{"id":82498,"date":"2024-02-03T19:08:45","date_gmt":"2024-02-03T16:08:45","guid":{"rendered":"https:\/\/acesaudi.org\/newintake\/"},"modified":"2024-02-15T00:13:18","modified_gmt":"2024-02-14T21:13:18","slug":"newintake","status":"publish","type":"page","link":"https:\/\/acesaudi.org\/en\/newintake\/","title":{"rendered":"Registration Form to Autism Center Services"},"content":{"rendered":"<div class=\"frm_forms  with_frm_style frm_style_formidable-style frm_rtl\" id=\"frm_form_55_container\" data-token=\"d8f5823090f24ff9756bbba197455d41\">\n<form enctype=\"multipart\/form-data\" method=\"post\" class=\"frm-show-form  frm_pro_form \" id=\"form_intake-new\" data-token=\"d8f5823090f24ff9756bbba197455d41\">\n<div class=\"frm_form_fields \">\n<fieldset>\n<legend class=\"frm_screen_reader\">intake NEW<\/legend>\r\n\r\n<div class=\"frm_fields_container\">\n<input type=\"hidden\" name=\"frm_action\" value=\"create\" \/>\n<input type=\"hidden\" name=\"form_id\" value=\"55\" \/>\n<input type=\"hidden\" name=\"frm_hide_fields_55\" id=\"frm_hide_fields_55\" value=\"\" \/>\n<input type=\"hidden\" name=\"form_key\" value=\"intake-new\" \/>\n<input type=\"hidden\" name=\"item_meta[0]\" value=\"\" \/>\n<input type=\"hidden\" id=\"frm_submit_entry_55\" name=\"frm_submit_entry_55\" value=\"decaaf28b3\" \/><input type=\"hidden\" name=\"_wp_http_referer\" value=\"\/en\/wp-json\/wp\/v2\/pages\/82498\" \/><div id=\"frm_field_852_container\" class=\"frm_form_field form-field  frm_required_field frm_top_container frm_third\">\r\n    <label for=\"field_b3z9q\" id=\"field_b3z9q_label\" class=\"frm_primary_label\">Triple Beneficiary Name\r\n        <span class=\"frm_required\" aria-hidden=\"true\">*<\/span>\r\n    <\/label>\r\n    <input  type=\"text\" id=\"field_b3z9q\" name=\"item_meta[852]\" value=\"\"  data-reqmsg=\"Please fill this field\" aria-required=\"true\" data-invmsg=\"Text is invalid\" aria-invalid=\"false\"   \/>\r\n    \r\n    \r\n<\/div>\n<div id=\"frm_field_853_container\" class=\"frm_form_field form-field  frm_required_field frm_top_container frm_third\">\r\n    <label for=\"field_xgkay\" id=\"field_xgkay_label\" class=\"frm_primary_label\">Beneficiary ID Number\r\n        <span class=\"frm_required\" aria-hidden=\"true\">*<\/span>\r\n    <\/label>\r\n    <input  type=\"text\" id=\"field_xgkay\" name=\"item_meta[853]\" value=\"\"  data-frmmask=\"0000000000\" data-reqmsg=\"Please fill this field\" aria-required=\"true\" data-invmsg=\"Number is invalid\" aria-invalid=\"false\" pattern=\"\\d\\d\\d\\d\\d\\d\\d\\d\\d\\d$\"   \/>\r\n    \r\n    \r\n<\/div>\n<div id=\"frm_field_854_container\" class=\"frm_form_field form-field  frm_required_field frm_top_container frm_third frm_two_col\">\r\n    <label for=\"field_yndts\" id=\"field_yndts_label\" class=\"frm_primary_label\">Beneficiary's Age\r\n        <span class=\"frm_required\" aria-hidden=\"true\">*<\/span>\r\n    <\/label>\r\n    \t\t<div class=\"frm_radio\" id=\"frm_radio_854-1\">\t\t\t<label  for=\"field_yndts-1\">\n\t\t\t\t\t<input type=\"radio\" name=\"item_meta[854]\" id=\"field_yndts-1\" value=\"\u0623\u0642\u0644 \u0645\u0646 \u0665 \u0633\u0646\u0648\u0627\u062a\"\n\t\t data-reqmsg=\"Please fill this field\" data-invmsg=\"Beneficiary&#039;s Age is invalid\"   \/> Less