{"id":676,"date":"2024-09-17T20:24:52","date_gmt":"2024-09-17T20:24:52","guid":{"rendered":"https:\/\/artisseniorliving.com\/memory-care-davie\/?page_id=676"},"modified":"2024-10-25T11:11:59","modified_gmt":"2024-10-25T15:11:59","slug":"referral-portal","status":"publish","type":"page","link":"https:\/\/artisseniorliving.com\/memory-care-davie\/referral-portal\/","title":{"rendered":"Referral Portal"},"content":{"rendered":"\n<section class=\"wp-block-cover alignfull block cta-3\" style=\"padding-top:var(--wp--preset--spacing--80);padding-right:var(--wp--preset--spacing--50);padding-bottom:var(--wp--preset--spacing--80);padding-left:var(--wp--preset--spacing--50)\"><span aria-hidden=\"true\" class=\"wp-block-cover__background has-background-dim-0 has-background-dim\" style=\"background-color:#3b6fab\"><\/span><img decoding=\"async\" class=\"wp-block-cover__image-background wp-image-2097\" alt=\"a group of glasses on a table\" src=\"https:\/\/artisseniorliving.com\/app\/uploads\/2024\/07\/Community_Homepage_POD_Background_B-1.jpg\" data-object-fit=\"cover\"\/><div class=\"wp-block-cover__inner-container is-layout-constrained wp-container-core-cover-is-layout-a47e864c wp-block-cover-is-layout-constrained\">\n<div class=\"wp-block-columns has-tan-background-color has-background is-layout-flex wp-container-core-columns-is-layout-59079b25 wp-block-columns-is-layout-flex\" style=\"border-radius:25px;padding-top:var(--wp--preset--spacing--80);padding-right:var(--wp--preset--spacing--80);padding-bottom:var(--wp--preset--spacing--80);padding-left:var(--wp--preset--spacing--80)\">\n<div class=\"wp-block-column is-layout-flow wp-block-column-is-layout-flow\" style=\"flex-basis:100%\">\n<h2 class=\"wp-block-heading has-text-align-center wp-embed-aspect-16-9 wp-has-aspect-ratio has-black-color has-text-color has-link-color has-nunito-sans-font-family has-medium-font-size wp-elements-bb9b7a55836b8c8546107bb2c1f92f57\" style=\"font-style:normal;font-weight:800;text-transform:uppercase\">MAKE A REFERRAL<\/h2>\n\n\n\n<h3 class=\"wp-block-heading has-text-align-center wp-embed-aspect-16-9 wp-has-aspect-ratio has-blue-color has-text-color has-link-color has-xx-large-font-size wp-elements-76061268ce7943da981b44e78a5068fc\" style=\"font-style:normal;font-weight:400\">Safer, more honored, more celebrated lives<\/h3>\n\n\n\n<p class=\"has-text-align-center wp-embed-aspect-16-9 wp-has-aspect-ratio has-black-color has-text-color has-link-color has-nunito-sans-font-family has-small-font-size wp-elements-82f2fcf1bdd49056328fd4c4ef098f0a\" style=\"font-style:normal;font-weight:600\">To refer a client to our community, share their details below.&nbsp;&nbsp;<\/p>\n<\/div>\n<\/div>\n<\/div><\/section>\n\n\n\n<div style=\"height:100px\" aria-hidden=\"true\" class=\"wp-block-spacer\"><\/div>\n\n\n<script type=\"text\/javascript\">\n\/* <![CDATA[ *\/\nvar 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class=\"gfield_required gfield_required_asterisk\">*<\/span>&quot; indicates required fields<\/p>\n                        <\/div><form method='post' enctype='multipart\/form-data'  id='gform_2'  action='\/memory-care-davie\/wp-json\/wp\/v2\/pages\/676' data-formid='2' novalidate> \r\n <input type='hidden' class='gforms-pum' value='{\"closepopup\":false,\"closedelay\":0,\"openpopup\":false,\"openpopup_id\":0}' \/>\n                        <div class='gform-body gform_body'><div id='gform_fields_2' class='gform_fields top_label form_sublabel_below description_below validation_below'><div id=\"field_2_12\" class=\"gfield gfield--type-section gsection field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><h3 class=\"gsection_title\">Your Information<\/h3><\/div><fieldset id=\"field_2_1\" class=\"gfield gfield--type-name gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Name<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class='ginput_complex ginput_container ginput_container--name no_prefix has_first_name no_middle_name has_last_name no_suffix gf_name_has_2 ginput_container_name gform-grid-row' id='input_2_1'>\n                            \n                            <span id='input_2_1_3_container' class='name_first gform-grid-col gform-grid-col--size-auto' >\n                                                    <input type='text' name='input_1.3' id='input_2_1_3' value=''   aria-required='true'     \/>\n                                                    <label for='input_2_1_3' class='gform-field-label gform-field-label--type-sub '>First<\/label>\n                                                <\/span>\n                            \n                            <span id='input_2_1_6_container' class='name_last gform-grid-col gform-grid-col--size-auto' >\n                                                    <input type='text' name='input_1.6' id='input_2_1_6' value=''   aria-required='true'     \/>\n                                                    <label for='input_2_1_6' class='gform-field-label gform-field-label--type-sub '>Last<\/label>\n                                                <\/span>\n                            \n                        <\/div><\/fieldset><div id=\"field_2_3\" class=\"gfield gfield--type-phone gfield--width-half gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_2_3'>Phone<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_phone'><input name='input_3' id='input_2_3' type='tel' value='' class='large'   aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_2_4\" class=\"gfield gfield--type-email gfield--width-half gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_2_4'>Email<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_email'>\n                            <input name='input_4' id='input_2_4' type='email' value='' class='large'    aria-required=\"true\" aria-invalid=\"false\"  \/>\n                        <\/div><\/div><div