{"id":2343,"date":"2016-03-04T17:12:14","date_gmt":"2016-03-04T22:12:14","guid":{"rendered":"https:\/\/www.bu.edu\/scnc\/?page_id=2343"},"modified":"2023-10-04T20:03:13","modified_gmt":"2023-10-05T00:03:13","slug":"student","status":"publish","type":"page","link":"https:\/\/www.bu.edu\/scnc\/forms\/student\/","title":{"rendered":"Counseling Registration"},"content":{"rendered":"<p><script>\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) && 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) && isChecked(\"primary_reason_for_visit\", \"Please check your primary reason for visit.\", elmprimary_reason_for_visitError) \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; else, clear.\r\n     * @param inputElm (object)(optional): set focus to this element,\r\n     *        if isValid is false\r\n     *\/\r\n    function postValidate(isValid, errMsg, errElm, inputElm) {\r\n        if (!isValid) {\r\n            \/\/ Show errMsg on errElm, if provided.\r\n            if (errElm !== undefined && errElm !== null && errMsg !== undefined && errMsg !== null) {\r\n                errElm.innerHTML = errMsg;\r\n            }\r\n            \/\/ Set focus on Input Element for correcting error, if provided.\r\n            if (inputElm !== undefined && inputElm !== null) {\r\n                inputElm.classList.add(\"errorBox\"); \/\/ Add class for styling\r\n                inputElm.focus();\r\n            }\r\n        } else {\r\n            \/\/ Clear previous error message on errElm, if provided.\r\n            if (errElm !== undefined && errElm !== null) {\r\n                errElm.innerHTML = \"\";\r\n            }\r\n            if (inputElm !== undefined && inputElm !== null) {\r\n                inputElm.classList.remove(\"errorBox\");\r\n            }\r\n        }\r\n    }\r\n\r\n    \/*\r\n     * Validate that input value is not empty.\r\n     *\r\n     * @param inputElm (object): input element\r\n     * @param errMsg (string): error message\r\n     * @param errElm (object): element to place error message\r\n     *\/\r\n    function isNotEmpty(inputElm, errMsg, errElm) {\r\n        var isValid = (inputElm.value.trim() !== \"\");\r\n        postValidate(isValid, errMsg, errElm, inputElm);\r\n        return isValid;\r\n    }\r\n\r\n    \/* Validate that input value contains one or more digits *\/\r\n    function isNumeric(inputElm, errMsg, errElm) {\r\n        var isValid = (inputElm.value.trim().match(\/^\\d+$\/) !== null);\r\n        postValidate(isValid, errMsg, errElm, inputElm);\r\n        return isValid;\r\n    }\r\n\r\n    \/* Validate that input value contains only one or more letters *\/\r\n    function isAlphabetic(inputElm, errMsg, errElm) {\r\n        var isValid = (inputElm.value.trim().match(\/^[a-zA-Z]+$\/) !== null);\r\n        postValidate(isValid, errMsg, errElm, inputElm);\r\n        return isValid;\r\n    }\r\n\r\n    \/* Validate that input value contains one or more digits or letters *\/\r\n    function isAlphanumeric(inputElm, errMsg, errElm) {\r\n        var isValid = (inputElm.value.trim().match(\/^[0-9a-zA-Z]+$\/) !== null);\r\n        postValidate(isValid, errMsg, errElm, inputElm);\r\n        return isValid;\r\n    }\r\n\r\n    \/* Validate that input value length is between minLength and maxLength *\/\r\n    function isLengthMinMax(inputElm, minLength, maxLength, errMsg, errElm) {\r\n        var inputValue = inputElm.value.trim();\r\n        var isValid = (inputValue.length >= minLength) && (inputValue.length <= maxLength);\r\n        postValidate(isValid, errMsg, errElm, inputElm);\r\n        return isValid;\r\n    }\r\n\r\n    \/\/ Validate that input value is a valid email address\r\n    function isValidEmail(inputElm, errMsg, errElm) {\r\n        var isValid = (inputElm.value.trim().match(\r\n            \/^\\w+([\\.-]?\\w+)*@\\w+([\\.-]?\\w+)*(\\.\\w{2,3})+$\/) !== null);\r\n        postValidate(isValid, errMsg, errElm, inputElm);\r\n        return isValid;\r\n    }\r\n\r\n    \/*\r\n     * Validate that a selection is made (not default of \"\") in <select> input\r\n     *\r\n     * @param selectElm (object): the <select> element\r\n     *\/\r\n    function isSelected(selectElm, errMsg, errElm) {\r\n        \/\/ You need to set the default value of <select>'s <option> to \"\".\r\n        var isValid = (selectElm.value !== \"\"); \/\/ value in selected <option>\r\n        postValidate(isValid, errMsg, errElm, selectElm);\r\n        return isValid;\r\n    }\r\n\r\n    \/*\r\n     * Validate that one of the checkboxes or radio buttons is checked.\r\n     * Checkbox and radio are based on name attribute, not id.