{"id":546,"date":"2020-03-13T09:44:04","date_gmt":"2020-03-13T09:44:04","guid":{"rendered":"https:\/\/salute.vamtam.com\/?page_id=546"},"modified":"2024-11-07T19:27:12","modified_gmt":"2024-11-07T19:27:12","slug":"intake-form-new-patient","status":"publish","type":"page","link":"https:\/\/mymentalhealthtms.com\/index.php\/intake-form-new-patient\/","title":{"rendered":"Intake Form &#038; New Patient Paperwork"},"content":{"rendered":"\t\t<div data-elementor-type=\"wp-page\" data-elementor-id=\"546\" class=\"elementor elementor-546\" data-elementor-post-type=\"page\">\n\t\t\t\t\t\t<section class=\"elementor-section elementor-top-section elementor-element elementor-element-476119cb elementor-section-height-min-height elementor-section-items-stretch elementor-section-boxed elementor-section-height-default\" data-id=\"476119cb\" 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-450aa483\" data-id=\"450aa483\" data-element_type=\"column\" data-settings=\"{&quot;background_background&quot;:&quot;classic&quot;}\">\n\t\t\t<div class=\"elementor-widget-wrap elementor-element-populated\">\n\t\t\t\t\t\t<section class=\"elementor-section elementor-inner-section elementor-element elementor-element-324556e0 elementor-section-boxed elementor-section-height-default elementor-section-height-default\" data-id=\"324556e0\" 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-inner-column elementor-element elementor-element-1f6d39a0\" data-id=\"1f6d39a0\" 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-2ae3b0e0 elementor-widget elementor-widget-heading\" data-id=\"2ae3b0e0\" data-element_type=\"widget\" data-widget_type=\"heading.default\">\n\t\t\t\t<div class=\"elementor-widget-container\">\n\t\t\t<h1 class=\"elementor-heading-title elementor-size-default\">New Patients<\/h1>\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\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-50bb9989 elementor-section-height-min-height elementor-section-items-stretch elementor-section-boxed elementor-section-height-default\" data-id=\"50bb9989\" 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-2e69d87b\" data-id=\"2e69d87b\" data-element_type=\"column\" data-settings=\"{&quot;background_background&quot;:&quot;classic&quot;}\">\n\t\t\t<div class=\"elementor-widget-wrap elementor-element-populated\">\n\t\t\t\t\t\t<section class=\"elementor-section elementor-inner-section elementor-element elementor-element-282a5168 elementor-section-boxed elementor-section-height-default elementor-section-height-default\" data-id=\"282a5168\" 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-50 elementor-inner-column elementor-element elementor-element-328bbb9\" data-id=\"328bbb9\" 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-9ba99fb elementor-align-left elementor-mobile-align-left elementor-widget-mobile__width-auto elementor-widget elementor-widget-button\" data-id=\"9ba99fb\" data-element_type=\"widget\" data-widget_type=\"button.default\">\n\t\t\t\t<div class=\"elementor-widget-container\">\n\t\t\t\t\t<div class=\"elementor-button-wrapper\">\n\t\t\t<a class=\"elementor-button elementor-button-link elementor-size-sm\" href=\"https:\/\/mymentalhealthtms.com\/index.php\/request-an-appointment\/\">\n\t\t\t\t\t\t<span class=\"elementor-button-content-wrapper\">\n\t\t\t\t\t\t\t\t\t<span class=\"elementor-button-text\">Request Appointment ><\/span>\n\t\t\t\t\t<\/span>\n\t\t\t\t\t<\/a>\n\t\t<\/div>\n\t\t\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<div class=\"elementor-column elementor-col-50 elementor-inner-column elementor-element elementor-element-2f5b3eb6 elementor-hidden-phone\" data-id=\"2f5b3eb6\" 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-785a8f05 elementor-widget__width-auto elementor-view-default elementor-widget elementor-widget-icon\" data-id=\"785a8f05\" data-element_type=\"widget\" data-widget_type=\"icon.default\">\n\t\t\t\t<div class=\"elementor-widget-container\">\n\t\t\t\t\t<div class=\"elementor-icon-wrapper\">\n\t\t\t<div class=\"elementor-icon\">\n\t\t\t<i aria-hidden=\"true\" class=\"vamtamtheme- vamtam-theme-emergency-phone\"><\/i>\t\t\t<\/div>\n\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t<div class=\"elementor-element elementor-element-44af653d elementor-widget__width-auto elementor-widget elementor-widget-heading\" data-id=\"44af653d\" data-element_type=\"widget\" data-widget_type=\"heading.default\">\n\t\t\t\t<div class=\"elementor-widget-container\">\n\t\t\t<h5 class=\"elementor-heading-title elementor-size-default\"><a href=\"tel:+1%20443-354-1200\">+1 443-354-1200<\/a><\/h5>\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\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-53ed28a elementor-section-boxed elementor-section-height-default elementor-section-height-default\" data-id=\"53ed28a\" 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-15433ab\" data-id=\"15433ab\" 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-9857214 elementor-widget elementor-widget-template\" data-id=\"9857214\" data-element_type=\"widget\" data-widget_type=\"template.default\">\n\t\t\t\t<div class=\"elementor-widget-container\">\n\t\t\t\t\t<div class=\"elementor-template\">\n\t\t\t\t\t<div data-elementor-type=\"section\" data-elementor-id=\"989258\" class=\"elementor