"><span class=\"vc_empty_space_inner\"><\/span><\/div><\/div><\/div><\/div><\/div><div data-vc-full-width=\"true\" data-vc-full-width-init=\"false\" class=\"vc_row wpb_row vc_row-fluid sc_layouts_row sc_layouts_row_type_normal\"><div class=\"wpb_column vc_column_container vc_col-sm-12 sc_layouts_column_icons_position_left\"><div class=\"vc_column-inner\"><div class=\"wpb_wrapper\"><div id=\"sc_content_70547858\"\r\n\t\tclass=\"sc_content color_style_default sc_content_default sc_content_width_100p sc_float_center  vc_custom_1605498725524\"><div class=\"sc_content_container\"><div class=\"vc_empty_space  hide_on_notebook hide_on_tablet hide_on_mobile\"   style=\"height: 113px\"><span class=\"vc_empty_space_inner\"><\/span><\/div><div class=\"vc_empty_space  hide_on_desktop hide_on_mobile\"   style=\"height: 80px\"><span class=\"vc_empty_space_inner\"><\/span><\/div><div class=\"vc_empty_space  hide_on_desktop hide_on_notebook hide_on_tablet\"   style=\"height: 50px\"><span class=\"vc_empty_space_inner\"><\/span><\/div><div id=\"sc_title_298452130\"\r\n\t\tclass=\"sc_title color_style_default sc_title_default\"><h3 class=\"sc_item_title sc_title_title sc_align_center sc_item_title_style_default\">Referral Form<\/h3><\/div><!-- \/.sc_title --><div class=\"vc_empty_space  hide_on_notebook hide_on_tablet hide_on_mobile\"   style=\"height: 80px\"><span class=\"vc_empty_space_inner\"><\/span><\/div><div class=\"vc_empty_space  hide_on_desktop hide_on_mobile\"   style=\"height: 40px\"><span class=\"vc_empty_space_inner\"><\/span><\/div><div class=\"vc_empty_space  hide_on_desktop hide_on_notebook hide_on_tablet\"   style=\"height: 30px\"><span class=\"vc_empty_space_inner\"><\/span><\/div><div class=\"vc_row wpb_row vc_inner vc_row-fluid\"><div class=\"wpb_column vc_column_container vc_col-sm-2 sc_layouts_column_icons_position_left\"><div class=\"vc_column-inner\"><div class=\"wpb_wrapper\"><\/div><\/div><\/div><div class=\"wpb_column vc_column_container vc_col-sm-8 sc_layouts_column_icons_position_left\"><div class=\"vc_column-inner\"><div class=\"wpb_wrapper\"><div role=\"form\" class=\"wpcf7\" id=\"wpcf7-f1183-o1\" lang=\"en-US\" dir=\"ltr\">\n<div class=\"screen-reader-response\"><p role=\"status\" aria-live=\"polite\" aria-atomic=\"true\"><\/p> <ul><\/ul><\/div>\n<form action=\"\/zh\/wp-json\/wp\/v2\/pages\/1211\/#wpcf7-f1183-o1\" method=\"post\" class=\"wpcf7-form init\" enctype=\"multipart\/form-data\" novalidate=\"novalidate\" data-status=\"init\" data-trp-original-action=\"\/zh\/wp-json\/wp\/v2\/pages\/1211\/#wpcf7-f1183-o1\">\n<div style=\"display: none;\">\n<input type=\"hidden\" name=\"_wpcf7\" value=\"1183\" \/>\n<input type=\"hidden\" name=\"_wpcf7_version\" value=\"5.5.3\" \/>\n<input type=\"hidden\" name=\"_wpcf7_locale\" value=\"en_US\" \/>\n<input type=\"hidden\" name=\"_wpcf7_unit_tag\" value=\"wpcf7-f1183-o1\" \/>\n<input type=\"hidden\" name=\"_wpcf7_container_post\" value=\"0\" \/>\n<input type=\"hidden\" name=\"_wpcf7_posted_data_hash\" value=\"\" \/>\n<\/div>\n<h5>Referral Details<\/h5>\n<div class=\"trx_addons_columns_wrap\">\n<div class=\"trx_addons_column-1_2\">\n<p><label>Name <\/label><\/p>\n<div><span class=\"wpcf7-form-control-wrap yname\"><input type=\"text\" name=\"yname\" value=\"\" size=\"40\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" placeholder=\"Name\" \/><\/span><\/div>\n<\/div>\n<div class=\"trx_addons_column-1_2\">\n<p><label>Provider Number <\/label><\/p>\n<div><span class=\"wpcf7-form-control-wrap pnumber\"><input type=\"text\" name=\"pnumber\" value=\"\" size=\"40\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" placeholder=\"Provider Number\" \/><\/span><\/div>\n<\/div>\n<div class=\"trx_addons_column-1_2\">\n<p><label>Contact Number<\/label><\/p>\n<div><span class=\"wpcf7-form-control-wrap ycontact\"><input type=\"tel\" name=\"ycontact\" value=\"\" size=\"40\" class=\"wpcf7-form-control wpcf7-text wpcf7-tel wpcf7-validates-as-tel\" aria-invalid=\"false\" placeholder=\"Contact Number\" \/><\/span><\/div>\n<\/div>\n<div class=\"trx_addons_column-1_2\">\n<p><label>Practice Name <\/label><\/p>\n<div><span class=\"wpcf7-form-control-wrap pname\"><input type=\"text\" name=\"pname\" value=\"\" size=\"40\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" placeholder=\"Practice Name\" \/><\/span><\/div>\n<\/div>\n<div class=\"trx_addons_column-1_2\">\n<p><label>Practice Address <\/label><\/p>\n<div><span class=\"wpcf7-form-control-wrap paddress\"><input type=\"text\" name=\"paddress\" value=\"\" size=\"40\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" placeholder=\"Practice Address\" \/><\/span><\/div>\n<\/div>\n<div class=\"trx_addons_column-1_2\">\n<p><label>Email <\/label><\/p>\n<div><span class=\"wpcf7-form-control-wrap yemail\"><input type=\"email\" name=\"yemail\" value=\"\" size=\"40\" class=\"wpcf7-form-control wpcf7-text wpcf7-email wpcf7-validates-as-email\" aria-invalid=\"false\" placeholder=\"Email\" \/><\/span><\/div>\n<\/div>\n<\/div>\n<h5>Patient Details<\/h5>\n<div class=\"trx_addons_columns_wrap\">\n<div class=\"trx_addons_column-1_2\">\n<p><label>Name <\/label><\/p>\n<div><span class=\"wpcf7-form-control-wrap patientname\"><input type=\"text\" name=\"patientname\" value=\"\" 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size=\"40\" class=\"wpcf7-form-control wpcf7-text wpcf7-email wpcf7-validates-as-email\" aria-invalid=\"false\" placeholder=\"Email\" \/><\/span><\/div>\n<\/div>\n<div class=\"trx_addons_column-1_2\">\n<p><label>Parent \/ Guardian <\/label><\/p>\n<div><span class=\"wpcf7-form-control-wrap guardianname\"><input type=\"text\" name=\"guardianname\" value=\"\" size=\"40\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" placeholder=\"Name\" \/><\/span><\/div>\n<\/div>\n<div class=\"trx_addons_column-1_2\">\n<p><label>Contact Number<\/label><\/p>\n<div><span class=\"wpcf7-form-control-wrap guardiancontact\"><input type=\"tel\" name=\"guardiancontact\" value=\"\" size=\"40\" class=\"wpcf7-form-control wpcf7-text wpcf7-tel wpcf7-validates-as-tel\" aria-invalid=\"false\" placeholder=\"Contact Number\" \/><\/span><\/div>\n<\/div>\n<div class=\"trx_addons_column-1_2\">\n<p><label>Next of Kin <\/label><\/p>\n<div><span class=\"wpcf7-form-control-wrap nxofkin\"><input