than 5 years<\/label><\/div>\n\t\t<div class=\"frm_radio\" id=\"frm_radio_854-2\">\t\t\t<label  for=\"field_yndts-2\">\n\t\t\t\t\t<input type=\"radio\" name=\"item_meta[854]\" id=\"field_yndts-2\" value=\"\u0645\u0646 \u0665 \u0633\u0646\u0648\u0627\u062a \u0625\u0644\u0649 \u0661\u0662 \u0633\u0646\u0629\"\n\t\t data-reqmsg=\"Please fill this field\" data-invmsg=\"Beneficiary&#039;s Age is invalid\"   \/> From 5 to 12 years<\/label><\/div>\n\t\t<div class=\"frm_radio\" id=\"frm_radio_854-3\">\t\t\t<label  for=\"field_yndts-3\">\n\t\t\t\t\t<input type=\"radio\" name=\"item_meta[854]\" id=\"field_yndts-3\" value=\"\u0645\u0646 \u0661\u0662 \u0633\u0646\u0629 \u0625\u0644\u0649 \u0661\u0668 \u0633\u0646\u0629\"\n\t\t data-reqmsg=\"Please fill this field\" data-invmsg=\"Beneficiary&#039;s Age is invalid\"   \/> From 12 to 18 years<\/label><\/div>\n\t\t<div class=\"frm_radio\" id=\"frm_radio_854-4\">\t\t\t<label  for=\"field_yndts-4\">\n\t\t\t\t\t<input type=\"radio\" name=\"item_meta[854]\" id=\"field_yndts-4\" value=\"\u0623\u0643\u0628\u0631 \u0645\u0646 \u0661\u0668 \u0633\u0646\u0629\"\n\t\t data-reqmsg=\"Please fill this field\" data-invmsg=\"Beneficiary&#039;s Age is invalid\"   \/> Over 18 years<\/label><\/div>\n\r\n    \r\n    \r\n<\/div>\n<div id=\"frm_field_855_container\" class=\"frm_form_field form-field  frm_required_field frm_top_container frm4 frm_first\">\r\n    <label for=\"field_n0jxj\" id=\"field_n0jxj_label\" class=\"frm_primary_label\">Parent's Triple Name\r\n        <span class=\"frm_required\" aria-hidden=\"true\">*<\/span>\r\n    <\/label>\r\n    <input  type=\"text\" id=\"field_n0jxj\" name=\"item_meta[855]\" value=\"\"  data-reqmsg=\"Please fill this field\" aria-required=\"true\" data-invmsg=\"Text is invalid\" aria-invalid=\"false\"   \/>\r\n    \r\n    \r\n<\/div>\n<div id=\"frm_field_857_container\" class=\"frm_form_field form-field  frm_required_field frm_top_container frm4\">\r\n    <label for=\"field_3arzx\" id=\"field_3arzx_label\" class=\"frm_primary_label\">Contact Number\r\n        <span class=\"frm_required\" aria-hidden=\"true\">*<\/span>\r\n    <\/label>\r\n    <input  type=\"text\" id=\"field_3arzx\" name=\"item_meta[857]\" value=\"\"  data-frmmask=\"0000000000\" placeholder=\"0xxxxxxxxxx\" data-reqmsg=\"Please fill this field\" aria-required=\"true\" data-invmsg=\"Text is invalid\" aria-invalid=\"false\" pattern=\"\\d\\d\\d\\d\\d\\d\\d\\d\\d\\d$\"   \/>\r\n    \r\n    \r\n<\/div>\n<div id=\"frm_field_858_container\" class=\"frm_form_field form-field  frm_top_container frm4\">\r\n    <label for=\"field_a2xeu\" id=\"field_a2xeu_label\" class=\"frm_primary_label\">Email\r\n        <span class=\"frm_required\" aria-hidden=\"true\"><\/span>\r\n    <\/label>\r\n    <input type=\"email\" id=\"field_a2xeu\" name=\"item_meta[858]\" value=\"\"  autocomplete=\"email\"  data-invmsg=\"Email is invalid\" aria-invalid=\"false\"  \/>\r\n    \r\n    \r\n<\/div>\n<div id=\"frm_field_859_container\" class=\"frm_form_field form-field  frm_required_field frm_top_container frm6 frm_first horizontal_radio\">\r\n    <div  id=\"field_za0q8_label\" class=\"frm_primary_label\">Has he\/she been diagnosed with autism spectrum disorder or a developmental disorder?