id=\"field_2_5\" class=\"gfield gfield--type-select gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_2_5'>Relationship<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_select'><select name='input_5' id='input_2_5' class='large gfield_select'    aria-required=\"true\" aria-invalid=\"false\" ><option value='' selected='selected' class='gf_placeholder'>Choose your relationship<\/option><option value='Brother' >Brother<\/option><option value='Sister' >Sister<\/option><option value='Father' >Father<\/option><option value='Mother' >Mother<\/option><option value='Lawyer' >Lawyer<\/option><option value='Neighbor' >Neighbor<\/option><option value='Realtor' >Realtor<\/option><option value='Unknown' >Unknown<\/option><option value='Funeral' >Funeral<\/option><option value='Brother-in-law' >Brother-in-law<\/option><option value='Daughter' >Daughter<\/option><option value='Daughter-in-law' >Daughter-in-law<\/option><option value='Friend' >Friend<\/option><option value='Granddaughter' >Granddaughter<\/option><option value='Grandson' >Grandson<\/option><option value='Health Care Provider' >Health Care Provider<\/option><option value='Nephew' >Nephew<\/option><option value='Niece' >Niece<\/option><option value='Other' >Other<\/option><option value='Referral' >Referral<\/option><option value='Sister-in-law' >Sister-in-law<\/option><option value='Son' >Son<\/option><option value='Son-in-law' >Son-in-law<\/option><option value='Spouse' >Spouse<\/option><option value='Trust Officer' >Trust Officer<\/option><option value='Cousin' >Cousin<\/option><option value='Self' >Self<\/option><option value='Other Relative' >Other Relative<\/option><option value='Son-in-law' >Son-in-law<\/option><option value='Grandchild' >Grandchild<\/option><option value='Healthcare Professional' >Healthcare Professional<\/option><option value='Sibling' >Sibling<\/option><option value='Conservator\/Trustee' >Conservator\/Trustee<\/option><option value='Employed Caregiver' >Employed Caregiver<\/option><option value='Professional Caregiver' >Professional Caregiver<\/option><option value='Real Estate Agent' >Real Estate Agent<\/option><option value='Referral Agency' >Referral Agency<\/option><option value='Aunt' >Aunt<\/option><option value='Uncle' >Uncle<\/option><option value='Guardian' >Guardian<\/option><option value='Partner' >Partner<\/option><option value='Step Child' >Step Child<\/option><option value='Family Other' >Family Other<\/option><option value='Financial Advisor' >Financial Advisor<\/option><option value='Power of Attorney' >Power of Attorney<\/option><\/select><\/div><\/div><div id=\"field_2_14\" class=\"gfield gfield--type-text gfield--width-full field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_2_14'>Your Organization<\/label><div class='ginput_container ginput_container_text'><input name='input_14' id='input_2_14' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_2_20\" class=\"gfield gfield--type-section gsection field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><h3 class=\"gsection_title\"><\/h3><\/div><div id=\"field_2_13\" class=\"gfield gfield--type-section gsection field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><h3 class=\"gsection_title\">Client Details<\/h3><\/div><div id=\"field_2_15\" class=\"gfield gfield--type-text gfield--width-half field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_2_15'>Client&#039;s First Name<\/label><div class='ginput_container ginput_container_text'><input name='input_15' id='input_2_15' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_2_16\" class=\"gfield gfield--type-text gfield--width-half field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_2_16'>Client&#039;s Last Name<\/label><div class='ginput_container ginput_container_text'><input name='input_16' id='input_2_16' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_2_17\" class=\"gfield gfield--type-text gfield--width-half field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_2_17'>Client&#039;s Email<\/label><div class='ginput_container ginput_container_text'><input name='input_17' id='input_2_17' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_2_18\" class=\"gfield gfield--type-text gfield--width-half field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_2_18'>Client&#039;s Phone Number<\/label><div class='ginput_container ginput_container_text'><input name='input_18' id='input_2_18' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_2_19\" class=\"gfield gfield--type-textarea gfield--width-full field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_2_19'>How can we help you?<\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_19' id='input_2_19' class='textarea large'      aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/div><fieldset id=\"field_2_6\" class=\"gfield gfield--type-consent gfield--type-choice gfield--width-full gfield_contains_required field_sublabel_below gfield--has-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Consent<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class='ginput_container ginput_container_consent'><input name='input_6.1' id='input_2_6_1' type='checkbox' value='1'  aria-describedby=\"gfield_consent_description_2_6\" aria-required=\"true\" aria-invalid=\"false\"   \/> <label class=\"gform-field-label gform-field-label--type-inline gfield_consent_label\" for='input_2_6_1' >I agree to the privacy policy.<\/label><input type='hidden' name='input_6.2' value='I agree to the privacy policy.' class='gform_hidden' \/><input type='hidden' name='input_6.3' value='5' class='gform_hidden' \/><\/div><div class='gfield_description gfield_consent_description' id='gfield_consent_description_2_6' tabindex='0'>Information entered on this page will not be used to send unsolicited email, and will not be sold to a third party. 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