type=\"text\" name=\"nxofkin\" value=\"\" size=\"40\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" placeholder=\"Name\" \/><\/span><\/div>\n<\/div>\n<div class=\"trx_addons_column-1_2\">\n<p><label>Contact Number<\/label><\/p>\n<div><span class=\"wpcf7-form-control-wrap kincontact\"><input type=\"tel\" name=\"kincontact\" value=\"\" size=\"40\" class=\"wpcf7-form-control wpcf7-text wpcf7-tel wpcf7-validates-as-tel\" aria-invalid=\"false\" placeholder=\"Contact Number\" \/><\/span><\/div>\n<\/div>\n<div class=\"trx_addons_column-1_1\">\n<p><label>\u4f4f\u5740 <\/label><\/p>\n<div><span class=\"wpcf7-form-control-wrap raddress\"><input type=\"text\" name=\"raddress\" value=\"\" size=\"40\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" placeholder=\"\u4f4f\u5740\" \/><\/span><\/div>\n<\/div>\n<div class=\"trx_addons_column-1_1\">\n<p><label>Please detailed referral question\/ purpose of referral<\/label><\/p>\n<div><span class=\"wpcf7-form-control-wrap 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aria-invalid=\"false\" \/><\/span><\/div>\n<\/div>\n<div class=\"trx_addons_column-1_2\">\n<p><label>Referrer\u2019s Signature <\/label><\/p>\n<div><div class=\"dscf7_signature\">\n\t\t\t<div class=\"dscf7_signature_inner\">\n\t\t\t\t<canvas id=\"digital_signature-pad_ysignature\" name=\"ysignature\" class=\"digital_signature-pad\" color=\"#000000\" backcolor=\"#eceae6\" width=\"300\" height=\"200\"><\/canvas>\n\t\t\t\t<input class=\"clearButton\" type=\"button\" value=\"+\">\n\t\t\t<\/div>\n\t\t\t<span class=\"wpcf7-form-control-wrap ysignature\">\n\t\t\t\t<input type=\"hidden\" name=\"ysignature\" value=\"\" class=\"wpcf7-form-control wpcf7-signaturewpcf7-validates-as-signaturedscf7-signature\"\/>\n\t\t\t\t<input type=\"hidden\" name=\"ysignature-attachment\" value=\"\" class=\"wpcf7_input_ysignature_attachment\"\/>\n\t\t\t\t<input type=\"hidden\" name=\"ysignature-inline\" value=\"\" class=\"wpcf7_input_ysignature_inline\"\/>\n\t\t\t<\/span>\n\t\t<\/div><\/div>\n<\/div>\n<div 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Practice Address Email Patient Details Name Date Of Birth Contact Number Email Parent \/ Guardian Contact Number Next of Kin Contact Number Residential Address Please detailed referral question\/ purpose of referral Patient\u2019s medical history Note: Please attach Mental Health Care Plan for patient Medicare claiming purposes Referrer\u2019s Signature Referral&hellip;","protected":false},"author":1,"featured_media":1861,"parent":0,"menu_order":0,"comment_status":"closed","ping_status":"closed","template":"","meta":{"om_disable_all_campaigns":false,"_mi_skip_tracking":false,"_monsterinsights_sitenote_active":false,"_monsterinsights_sitenote_note":"","_monsterinsights_sitenote_category":0,"footnotes":""},"aioseo_notices":[],"yoast_head":"<!-- This site is optimized with the Yoast SEO Premium plugin v17.8 (Yoast SEO v17.8) - https:\/\/yoast.com\/wordpress\/plugins\/seo\/ -->\n<title>Referral - Back On Track Psychology | Telepsychology Melbourne<\/title>\n<meta name=\"description\" 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