\r\n        <span class=\"frm_required\" aria-hidden=\"true\">*<\/span>\r\n    <\/div>\r\n    <div class=\"frm_opt_container\" aria-labelledby=\"field_za0q8_label\" role=\"radiogroup\" aria-required=\"true\">\t\t<div class=\"frm_radio\" id=\"frm_radio_859-0\">\t\t\t<label  for=\"field_za0q8-0\">\n\t\t\t\t\t<input type=\"radio\" name=\"item_meta[859]\" id=\"field_za0q8-0\" value=\"\u0646\u0639\u0645\"\n\t\t data-reqmsg=\"Please fill this field\" data-invmsg=\"Has he\/she been diagnosed with autism spectrum disorder or a developmental disorder? is invalid\"   \/> Yes<\/label><\/div>\n\t\t<div class=\"frm_radio\" id=\"frm_radio_859-1\">\t\t\t<label  for=\"field_za0q8-1\">\n\t\t\t\t\t<input type=\"radio\" name=\"item_meta[859]\" id=\"field_za0q8-1\" value=\"\u0644\u0627\"\n\t\t data-reqmsg=\"Please fill this field\" data-invmsg=\"Has he\/she been diagnosed with autism spectrum disorder or a developmental disorder? is invalid\"   \/> No<\/label><\/div>\n<\/div>\r\n    \r\n    \r\n<\/div>\n<div id=\"frm_field_863_container\" class=\"frm_form_field form-field  frm_top_container frm6\">\r\n    <label for=\"field_svom2\" id=\"field_svom2_label\" class=\"frm_primary_label\">Upload a diagnostic report\r\n        <span class=\"frm_required\" aria-hidden=\"true\"><\/span>\r\n    <\/label>\r\n    <input type=\"hidden\"  data-invmsg=\"File Upload is invalid\" class=\"auto_width\" aria-invalid=\"false\"   name=\"item_meta[863]\"  value=\"\" data-frmfile=\"863\" \/>\n\n<div class=\"frm_dropzone frm_single_upload frm_clearfix\" id=\"file863_dropzone\" role=\"group\" >\n\t<div class=\"fallback\">\n\t\t<input type=\"file\" name=\"file863\" id=\"field_svom2\"\n\t\t\t data-invmsg=\"File Upload is invalid\" class=\"auto_width\" aria-invalid=\"false\"  \t\t\t\/>\n\t\t\t\t<div class=\"frm_clearfix \"><\/div>\n\t<\/div>\n\t<div class=\"dz-message needsclick\">\n\t\t\t\t<svg  viewBox=\"0 0 18 18\" class=\"frmsvg frm-svg-icon\">\n\t<path viewBox=\"0 0 18 18\" fill-rule=\"evenodd\" clip-rule=\"evenodd\" d=\"M8.2 4v8a.8.8 0 001.5 0V4l2.1 2.2A.7.7 0 1013 5L9.5 1.7a.7.7 0 00-1.1 0L5.1 5.2a.8.8 0 001 1l2.1-2zm7.6 4.3c.4 0 .7.3.7.7v6.8c0 .4-.3.7-.8.7H2.3a.8.8 0 01-.8-.8V9A.8.8 0 013 9v6h12V9c0-.4.3-.8.8-.8z\"><\/path>\n<\/svg>\t\t<span class=\"frm_upload_text\"><button type=\"button\" aria-label=\"Upload a diagnostic report. upload file from here. Maximum file size: 5MB\">upload file from here<\/button><\/span>\n\t\t<span class=\"frm_compact_text\"><button type=\"button\" aria-label=\"Upload a diagnostic report. choose file. Maximum file size: 5MB\">choose file<\/button><\/span>\n\t\t<div class=\"frm_small_text\">\n\t\t\t<p>Maximum file size: 5MB<\/p>\n\t\t<\/div>\n\t<\/div>\n<\/div>\n\t\r\n    \r\n    \r\n<\/div>\n<div id=\"frm_field_861_container\" class=\"frm_form_field form-field  frm_required_field frm_top_container frm6 frm_first horizontal_radio\">\r\n    <div  id=\"field_vf2j8_label\" class=\"frm_primary_label\">Has the hearing test been performed?