elementor-989258\" data-elementor-post-type=\"elementor_library\">\n\t\t\t\t\t<section class=\"elementor-section elementor-top-section elementor-element elementor-element-7a28ac19 elementor-section-boxed elementor-section-height-default elementor-section-height-default\" data-id=\"7a28ac19\" 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-50 elementor-top-column elementor-element elementor-element-79f2e67a\" data-id=\"79f2e67a\" data-element_type=\"column\" data-settings=\"{&quot;background_background&quot;:&quot;classic&quot;}\">\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-3ec94a8a elementor-widget__width-auto elementor-widget elementor-widget-text-editor\" data-id=\"3ec94a8a\" data-element_type=\"widget\" data-widget_type=\"text-editor.default\">\n\t\t\t\t<div class=\"elementor-widget-container\">\n\t\t\t\t\t\t\t<h6>ACCEPTED<br>INSURANCE:<\/h6>\t\t\t\t\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<div class=\"elementor-column elementor-col-50 elementor-top-column elementor-element elementor-element-76063e77\" data-id=\"76063e77\" 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-14a029b7 elementor-widget elementor-widget-image-carousel\" data-id=\"14a029b7\" data-element_type=\"widget\" data-settings=\"{&quot;slides_to_show&quot;:&quot;4&quot;,&quot;navigation&quot;:&quot;none&quot;,&quot;slides_to_show_mobile&quot;:&quot;2&quot;,&quot;slides_to_scroll_mobile&quot;:&quot;1&quot;,&quot;slides_to_show_tablet&quot;:&quot;4&quot;,&quot;slides_to_scroll_tablet&quot;:&quot;3&quot;,&quot;pause_on_hover&quot;:&quot;no&quot;,&quot;autoplay_speed&quot;:1500,&quot;speed&quot;:600,&quot;autoplay&quot;:&quot;yes&quot;,&quot;pause_on_interaction&quot;:&quot;yes&quot;,&quot;infinite&quot;:&quot;yes&quot;}\" data-widget_type=\"image-carousel.default\">\n\t\t\t\t<div class=\"elementor-widget-container\">\n\t\t\t\t\t<div class=\"elementor-image-carousel-wrapper swiper\" dir=\"ltr\">\n\t\t\t<div class=\"elementor-image-carousel swiper-wrapper\" aria-live=\"off\">\n\t\t\t\t\t\t\t\t<div class=\"swiper-slide\" role=\"group\" aria-roledescription=\"slide\" aria-label=\"1 of 4\"><figure class=\"swiper-slide-inner\"><img decoding=\"async\" class=\"swiper-slide-image\" src=\"https:\/\/mymentalhealthtms.com\/wp-content\/uploads\/2021\/09\/logos-6.webp\" alt=\"logos-6\" \/><\/figure><\/div><div class=\"swiper-slide\" role=\"group\" aria-roledescription=\"slide\" aria-label=\"2 of 4\"><figure class=\"swiper-slide-inner\"><img decoding=\"async\" class=\"swiper-slide-image\" src=\"https:\/\/mymentalhealthtms.com\/wp-content\/uploads\/2021\/10\/logo-medicare.png\" alt=\"logo-medicare\" \/><\/figure><\/div><div class=\"swiper-slide\" role=\"group\" aria-roledescription=\"slide\" aria-label=\"3 of 4\"><figure class=\"swiper-slide-inner\"><img decoding=\"async\" class=\"swiper-slide-image\" src=\"https:\/\/mymentalhealthtms.com\/wp-content\/uploads\/2021\/10\/logo-carefirst-1.png\" alt=\"logo-carefirst\" \/><\/figure><\/div><div class=\"swiper-slide\" role=\"group\" aria-roledescription=\"slide\" aria-label=\"4 of 4\"><figure class=\"swiper-slide-inner\"><img decoding=\"async\" class=\"swiper-slide-image\" src=\"https:\/\/mymentalhealthtms.com\/wp-content\/uploads\/2021\/10\/logo-tricare-1.png\" alt=\"logo-tricare\" \/><\/figure><\/div>\t\t\t<\/div>\n\t\t\t\t\t\t\t\n\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\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<\/div>\n\t\t\t\t<\/div>\n\t\t\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-5487782 elementor-section-height-min-height elementor-section-items-stretch elementor-section-boxed elementor-section-height-default\" data-id=\"5487782\" 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-e963990\" data-id=\"e963990\" data-element_type=\"column\">\n\t\t\t<div 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<a href=\\\"#\\\" class=\\\"nf-add-new\\\">Add New<\\\/a> <a href=\\\"#\\\" class=\\\"extra nf-open-import-tooltip\\\"><i class=\\\"fa fa-sign-in\\\" aria-hidden=\\\"true\\\"><\\\/i> Import<\\\/a>\",\"width\":\"full\",\"group\":\"\",\"value\":[{\"label\":\"One\",\"value\":\"one\",\"calc\":\"\",\"selected\":0,\"order\":0},{\"label\":\"Two\",\"value\":\"two\",\"calc\":\"\",\"selected\":0,\"order\":1},{\"label\":\"Three\",\"value\":\"three\",\"calc\":\"\",\"selected\":0,\"order\":2}],\"columns\":{\"label\":{\"header\":\"Label\",\"default\":\"\"},\"value\":{\"header\":\"Value\",\"default\":\"\"},\"calc\":{\"header\":\"Calc Value\",\"default\":\"\"},\"selected\":{\"header\":\"<span class=\\\"dashicons 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Value\",\"default\":\"\"},\"selected\":{\"header\":\"<span class=\\\"dashicons dashicons-yes\\\"><\\\/span>\",\"default\":0}}},\"manual_value\":true},{\"errors\":[],\"max_options\":0,\"label\":\"Transgender\",\"value\":\"transgender\",\"calc\":\"\",\"selected\":0,\"order\":3,\"settingModel\":{\"settings\":false,\"hide_merge_tags\":false,\"error\":false,\"name\":\"options\",\"type\":\"option-repeater\",\"label\":\"Options <a href=\\\"#\\\" class=\\\"nf-add-new\\\">Add New<\\\/a> <a href=\\\"#\\\" class=\\\"extra nf-open-import-tooltip\\\"><i class=\\\"fa