{"id":2341,"date":"2016-03-04T17:08:45","date_gmt":"2016-03-04T22:08:45","guid":{"rendered":"https:\/\/www.bu.edu\/scnc\/?page_id=2341"},"modified":"2016-06-29T10:03:46","modified_gmt":"2016-06-29T14:03:46","slug":"employee","status":"publish","type":"page","link":"https:\/\/www.bu.edu\/scnc\/forms\/employee\/","title":{"rendered":"Counseling Registration"},"content":{"rendered":"<p><script type=\"text\/javascript\">\r\n    \/\/ JSFormValidation.js\r\n    \/*\r\n     * Run init() after the page is loaded\r\n     *\/\r\n    window.onload = init;\r\n\r\n    \/*\r\n     * Initialization\r\n     *\/\r\n    function init() {\r\n        \/\/ Bind \"onsubmit\" event handler to the \"submit\" button\r\n        document.getElementById(\"scnc_form\").onsubmit = validateForm;\r\n        \/\/ Bind \"onclick\" event handler to \"reset\" button\r\n        document.getElementById(\"btnReset\").onclick = clearForm;\r\n        \/\/ Set initial focus\r\n        document.getElementById(\"first_name\").focus();\r\n    }\r\n\r\n    \/*\r\n     * The \"onsubmit\" event handler to validate the input fields.\r\n     *\r\n     * Most of the input validation functions take 3 arguments:\r\n     *   inputElm: Input element to be validated.\r\n     *   errMsg: the error message to be displayed if validation fails.\r\n     *   errElm: to place the error message\r\n     *\r\n     * @param theForm: the form to be validated\r\n     *\/\r\n     function validateForm(theForm) {\r\n        with(theForm) {\r\n            \/\/ return false would prevent default submission\r\n            return (isNotEmpty(first_name, \"Please enter your first name.\", elmfirst_nameError) && isNotEmpty(last_name, \"Please enter your last name.\", elmlast_nameError) && isNumeric(buid, \"Please enter your  8-digit Boston BUID (after U).\", elmbuidError) && isLengthMinMax(buid, 8, 8, \"Please enter your 8-digit BU ID after U.\", elmbuidError) && isNotEmpty(dob,\"Please enter your date of birth (MM\/DD\/YYYY format).\", elmdobError) && isLengthMinMax(dob, 10, 10, \"Please use MM\/DD\/YYYY format.\", elmdobError) && isValidEmail(email, \"Enter a valid email.\", elmemailError) && isNotEmpty(phone, \"Please enter your phone.\", elmphoneError) && isNotEmpty(street, \"Please enter your street address.\", elmstreetError) && isNotEmpty(city, \"Please enter your city.\", elmcityError) && isSelected(state, \"Please select your state.\", elmstateError) && isNotEmpty(zip,\"Please enter your five-digit zip code.\", elmzipError) && isLengthMinMax(zip, 5, 5, \"Please use five-digit format.\", elmzipError) \r\n            );\r\n        }\r\n    }\r\n\r\n    \/*\r\n     * Helper function, to be called after validation, to show or clear\r\n     *   existing error message, and to set focus to the input element\r\n     *   for correcting error.\r\n     * If isValid is false, show the errMsg on errElm, and place the\r\n     *   focus on the inputElm for correcting the error.\r\n     * Else, clear previous errMsg on errElm, if any.\r\n     *\r\n     * @param isValid (boolean): flag indicating the result of validation\r\n     * @param errMsg (string)(optional): error message\r\n     * @param errElm (object)(optional): if isValid is false, show errMsg; 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Please <a href=\"http:\/\/www.bu.edu\/tech\/support\/browsers\/enable-cookies-and-javascript\/\">enable JavaScript<\/a> in your browser settings and try link again.