\r\n     *\r\n     * @param inputName (string): name attribute of the checkbox or radio\r\n     *\/\r\n    function isChecked(inputName, errMsg, errElm) {\r\n        var elms = document.getElementsByName(inputName);\r\n        var isChecked = false;\r\n        for (var i = 0; i < elms.length; ++i) {\r\n            if (elms[i].checked) {\r\n                isChecked = true;\r\n                break;\r\n            }\r\n        }\r\n        postValidate(isChecked, errMsg, errElm, null); \/\/ no focus element\r\n        return isChecked;\r\n    }\r\n\r\n    \/\/ Validate password, 6-8 characters of [a-zA-Z0-9_]\r\n    function isValidPassword(inputElm, errMsg, errElm) {\r\n        var isValid = (inputElm.value.trim().match(\/^\\w{6,8}$\/) !== null);\r\n        postValidate(isValid, errMsg, errElm, inputElm);\r\n        return isValid;\r\n    }\r\n\r\n    \/*\r\n     * The \"onclick\" handler for the \"reset\" button to clear the display,\r\n     * including the previous error messages and error box.\r\n     *\/\r\n    function clearForm() {\r\n        \/\/ Remove class \"errorBox\" from input elements\r\n        var elms = document.querySelectorAll('.errorBox'); \/\/ class\r\n        for (var i = 0; i < elms.length; i++) {\r\n            elms[i].classList.remove(\"errorBox\");\r\n        }\r\n\r\n        \/\/ Remove previous error messages\r\n        elms = document.querySelectorAll('[id$=\"Error\"]'); \/\/ id ends with Error\r\n        for (var i = 0; i < elms.length; i++) {\r\n            elms[i].innerHTML = \"\";\r\n        }\r\n\r\n        \/\/ Set initial focus\r\n        document.getElementById(\"first_name\").focus();\r\n    }\r\n\t\r\n<\/script><br \/>\n<noscript><\/p>\n<div class=\"noscriptmsg\"> You don&#8217;t have JavaScript enabled. 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>\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\t<input type=\"hidden\" name=\"txtto\" value=\"scnc@bu.edu\" ><br \/>\n\t<input type=\"hidden\" name=\"txtsubject\" value=\"BU Student Registration\" ><br \/>\n\t<input type=\"hidden\" name=\"txtDone\" value=\"https:\/\/www.bu.edu\/scnc\/wp-assets\/student\/thanks\/index.html\" ><\/p>\n<fieldset>\n<legend class=\"secure-lock\"> BU Student Counseling Registration Form<\/legend>\n<p><em class=\"required\">*<\/em> = mandatory field<\/p>\n<div>\n\t\t\t<label for=\"first_name\"> First Name: <em class=\"required\">*<\/em><\/label><br \/>\n\t\t\t<input name=\"first_name\" id=\"first_name\" type=\"text\" >\n\t\t<\/div>\n<div id=\"elmfirst_nameError\" class=\"errorMsg\">&nbsp;<\/div>\n<div>\n\t\t\t<label for=\"last_name\"> Last Name: <em class=\"required\">*<\/em><\/label><br \/>\n\t\t\t<input name=\"last_name\" id=\"last_name\" type=\"text\" >\n\t\t<\/div>\n<div id=\"elmlast_nameError\" class=\"errorMsg\">&nbsp;<\/div>\n<div>\n\t\t\t<label for=\"gender\">Gender:<\/label><br \/>\n\t\t\t<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\t\t<\/div>\n<div>\n\t\t\t<label for=\"dob\">DOB: <em class=\"required\">*<\/em><\/label><br \/>\n\t\t\t<input name=\"dob\" id=\"dob\" type=\"text\" >\n\t\t<\/div>\n<div id=\"elmdobError\" class=\"errorMsg\">&nbsp;<\/div>\n<div>\n\t\t\t<label for=\"email\">Email: <em class=\"required\">*<\/em><\/label><br \/>\n\t\t\t<input type=\"text\" name=\"email\" id=\"email\" >\n\t\t<\/div>\n<div id=\"elmemailError\" class=\"errorMsg\">&nbsp;<\/div>\n<div>\n\t\t\t<label for=\"phone\">Phone: <em class=\"required\">*<\/em><\/label><br \/>\n\t\t\t<input name=\"phone\" id=\"phone\" type=\"text\" >\n\t\t<\/div>\n<div id=\"elmphoneError\" class=\"errorMsg\">&nbsp;<\/div>\n<fieldset>\n<legend>Current Address<\/legend>\n<div>\n\t\t\t\t<label for=\"street\">Street: <em class=\"required\">*<\/em><\/label><br \/>\n\t\t\t\t<input name=\"street\" id=\"street\" type=\"text\" >\n\t\t\t<\/div>\n<div id=\"elmstreetError\" class=\"errorMsg\">&nbsp;<\/div>\n<div>\n\t\t\t\t<label for=\"city\"> City: <em class=\"required\">*<\/em><\/label><br \/>\n\t\t\t\t<input name=\"city\" id=\"city\" type=\"text\" >\n\t\t\t<\/div>\n<div id=\"elmcityError\" class=\"errorMsg\">&nbsp;<\/div>\n<div>\n\t\t\t\t<label for=\"state\">State: <em class=\"required\">*<\/em><\/label><br \/>\n\t\t\t\t<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\t\t\t<\/div>\n<div id=\"elmstateError\" class=\"errorMsg\">&nbsp;<\/div>\n<div>\n\t\t\t\t<label for=\"zip\">Zip Code: <em class=\"required\">*<\/em><\/label><br \/>\n\t\t\t\t<input name=\"zip\" type=\"text\" id=\"zip\" maxlength=\"5\" >\n\t\t\t<\/div>\n<div id=\"elmzipError\" class=\"errorMsg\">&nbsp;<\/div>\n<\/fieldset>\n<div>\n\t\t\t<label