fa-sign-in\\\" aria-hidden=\\\"true\\\"><\\\/i> Import<\\\/a>\",\"width\":\"full\",\"group\":\"\",\"value\":[{\"label\":\"One\",\"value\":\"one\",\"calc\":\"\",\"selected\":0,\"order\":0},{\"label\":\"Two\",\"value\":\"two\",\"calc\":\"\",\"selected\":0,\"order\":1},{\"label\":\"Three\",\"value\":\"three\",\"calc\":\"\",\"selected\":0,\"order\":2}],\"columns\":{\"label\":{\"header\":\"Label\",\"default\":\"\"},\"value\":{\"header\":\"Value\",\"default\":\"\"},\"calc\":{\"header\":\"Calc Value\",\"default\":\"\"},\"selected\":{\"header\":\"<span class=\\\"dashicons dashicons-yes\\\"><\\\/span>\",\"default\":0}}},\"manual_value\":true},{\"errors\":[],\"max_options\":0,\"order\":4,\"new\":false,\"options\":[],\"label\":\"Non-binary\\\/non-conforming\",\"value\":\"non-binary-non-conforming\",\"calc\":\"\",\"selected\":0,\"settingModel\":{\"settings\":false,\"hide_merge_tags\":false,\"error\":false,\"name\":\"options\",\"type\":\"option-repeater\",\"label\":\"Options <a href=\\\"#\\\" class=\\\"nf-add-new\\\">Add New<\\\/a> <a href=\\\"#\\\" class=\\\"extra nf-open-import-tooltip\\\"><i class=\\\"fa fa-sign-in\\\" aria-hidden=\\\"true\\\"><\\\/i> Import<\\\/a>\",\"width\":\"full\",\"group\":\"\",\"value\":[{\"label\":\"One\",\"value\":\"one\",\"calc\":\"\",\"selected\":0,\"order\":0},{\"label\":\"Two\",\"value\":\"two\",\"calc\":\"\",\"selected\":0,\"order\":1},{\"label\":\"Three\",\"value\":\"three\",\"calc\":\"\",\"selected\":0,\"order\":2}],\"columns\":{\"label\":{\"header\":\"Label\",\"default\":\"\"},\"value\":{\"header\":\"Value\",\"default\":\"\"},\"calc\":{\"header\":\"Calc Value\",\"default\":\"\"},\"selected\":{\"header\":\"<span class=\\\"dashicons dashicons-yes\\\"><\\\/span>\",\"default\":0}}},\"manual_value\":true},{\"errors\":[],\"max_options\":0,\"order\":5,\"new\":false,\"options\":[],\"label\":\"Prefer not to respond\",\"value\":\"prefer-not-to-respond\",\"calc\":\"\",\"selected\":0,\"settingModel\":{\"settings\":false,\"hide_merge_tags\":false,\"error\":false,\"name\":\"options\",\"type\":\"option-repeater\",\"label\":\"Options <a href=\\\"#\\\" class=\\\"nf-add-new\\\">Add New<\\\/a> <a href=\\\"#\\\" class=\\\"extra nf-open-import-tooltip\\\"><i class=\\\"fa fa-sign-in\\\" aria-hidden=\\\"true\\\"><\\\/i> Import<\\\/a>\",\"width\":\"full\",\"group\":\"\",\"value\":[{\"label\":\"One\",\"value\":\"one\",\"calc\":\"\",\"selected\":0,\"order\":0},{\"label\":\"Two\",\"value\":\"two\",\"calc\":\"\",\"selected\":0,\"order\":1},{\"label\":\"Three\",\"value\":\"three\",\"calc\":\"\",\"selected\":0,\"order\":2}],\"columns\":{\"label\":{\"header\":\"Label\",\"default\":\"\"},\"value\":{\"header\":\"Value\",\"default\":\"\"},\"calc\":{\"header\":\"Calc Value\",\"default\":\"\"},\"selected\":{\"header\":\"<span class=\\\"dashicons dashicons-yes\\\"><\\\/span>\",\"default\":0}}},\"manual_value\":true}],\"container_class\":\"\",\"element_class\":\"\",\"admin_label\":\"Gender\",\"help_text\":\"<p><span style=\\\"caret-color: rgb(34, 34, 34); color: rgb(34, 34, 34); font-family: Arial, Helvetica, sans-serif; font-size: small;\\\">Please select one of the following<\\\/span><br><\\\/p>\",\"desc_text\":\"<p><span style=\\\"caret-color: rgb(34, 34, 34); color: rgb(34, 34, 34); font-family: Arial, Helvetica, sans-serif; font-size: small;\\\">Please select one of the following<\\\/span><br><\\\/p>\",\"drawerDisabled\":false,\"id\":79,\"beforeField\":\"\",\"afterField\":\"\",\"value\":\"\",\"parentType\":\"list\",\"element_templates\":[\"listselect\",\"input\"],\"old_classname\":\"list-select\",\"wrap_template\":\"wrap\"},{\"objectType\":\"Field\",\"objectDomain\":\"fields\",\"editActive\":false,\"order\":4,\"idAttribute\":\"id\",\"label\":\"Preferred Pronouns\",\"type\":\"textbox\",\"key\":\"preferred_pronouns_1683092083482\",\"label_pos\":\"above\",\"required\":false,\"default\":\"\",\"placeholder\":\"\",\"container_class\":\"\",\"element_class\":\"\",\"input_limit\":\"\",\"input_limit_type\":\"characters\",\"input_limit_msg\":\"Character(s) left\",\"manual_key\":false,\"admin_label\":\"Preferred Pronouns\",\"help_text\":\"\",\"mask\":\"\",\"custom_mask\":\"\",\"custom_name_attribute\":\"\",\"personally_identifiable\":\"\",\"value\":\"\",\"drawerDisabled\":false,\"id\":80,\"beforeField\":\"\",\"afterField\":\"\",\"parentType\":\"textbox\",\"element_templates\":[\"textbox\",\"input\"],\"old_classname\":\"\",\"wrap_template\":\"wrap\"},{\"objectType\":\"Field\",\"objectDomain\":\"fields\",\"editActive\":false,\"order\":5,\"idAttribute\":\"id\",\"type\":\"date\",\"label\":\"D.O.B\",\"key\":\"d_o_b_1504525249967\",\"label_pos\":\"above\",\"required\":1,\"container_class\":\"\",\"element_class\":\"\",\"manual_key\":\"\",\"admin_label\":\"\",\"help_text\":\"\",\"desc_text\":\"\",\"date_default\":\"\",\"date_format\":\"dddd, MMMM D