\r\n        <span class=\"frm_required\" aria-hidden=\"true\">*<\/span>\r\n    <\/div>\r\n    <div class=\"frm_opt_container\" aria-labelledby=\"field_vf2j8_label\" role=\"radiogroup\" aria-required=\"true\">\t\t<div class=\"frm_radio\" id=\"frm_radio_861-0\">\t\t\t<label  for=\"field_vf2j8-0\">\n\t\t\t\t\t<input type=\"radio\" name=\"item_meta[861]\" id=\"field_vf2j8-0\" value=\"\u0646\u0639\u0645\"\n\t\t data-reqmsg=\"Please fill this field\" data-invmsg=\"Has the hearing test been performed? is invalid\"   \/> Yes<\/label><\/div>\n\t\t<div class=\"frm_radio\" id=\"frm_radio_861-1\">\t\t\t<label  for=\"field_vf2j8-1\">\n\t\t\t\t\t<input type=\"radio\" name=\"item_meta[861]\" id=\"field_vf2j8-1\" value=\"\u0644\u0627\"\n\t\t data-reqmsg=\"Please fill this field\" data-invmsg=\"Has the hearing test been performed? is invalid\"   \/> No<\/label><\/div>\n<\/div>\r\n    \r\n    \r\n<\/div>\n<div id=\"frm_field_862_container\" class=\"frm_form_field form-field  frm_top_container frm6\">\r\n    <label for=\"field_h7udp\" id=\"field_h7udp_label\" class=\"frm_primary_label\">Upload a hearing test report\r\n        <span class=\"frm_required\" aria-hidden=\"true\"><\/span>\r\n    <\/label>\r\n    <input type=\"hidden\"  data-invmsg=\"File Upload is invalid\" aria-invalid=\"false\"   name=\"item_meta[862]\"  value=\"\" data-frmfile=\"862\" \/>\n\n<div class=\"frm_dropzone frm_single_upload frm_clearfix\" id=\"file862_dropzone\" role=\"group\" >\n\t<div class=\"fallback\">\n\t\t<input type=\"file\" name=\"file862\" id=\"field_h7udp\"\n\t\t\t data-invmsg=\"File Upload is invalid\" aria-invalid=\"false\"  \t\t\t\/>\n\t\t\t\t<div class=\"frm_clearfix \"><\/div>\n\t<\/div>\n\t<div class=\"dz-message needsclick\">\n\t\t\t\t<svg  viewBox=\"0 0 18 18\" class=\"frmsvg frm-svg-icon\">\n\t<path viewBox=\"0 0 18 18\" fill-rule=\"evenodd\" clip-rule=\"evenodd\" d=\"M8.2 4v8a.8.8 0 001.5 0V4l2.1 2.2A.7.7 0 1013 5L9.5 1.7a.7.7 0 00-1.1 0L5.1 5.2a.8.8 0 001 1l2.1-2zm7.6 4.3c.4 0 .7.3.7.7v6.8c0 .4-.3.7-.8.7H2.3a.8.8 0 01-.8-.8V9A.8.8 0 013 9v6h12V9c0-.4.3-.8.8-.8z\"><\/path>\n<\/svg>\t\t<span class=\"frm_upload_text\"><button type=\"button\" aria-label=\"Upload a hearing test report. upload file from here. Maximum file size: 67.11MB\">upload file from here<\/button><\/span>\n\t\t<span class=\"frm_compact_text\"><button type=\"button\" aria-label=\"Upload a hearing test report. choose file. Maximum file size: 67.11MB\">choose file<\/button><\/span>\n\t\t<div class=\"frm_small_text\">\n\t\t\t<p>Maximum file size: 67.11MB<\/p>\n\t\t<\/div>\n\t<\/div>\n<\/div>\n\t\r\n    \r\n    \r\n<\/div>\n<div id=\"frm_field_864_container\" class=\"frm_form_field form-field  frm_required_field frm_top_container frm_two_col\">\r\n    <div  id=\"field_8j93f_label\" class=\"frm_primary_label\">Desired Rehabilitation Services: (More than one service can be selected)\r\n        <span class=\"frm_required\" aria-hidden=\"true\">*<\/span>\r\n    <\/div>\r\n    <div class=\"frm_opt_container\" aria-labelledby=\"field_8j93f_label\" role=\"group\">\t\t<div class=\"frm_checkbox\" id=\"frm_checkbox_864-0\">\t\t\t<label  for=\"field_8j93f-0\">\n\t\t\t<input type=\"checkbox\" name=\"item_meta[864][]\" id=\"field_8j93f-0\" value=\"\u0627\u0633\u062a\u0634\u0627\u0631\u0629 \u0645\u062c\u0627\u0646\u064a\u0629\"  data-reqmsg=\"Please fill this field\" data-invmsg=\"Desired Rehabilitation Services: (More than one service can be selected) is invalid\"   aria-required=\"true\"  \/> Free Consultation<\/label><\/div>\n\t\t<div class=\"frm_checkbox\" id=\"frm_checkbox_864-5\">\t\t\t<label  for=\"field_8j93f-5\">\n\t\t\t<input