for=\"graduation_date\">Graduation Date:<\/label><br \/>\n\t\t\t<input name=\"graduation_date\" id=\"graduation_date\" type=\"text\" >\n\t\t<\/div>\n<fieldset>\n<legend>Who referred you to us?:<\/legend>\n<div>\n\t\t\t\t<label for=\"self\"><br \/>\n\t\t\t\t\t<input id=\"self\" name=\"who_referred_you\" type=\"radio\" value=\"Self\" ><br \/>\n\t\t\t\t\tSelf<\/label>\n\t\t\t<\/div>\n<div>\n\t\t\t\t<label for=\"student_health_services\"><br \/>\n\t\t\t\t\t<input id=\"student_health_services\" name=\"who_referred_you\" type=\"radio\" value=\"Student Health Services\" ><br \/>\n\t\t\t\t\tStudent Health Services<\/label>\n\t\t\t<\/div>\n<div>\n\t\t\t\t<label for=\"behavioral_medicine\"><br \/>\n\t\t\t\t\t<input id=\"behavioral_medicine\" name=\"who_referred_you\" type=\"radio\" value=\"Behavioral Medicine\" ><br \/>\n\t\t\t\t\tBehavioral Medicine <\/label>\n\t\t\t<\/div>\n<div>\n\t\t\t\t<label for=\"coach_athletic_trainer\"><br \/>\n\t\t\t\t\t<input id=\"coach_athletic_trainer\" name=\"who_referred_you\" type=\"radio\" value=\"Coach\/Athletic Trainer\" ><br \/>\n\t\t\t\t\tCoach\/Athletic Trainer<\/label>\n\t\t\t<\/div>\n<div>\n\t\t\t\t<label for=\"friend\"><br \/>\n\t\t\t\t\t<input id=\"friend\" type=\"radio\" name=\"who_referred_you\" value=\"Friend\" ><br \/>\n\t\t\t\t\tFriend <\/label>\n\t\t\t<\/div>\n<div>\n\t\t\t\t<label for=\"other_referred\"><br \/>\n\t\t\t\t\t<input id=\"other_referred\" type=\"radio\" name=\"who_referred_you\" value=\"Other:\" ><br \/>\n\t\t\t\t\tOther:<\/label><br \/>\n\t\t\t\t<label for=\"referred_by_other\">If referred by other, who?:<\/label><br \/>\n\t\t\t\t<input type=\"text\" id=\"referred_by_other\" name=\"referred_by_other\" >\n\t\t\t<\/div>\n<\/fieldset>\n<fieldset>\n<legend>1. Please select the option below that best reflects the <strong>PRIMARY<\/strong> reason for your visit so that we can schedule you with the appropriate provider. You may select additional reasons for your visit in the next section: <em class=\"required\">*<\/em> <\/legend>\n<div>\n\t\t\t\t<label for=\"healthy_meal_planning\"><br \/>\n\t\t\t\t\t<input id=\"healthy_meal_planning\" name=\"primary_reason_for_visit\" type=\"radio\" value=\"Healthy meal planning\" ><br \/>\n\t\t\t\t\tHealthy meal planning<\/label>\n\t\t\t<\/div>\n<div>\n\t\t\t\t<label for=\"concern_about_weight_gain_in_college\"><br \/>\n\t\t\t\t\t<input id=\"concern_about_weight_gain_in_college\" name=\"primary_reason_for_visit\" type=\"radio\" value=\"Concern about weight gain in college\" ><br \/>\n\t\t\t\t\tConcern about weight gain in college<\/label>\n\t\t\t<\/div>\n<div>\n\t\t\t\t<label for=\"healthy_weight_loss\"><br \/>\n\t\t\t\t\t<input id=\"healthy_weight_loss\" name=\"primary_reason_for_visit\" type=\"radio\" value=\"Healthy weight loss\" ><br \/>\n\t\t\t\t\tHealthy weight loss <\/label>\n\t\t\t<\/div>\n<div>\n\t\t\t\t<label for=\"sports_nutrition\"><br \/>\n\t\t\t\t\t<input id=\"sports_nutrition\" name=\"primary_reason_for_visit\" type=\"radio\" value=\"Sports nutrition\" ><br \/>\n\t\t\t\t\tSports nutrition<\/label>\n\t\t\t<\/div>\n<div>\n\t\t\t\t<label for=\"stress_over_undereating\"><br \/>\n\t\t\t\t\t<input id=\"stress_over_undereating\" type=\"radio\" name=\"primary_reason_for_visit\" value=\"Stress over\/undereating\" ><br \/>\n\t\t\t\t\tStress over\/undereating<\/label>\n\t\t\t<\/div>\n<div>\n\t\t\t\t<label for=\"emotional_over_undereating\"><br \/>\n\t\t\t\t\t<input id=\"emotional_over_undereating\" type=\"radio\" name=\"primary_reason_for_visit\" value=\"Emotional over\/undereating\" ><br \/>\n\t\t\t\t\tEmotional over\/undereating<\/label>\n\t\t\t<\/div>\n<div>\n\t\t\t\t<label for=\"social_over_undereating\"><br \/>\n\t\t\t\t\t<input id=\"social_over_undereating\" type=\"radio\" name=\"primary_reason_for_visit\" value=\"Social over\/undereating\" ><br \/>\n\t\t\t\t\tSocial over\/undereating<\/label>\n\t\t\t<\/div>\n<div>\n\t\t\t\t<label for=\"dining_hall_over_undereating\"><br \/>\n\t\t\t\t\t<input id=\"dining_hall_over_undereating\" type=\"radio\" name=\"primary_reason_for_visit\" value=\"Dining hall over\/undereating\" ><br \/>\n\t\t\t\t\tDining hall over\/undereating<\/label>\n\t\t\t<\/div>\n<div>\n\t\t\t\t<label for=\"hunger_management\"><br \/>\n\t\t\t\t\t<input id=\"hunger_management\" type=\"radio\" name=\"primary_reason_for_visit\" value=\"Hunger management\" ><br \/>\n\t\t\t\t\tHunger management<\/label>\n\t\t\t<\/div>\n<div>\n\t\t\t\t<label for=\"unhealthy_weight_control_practices\"><br \/>\n\t\t\t\t\t<input id=\"unhealthy_weight_control_practices\" type=\"radio\" name=\"primary_reason_for_visit\" value=\"Unhealthy