YYYY\",\"year_range_start\":\"\",\"year_range_end\":\"\",\"drawerDisabled\":false,\"placeholder\":\"\",\"date_mode\":\"date_only\",\"hours_24\":0,\"minute_increment\":5,\"field_label\":\"D.O.B\",\"field_key\":\"d_o_b_1504525249967\",\"id\":6,\"beforeField\":\"\",\"afterField\":\"\",\"value\":\"\",\"parentType\":\"date\",\"element_templates\":[\"date\",\"textbox\",\"input\"],\"old_classname\":\"\",\"wrap_template\":\"wrap\"},{\"objectType\":\"Field\",\"objectDomain\":\"fields\",\"editActive\":false,\"order\":6,\"idAttribute\":\"id\",\"type\":\"address\",\"label\":\"Address\",\"key\":\"address_1504524507300\",\"label_pos\":\"above\",\"required\":1,\"default\":\"\",\"placeholder\":\"\",\"container_class\":\"\",\"element_class\":\"\",\"input_limit\":\"\",\"input_limit_type\":\"characters\",\"input_limit_msg\":\"Character(s) left\",\"manual_key\":\"\",\"disable_input\":\"\",\"admin_label\":\"\",\"help_text\":\"\",\"desc_text\":\"\",\"disable_browser_autocomplete\":\"\",\"mask\":\"\",\"custom_mask\":\"\",\"custom_name_attribute\":\"address\",\"personally_identifiable\":1,\"value\":\"\",\"field_label\":\"Address\",\"field_key\":\"address_1504524507300\",\"id\":7,\"beforeField\":\"\",\"afterField\":\"\",\"parentType\":\"address\",\"element_templates\":[\"address\",\"textbox\",\"input\"],\"old_classname\":\"\",\"wrap_template\":\"wrap\"},{\"objectType\":\"Field\",\"objectDomain\":\"fields\",\"editActive\":false,\"order\":7,\"idAttribute\":\"id\",\"type\":\"textbox\",\"label\":\"Apt\",\"key\":\"apt_1504525286657\",\"label_pos\":\"above\",\"required\":0,\"default\":\"\",\"placeholder\":\"\",\"container_class\":\"\",\"element_class\":\"\",\"input_limit\":\"\",\"input_limit_type\":\"characters\",\"input_limit_msg\":\"Character(s) left\",\"manual_key\":\"\",\"disable_input\":\"\",\"admin_label\":\"\",\"help_text\":\"\",\"desc_text\":\"\",\"disable_browser_autocomplete\":\"\",\"mask\":\"\",\"custom_mask\":\"\",\"drawerDisabled\":\"\",\"custom_name_attribute\":\"\",\"personally_identifiable\":\"\",\"value\":\"\",\"field_label\":\"Apt\",\"field_key\":\"apt_1504525286657\",\"id\":8,\"beforeField\":\"\",\"afterField\":\"\",\"parentType\":\"textbox\",\"element_templates\":[\"textbox\",\"input\"],\"old_classname\":\"\",\"wrap_template\":\"wrap\"},{\"objectType\":\"Field\",\"objectDomain\":\"fields\",\"editActive\":false,\"order\":8,\"idAttribute\":\"id\",\"type\":\"city\",\"label\":\"City\",\"key\":\"city_1504524535390\",\"label_pos\":\"above\",\"required\":1,\"default\":\"\",\"placeholder\":\"\",\"container_class\":\"\",\"element_class\":\"\",\"input_limit\":\"\",\"input_limit_type\":\"characters\",\"input_limit_msg\":\"Character(s) left\",\"manual_key\":\"\",\"disable_input\":\"\",\"admin_label\":\"\",\"help_text\":\"\",\"desc_text\":\"\",\"disable_browser_autocomplete\":\"\",\"mask\":\"\",\"custom_mask\":\"\",\"custom_name_attribute\":\"city\",\"personally_identifiable\":\"\",\"value\":\"\",\"field_label\":\"City\",\"field_key\":\"city_1504524535390\",\"id\":9,\"beforeField\":\"\",\"afterField\":\"\",\"parentType\":\"city\",\"element_templates\":[\"city\",\"textbox\",\"input\"],\"old_classname\":\"\",\"wrap_template\":\"wrap\"},{\"objectType\":\"Field\",\"objectDomain\":\"fields\",\"editActive\":false,\"order\":9,\"idAttribute\":\"id\",\"type\":\"zip\",\"label\":\"Zip\",\"key\":\"zip_1504524544482\",\"label_pos\":\"above\",\"required\":1,\"default\":\"\",\"placeholder\":\"\",\"container_class\":\"\",\"element_class\":\"\",\"input_limit\":\"\",\"input_limit_type\":\"characters\",\"input_limit_msg\":\"Character(s) left\",\"manual_key\":\"\",\"disable_input\":\"\",\"admin_label\":\"\",\"help_text\":\"\",\"desc_text\":\"\",\"disable_browser_autocomplete\":\"\",\"mask\":\"\",\"custom_mask\":\"\",\"custom_name_attribute\":\"zip\",\"personally_identifiable\":\"\",\"value\":\"\",\"field_label\":\"Zip\",\"field_key\":\"zip_1504524544482\",\"id\":10,\"beforeField\":\"\",\"afterField\":\"\",\"parentType\":\"zip\",\"element_templates\":[\"zip\",\"textbox\",\"input\",\"textbox\",\"input\"],\"old_classname\":\"\",\"wrap_template\":\"wrap\"},{\"objectType\":\"Field\",\"objectDomain\":\"fields\",\"editActive\":false,\"order\":10,\"idAttribute\":\"id\",\"type\":\"phone\",\"label\":\"Phone\",\"key\":\"phone_1504524564888\",\"label_pos\":\"above\",\"required\":1,\"default\":\"\",\"placeholder\":\"\",\"container_class\":\"\",\"element_class\":\"\",\"input_limit\":\"\",\"input_limit_type\":\"characters\",\"input_limit_msg\":\"Character(s) left\",\"manual_key\":\"\",\"disable_input\":\"\",\"admin_label\":\"\",\"help_text\":\"\",\"desc_text\":\"\",\"disable_browser_autocomplete\":\"\",\"mask\":\"\",\"custom_mask\":\"\",\"custom_name_attribute\":\"phone\",\"personally_identifiable\":1,\"value\":\"\",\"field_label\":\"Phone\",\"field_key\":\"phone_1504524564888\",\"id\":11,\"beforeField\":\"\",\"afterField\":\"\",\"parentType\":\"textbox\",\"element_templates\":[\"tel\",\"textbox\",\"input\"],\"old_classname\":\"\",\"wrap_template\":\"wrap\"},{\"objectType\":\"Field\",\"objectDomain\":\"fields\",\"editActive\":false,\"order\":11,\"idAttribute\":\"id\",\"type\":\"email\",\"label\":\"Email (You will be contacted by email for scheduling)\",\"key\":\"email_you_will_be_contacted_by_email_for_scheduling_1603394307682\",\"label_pos\":\"above\",\"required\":1,\"default\":\"\",\"placeholder\":\"\",\"container_class\":\"\",\"element_class\":\"\",\"admin_label\":\"\",\"help_text\":\"\",\"desc_text\":\"\",\"custom_name_attribute\":\"email\",\"personally_identifiable\":1,\"value\":\"\",\"drawerDisabled\":\"\",\"field_label\":\"Email (You will be contacted by email for