<\/p>\n<style type=\"text\/css\">\n\t\t#scnc_form { display:none; }\n\t<\/style>\n<\/div>\n<p><\/noscript><\/p>\n<form action=\"https:\/\/ssl.datamotion.com\/form2.aspx\" method=\"post\" id=\"scnc_form\" onSubmit=\"return validateForm()\">\n  <input type=\"hidden\" name=\"txtto\" value=\"scnc@bu.edu\" \/><br \/>\n  <input type=\"hidden\" name=\"txtsubject\" value=\"BU Faculty\/Staff Registration\" \/><br \/>\n  <input type=\"hidden\" name=\"txtDone\" value=\"https:\/\/www.bu.edu\/scnc\/wp-assets\/employee\/thanks\/index.html\" \/><\/p>\n<fieldset>\n<legend class=\"secure-lock\">BU Faculty &#038; Staff Counseling Registration Form<\/legend>\n<p><em class=\"required\">*<\/em> = mandatory field<\/p>\n<div>\n      <label for=\"first_name\"> First Name: <em class=\"required\">*<\/em><\/label><br \/>\n      <input name=\"first_name\" id=\"first_name\" type=\"text\" \/>\n    <\/div>\n<div id=\"elmfirst_nameError\" class=\"errorMsg\">&nbsp;<\/div>\n<div>\n      <label for=\"last_name\"> Last Name: <em class=\"required\">*<\/em><\/label><br \/>\n      <input name=\"last_name\" id=\"last_name\" type=\"text\" \/>\n    <\/div>\n<div id=\"elmlast_nameError\" class=\"errorMsg\">&nbsp;<\/div>\n<div>\n      <label for=\"gender\">Gender:<\/label><br \/>\n      <select name=\"gender\" id=\"gender\"><option value=\"\">Please select<\/option><option value=\"Male\">Male<\/option><option value=\"Female\">Female<\/option><option value=\"Other\">Other<\/option><\/select>\n    <\/div>\n<div>\n      <label for=\"buid\">BUID ID: <em class=\"required\">*<\/em><\/label><br \/>\n      U<br \/>\n      <input name=\"buid\" id=\"buid\" type=\"text\" maxlength=\"8\" \/>\n    <\/div>\n<div id=\"elmbuidError\" class=\"errorMsg\">&nbsp;<\/div>\n<div>\n      <label for=\"dob\">DOB: <em class=\"required\">*<\/em><\/label><br \/>\n      <input name=\"dob\" id=\"dob\" type=\"text\" \/>\n    <\/div>\n<div id=\"elmdobError\" class=\"errorMsg\">&nbsp;<\/div>\n<div>\n      <label for=\"email\">Email: <em class=\"required\">*<\/em><\/label><br \/>\n      <input type=\"text\" name=\"email\" id=\"email\"\/>\n    <\/div>\n<div id=\"elmemailError\" class=\"errorMsg\">&nbsp;<\/div>\n<div>\n      <label for=\"phone\">Primary Phone: <em class=\"required\">*<\/em><\/label><br \/>\n      <input name=\"phone\" id=\"phone\" type=\"text\" \/>\n    <\/div>\n<div id=\"elmphoneError\" class=\"errorMsg\">&nbsp;<\/div>\n<div>\n      <label for=\"secondary_phone\">Secondary Phone: <\/label><br \/>\n      <input name=\"secondary_phone\" id=\"secondary_phone\" type=\"text\" \/>\n    <\/div>\n<fieldset>\n<legend>Current Address<\/legend>\n<div>\n        <label for=\"address\">Street: <em class=\"required\">*<\/em><\/label><br \/>\n        <input name=\"address\" id=\"address\" type=\"text\" \/>\n      <\/div>\n<div id=\"elmaddressError\" class=\"errorMsg\">&nbsp;<\/div>\n<div>\n        <label for=\"city\"> City: <em class=\"required\">*<\/em><\/label><br \/>\n        <input name=\"city\" id=\"city\" type=\"text\" \/>\n      <\/div>\n<div id=\"elmcityError\" class=\"errorMsg\">&nbsp;<\/div>\n<div>\n        <label for=\"state\">State: <em class=\"required\">*<\/em><\/label><br \/>\n        <select name=\"state\" id=\"state\"><option value=\"\" selected=\"selected\">Please Select:<\/option><option value=\"AL\">Alabama<\/option><option value=\"AK\">Alaska<\/option><option value=\"AZ\">Arizona<\/option><option value=\"AR\">Arkansas<\/option><option value=\"CA\">California<\/option><option value=\"CO\">Colorado<\/option><option value=\"CT\">Connecticut<\/option><option value=\"DE\">Delaware<\/option><option value=\"DC\">District Of Columbia<\/option><option value=\"FL\">Florida<\/option><option value=\"GA\">Georgia<\/option><option value=\"HI\">Hawaii<\/option><option value=\"ID\">Idaho<\/option><option