type=\"checkbox\" name=\"item_meta[864][]\" id=\"field_8j93f-5\" value=\"\u0645\u0634\u0627\u0643\u0644 \u0627\u0644\u0625\u0637\u0639\u0627\u0645 \u0648\u0627\u0646\u062a\u0642\u0627\u0626\u064a\u0629 \u0627\u0644\u0637\u0639\u0627\u0645\"  data-reqmsg=\"Please fill this field\" data-invmsg=\"Desired Rehabilitation Services: (More than one service can be selected) is invalid\"   \/> Feeding problems and food selectivity<\/label><\/div>\n\t\t<div class=\"frm_checkbox\" id=\"frm_checkbox_864-1\">\t\t\t<label  for=\"field_8j93f-1\">\n\t\t\t<input type=\"checkbox\" name=\"item_meta[864][]\" id=\"field_8j93f-1\" value=\"\u0627\u0644\u062a\u0642\u064a\u064a\u0645 \u0627\u0644\u0646\u0645\u0627\u0626\u064a \u0627\u0644\u0634\u0627\u0645\u0644\"  data-reqmsg=\"Please fill this field\" data-invmsg=\"Desired Rehabilitation Services: (More than one service can be selected) is invalid\"   \/> Comprehensive Development Assessment<\/label><\/div>\n\t\t<div class=\"frm_checkbox\" id=\"frm_checkbox_864-6\">\t\t\t<label  for=\"field_8j93f-6\">\n\t\t\t<input type=\"checkbox\" name=\"item_meta[864][]\" id=\"field_8j93f-6\" value=\"\u0627\u0644\u062e\u062f\u0645\u0627\u062a \u0627\u0644\u0645\u0646\u0632\u0644\u064a\u0629\"  data-reqmsg=\"Please fill this field\" data-invmsg=\"Desired Rehabilitation Services: (More than one service can be selected) is invalid\"   \/> Home Services<\/label><\/div>\n\t\t<div class=\"frm_checkbox\" id=\"frm_checkbox_864-2\">\t\t\t<label  for=\"field_8j93f-2\">\n\t\t\t<input type=\"checkbox\" name=\"item_meta[864][]\" id=\"field_8j93f-2\" value=\"\u0627\u0644\u0628\u0631\u0646\u0627\u0645\u062c \u0627\u0644\u062a\u0623\u0647\u064a\u0644\u064a \u0627\u0644\u0645\u0643\u062b\u0641\"  data-reqmsg=\"Please fill this field\" data-invmsg=\"Desired Rehabilitation Services: (More than one service can be selected) is invalid\"   \/> Intensive Rehabilitation Program<\/label><\/div>\n\t\t<div class=\"frm_checkbox\" id=\"frm_checkbox_864-7\">\t\t\t<label  for=\"field_8j93f-7\">\n\t\t\t<input type=\"checkbox\" name=\"item_meta[864][]\" id=\"field_8j93f-7\" value=\"\u0627\u0644\u062a\u0623\u0647\u064a\u0644 \u0627\u0644\u0645\u0647\u0646\u064a\"  data-reqmsg=\"Please fill this field\" data-invmsg=\"Desired Rehabilitation Services: (More than one service can be selected) is invalid\"   \/> Vocational Rehabilitation<\/label><\/div>\n\t\t<div class=\"frm_checkbox\" id=\"frm_checkbox_864-3\">\t\t\t<label  for=\"field_8j93f-3\">\n\t\t\t<input type=\"checkbox\" name=\"item_meta[864][]\" id=\"field_8j93f-3\" value=\"\u0627\u0644\u0628\u0627\u0642\u0629 \u0627\u0644\u0648\u0627\u062d\u062f\u0629 (24 \u062c\u0644\u0633\u0629 \u0641\u064a \u0639\u0644\u0627\u062c \u0627\u0644\u062a\u062e\u0627\u0637\u0628 \u0648\u0627\u0644\u0644\u063a\u0629 \u0623\u0648 \u0627\u0644\u0639\u0644\u0627\u062c \u0627\u0644\u0648\u0638\u064a\u0641\u064a)\"  data-reqmsg=\"Please fill this field\" data-invmsg=\"Desired Rehabilitation Services: (More than one service can be selected) is invalid\"   \/> One package (24 sessions in speech-language therapy or occupational therapy)<\/label><\/div>\n\t\t<div class=\"frm_checkbox\" id=\"frm_checkbox_864-8\">\t\t\t<label  for=\"field_8j93f-8\">\n\t\t\t<input