scheduling)\",\"field_key\":\"email_you_will_be_contacted_by_email_for_scheduling_1603394307682\",\"id\":12,\"beforeField\":\"\",\"afterField\":\"\",\"parentType\":\"email\",\"element_templates\":[\"email\",\"input\"],\"old_classname\":\"\",\"wrap_template\":\"wrap\"},{\"objectType\":\"Field\",\"objectDomain\":\"fields\",\"editActive\":false,\"order\":12,\"idAttribute\":\"id\",\"type\":\"textbox\",\"label\":\"Primary Physician \",\"key\":\"primary_physician_1504525329848\",\"label_pos\":\"above\",\"required\":\"\",\"default\":\"\",\"placeholder\":\"\",\"container_class\":\"\",\"element_class\":\"\",\"input_limit\":\"\",\"input_limit_type\":\"characters\",\"input_limit_msg\":\"Character(s) left\",\"manual_key\":\"\",\"disable_input\":\"\",\"admin_label\":\"\",\"help_text\":\"\",\"desc_text\":\"\",\"disable_browser_autocomplete\":\"\",\"mask\":\"\",\"custom_mask\":\"\",\"drawerDisabled\":\"\",\"custom_name_attribute\":\"\",\"personally_identifiable\":\"\",\"value\":\"\",\"field_label\":\"Primary Physician \",\"field_key\":\"primary_physician_1504525329848\",\"id\":13,\"beforeField\":\"\",\"afterField\":\"\",\"parentType\":\"textbox\",\"element_templates\":[\"textbox\",\"input\"],\"old_classname\":\"\",\"wrap_template\":\"wrap\"},{\"objectType\":\"Field\",\"objectDomain\":\"fields\",\"editActive\":false,\"order\":13,\"idAttribute\":\"id\",\"label\":\"Did they refer you to MMH?\",\"type\":\"listradio\",\"key\":\"did_they_refer_you_to_mmh_1504588819185\",\"label_pos\":\"above\",\"required\":\"\",\"options\":[{\"errors\":[],\"max_options\":\"0\",\"label\":\"Yes \",\"value\":\"yes\",\"calc\":\"\",\"selected\":\"0\",\"order\":\"0\",\"settingModel\":{\"settings\":false,\"hide_merge_tags\":false,\"error\":false,\"name\":\"options\",\"type\":\"option-repeater\",\"label\":\"Options <a href=\\\"#\\\" class=\\\"nf-add-new\\\">Add New<\\\/a> <a href=\\\"#\\\" class=\\\"extra nf-open-import-tooltip\\\"><i class=\\\"fa fa-sign-in\\\" aria-hidden=\\\"true\\\"><\\\/i> Import<\\\/a>\",\"width\":\"full\",\"group\":\"\",\"value\":[{\"label\":\"One\",\"value\":\"one\",\"calc\":\"\",\"selected\":0,\"order\":0},{\"label\":\"Two\",\"value\":\"two\",\"calc\":\"\",\"selected\":0,\"order\":1},{\"label\":\"Three\",\"value\":\"three\",\"calc\":\"\",\"selected\":0,\"order\":2}],\"columns\":{\"label\":{\"header\":\"Label\",\"default\":\"\"},\"value\":{\"header\":\"Value\",\"default\":\"\"},\"calc\":{\"header\":\"Calc Value\",\"default\":\"\"},\"selected\":{\"header\":\"<span class=\\\"dashicons dashicons-yes\\\"><\\\/span>\",\"default\":0}}}},{\"errors\":[],\"max_options\":\"0\",\"label\":\"No\",\"value\":\"no\",\"calc\":\"\",\"selected\":\"0\",\"order\":\"1\",\"settingModel\":{\"settings\":false,\"hide_merge_tags\":false,\"error\":false,\"name\":\"options\",\"type\":\"option-repeater\",\"label\":\"Options <a href=\\\"#\\\" class=\\\"nf-add-new\\\">Add New<\\\/a> <a href=\\\"#\\\" class=\\\"extra nf-open-import-tooltip\\\"><i class=\\\"fa fa-sign-in\\\" aria-hidden=\\\"true\\\"><\\\/i> Import<\\\/a>\",\"width\":\"full\",\"group\":\"\",\"value\":[{\"label\":\"One\",\"value\":\"one\",\"calc\":\"\",\"selected\":0,\"order\":0},{\"label\":\"Two\",\"value\":\"two\",\"calc\":\"\",\"selected\":0,\"order\":1},{\"label\":\"Three\",\"value\":\"three\",\"calc\":\"\",\"selected\":0,\"order\":2}],\"columns\":{\"label\":{\"header\":\"Label\",\"default\":\"\"},\"value\":{\"header\":\"Value\",\"default\":\"\"},\"calc\":{\"header\":\"Calc Value\",\"default\":\"\"},\"selected\":{\"header\":\"<span class=\\\"dashicons dashicons-yes\\\"><\\\/span>\",\"default\":0}}}}],\"container_class\":\"\",\"element_class\":\"\",\"admin_label\":\"\",\"help_text\":\"\",\"desc_text\":\"\",\"drawerDisabled\":\"\",\"field_label\":\"Did they refer you to MMH?\",\"field_key\":\"did_they_refer_you_to_mmh_1504588819185\",\"id\":14,\"beforeField\":\"\",\"afterField\":\"\",\"value\":\"\",\"parentType\":\"list\",\"element_templates\":[\"listradio\",\"input\"],\"old_classname\":\"list-radio\",\"wrap_template\":\"wrap\"},{\"objectType\":\"Field\",\"objectDomain\":\"fields\",\"editActive\":false,\"order\":14,\"idAttribute\":\"id\",\"label\":\"If not, how did they hear about MMH \",\"type\":\"listcheckbox\",\"key\":\"if_not_how_did_they_hear_about_mmh_1590678505730\",\"label_pos\":\"above\",\"required\":\"\",\"options\":[{\"errors\":[],\"max_options\":\"0\",\"label\":\"Friend\",\"value\":\"friend\",\"calc\":\"\",\"selected\":\"0\",\"order\":\"0\",\"settingModel\":{\"settings\":false,\"hide_merge_tags\":false,\"error\":false,\"name\":\"options\",\"type\":\"option-repeater\",\"label\":\"Options <a href=\\\"#\\\" class=\\\"nf-add-new\\\">Add New<\\\/a> <a href=\\\"#\\\" class=\\\"extra nf-open-import-tooltip\\\"><i class=\\\"fa fa-sign-in\\\" aria-hidden=\\\"true\\\"><\\\/i> Import<\\\/a>\",\"width\":\"full\",\"group\":\"\",\"value\":[{\"label\":\"One\",\"value\":\"one\",\"calc\":\"\",\"selected\":0,\"order\":0},{\"label\":\"Two\",\"value\":\"two\",\"calc\":\"\",\"selected\":0,\"order\":1},{\"label\":\"Three\",\"value\":\"three\",\"calc\":\"\",\"selected\":0,\"order\":2}],\"columns\":{\"label\":{\"header\":\"Label\",\"default\":\"\"},\"value\":{\"header\":\"Value\",\"default\":\"\"},\"calc\":{\"header\":\"Calc Value\",\"default\":\"\"},\"selected\":{\"header\":\"<span class=\\\"dashicons