weight control practices\" ><br \/>\n\t\t\t\t\tUnhealthy weight control practices<\/label>\n\t\t\t<\/div>\n<div>\n\t\t\t\t<input id=\"eating_disorder\" name=\"primary_reason_for_visit\" type=\"radio\" value=\"Eating disorder\" class=\"eating_disorder\" ><br \/>\n\t\t\t\t<label for=\"eating_disorder\">Eating disorder <\/label><\/p>\n<div class=\"reveal-if-active\">\n<fieldset>\n<legend>(Check all that apply)<\/legend>\n<div>\n\t\t\t\t\t\t\t<label for=\"eating_disorder_anorexia_nervosa\"><br \/>\n\t\t\t\t\t\t\t\t<input id=\"eating_disorder_anorexia_nervosa\" name=\"eating_disorder_anorexia_nervosa\" type=\"checkbox\" value=\"Anorexia Nervosa\" ><br \/>\n\t\t\t\t\t\t\t\tAnorexia Nervosa<\/label>\n\t\t\t\t\t\t<\/div>\n<div>\n\t\t\t\t\t\t\t<label for=\"eating_disorder_bulimia_nervosa\"><br \/>\n\t\t\t\t\t\t\t\t<input id=\"eating_disorder_bulimia_nervosa\" name=\"eating_disorder_bulimia_nervosa\" type=\"checkbox\" value=\"Bulimia Nervosa\" ><br \/>\n\t\t\t\t\t\t\t\tBulimia Nervosa<\/label>\n\t\t\t\t\t\t<\/div>\n<div>\n\t\t\t\t\t\t\t<label for=\"eating_disorder_binge_eating_disorder\"><br \/>\n\t\t\t\t\t\t\t\t<input id=\"eating_disorder_binge_eating_disorder\" name=\"eating_disorder_binge_eating_disorder\" type=\"checkbox\" value=\"Binge Eating Disorder\" ><br \/>\n\t\t\t\t\t\t\t\tBinge eating disorder<\/label>\n\t\t\t\t\t\t<\/div>\n<div>\n\t\t\t\t\t\t\t<label for=\"eating_disorder_other\"><br \/>\n\t\t\t\t\t\t\t\t<input id=\"eating_disorder_other\" type=\"checkbox\" name=\"eating_disorder_other\" value=\"Other Eating Disorder\" ><br \/>\n\t\t\t\t\t\t\t\tOther Eating Disorder <\/label>\n\t\t\t\t\t\t<\/div>\n<\/fieldset><\/div>\n<\/p><\/div>\n<div>\n\t\t\t\t<input id=\"food_allergy_intolerances\" name=\"primary_reason_for_visit\" type=\"radio\" value=\"Food allergies or intolerances\" ><br \/>\n\t\t\t\t<label for=\"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\t\t\t\t\t\t\t<label for=\"food_allergy_intolerance_wheat\"><br \/>\n\t\t\t\t\t\t\t\t<input id=\"food_allergy_intolerance_wheat\" name=\"food_allergy_intolerance_wheat\" type=\"checkbox\" value=\"Wheat\" ><br \/>\n\t\t\t\t\t\t\t\tWheat<\/label>\n\t\t\t\t\t\t<\/div>\n<div>\n\t\t\t\t\t\t\t<label for=\"food_allergy_intolerance_milk\"><br \/>\n\t\t\t\t\t\t\t\t<input id=\"food_allergy_intolerance_milk\" name=\"food_allergy_intolerance_milk\" type=\"checkbox\" value=\"Milk\" ><br \/>\n\t\t\t\t\t\t\t\tMilk<\/label>\n\t\t\t\t\t\t<\/div>\n<div>\n\t\t\t\t\t\t\t<label for=\"food_allergy_intolerance_peanuts\"><br \/>\n\t\t\t\t\t\t\t\t<input id=\"food_allergy_intolerance_peanuts\" name=\"food_allergy_intolerance_peanuts\" type=\"checkbox\" value=\"Peanuts\" ><br \/>\n\t\t\t\t\t\t\t\tPeanuts<\/label>\n\t\t\t\t\t\t<\/div>\n<div>\n\t\t\t\t\t\t\t<label for=\"food_allergy_intolerance_tree_nuts\"><br \/>\n\t\t\t\t\t\t\t\t<input id=\"food_allergy_intolerance_tree_nuts\" type=\"checkbox\" name=\"food_allergy_intolerance_tree_nuts\" value=\"Tree nuts\" ><br \/>\n\t\t\t\t\t\t\t\tTree nuts<\/label>\n\t\t\t\t\t\t<\/div>\n<div>\n\t\t\t\t\t\t\t<label for=\"food_allergy_intolerance_eggs\"><br \/>\n\t\t\t\t\t\t\t\t<input id=\"food_allergy_intolerance_eggs\" name=\"food_allergy_intolerance_eggs\" type=\"checkbox\" value=\"Eggs\" ><br \/>\n\t\t\t\t\t\t\t\tEggs<\/label>\n\t\t\t\t\t\t<\/div>\n<div>\n\t\t\t\t\t\t\t<label for=\"food_allergy_intolerance_shellfish\"><br \/>\n\t\t\t\t\t\t\t\t<input id=\"food_allergy_intolerance_shellfish\" name=\"food_allergy_intolerance_shellfish\" type=\"checkbox\" value=\"Shellfish\" ><br \/>\n\t\t\t\t\t\t\t\tShellfish<\/label>\n\t\t\t\t\t\t<\/div>\n<div>\n\t\t\t\t\t\t\t<label for=\"food_allergy_intolerance_soy\"><br \/>\n\t\t\t\t\t\t\t\t<input id=\"food_allergy_intolerance_soy\" name=\"food_allergy_intolerance_soy\" type=\"checkbox\" value=\"Soy\" ><br \/>\n\t\t\t\t\t\t\t\tSoy<\/label>\n\t\t\t\t\t\t<\/div>\n<div>\n\t\t\t\t\t\t\t<label for=\"food_allergy_intolerance_fish\"><br \/>\n\t\t\t\t\t\t\t\t<input id=\"food_allergy_intolerance_fish\" type=\"checkbox\" name=\"food_allergy_intolerance_fish\" value=\"Fish\" ><br \/>\n\t\t\t\t\t\t\t\tFish<\/label>\n\t\t\t\t\t\t<\/div>\n<div>\n\t\t\t\t\t\t\t<label for=\"food_allergy_intolerance_lactose_intolerance\"><br \/>\n\t\t\t\t\t\t\t\t<input id=\"food_allergy_intolerance_lactose_intolerance\" name=\"food_allergy_intolerance_lactose_intolerance\" type=\"checkbox\" value=\"Lactose intolerance\" ><br \/>\n\t\t\t\t\t\t\t\tLactose intolerance<\/label>\n\t\t\t\t\t\t<\/div>\n<div>\n\t\t\t\t\t\t\t<label for=\"food_allergy_intolerance_gluten_intolerance\"><br \/>\n\t\t\t\t\t\t\t\t<input