value=\"IL\">Illinois<\/option><option value=\"IN\">Indiana<\/option><option value=\"IA\">Iowa<\/option><option value=\"KS\">Kansas<\/option><option value=\"KY\">Kentucky<\/option><option value=\"LA\">Louisiana<\/option><option value=\"ME\">Maine<\/option><option value=\"MD\">Maryland<\/option><option value=\"MA\">Massachusetts<\/option><option value=\"MI\">Michigan<\/option><option value=\"MN\">Minnesota<\/option><option value=\"MS\">Mississippi<\/option><option value=\"MO\">Missouri<\/option><option value=\"MT\">Montana<\/option><option value=\"NE\">Nebraska<\/option><option value=\"NV\">Nevada<\/option><option value=\"NH\">New Hampshire<\/option><option value=\"NJ\">New Jersey<\/option><option value=\"NM\">New Mexico<\/option><option value=\"NY\">New York<\/option><option value=\"NC\">North Carolina<\/option><option value=\"ND\">North Dakota<\/option><option value=\"OH\">Ohio<\/option><option value=\"OK\">Oklahoma<\/option><option value=\"OR\">Oregon<\/option><option value=\"PA\">Pennsylvania<\/option><option value=\"RI\">Rhode Island<\/option><option value=\"SC\">South Carolina<\/option><option value=\"SD\">South Dakota<\/option><option value=\"TN\">Tennessee<\/option><option value=\"TX\">Texas<\/option><option value=\"UT\">Utah<\/option><option value=\"VT\">Vermont<\/option><option value=\"VA\">Virginia<\/option><option value=\"WA\">Washington<\/option><option value=\"WV\">West Virginia<\/option><option value=\"WI\">Wisconsin<\/option><option value=\"WY\">Wyoming<\/option><\/select>\n      <\/div>\n<div id=\"elmstateError\" class=\"errorMsg\">&nbsp;<\/div>\n<div>\n        <label for=\"zip\">Zip Code: <em class=\"required\">*<\/em><\/label><br \/>\n        <input name=\"zip\" type=\"text\" id=\"zip\" maxlength=\"5\" \/>\n      <\/div>\n<div id=\"elmzipError\" class=\"errorMsg\">&nbsp;<\/div>\n<\/fieldset>\n<p>The SCNC offers a unique Risk Factor Management Package as part of BU&#8217;s health and wellness program. The package is designed for BU employees with cardiac risk factors such as a <a href=\"http:\/\/www.nhlbi.nih.gov\/health\/educational\/lose_wt\/BMI\/bmicalc.htm\">Body Mass Index<\/a> of 25 or higher, diabetes or prediabetes, and elevated blood pressure or cholesterol. Please indicate all nutrition concerns below.<\/p>\n<fieldset>\n<legend>Nutrition Concerns (check all that apply): <em class=\"required\">*<\/em> <\/legend>\n<div>\n        <label for=\"nutrition_concerns_healthy_meal_planning\"><br \/>\n          <input id=\"nutrition_concerns_healthy_meal_planning\" name=\"nutrition_concerns_healthy_meal_planning\" type=\"checkbox\" value=\"Healthy meal planning\" \/><br \/>\n          Healthy meal planning<\/label>\n      <\/div>\n<div>\n        <label for=\"nutrition_concerns_healthy_weight_loss\"><br \/>\n          <input id=\"nutrition_concerns_healthy_weight_loss\" name=\"nutrition_concerns_healthy_weight_loss\" type=\"checkbox\" value=\"Healthy weight loss\" \/><br \/>\n          Healthy weight loss <\/label>\n      <\/div>\n<div>\n        <label for=\"nutrition_concerns_sports_nutrition\"><br \/>\n          <input id=\"nutrition_concerns_sports_nutrition\" name=\"nutrition_concerns_sports_nutrition\" type=\"checkbox\" value=\"Sports nutrition\" \/><br \/>\n          Sports nutrition<\/label>\n      <\/div>\n<div>\n        <label for=\"nutrition_concerns_stress_over_undereating\"><br \/>\n          <input id=\"nutrition_concerns_stress_over_undereating\" type=\"checkbox\" name=\"nutrition_concerns_stress_over_undereating\" value=\"Stress over\/undereating\" \/><br \/>\n          Stress over\/undereating<\/label>\n      <\/div>\n<div>\n        <label