dashicons-yes\\\"><\\\/span>\",\"default\":0}}}},{\"errors\":[],\"max_options\":\"0\",\"label\":\"Website\",\"value\":\"website\",\"calc\":\"\",\"selected\":\"0\",\"order\":\"1\",\"settingModel\":{\"settings\":false,\"hide_merge_tags\":false,\"error\":false,\"name\":\"options\",\"type\":\"option-repeater\",\"label\":\"Options <a href=\\\"#\\\" class=\\\"nf-add-new\\\">Add New<\\\/a> <a href=\\\"#\\\" class=\\\"extra nf-open-import-tooltip\\\"><i class=\\\"fa fa-sign-in\\\" aria-hidden=\\\"true\\\"><\\\/i> Import<\\\/a>\",\"width\":\"full\",\"group\":\"\",\"value\":[{\"label\":\"One\",\"value\":\"one\",\"calc\":\"\",\"selected\":0,\"order\":0},{\"label\":\"Two\",\"value\":\"two\",\"calc\":\"\",\"selected\":0,\"order\":1},{\"label\":\"Three\",\"value\":\"three\",\"calc\":\"\",\"selected\":0,\"order\":2}],\"columns\":{\"label\":{\"header\":\"Label\",\"default\":\"\"},\"value\":{\"header\":\"Value\",\"default\":\"\"},\"calc\":{\"header\":\"Calc Value\",\"default\":\"\"},\"selected\":{\"header\":\"<span class=\\\"dashicons dashicons-yes\\\"><\\\/span>\",\"default\":0}}}},{\"errors\":[],\"max_options\":\"0\",\"label\":\"Insurance\",\"value\":\"insurance\",\"calc\":\"\",\"selected\":\"0\",\"order\":\"2\",\"settingModel\":{\"settings\":false,\"hide_merge_tags\":false,\"error\":false,\"name\":\"options\",\"type\":\"option-repeater\",\"label\":\"Options <a href=\\\"#\\\" class=\\\"nf-add-new\\\">Add New<\\\/a> <a href=\\\"#\\\" class=\\\"extra nf-open-import-tooltip\\\"><i class=\\\"fa fa-sign-in\\\" aria-hidden=\\\"true\\\"><\\\/i> Import<\\\/a>\",\"width\":\"full\",\"group\":\"\",\"value\":[{\"label\":\"One\",\"value\":\"one\",\"calc\":\"\",\"selected\":0,\"order\":0},{\"label\":\"Two\",\"value\":\"two\",\"calc\":\"\",\"selected\":0,\"order\":1},{\"label\":\"Three\",\"value\":\"three\",\"calc\":\"\",\"selected\":0,\"order\":2}],\"columns\":{\"label\":{\"header\":\"Label\",\"default\":\"\"},\"value\":{\"header\":\"Value\",\"default\":\"\"},\"calc\":{\"header\":\"Calc Value\",\"default\":\"\"},\"selected\":{\"header\":\"<span class=\\\"dashicons dashicons-yes\\\"><\\\/span>\",\"default\":0}}}},{\"errors\":[],\"max_options\":\"0\",\"order\":\"3\",\"new\":\"\",\"options\":[],\"label\":\"Radio\",\"value\":\"radio\",\"calc\":\"\",\"selected\":\"0\",\"settingModel\":{\"settings\":false,\"hide_merge_tags\":false,\"error\":false,\"name\":\"options\",\"type\":\"option-repeater\",\"label\":\"Options <a href=\\\"#\\\" class=\\\"nf-add-new\\\">Add New<\\\/a> <a href=\\\"#\\\" class=\\\"extra nf-open-import-tooltip\\\"><i class=\\\"fa fa-sign-in\\\" aria-hidden=\\\"true\\\"><\\\/i> Import<\\\/a>\",\"width\":\"full\",\"group\":\"\",\"value\":[{\"label\":\"One\",\"value\":\"one\",\"calc\":\"\",\"selected\":0,\"order\":0},{\"label\":\"Two\",\"value\":\"two\",\"calc\":\"\",\"selected\":0,\"order\":1},{\"label\":\"Three\",\"value\":\"three\",\"calc\":\"\",\"selected\":0,\"order\":2}],\"columns\":{\"label\":{\"header\":\"Label\",\"default\":\"\"},\"value\":{\"header\":\"Value\",\"default\":\"\"},\"calc\":{\"header\":\"Calc Value\",\"default\":\"\"},\"selected\":{\"header\":\"<span class=\\\"dashicons dashicons-yes\\\"><\\\/span>\",\"default\":0}}},\"manual_value\":\"1\"}],\"container_class\":\"\",\"element_class\":\"\",\"admin_label\":\"\",\"help_text\":\"\",\"desc_text\":\"\",\"drawerDisabled\":\"\",\"field_label\":\"If not, how did they hear about MMH \",\"field_key\":\"if_not_how_did_they_hear_about_mmh_1590678505730\",\"id\":15,\"beforeField\":\"\",\"afterField\":\"\",\"value\":\"\",\"parentType\":\"list\",\"element_templates\":[\"listcheckbox\",\"input\"],\"old_classname\":\"list-checkbox\",\"wrap_template\":\"wrap\"},{\"objectType\":\"Field\",\"objectDomain\":\"fields\",\"editActive\":false,\"order\":15,\"idAttribute\":\"id\",\"label\":\"Other\",\"type\":\"textbox\",\"key\":\"other_1504589203482\",\"label_pos\":\"above\",\"required\":\"\",\"default\":\"\",\"placeholder\":\"\",\"container_class\":\"\",\"element_class\":\"\",\"input_limit\":\"\",\"input_limit_type\":\"characters\",\"input_limit_msg\":\"Character(s) left\",\"manual_key\":\"\",\"disable_input\":\"\",\"admin_label\":\"\",\"help_text\":\"\",\"desc_text\":\"\",\"disable_browser_autocomplete\":\"\",\"mask\":\"\",\"custom_mask\":\"\",\"drawerDisabled\":\"\",\"custom_name_attribute\":\"\",\"personally_identifiable\":\"\",\"value\":\"\",\"field_label\":\"Other\",\"field_key\":\"other_1504589203482\",\"id\":16,\"beforeField\":\"\",\"afterField\":\"\",\"parentType\":\"textbox\",\"element_templates\":[\"textbox\",\"input\"],\"old_classname\":\"\",\"wrap_template\":\"wrap\"},{\"objectType\":\"Field\",\"objectDomain\":\"fields\",\"editActive\":false,\"order\":16,\"idAttribute\":\"id\",\"label\":\"Insurance 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Import<\\\/a>\",\"width\":\"full\",\"group\":\"\",\"value\":[{\"label\":\"One\",\"value\":\"one\",\"calc\":\"\",\"selected\":0,\"order\":0},{\"label\":\"Two\",\"value\":\"two\",\"calc\":\"\",\"selected\":0,\"order\":1},{\"label\":\"Three\",\"value\":\"three\",\"calc\":\"\",\"selected\":0,\"order\":2}],\"columns\":{\"label\":{\"header\":\"Label\",\"default\":\"\"},\"value\":{\"header\":\"Value\",\"default\":\"\"},\"calc\":{\"header\":\"Calc Value\",\"default\":\"\"},\"selected\":{\"header\":\"<span class=\\\"dashicons