id=\"food_allergy_intolerance_gluten_intolerance\" name=\"food_allergy_intolerance_gluten_intolerance\" type=\"checkbox\" value=\"Gluten intolerance\" ><br \/>\n\t\t\t\t\t\t\t\tGluten intolerance<\/label>\n\t\t\t\t\t\t<\/div>\n<div>\n\t\t\t\t\t\t\t<label for=\"food_allergy_intolerance_fodmaps\"><br \/>\n\t\t\t\t\t\t\t\t<input id=\"food_allergy_intolerance_fodmaps\" name=\"food_allergy_intolerance_fodmaps\" type=\"checkbox\" value=\"FODMAPs\" ><br \/>\n\t\t\t\t\t\t\t\tFODMAPs<\/label>\n\t\t\t\t\t\t<\/div>\n<div>\n\t\t\t\t\t\t\t<label for=\"food_allergy_intolerance_other\"><br \/>\n\t\t\t\t\t\t\t\t<input id=\"food_allergy_intolerance_other\" type=\"checkbox\" name=\"food_allergy_intolerance_other\" value=\"Other Allergy\/Intolerance: \" ><br \/>\n\t\t\t\t\t\t\t\tOther:<\/label><br \/>\n\t\t\t\t\t\t\t<label for=\"other_allergy_intolerance_text\">If other allegy or intolerance, please describe:<\/label><br \/>\n\t\t\t\t\t\t\t<input type=\"text\" id=\"other_allergy_intolerance_text\" name=\"other_allergy_intolerance_text\" >\n\t\t\t\t\t\t<\/div>\n<\/fieldset><\/div>\n<\/p><\/div>\n<div>\n\t\t\t\t<input id=\"gastrointestinal_disorder\" name=\"primary_reason_for_visit\" type=\"radio\" value=\"Gastrointestinal disorder\" ><br \/>\n\t\t\t\t<label for=\"gastrointestinal_disorder\">Gastrointestinal disorder<\/label><\/p>\n<div class=\"reveal-if-active\">\n<fieldset>\n<legend>(Check all that apply)<\/legend>\n<div>\n\t\t\t\t\t\t\t<label for=\"gastrointestinal_disorders_ibs\"><br \/>\n\t\t\t\t\t\t\t\t<input id=\"gastrointestinal_disorders_ibs\" name=\"gastrointestinal_disorders_ibs\" type=\"checkbox\" value=\"IBS\" ><br \/>\n\t\t\t\t\t\t\t\tIBS<\/label>\n\t\t\t\t\t\t<\/div>\n<div>\n\t\t\t\t\t\t\t<label for=\"gastrointestinal_disorders_crohns_disease\"><br \/>\n\t\t\t\t\t\t\t\t<input id=\"gastrointestinal_disorders_crohns_disease\" name=\"gastrointestinal_disorders_crohns_disease\" type=\"checkbox\" value=\"Crohn's Disease\" ><br \/>\n\t\t\t\t\t\t\t\tCrohn&#8217;s Disease<\/label>\n\t\t\t\t\t\t<\/div>\n<div>\n\t\t\t\t\t\t\t<label for=\"gastrointestinal_disorders_ulcerative_colitis\"><br \/>\n\t\t\t\t\t\t\t\t<input id=\"gastrointestinal_disorders_ulcerative_colitis\" name=\"gastrointestinal_disorders_ulcerative_colitis\" type=\"checkbox\" value=\"Ulcerative Colitis\" ><br \/>\n\t\t\t\t\t\t\t\tUlcerative Colitis<\/label>\n\t\t\t\t\t\t<\/div>\n<div>\n\t\t\t\t\t\t\t<label for=\"gastrointestinal_disorders_gerd\"><br \/>\n\t\t\t\t\t\t\t\t<input id=\"gastrointestinal_disorders_gerd\" type=\"checkbox\" name=\"gastrointestinal_disorders_gerd\" value=\"GERD\" ><br \/>\n\t\t\t\t\t\t\t\tGERD <\/label>\n\t\t\t\t\t\t<\/div>\n<div>\n\t\t\t\t\t\t\t<label for=\"gastrointestinal_disorders_celiac_disease\"><br \/>\n\t\t\t\t\t\t\t\t<input id=\"gastrointestinal_disorders_celiac_disease\" name=\"gastrointestinal_disorders_celiac_disease\" type=\"checkbox\" value=\"Celiac Disease\" ><br \/>\n\t\t\t\t\t\t\t\tCeliac Disease<\/label>\n\t\t\t\t\t\t<\/div>\n<div>\n\t\t\t\t\t\t\t<label for=\"gastrointestinal_disorders_other\"><br \/>\n\t\t\t\t\t\t\t\t<input id=\"gastrointestinal_disorders_other\" type=\"checkbox\" name=\"gastrointestinal_disorders_other\" value=\"Other Gastrointestinal disorder: \" ><br \/>\n\t\t\t\t\t\t\t\tOther:<\/label><br \/>\n\t\t\t\t\t\t\t<label for=\"other_gastrointestinal_disorders_text\">If other gastrointestinal disorder, please describe:<\/label><br \/>\n\t\t\t\t\t\t\t<input type=\"text\" id=\"other_gastrointestinal_disorders_text\" name=\"other_gastrointestinal_disorders_text\" >\n\t\t\t\t\t\t<\/div>\n<\/fieldset><\/div>\n<\/p><\/div>\n<div>\n\t\t\t\t<label for=\"high_blood_pressure\"><br \/>\n\t\t\t\t\t<input id=\"high_blood_pressure\" name=\"primary_reason_for_visit\" type=\"radio\" value=\"High blood pressure\" ><br \/>\n\t\t\t\t\tHigh blood pressure<\/label>\n\t\t\t<\/div>\n<div>\n\t\t\t\t<label for=\"high_cholesterol\"><br \/>\n\t\t\t\t\t<input id=\"high_cholesterol\" name=\"primary_reason_for_visit\" type=\"radio\" value=\"High cholesterol\" ><br \/>\n\t\t\t\t\tHigh cholesterol<\/label>\n\t\t\t<\/div>\n<div>\n\t\t\t\t<label for=\"diabetes_prediabetes\"><br \/>\n\t\t\t\t\t<input id=\"diabetes_prediabetes\" name=\"primary_reason_for_visit\" type=\"radio\" value=\"Diabetes\/Pre-diabetes\" ><br \/>\n\t\t\t\t\tDiabetes\/Pre-diabetes<\/label>\n\t\t\t<\/div>\n<div>\n\t\t\t\t<label for=\"vegetarian_vegan\"><br \/>\n\t\t\t\t\t<input id=\"vegetarian_vegan\" name=\"primary_reason_for_visit\" type=\"radio\" value=\"Vegetarian\/vegan\" ><br \/>\n\t\t\t\t\tVegetarian\/vegan<\/label>\n\t\t\t<\/div>\n<div>\n\t\t\t\t<label for=\"iron_deficiency_anemia\"><br \/>\n\t\t\t\t\t<input id=\"iron_deficiency_anemia\" name=\"primary_reason_for_visit\" type=\"radio\" value=\"Iron-deficiency anemia\" ><br \/>\n\t\t\t\t\tIron-deficiency anemia<\/label>\n\t\t\t<\/div>\n<div>\n\t\t\t\t<label for=\"polycystic_ovary_syndrome\"><br \/>\n\t\t\t\t\t<input id=\"polycystic_ovary_syndrome\" name=\"primary_reason_for_visit\" type=\"radio\" value=\"Polycystic ovary syndrome\" ><br \/>\n\t\t\t\t\tPolycystic ovary syndrome <\/label>\n\t\t\t<\/div>\n<div>\n\t\t\t\t<label for=\"bariatric_surgery\"><br \/>\n\t\t\t\t\t<input id=\"bariatric_surgery\" name=\"primary_reason_for_visit\" type=\"radio\" value=\"Bariatric surgery\" ><br \/>\n\t\t\t\t\tBariatric surgery<\/label>\n\t\t\t<\/div>\n<div>\n\t\t\t\t<label for=\"other_primary_reason_for_visit\"><br \/>\n\t\t\t\t\t<input id=\"other_primary_reason_for_visit\" name=\"primary_reason_for_visit\" type=\"radio\" value=\"Other Primary Reason\" ><br \/>\n\t\t\t\t\tOther:<\/label><br \/>\n\t\t\t\t<label for=\"other_primary_reason_for_visit_text\">If other primary reason for visit, please describe:<\/label><br \/>\n\t\t\t\t<input type=\"text\" id=\"other_primary_reason_for_visit_text\" name=\"other_primary_reason_for_visit_text\" >\n\t\t\t<\/div>\n<\/fieldset>\n<fieldset>\n<legend>2. Please select any secondary reason(s) for your appointment (check all that apply): <em class=\"required\">*<\/em> <\/legend>\n<div>\n\t\t\t\t<label for=\"secondary_reasons_for_visit_healthy_meal_planning\"><br \/>\n\t\t\t\t\t<input id=\"secondary_reasons_for_visit_healthy_meal_planning\" name=\"secondary_reasons_for_visit\" type=\"checkbox\" value=\"Healthy meal planning\" ><br \/>\n\t\t\t\t\tHealthy meal planning<\/label>\n\t\t\t<\/div>\n<div>\n\t\t\t\t<label for=\"secondary_reasons_for_visit_concern_about_weight_gain_in_college\"><br \/>\n\t\t\t\t\t<input id=\"secondary_reasons_for_visit_concern_about_weight_gain_in_college\" name=\"secondary_reasons_for_visit\" type=\"checkbox\" value=\"Concern about weight gain in college\" ><br \/>\n\t\t\t\t\tConcern about weight gain in college<\/label>\n\t\t\t<\/div>\n<div>\n\t\t\t\t<label for=\"secondary_reasons_for_visit_healthy_weight_loss\"><br \/>\n\t\t\t\t\t<input id=\"secondary_reasons_for_visit_healthy_weight_loss\" name=\"secondary_reasons_for_visit\" type=\"checkbox\" value=\"Healthy weight loss\" ><br \/>\n\t\t\t\t\tHealthy weight loss <\/label>\n\t\t\t<\/div>\n<div>\n\t\t\t\t<label for=\"secondary_reasons_for_visit_sports_nutrition\"><br \/>\n\t\t\t\t\t<input id=\"secondary_reasons_for_visit_sports_nutrition\" name=\"secondary_reasons_for_visit\" type=\"checkbox\" value=\"Sports nutrition\" ><br \/>\n\t\t\t\t\tSports nutrition<\/label>\n\t\t\t<\/div>\n<div>\n\t\t\t\t<label for=\"secondary_reasons_for_visit_stress_over_undereating\"><br \/>\n\t\t\t\t\t<input id=\"secondary_reasons_for_visit_stress_over_undereating\" type=\"checkbox\" name=\"secondary_reasons_for_visit\" value=\"Stress over\/undereating\" ><br \/>\n\t\t\t\t\tStress over\/undereating<\/label>\n\t\t\t<\/div>\n<div>\n\t\t\t\t<label for=\"secondary_reasons_for_visit_emotional_over_undereating\"><br \/>\n\t\t\t\t\t<input id=\"secondary_reasons_for_visit_emotional_over_undereating\" type=\"checkbox\" name=\"secondary_reasons_for_visit\" value=\"Emotional over\/undereating\" ><br \/>\n\t\t\t\t\tEmotional over\/undereating<\/label>\n\t\t\t<\/div>\n<div>\n\t\t\t\t<label for=\"secondary_reasons_for_visit_social_over_undereating\"><br \/>\n\t\t\t\t\t<input id=\"secondary_reasons_for_visit_social_over_undereating\" type=\"checkbox\" name=\"secondary_reasons_for_visit\" value=\"Social over\/undereating\" ><br \/>\n\t\t\t\t\tSocial over\/undereating<\/label>\n\t\t\t<\/div>\n<div>\n\t\t\t\t<label for=\"secondary_reasons_for_visit_dining_hall_over_undereating\"><br \/>\n\t\t\t\t\t<input id=\"secondary_reasons_for_visit_dining_hall_over_undereating\" type=\"checkbox\" name=\"secondary_reasons_for_visit\" value=\"Dining hall over\/undereating\" ><br \/>\n\t\t\t\t\tDining hall over\/undereating<\/label>\n\t\t\t<\/div>\n<div>\n\t\t\t\t<label for=\"secondary_reasons_for_visit_hunger_management\"><br \/>\n\t\t\t\t\t<input id=\"secondary_reasons_for_visit_hunger_management\" type=\"checkbox\" name=\"secondary_reasons_for_visit\" value=\"Hunger management\" ><br \/>\n\t\t\t\t\tHunger management<\/label>\n\t\t\t<\/div>\n<div>\n\t\t\t\t<label for=\"secondary_reasons_for_visit_unhealthy_weight_control_practices\"><br \/>\n\t\t\t\t\t<input id=\"secondary_reasons_for_visit_unhealthy_weight_control_practices\" type=\"checkbox\" name=\"secondary_reasons_for_visit\" value=\"Unhealthy weight