type=\"checkbox\" name=\"item_meta[864][]\" id=\"field_8j93f-8\" value=\"\u062a\u062f\u0631\u064a\u0628 \u0627\u0644\u0623\u0633\u0631\u0629 \u0639\u0646 \u0628\u0639\u062f\"  data-reqmsg=\"Please fill this field\" data-invmsg=\"Desired Rehabilitation Services: (More than one service can be selected) is invalid\"   \/> Remote Family Training<\/label><\/div>\n\t\t<div class=\"frm_checkbox\" id=\"frm_checkbox_864-4\">\t\t\t<label  for=\"field_8j93f-4\">\n\t\t\t<input type=\"checkbox\" name=\"item_meta[864][]\" id=\"field_8j93f-4\" value=\"\u0627\u0644\u0645\u0634\u0627\u0643\u0644 \u0627\u0644\u0633\u0644\u0648\u0643\u064a\u0629 \u0627\u0644\u0634\u062f\u064a\u062f\u0629 \u0648\u0627\u0644\u062a\u0648\u0627\u0635\u0644 \u0627\u0644\u0648\u0638\u064a\u0641\u064a (24  \u062c\u0644\u0633\u0629)\"  data-reqmsg=\"Please fill this field\" data-invmsg=\"Desired Rehabilitation Services: (More than one service can be selected) is invalid\"   \/> For severe behavioral problems and functional communication (24 sessions)<\/label><\/div>\n\t\t<div class=\"frm_checkbox\" id=\"frm_checkbox_864-9\">\t\t\t<label  for=\"field_8j93f-9\">\n\t\t\t<input type=\"checkbox\" name=\"item_meta[864][]\" id=\"field_8j93f-9\" value=\"\u0628\u0631\u0646\u0627\u0645\u062c \u0627\u0644\u062a\u0647\u064a\u0626\u0629 \u0644\u0644\u0645\u062f\u0631\u0633\u0629\"  data-reqmsg=\"Please fill this field\" data-invmsg=\"Desired Rehabilitation Services: (More than one service can be selected) is invalid\"   \/> School Induction Program<\/label><\/div>\n<\/div>\r\n    \r\n    \r\n<\/div>\n<div id=\"frm_field_865_container\" class=\"frm_form_field form-field  frm_required_field frm_top_container horizontal_radio\">\r\n    <div  id=\"field_r95xf_label\" class=\"frm_primary_label\">Payment Method\r\n        <span class=\"frm_required\" aria-hidden=\"true\">*<\/span>\r\n    <\/div>\r\n    <div class=\"frm_opt_container\" aria-labelledby=\"field_r95xf_label\" role=\"radiogroup\" aria-required=\"true\">\t\t<div class=\"frm_radio\" id=\"frm_radio_865-0\">\t\t\t<label  for=\"field_r95xf-0\">\n\t\t\t\t\t<input type=\"radio\" name=\"item_meta[865]\" id=\"field_r95xf-0\" value=\"\u0646\u0642\u062f\u064a\"\n\t\t data-reqmsg=\"Please fill this field\" data-invmsg=\"Payment Method is invalid\"   \/> Cash<\/label><\/div>\n\t\t<div class=\"frm_radio\" id=\"frm_radio_865-1\">\t\t\t<label  for=\"field_r95xf-1\">\n\t\t\t\t\t<input type=\"radio\" name=\"item_meta[865]\" id=\"field_r95xf-1\" value=\"\u062a\u0623\u0645\u064a\u0646 (\u0627\u0644\u062a\u0639\u0627\u0648\u0646\u064a\u0629)\"\n\t\t data-reqmsg=\"Please fill this field\" data-invmsg=\"Payment Method is invalid\"   \/> Insurance (Tawuniya)<\/label><\/div>\n\t\t<div class=\"frm_radio\" id=\"frm_radio_865-2\">\t\t\t<label  for=\"field_r95xf-2\">\n\t\t\t\t\t<input type=\"radio\" name=\"item_meta[865]\" id=\"field_r95xf-2\" value=\"\u062a\u0623\u0645\u064a\u0646 (\u0628\u0648\u0628\u0627)\"\n\t\t data-reqmsg=\"Please fill this field\" data-invmsg=\"Payment Method is invalid\"   \/> Insurance (Bupa)<\/label><\/div>\n\t\t<div class=\"frm_radio\" id=\"frm_radio_865-3\">\t\t\t<label  for=\"field_r95xf-3\">\n\t\t\t\t\t<input type=\"radio\" name=\"item_meta[865]\" id=\"field_r95xf-3\" value=\"\u062a\u0623\u0645\u064a\u0646 (\u0645\u0644\u0627\u0630)\"\n\t\t data-reqmsg=\"Please