dashicons-yes\\\"><\\\/span>\",\"default\":0}}}},{\"errors\":[],\"max_options\":\"0\",\"order\":\"1\",\"new\":\"\",\"options\":[],\"label\":\"BlueChoice \",\"value\":\"bluechoice \",\"calc\":\"\",\"selected\":\"0\",\"settingModel\":{\"settings\":false,\"hide_merge_tags\":false,\"error\":false,\"name\":\"options\",\"type\":\"option-repeater\",\"label\":\"Options <a href=\\\"#\\\" class=\\\"nf-add-new\\\">Add New<\\\/a> <a href=\\\"#\\\" class=\\\"extra nf-open-import-tooltip\\\"><i class=\\\"fa fa-sign-in\\\" aria-hidden=\\\"true\\\"><\\\/i> Import<\\\/a>\",\"width\":\"full\",\"group\":\"\",\"value\":[{\"label\":\"One\",\"value\":\"one\",\"calc\":\"\",\"selected\":0,\"order\":0},{\"label\":\"Two\",\"value\":\"two\",\"calc\":\"\",\"selected\":0,\"order\":1},{\"label\":\"Three\",\"value\":\"three\",\"calc\":\"\",\"selected\":0,\"order\":2}],\"columns\":{\"label\":{\"header\":\"Label\",\"default\":\"\"},\"value\":{\"header\":\"Value\",\"default\":\"\"},\"calc\":{\"header\":\"Calc Value\",\"default\":\"\"},\"selected\":{\"header\":\"<span class=\\\"dashicons dashicons-yes\\\"><\\\/span>\",\"default\":0}}},\"manual_value\":\"1\"},{\"errors\":[],\"max_options\":\"0\",\"label\":\"Cigna\",\"value\":\"cigna\",\"calc\":\"\",\"selected\":\"0\",\"order\":\"2\",\"settingModel\":{\"settings\":false,\"hide_merge_tags\":false,\"error\":false,\"name\":\"options\",\"type\":\"option-repeater\",\"label\":\"Options <a href=\\\"#\\\" class=\\\"nf-add-new\\\">Add New<\\\/a> <a href=\\\"#\\\" class=\\\"extra nf-open-import-tooltip\\\"><i class=\\\"fa fa-sign-in\\\" aria-hidden=\\\"true\\\"><\\\/i> Import<\\\/a>\",\"width\":\"full\",\"group\":\"\",\"value\":[{\"label\":\"One\",\"value\":\"one\",\"calc\":\"\",\"selected\":0,\"order\":0},{\"label\":\"Two\",\"value\":\"two\",\"calc\":\"\",\"selected\":0,\"order\":1},{\"label\":\"Three\",\"value\":\"three\",\"calc\":\"\",\"selected\":0,\"order\":2}],\"columns\":{\"label\":{\"header\":\"Label\",\"default\":\"\"},\"value\":{\"header\":\"Value\",\"default\":\"\"},\"calc\":{\"header\":\"Calc Value\",\"default\":\"\"},\"selected\":{\"header\":\"<span class=\\\"dashicons dashicons-yes\\\"><\\\/span>\",\"default\":0}}}},{\"errors\":[],\"max_options\":\"0\",\"order\":\"4\",\"new\":\"\",\"options\":[],\"label\":\" Medicare\",\"value\":\"medicare\",\"calc\":\"\",\"selected\":\"0\",\"settingModel\":{\"settings\":false,\"hide_merge_tags\":false,\"error\":false,\"name\":\"options\",\"type\":\"option-repeater\",\"label\":\"Options <a href=\\\"#\\\" class=\\\"nf-add-new\\\">Add New<\\\/a> <a href=\\\"#\\\" class=\\\"extra nf-open-import-tooltip\\\"><i class=\\\"fa fa-sign-in\\\" aria-hidden=\\\"true\\\"><\\\/i> Import<\\\/a>\",\"width\":\"full\",\"group\":\"\",\"value\":[{\"label\":\"One\",\"value\":\"one\",\"calc\":\"\",\"selected\":0,\"order\":0},{\"label\":\"Two\",\"value\":\"two\",\"calc\":\"\",\"selected\":0,\"order\":1},{\"label\":\"Three\",\"value\":\"three\",\"calc\":\"\",\"selected\":0,\"order\":2}],\"columns\":{\"label\":{\"header\":\"Label\",\"default\":\"\"},\"value\":{\"header\":\"Value\",\"default\":\"\"},\"calc\":{\"header\":\"Calc Value\",\"default\":\"\"},\"selected\":{\"header\":\"<span class=\\\"dashicons 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Import<\\\/a>\",\"width\":\"full\",\"group\":\"\",\"value\":[{\"label\":\"One\",\"value\":\"one\",\"calc\":\"\",\"selected\":0,\"order\":0},{\"label\":\"Two\",\"value\":\"two\",\"calc\":\"\",\"selected\":0,\"order\":1},{\"label\":\"Three\",\"value\":\"three\",\"calc\":\"\",\"selected\":0,\"order\":2}],\"columns\":{\"label\":{\"header\":\"Label\",\"default\":\"\"},\"value\":{\"header\":\"Value\",\"default\":\"\"},\"calc\":{\"header\":\"Calc Value\",\"default\":\"\"},\"selected\":{\"header\":\"<span class=\\\"dashicons dashicons-yes\\\"><\\\/span>\",\"default\":0}}},\"manual_value\":\"1\"}],\"container_class\":\"\",\"element_class\":\"\",\"admin_label\":\"\",\"help_text\":\"\",\"desc_text\":\"\",\"drawerDisabled\":\"\",\"field_label\":\"Insurance 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Import<\\\/a>\",\"width\":\"full\",\"group\":\"\",\"value\":[{\"label\":\"One\",\"value\":\"one\",\"calc\":\"\",\"selected\":0,\"order\":0},{\"label\":\"Two\",\"value\":\"two\",\"calc\":\"\",\"selected\":0,\"order\":1},{\"label\":\"Three\",\"value\":\"three\",\"calc\":\"\",\"selected\":0,\"order\":2}],\"columns\":{\"label\":{\"header\":\"Label\",\"default\":\"\"},\"value\":{\"header\":\"Value\",\"default\":\"\"},\"calc\":{\"header\":\"Calc Value\",\"default\":\"\"},\"selected\":{\"header\":\"<span class=\\\"dashicons dashicons-yes\\\"><\\\/span>\",\"default\":0}}}},{\"errors\":[],\"max_options\":0,\"order\":1,\"new\":false,\"options\":[],\"label\":\"Anger Management\",\"value\":\"anger-management\",\"calc\":\"\",\"selected\":0,\"settingModel\":{\"settings\":false,\"hide_merge_tags\":false,\"error\":false,\"name\":\"options\",\"type\":\"option-repeater\",\"label\":\"Options <a href=\\\"#\\\" class=\\\"nf-add-new\\\">Add New<\\\/a> <a href=\\\"#\\\" class=\\\"extra nf-open-import-tooltip\\\"><i class=\\\"fa fa-sign-in\\\" aria-hidden=\\\"true\\\"><\\\/i> Import<\\\/a>\",\"width\":\"full\",\"group\":\"\",\"value\":[{\"label\":\"One\",\"value\":\"one\",\"calc\":\"\",\"selected\":0,\"order\":0},{\"label\":\"Two\",\"value\":\"two\",\"calc\":\"\",\"selected\":0,\"order\":1},{\"label\":\"Three\",\"value\":\"three\",\"calc\":\"\",\"selected\":0,\"order\":2}],\"columns\":{\"label\":{\"header\":\"Label\",\"default\":\"\"},\"value\":{\"header\":\"Value\",\"default\":\"\"},\"calc\":{\"header\":\"Calc