control practices\" ><br \/>\n\t\t\t\t\tUnhealthy weight control practices<\/label>\n\t\t\t<\/div>\n<div>\n\t\t\t\t<input id=\"secondary_reasons_for_visit_eating_disorder\" name=\"secondary_reasons_for_visit\" type=\"checkbox\" value=\"Eating disorder\" ><br \/>\n\t\t\t\t<label for=\"secondary_reasons_for_visit_eating_disorder\">Eating disorder <\/label><\/p>\n<div class=\"reveal-if-active\">\n<fieldset>\n<legend>(Check all that apply)<\/legend>\n<div>\n\t\t\t\t\t\t\t<label for=\"secondary_eating_disorder_anorexia_nervosa\"><br \/>\n\t\t\t\t\t\t\t\t<input id=\"secondary_eating_disorder_anorexia_nervosa\" name=\"secondary_eating_disorder_anorexia_nervosa\" type=\"checkbox\" value=\"Anorexia Nervosa\" ><br \/>\n\t\t\t\t\t\t\t\tAnorexia Nervosa<\/label>\n\t\t\t\t\t\t<\/div>\n<div>\n\t\t\t\t\t\t\t<label for=\"secondary_eating_disorder_bulimia_nervosa\"><br \/>\n\t\t\t\t\t\t\t\t<input id=\"secondary_eating_disorder_bulimia_nervosa\" name=\"secondary_eating_disorder_bulimia_nervosa\" type=\"checkbox\" value=\"Bulimia Nervosa\" ><br \/>\n\t\t\t\t\t\t\t\tBulimia Nervosa<\/label>\n\t\t\t\t\t\t<\/div>\n<div>\n\t\t\t\t\t\t\t<label for=\"secondary_eating_disorder_binge_eating_disorder\"><br \/>\n\t\t\t\t\t\t\t\t<input id=\"secondary_eating_disorder_binge_eating_disorder\" name=\"secondary_eating_disorder_binge_eating_disorder\" type=\"checkbox\" value=\"Binge Eating Disorder\" ><br \/>\n\t\t\t\t\t\t\t\tBinge eating disorder<\/label>\n\t\t\t\t\t\t<\/div>\n<div>\n\t\t\t\t\t\t\t<label for=\"secondary_eating_disorder_other\"><br \/>\n\t\t\t\t\t\t\t\t<input id=\"secondary_eating_disorder_other\" type=\"checkbox\" name=\"secondary_eating_disorder_other\" value=\"Other Eating Disorder\" ><br \/>\n\t\t\t\t\t\t\t\tOther Eating Disorder <\/label>\n\t\t\t\t\t\t<\/div>\n<\/fieldset><\/div>\n<\/p><\/div>\n<div>\n\t\t\t\t<input id=\"secondary_reasons_for_visit_food_allergy_intolerances\" name=\"secondary_reasons_for_visit\" type=\"checkbox\" value=\"Food allergies or intolerances\" ><br \/>\n\t\t\t\t<label for=\"secondary_reasons_for_visit_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\t\t\t\t\t\t\t<label for=\"secondary_food_allergy_intolerance_wheat\"><br \/>\n\t\t\t\t\t\t\t\t<input id=\"secondary_food_allergy_intolerance_wheat\" name=\"secondary_food_allergy_intolerance_wheat\" type=\"checkbox\" value=\"Wheat\" ><br \/>\n\t\t\t\t\t\t\t\tWheat<\/label>\n\t\t\t\t\t\t<\/div>\n<div>\n\t\t\t\t\t\t\t<label for=\"secondary_food_allergy_intolerance_milk\"><br \/>\n\t\t\t\t\t\t\t\t<input id=\"secondary_food_allergy_intolerance_milk\" name=\"secondary_food_allergy_intolerance_milk\" type=\"checkbox\" value=\"Milk\" ><br \/>\n\t\t\t\t\t\t\t\tMilk<\/label>\n\t\t\t\t\t\t<\/div>\n<div>\n\t\t\t\t\t\t\t<label for=\"secondary_food_allergy_intolerance_peanuts\"><br \/>\n\t\t\t\t\t\t\t\t<input id=\"secondary_food_allergy_intolerance_peanuts\" name=\"secondary_food_allergy_intolerance_peanuts\" type=\"checkbox\" value=\"Peanuts\" ><br \/>\n\t\t\t\t\t\t\t\tPeanuts<\/label>\n\t\t\t\t\t\t<\/div>\n<div>\n\t\t\t\t\t\t\t<label for=\"secondary_food_allergy_intolerance_tree_nuts\"><br \/>\n\t\t\t\t\t\t\t\t<input id=\"secondary_food_allergy_intolerance_tree_nuts\" type=\"checkbox\" name=\"secondary_food_allergy_intolerance_tree_nuts\" value=\"Tree nuts\" ><br \/>\n\t\t\t\t\t\t\t\tTree nuts<\/label>\n\t\t\t\t\t\t<\/div>\n<div>\n\t\t\t\t\t\t\t<label for=\"secondary_food_allergy_intolerance_eggs\"><br \/>\n\t\t\t\t\t\t\t\t<input id=\"secondary_food_allergy_intolerance_eggs\" name=\"secondary_food_allergy_intolerance_eggs\" type=\"checkbox\" value=\"Eggs\" ><br \/>\n\t\t\t\t\t\t\t\tEggs<\/label>\n\t\t\t\t\t\t<\/div>\n<div>\n\t\t\t\t\t\t\t<label for=\"secondary_food_allergy_intolerance_shellfish\"><br \/>\n\t\t\t\t\t\t\t\t<input id=\"secondary_food_allergy_intolerance_shellfish\" name=\"secondary_food_allergy_intolerance_shellfish\" type=\"checkbox\" value=\"Shellfish\" ><br \/>\n\t\t\t\t\t\t\t\tShellfish<\/label>\n\t\t\t\t\t\t<\/div>\n<div>\n\t\t\t\t\t\t\t<label for=\"secondary_food_allergy_intolerance_soy\"><br \/>\n\t\t\t\t\t\t\t\t<input id=\"secondary_food_allergy_intolerance_soy\" name=\"secondary_food_allergy_intolerance_soy\" type=\"checkbox\" value=\"Soy\" ><br \/>\n\t\t\t\t\t\t\t\tSoy<\/label>\n\t\t\t\t\t\t<\/div>\n<div>\n\t\t\t\t\t\t\t<label for=\"secondary_food_allergy_intolerance_fish\"><br \/>\n\t\t\t\t\t\t\t\t<input id=\"secondary_food_allergy_intolerance_fish\" type=\"checkbox\" name=\"secondary_food_allergy_intolerance_fish\" value=\"Fish\" ><br \/>\n\t\t\t\t\t\t\t\tFish<\/label>\n\t\t\t\t\t\t<\/div>\n<div>\n\t\t\t\t\t\t\t<label