for=\"nutrition_concerns_emotional_over_undereating\"><br \/>\n          <input id=\"nutrition_concerns_emotional_over_undereating\" type=\"checkbox\" name=\"nutrition_concerns_emotional_over_undereating\" value=\"Emotional over\/undereating\" \/><br \/>\n          Emotional over\/undereating<\/label>\n      <\/div>\n<div>\n        <label for=\"nutrition_concerns_social_over_undereating\"><br \/>\n          <input id=\"nutrition_concerns_social_over_undereating\" type=\"checkbox\" name=\"nutrition_concerns_social_over_undereating\" value=\"Social over\/undereating\" \/><br \/>\n          Social over\/undereating<\/label>\n      <\/div>\n<div>\n        <label for=\"nutrition_concerns_hunger_management\"><br \/>\n          <input id=\"nutrition_concerns_hunger_management\" type=\"checkbox\" name=\"nutrition_concerns_hunger_management\" value=\"Hunger management\" \/><br \/>\n          Hunger management<\/label>\n      <\/div>\n<div>\n        <label for=\"nutrition_concerns_unhealthy_weight_control_practices\"><br \/>\n          <input id=\"nutrition_concerns_unhealthy_weight_control_practices\" type=\"checkbox\" name=\"nutrition_concerns_unhealthy_weight_control_practices\" value=\"Unhealthy weight control practices\" \/><br \/>\n          Unhealthy weight control practices<\/label>\n      <\/div>\n<div>\n        <input id=\"nutrition_concerns_eating_disorder\" name=\"nutrition_concerns_eating_disorder\" type=\"checkbox\" value=\"Eating disorder\" \/><br \/>\n        <label for=\"nutrition_concerns_eating_disorder\"> Eating disorder <\/label><\/p>\n<div class=\"reveal-if-active\">\n<fieldset>\n<legend>(Check all that apply)<\/legend>\n<div>\n              <label for=\"eating_disorder_anorexia_nervosa\"><br \/>\n                <input id=\"eating_disorder_anorexia_nervosa\" name=\"eating_disorder_anorexia_nervosa\" type=\"checkbox\" value=\"Anorexia Nervosa\" \/><br \/>\n                Anorexia Nervosa<\/label>\n            <\/div>\n<div>\n              <label for=\"eating_disorder_bulimia_nervosa\"><br \/>\n                <input id=\"eating_disorder_bulimia_nervosa\" name=\"eating_disorder_bulimia_nervosa\" type=\"checkbox\" value=\"Bulimia Nervosa\" \/><br \/>\n                Bulimia Nervosa<\/label>\n            <\/div>\n<div>\n              <label for=\"eating_disorder_binge_eating_disorder\"><br \/>\n                <input id=\"eating_disorder_binge_eating_disorder\" name=\"eating_disorder_binge_eating_disorder\" type=\"checkbox\" value=\"Binge Eating Disorder\" \/><br \/>\n                Binge eating disorder<\/label>\n            <\/div>\n<div>\n              <label for=\"eating_disorder_other\"><br \/>\n                <input id=\"eating_disorder_other\" type=\"checkbox\" name=\"eating_disorder_other\" value=\"Other Eating Disorder\" \/><br \/>\n                Other Eating Disorder <\/label>\n            <\/div>\n<\/fieldset><\/div>\n<\/p><\/div>\n<div>\n        <input id=\"nutrition_concerns_food_allergy_intolerances\" name=\"nutrition_concerns_food_allergy_intolerances\" type=\"checkbox\" value=\"Food allergies or intolerances\" \/><br \/>\n        <label for=\"nutrition_concerns_food_allergy_intolerances\"> Food allergies or intolerances<\/label><\/p>\n<div class=\"reveal-if-active\">\n<fieldset>\n<legend>(Check all that apply)<\/legend>\n<div>\n              <label for=\"food_allergy_intolerance_wheat\"><br \/>\n                <input id=\"food_allergy_intolerance_wheat\" name=\"food_allergy_intolerance_wheat\" type=\"checkbox\" value=\"Wheat\" \/><br \/>\n                Wheat<\/label>\n            <\/div>\n<div>\n              <label for=\"food_allergy_intolerance_milk\"><br \/>\n                <input id=\"food_allergy_intolerance_milk\" name=\"food_allergy_intolerance_milk\" type=\"checkbox\" value=\"Milk\" \/><br \/>\n                Milk<\/label>\n            <\/div>\n<div>\n              <label for=\"food_allergy_intolerance_peanuts\"><br \/>\n                <input id=\"food_allergy_intolerance_peanuts\" name=\"food_allergy_intolerance_peanuts\" type=\"checkbox\" value=\"Peanuts\" \/><br \/>\n                Peanuts<\/label>\n            <\/div>\n<div>\n              <label for=\"food_allergy_intolerance_tree_nuts\"><br \/>\n                <input id=\"food_allergy_intolerance_tree_nuts\" type=\"checkbox\" name=\"food_allergy_intolerance_tree_nuts\" value=\"Tree nuts\" \/><br \/>\n                Tree nuts<\/label>\n            <\/div>\n<div>\n              <label for=\"food_allergy_intolerance_eggs\"><br \/>\n                <input id=\"food_allergy_intolerance_eggs\" name=\"food_allergy_intolerance_eggs\" type=\"checkbox\" value=\"Eggs\" \/><br \/>\n                Eggs<\/label>\n            <\/div>\n<div>\n              <label for=\"food_allergy_intolerance_shellfish\"><br \/>\n                <input id=\"food_allergy_intolerance_shellfish\" name=\"food_allergy_intolerance_shellfish\" type=\"checkbox\" value=\"Shellfish\" \/><br \/>\n                Shellfish<\/label>\n            <\/div>\n<div>\n              <label for=\"food_allergy_intolerance_soy\"><br \/>\n                <input id=\"food_allergy_intolerance_soy\" name=\"food_allergy_intolerance_soy\" type=\"checkbox\" value=\"Soy\" \/><br \/>\n                Soy<\/label>\n            <\/div>\n<div>\n              <label for=\"food_allergy_intolerance_fish\"><br \/>\n                <input id=\"food_allergy_intolerance_fish\" type=\"checkbox\" name=\"food_allergy_intolerance_fish\" value=\"Fish\" \/><br \/>\n                Fish<\/label>\n            <\/div>\n<div>\n              <label for=\"food_allergy_intolerance_lactose_intolerance\"><br \/>\n                <input id=\"food_allergy_intolerance_lactose_intolerance\" name=\"food_allergy_intolerance_lactose_intolerance\" type=\"checkbox\" value=\"Lactose intolerance\" \/><br \/>\n                Lactose intolerance<\/label>\n            <\/div>\n<div>\n              <label for=\"food_allergy_intolerance_gluten_intolerance\"><br \/>\n                <input id=\"food_allergy_intolerance_gluten_intolerance\" name=\"food_allergy_intolerance_gluten_intolerance\" type=\"checkbox\" value=\"Gluten intolerance\" \/><br \/>\n                Gluten intolerance<\/label>\n            <\/div>\n<div>\n              <label for=\"food_allergy_intolerance_fodmaps\"><br \/>\n                <input id=\"food_allergy_intolerance_fodmaps\" name=\"food_allergy_intolerance_fodmaps\" type=\"checkbox\" value=\"FODMAPs\" \/><br \/>\n                FODMAPs<\/label>\n            <\/div>\n<div>\n              <label for=\"food_allergy_intolerance_other\"><br \/>\n                <input id=\"food_allergy_intolerance_other\" type=\"checkbox\" name=\"food_allergy_intolerance_other\" value=\"Other Allergy\/Intolerance: \" \/><br \/>\n                Other:<\/label><br \/>\n              <label for=\"other_allergy_intolerance_text\">If other allegy or intolerance, please describe:<\/label><br \/>\n              <input type=\"text\" id=\"other_allergy_intolerance_text\" name=\"other_allergy_intolerance_text\" \/>\n            <\/div>\n<\/fieldset><\/div>\n<\/p><\/div>\n<div>\n        <input id=\"nutrition_concerns_gastrointestinal_disorder\" name=\"nutrition_concerns_gastrointestinal_disorder\" type=\"checkbox\" value=\"Gastrointestinal