fill this field\" data-invmsg=\"Payment Method is invalid\"   \/> Insurance (Malath)<\/label><\/div>\n\t\t<div class=\"frm_radio\" id=\"frm_radio_865-4\">\t\t\t<label  for=\"field_r95xf-4\">\n\t\t\t\t\t<input type=\"radio\" name=\"item_meta[865]\" id=\"field_r95xf-4\" value=\"\u062a\u0623\u0645\u064a\u0646 (\u0645\u064a\u062f \u063a\u0644\u0641)\"\n\t\t data-reqmsg=\"Please fill this field\" data-invmsg=\"Payment Method is invalid\"   \/> Insurance (MidGulf)<\/label><\/div>\n<\/div>\r\n    \r\n    \r\n<\/div>\n<div id=\"frm_field_866_container\" class=\"frm_form_field form-field  frm_required_field frm_top_container horizontal_radio\">\r\n    <div  id=\"field_g7i4_label\" class=\"frm_primary_label\">Has the beneficiary been registered with Autism Center of Excellence previously?\r\n        <span class=\"frm_required\" aria-hidden=\"true\">*<\/span>\r\n    <\/div>\r\n    <div class=\"frm_opt_container\" aria-labelledby=\"field_g7i4_label\" role=\"radiogroup\" aria-required=\"true\">\t\t<div class=\"frm_radio\" id=\"frm_radio_866-0\">\t\t\t<label  for=\"field_g7i4-0\">\n\t\t\t\t\t<input type=\"radio\" name=\"item_meta[866]\" id=\"field_g7i4-0\" value=\"\u0646\u0639\u0645\"\n\t\t data-reqmsg=\"Please fill this field\" data-invmsg=\"Has the beneficiary been registered with Autism Center of Excellence previously? is invalid\"   \/> Yes<\/label><\/div>\n\t\t<div class=\"frm_radio\" id=\"frm_radio_866-1\">\t\t\t<label  for=\"field_g7i4-1\">\n\t\t\t\t\t<input type=\"radio\" name=\"item_meta[866]\" id=\"field_g7i4-1\" value=\"\u0644\u0627\"\n\t\t data-reqmsg=\"Please fill this field\" data-invmsg=\"Has the beneficiary been registered with Autism Center of Excellence previously? is invalid\"   \/> No<\/label><\/div>\n<\/div>\r\n    \r\n    \r\n<\/div>\n<div id=\"frm_field_872_container\" class=\"frm_form_field form-field  frm_required_field frm_top_container frm_half frm_other_container\">\n    <label for=\"field_lyks8\" id=\"field_lyks8_label\" class=\"frm_primary_label\">How did you learn about the Autism Center of Excellence and its services?\n        <span class=\"frm_required\" aria-hidden=\"true\">*<\/span>\n    <\/label>\n    \t\t<select name=\"item_meta[872]\" id=\"field_lyks8\"  data-reqmsg=\"Please fill this field\" aria-required=\"true\" data-invmsg=\"How did you learn about the Autism Center of Excellence and its services? is invalid\" aria-invalid=\"false\"  >\n\t\t<option  value=\"\" selected='selected'> <\/option><option  value=\"\u0639\u0646 \u0637\u0631\u064a\u0642 \u0627\u0644\u062a\u0648\u0627\u0635\u0644 \u0627\u0644\u0627\u062c\u062a\u0645\u0627\u0639\u064a\">Through social networking<\/option><option  value=\"\u0639\u0646 \u0637\u0631\u064a\u0642 \u0635\u062f\u064a\u0642\">Through a friend<\/option><option  value=\"\u0639\u0646 \u0637\u0631\u064a\u0642 \u0645\u0633\u062a\u0641\u064a\u062f \u0633\u0627\u0628\u0642 \u0645\u0646 \u062e\u062f\u0645\u0627\u062a \u0627\u0644\u0645\u0631\u0643\u0632\">Through a previous beneficiary of the center\u2019s services<\/option><option  value=\"\u0639\u0646 \u0637\u0631\u064a\u0642 \u0623\u062d\u062f \u0645\u0646\u0633\u0648\u0628\u064a \u0627\u0644\u0645\u0631\u0643\u0632\">Through one of the center\u2019s employees<\/option><option  value=\"\u0623\u062e\u0631\u0649\" class=\"frm_other_trigger\">Other<\/option>\t<\/select>\n\t<label for=\"field_lyks8-otext\" class=\"frm_screen_reader frm_hidden\">How did you learn about the Autism Center of Excellence and its services?