Value\",\"default\":\"\"},\"selected\":{\"header\":\"<span class=\\\"dashicons dashicons-yes\\\"><\\\/span>\",\"default\":0}}},\"manual_value\":true},{\"errors\":[],\"max_options\":\"0\",\"label\":\"Anxiety\",\"value\":\"anxiety\",\"calc\":\"\",\"selected\":\"0\",\"order\":2,\"settingModel\":{\"settings\":false,\"hide_merge_tags\":false,\"error\":false,\"name\":\"options\",\"type\":\"option-repeater\",\"label\":\"Options <a href=\\\"#\\\" class=\\\"nf-add-new\\\">Add New<\\\/a> <a href=\\\"#\\\" class=\\\"extra nf-open-import-tooltip\\\"><i class=\\\"fa fa-sign-in\\\" aria-hidden=\\\"true\\\"><\\\/i> Import<\\\/a>\",\"width\":\"full\",\"group\":\"\",\"value\":[{\"label\":\"One\",\"value\":\"one\",\"calc\":\"\",\"selected\":0,\"order\":0},{\"label\":\"Two\",\"value\":\"two\",\"calc\":\"\",\"selected\":0,\"order\":1},{\"label\":\"Three\",\"value\":\"three\",\"calc\":\"\",\"selected\":0,\"order\":2}],\"columns\":{\"label\":{\"header\":\"Label\",\"default\":\"\"},\"value\":{\"header\":\"Value\",\"default\":\"\"},\"calc\":{\"header\":\"Calc Value\",\"default\":\"\"},\"selected\":{\"header\":\"<span class=\\\"dashicons dashicons-yes\\\"><\\\/span>\",\"default\":0}}}},{\"errors\":[],\"max_options\":\"0\",\"label\":\"Bipolar Disorder\",\"value\":\"bipolar-disorder\",\"calc\":\"\",\"selected\":\"0\",\"order\":3,\"settingModel\":{\"settings\":false,\"hide_merge_tags\":false,\"error\":false,\"name\":\"options\",\"type\":\"option-repeater\",\"label\":\"Options <a href=\\\"#\\\" class=\\\"nf-add-new\\\">Add New<\\\/a> <a href=\\\"#\\\" class=\\\"extra nf-open-import-tooltip\\\"><i class=\\\"fa fa-sign-in\\\" aria-hidden=\\\"true\\\"><\\\/i> Import<\\\/a>\",\"width\":\"full\",\"group\":\"\",\"value\":[{\"label\":\"One\",\"value\":\"one\",\"calc\":\"\",\"selected\":0,\"order\":0},{\"label\":\"Two\",\"value\":\"two\",\"calc\":\"\",\"selected\":0,\"order\":1},{\"label\":\"Three\",\"value\":\"three\",\"calc\":\"\",\"selected\":0,\"order\":2}],\"columns\":{\"label\":{\"header\":\"Label\",\"default\":\"\"},\"value\":{\"header\":\"Value\",\"default\":\"\"},\"calc\":{\"header\":\"Calc Value\",\"default\":\"\"},\"selected\":{\"header\":\"<span class=\\\"dashicons 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Import<\\\/a>\",\"width\":\"full\",\"group\":\"\",\"value\":[{\"label\":\"One\",\"value\":\"one\",\"calc\":\"\",\"selected\":0,\"order\":0},{\"label\":\"Two\",\"value\":\"two\",\"calc\":\"\",\"selected\":0,\"order\":1},{\"label\":\"Three\",\"value\":\"three\",\"calc\":\"\",\"selected\":0,\"order\":2}],\"columns\":{\"label\":{\"header\":\"Label\",\"default\":\"\"},\"value\":{\"header\":\"Value\",\"default\":\"\"},\"calc\":{\"header\":\"Calc Value\",\"default\":\"\"},\"selected\":{\"header\":\"<span class=\\\"dashicons dashicons-yes\\\"><\\\/span>\",\"default\":0}}},\"manual_value\":true},{\"errors\":[],\"max_options\":0,\"order\":6,\"new\":false,\"options\":[],\"label\":\"Family\\\/Relationship Stress\",\"value\":\"family-relationship-stress\",\"calc\":\"\",\"selected\":0,\"settingModel\":{\"settings\":false,\"hide_merge_tags\":false,\"error\":false,\"name\":\"options\",\"type\":\"option-repeater\",\"label\":\"Options <a href=\\\"#\\\" class=\\\"nf-add-new\\\">Add New<\\\/a> <a href=\\\"#\\\" class=\\\"extra nf-open-import-tooltip\\\"><i class=\\\"fa fa-sign-in\\\" aria-hidden=\\\"true\\\"><\\\/i> Import<\\\/a>\",\"width\":\"full\",\"group\":\"\",\"value\":[{\"label\":\"One\",\"value\":\"one\",\"calc\":\"\",\"selected\":0,\"order\":0},{\"label\":\"Two\",\"value\":\"two\",\"calc\":\"\",\"selected\":0,\"order\":1},{\"label\":\"Three\",\"value\":\"three\",\"calc\":\"\",\"selected\":0,\"order\":2}],\"columns\":{\"label\":{\"header\":\"Label\",\"default\":\"\"},\"value\":{\"header\":\"Value\",\"default\":\"\"},\"calc\":{\"header\":\"Calc Value\",\"default\":\"\"},\"selected\":{\"header\":\"<span class=\\\"dashicons dashicons-yes\\\"><\\\/span>\",\"default\":0}}},\"manual_value\":true},{\"errors\":[],\"max_options\":0,\"order\":7,\"new\":false,\"options\":[],\"label\":\"Hallucinations (Auditory and\\\/or 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class=\\\"nf-add-new\\\">Add New<\\\/a> <a href=\\\"#\\\" class=\\\"extra nf-open-import-tooltip\\\"><i class=\\\"fa fa-sign-in\\\" aria-hidden=\\\"true\\\"><\\\/i> Import<\\\/a>\",\"width\":\"full\",\"group\":\"\",\"value\":[{\"label\":\"One\",\"value\":\"one\",\"calc\":\"\",\"selected\":0,\"order\":0},{\"label\":\"Two\",\"value\":\"two\",\"calc\":\"\",\"selected\":0,\"order\":1},{\"label\":\"Three\",\"value\":\"three\",\"calc\":\"\",\"selected\":0,\"order\":2}],\"columns\":{\"label\":{\"header\":\"Label\",\"default\":\"\"},\"value\":{\"header\":\"Value\",\"default\":\"\"},\"calc\":{\"header\":\"Calc Value\",\"default\":\"\"},\"selected\":{\"header\":\"<span class=\\\"dashicons dashicons-yes\\\"><\\\/span>\",\"default\":0}}},\"manual_value\":true},{\"errors\":[],\"max_options\":\"0\",\"order\":11,\"new\":\"\",\"options\":[],\"label\":\"Panic 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