disorder\" \/><br \/>\n        <label for=\"nutrition_concerns_gastrointestinal_disorder\"> Gastrointestinal disorder<\/label><\/p>\n<div class=\"reveal-if-active\">\n<fieldset>\n<legend>(Check all that apply)<\/legend>\n<div>\n              <label for=\"gastrointestinal_disorder_ibs\"><br \/>\n                <input id=\"gastrointestinal_disorder_ibs\" name=\"gastrointestinal_disorder_ibs\" type=\"checkbox\" value=\"IBS\" \/><br \/>\n                IBS<\/label>\n            <\/div>\n<div>\n              <label for=\"gastrointestinal_disorder_crohns_disease\"><br \/>\n                <input id=\"gastrointestinal_disorder_crohns_disease\" name=\"gastrointestinal_disorder_crohns_disease\" type=\"checkbox\" value=\"Crohn's Disease\" \/><br \/>\n                Crohn&#8217;s Disease<\/label>\n            <\/div>\n<div>\n              <label for=\"gastrointestinal_disorder_ulcerative_colitis\"><br \/>\n                <input id=\"gastrointestinal_disorder_ulcerative_colitis\" name=\"gastrointestinal_disorder_ulcerative_colitis\" type=\"checkbox\" value=\"Ulcerative Colitis\" \/><br \/>\n                Ulcerative Colitis<\/label>\n            <\/div>\n<div>\n              <label for=\"gastrointestinal_disorder_gerd\"><br \/>\n                <input id=\"gastrointestinal_disorder_gerd\" type=\"checkbox\" name=\"gastrointestinal_disorder_gerd\" value=\"GERD\" \/><br \/>\n                GERD <\/label>\n            <\/div>\n<div>\n              <label for=\"gastrointestinal_disorder_celiac_disease\"><br \/>\n                <input id=\"gastrointestinal_disorder_celiac_disease\" name=\"gastrointestinal_disorder_celiac_disease\" type=\"checkbox\" value=\"Celiac Disease\" \/><br \/>\n                Celiac Disease<\/label>\n            <\/div>\n<div>\n              <label for=\"gastrointestinal_disorder_other\"><br \/>\n                <input id=\"gastrointestinal_disorder_other\" type=\"checkbox\" name=\"gastrointestinal_disorder_other\" value=\"Other Gastrointestinal disorder: \" \/><br \/>\n                Other:<\/label><br \/>\n              <label for=\"gastrointestinal_disorder_other_text\">If other gastrointestinal disorder, please describe:<\/label><br \/>\n              <input type=\"text\" id=\"gastrointestinal_disorder_other_text\" name=\"gastrointestinal_disorder_other_text\" \/>\n            <\/div>\n<\/fieldset><\/div>\n<\/p><\/div>\n<div>\n        <label for=\"nutrition_concerns_high_blood_pressure\"><br \/>\n          <input id=\"nutrition_concerns_high_blood_pressure\" name=\"nutrition_concerns_high_blood_pressure\" type=\"checkbox\" value=\"High blood pressure\" \/><br \/>\n          High blood pressure<\/label>\n      <\/div>\n<div>\n        <label for=\"nutrition_concerns_high_cholesterol\"><br \/>\n          <input id=\"nutrition_concerns_high_cholesterol\" name=\"nutrition_concerns_high_cholesterol\" type=\"checkbox\" value=\"High cholesterol\" \/><br \/>\n          High cholesterol<\/label>\n      <\/div>\n<div>\n        <label for=\"nutrition_concerns_diabetes_prediabetes\"><br \/>\n          <input id=\"nutrition_concerns_diabetes_prediabetes\" name=\"nutrition_concerns_diabetes_prediabetes\" type=\"checkbox\" value=\"Diabetes\/Pre-diabetes\" \/><br \/>\n          Diabetes\/Pre-diabetes<\/label>\n      <\/div>\n<div>\n        <label for=\"nutrition_concerns_vegetarian_vegan\"><br \/>\n          <input id=\"nutrition_concerns_vegetarian_vegan\" name=\"nutrition_concerns_vegetarian_vegan\" type=\"checkbox\" value=\"Vegetarian\/vegan\" \/><br \/>\n          Vegetarian\/vegan<\/label>\n      <\/div>\n<div>\n        <label for=\"nutrition_concerns_iron_deficiency_anemia\"><br \/>\n          <input id=\"nutrition_concerns_iron_deficiency_anemia\" name=\"nutrition_concerns_iron_deficiency_anemia\" type=\"checkbox\" value=\"Iron-deficiency anemia\" \/><br \/>\n          Iron-deficiency anemia<\/label>\n      <\/div>\n<div>\n        <label for=\"nutrition_concerns_polycystic_ovary_syndrome\"><br \/>\n          <input id=\"nutrition_concerns_polycystic_ovary_syndrome\" name=\"nutrition_concerns_polycystic_ovary_syndrome\" type=\"checkbox\" value=\"Polycystic ovary syndrome\" \/><br \/>\n          Polycystic ovary syndrome <\/label>\n      <\/div>\n<div>\n        <label for=\"nutrition_concerns_bariatric_surgery\"><br \/>\n          <input id=\"nutrition_concerns_bariatric_surgery\" name=\"nutrition_concerns_bariatric_surgery\" type=\"checkbox\" value=\"Bariatric surgery\" \/><br \/>\n          Bariatric surgery<\/label>\n      <\/div>\n<div>\n        <label for=\"nutrition_concerns_other\"><br \/>\n          <input id=\"nutrition_concerns_other\" name=\"nutrition_concerns_other\" type=\"checkbox\" value=\"Other nutrition concern\" \/><br \/>\n          Other:<\/label><br \/>\n        <label for=\"nutrition_concerns_other_text\">If other reason for visit, please describe:<\/label><br \/>\n        <input type=\"text\" id=\"nutrition_concerns_other_text\" name=\"nutrition_concerns_other_text\" \/>\n      <\/div>\n<div>\n        <label for=\"nutrition_concerns_none\"><br \/>\n          <input id=\"nutrition_concerns_none\" name=\"nutrition_concerns_none\" type=\"checkbox\" value=\"No nutrition concern\" \/><br \/>\n          No nutrition concern<\/label>\n      <\/div>\n<\/fieldset>\n<div>\n      <label for=\"additional_information\">Additional information you would like to share: <\/label><br \/>\n      <textarea id=\"additional_information\" name=\"additional_information\" cols=\"\" rows=\"\"><\/textarea>\n    <\/div>\n<div>\n      <input type=\"submit\" id=\"__btnSubmit\" name=\"__btnSubmit\" value=\"Submit\" \/><br \/>\n      <input type=\"reset\" id=\"__btnReset\" name=\"__btnReset\" value=\"Reset\" \/>\n    <\/div>\n<\/fieldset>\n<\/form>\n","protected":false},"excerpt":{"rendered":"<p>You don&#8217;t have JavaScript enabled. Please enable JavaScript in your browser settings and try link again. BU Faculty &#038; Staff Counseling Registration Form * = mandatory field First Name: * &nbsp; Last Name: * &nbsp; Gender: Please selectMaleFemaleOther BUID ID: * U &nbsp; DOB: * &nbsp; Email: * &nbsp; Primary Phone: * &nbsp; Secondary Phone: [&hellip;]<\/p>\n","protected":false},"author":1251,"featured_media":0,"parent":61,"menu_order":8,"comment_status":"closed","ping_status":"closed","template":"","meta":[],"_links":{"self":[{"href":"https:\/\/www.bu.edu\/scnc\/wp-json\/wp\/v2\/pages\/2341"}],"collection":[{"href":"https:\/\/www.bu.edu\/scnc\/wp-json\/wp\/v2\/pages"}],"about":[{"href":"https:\/\/www.bu.edu\/scnc\/wp-json\/wp\/v2\/types\/page"}],"author":[{"embeddable":true,"href":"https:\/\/www.bu.edu\/scnc\/wp-json\/wp\/v2\/users\/1251"}],"replies":[{"embeddable":true,"href":"https:\/\/www.bu.edu\/scnc\/wp-json\/wp\/v2\/comments?post=2341"}],"version-history":[{"count":15,"href":"https:\/\/www.bu.edu\/scnc\/wp-json\/wp\/v2\/pages\/2341\/revisions"}],"predecessor-version":[{"id":3649,"href":"https:\/\/www.bu.edu\/scnc\/wp-json\/wp\/v2\/pages\/2341\/revisions\/3649"}],"up":[{"embeddable":true,"href":"https:\/\/www.bu.edu\/scnc\/wp-json\/wp\/v2\/pages\/61"}],"wp:attachment":[{"href":"https:\/\/www.bu.edu\/scnc\/wp-json\/wp\/v2\/media?parent=2341"}],"curies":[{"name":"wp","href":"https:\/\/api.w.org\/{rel}","templated":true}]}}