<\/label><input type=\"text\" id=\"field_lyks8-otext\" class=\"frm_other_input frm_pos_none\"  name=\"item_meta[other][872]\" value=\"\" \/>\n    \n    \n<\/div>\n<div id=\"frm_field_874_container\" class=\"frm_form_field form-field  frm_required_field frm_top_container frm12 frm_first\">\n    <label for=\"field_f247g\" id=\"field_f247g_label\" class=\"frm_primary_label\">Please enter employee ID number\n        <span class=\"frm_required\" aria-hidden=\"true\">*<\/span>\n    <\/label>\n    <input  type=\"text\" id=\"field_f247g\" name=\"item_meta[874]\" value=\"\"  data-reqmsg=\"Please fill this field\" aria-required=\"true\" data-invmsg=\"Text is invalid\" aria-invalid=\"false\"   \/>\n    \n    \n<\/div>\n<input type=\"hidden\" name=\"item_meta[867]\" id=\"field_9nc70\" value=\"\u062a\u062d\u062a \u0627\u0644\u0627\u062c\u0631\u0627\u0621\"  data-frmval=\"\u062a\u062d\u062a \u0627\u0644\u0627\u062c\u0631\u0627\u0621\"   \/>\n<input type=\"hidden\" name=\"item_meta[871]\" id=\"field_cf10k\" value=\"\" data-frmval=\"\"\/>\n<div id=\"frm_field_978_container\" class=\"frm_form_field form-field \">\n\t<div class=\"frm_submit frm_flex\">\r\n<button class=\"frm_button_submit frm_final_submit\" type=\"submit\"   formnovalidate=\"formnovalidate\">\u0627\u0631\u0633\u0627\u0644<\/button>\r\n\r\n\r\n\r\n<\/div>\n<\/div>\n\t<input type=\"hidden\" name=\"item_key\" value=\"\" \/>\n\t\t\t<div id=\"frm_field_1530_container\">\n\t\t\t<label for=\"field_fj1gw\" >\n\t\t\t\tIf you are human, leave this field blank.\t\t\t<\/label>\n\t\t\t<input  id=\"field_fj1gw\" type=\"text\" class=\"frm_form_field form-field frm_verify\" name=\"item_meta[1530]\" value=\"\"  \/>\n\t\t<\/div>\n\t\t<input name=\"frm_state\" type=\"hidden\" value=\"aM3ZlaT18zmXkrpPr8OE4pgyytnD5bkThpkXaZ7d7KTubOYTxAqTDLOvx5ZPl0Ky\" \/><\/div>\n<\/fieldset>\n<\/div>\n\n<\/form>\n<\/div>\n\n","protected":false},"excerpt":{"rendered":"","protected":false},"author":1,"featured_media":0,"parent":0,"menu_order":0,"comment_status":"closed","ping_status":"closed","template":"","meta":{"_acf_changed":false,"footnotes":""},"class_list":["post-82498","page","type-page","status-publish","hentry"],"acf":[],"meta_box":[],"_links":{"self":[{"href":"https:\/\/acesaudi.org\/en\/wp-json\/wp\/v2\/pages\/82498","targetHints":{"allow":["GET"]}}],"collection":[{"href":"https:\/\/acesaudi.org\/en\/wp-json\/wp\/v2\/pages"}],"about":[{"href":"https:\/\/acesaudi.org\/en\/wp-json\/wp\/v2\/types\/page"}],"author":[{"embeddable":true,"href":"https:\/\/acesaudi.org\/en\/wp-json\/wp\/v2\/users\/1"}],"replies":[{"embeddable":true,"href":"https:\/\/acesaudi.org\/en\/wp-json\/wp\/v2\/comments?post=82498"}],"version-history":[{"count":1,"href":"https:\/\/acesaudi.org\/en\/wp-json\/wp\/v2\/pages\/82498\/revisions"}],"predecessor-version":[{"id":82499,"href":"https:\/\/acesaudi.org\/en\/wp-json\/wp\/v2\/pages\/82498\/revisions\/82499"}],"wp:attachment":[{"href":"https:\/\/acesaudi.org\/en\/wp-json\/wp\/v2\/media?parent=82498"}],"curies":[{"name":"wp","href":"https:\/\/api.w.org\/{rel}","templated":true}]}}