for=\"secondary_food_allergy_intolerance_lactose_intolerance\"><br \/>\n\t\t\t\t\t\t\t\t<input id=\"secondary_food_allergy_intolerance_lactose_intolerance\" name=\"secondary_food_allergy_intolerance_lactose_intolerance\" type=\"checkbox\" value=\"Lactose intolerance\" ><br \/>\n\t\t\t\t\t\t\t\tLactose intolerance<\/label>\n\t\t\t\t\t\t<\/div>\n<div>\n\t\t\t\t\t\t\t<label for=\"secondary_food_allergy_intolerance_gluten_intolerance\"><br \/>\n\t\t\t\t\t\t\t\t<input id=\"secondary_food_allergy_intolerance_gluten_intolerance\" name=\"secondary_food_allergy_intolerance_gluten_intolerance\" type=\"checkbox\" value=\"Gluten intolerance\" ><br \/>\n\t\t\t\t\t\t\t\tGluten intolerance<\/label>\n\t\t\t\t\t\t<\/div>\n<div>\n\t\t\t\t\t\t\t<label for=\"secondary_food_allergy_intolerance_fodmaps\"><br \/>\n\t\t\t\t\t\t\t\t<input id=\"secondary_food_allergy_intolerance_fodmaps\" name=\"secondary_food_allergy_intolerance_fodmaps\" type=\"checkbox\" value=\"FODMAPs\" ><br \/>\n\t\t\t\t\t\t\t\tFODMAPs<\/label>\n\t\t\t\t\t\t<\/div>\n<div>\n\t\t\t\t\t\t\t<label for=\"secondary_food_allergy_intolerance_other\"><br \/>\n\t\t\t\t\t\t\t\t<input id=\"secondary_food_allergy_intolerance_other\" type=\"checkbox\" name=\"secondary_food_allergy_intolerance_other\" value=\"Other Allergy\/Intolerance: \" ><br \/>\n\t\t\t\t\t\t\t\tOther:<\/label><br \/>\n\t\t\t\t\t\t\t<label for=\"secondary_other_allergy_intolerance_text\">If other allegy or intolerance, please describe:<\/label><br \/>\n\t\t\t\t\t\t\t<input type=\"text\" id=\"secondary_other_allergy_intolerance_text\" name=\"secondary_other_allergy_intolerance_text\" >\n\t\t\t\t\t\t<\/div>\n<\/fieldset><\/div>\n<div>\n\t\t\t\t\t<input id=\"secondary_reasons_for_visit_gastrointestinal_disorder\" name=\"secondary_reasons_for_visit\" type=\"checkbox\" value=\"Gastrointestinal disorder\" ><br \/>\n\t\t\t\t\t<label for=\"secondary_reasons_for_visit_gastrointestinal_disorder\"> Gastrointestinal disorder<\/label><\/p>\n<div class=\"reveal-if-active\">\n<fieldset>\n<legend>(Check all that apply)<\/legend>\n<div>\n\t\t\t\t\t\t\t\t<label for=\"secondary_reasons_for_visit_ibs\"><br \/>\n\t\t\t\t\t\t\t\t\t<input id=\"secondary_reasons_for_visit_ibs\" name=\"secondary_gastrointestinal_disorders\" type=\"checkbox\" value=\"IBS\" ><br \/>\n\t\t\t\t\t\t\t\t\tIBS<\/label>\n\t\t\t\t\t\t\t<\/div>\n<div>\n\t\t\t\t\t\t\t\t<label for=\"secondary_reasons_for_visit_crohns_disease\"><br \/>\n\t\t\t\t\t\t\t\t\t<input id=\"secondary_reasons_for_visit_crohns_disease\" name=\"secondary_gastrointestinal_disorders\" type=\"checkbox\" value=\"Crohn's Disease\" ><br \/>\n\t\t\t\t\t\t\t\t\tCrohn&#8217;s Disease<\/label>\n\t\t\t\t\t\t\t<\/div>\n<div>\n\t\t\t\t\t\t\t\t<label for=\"secondary_reasons_for_visit_ulcerative_colitis\"><br \/>\n\t\t\t\t\t\t\t\t\t<input id=\"secondary_reasons_for_visit_ulcerative_colitis\" name=\"secondary_gastrointestinal_disorders\" type=\"checkbox\" value=\"Ulcerative Colitis\" ><br \/>\n\t\t\t\t\t\t\t\t\tUlcerative Colitis<\/label>\n\t\t\t\t\t\t\t<\/div>\n<div>\n\t\t\t\t\t\t\t\t<label for=\"secondary_reasons_for_visit_gerd\"><br \/>\n\t\t\t\t\t\t\t\t\t<input id=\"secondary_reasons_for_visit_gerd\" type=\"checkbox\" name=\"secondary_gastrointestinal_disorders\" value=\"GERD\" ><br \/>\n\t\t\t\t\t\t\t\t\tGERD <\/label>\n\t\t\t\t\t\t\t<\/div>\n<div>\n\t\t\t\t\t\t\t\t<label for=\"secondary_reasons_for_visit_celiac_disease\"><br \/>\n\t\t\t\t\t\t\t\t\t<input id=\"secondary_reasons_for_visit_celiac_disease\" name=\"secondary_gastrointestinal_disorders\" type=\"checkbox\" value=\"Celiac Disease\" ><br \/>\n\t\t\t\t\t\t\t\t\tCeliac Disease<\/label>\n\t\t\t\t\t\t\t<\/div>\n<div>\n\t\t\t\t\t\t\t\t<label for=\"secondary_gastrointestinal_disorder_other\"><br \/>\n\t\t\t\t\t\t\t\t\t<input id=\"secondary_gastrointestinal_disorder_other\" type=\"checkbox\" name=\"secondary_gastrointestinal_disorder_other\" value=\"Other Gastrointestinal disorder: \" ><br \/>\n\t\t\t\t\t\t\t\t\tOther:<\/label><br \/>\n\t\t\t\t\t\t\t\t<label for=\"secondary_gastrointestinal_disorder_other_text\">If other gastrointestinal disorder, please describe:<\/label><br \/>\n\t\t\t\t\t\t\t\t<input type=\"text\" id=\"secondary_gastrointestinal_disorder_other_text\" name=\"secondary_gastrointestinal_disorder_other_text\" >\n\t\t\t\t\t\t\t<\/div>\n<\/fieldset><\/div>\n<\/p><\/div>\n<div>\n\t\t\t\t\t<label for=\"secondary_reasons_for_visit_high_blood_pressure\"><br \/>\n\t\t\t\t\t\t<input id=\"secondary_reasons_for_visit_high_blood_pressure\" name=\"secondary_reasons_for_visit\" type=\"checkbox\" value=\"High blood pressure\" ><br \/>\n\t\t\t\t\t\tHigh blood pressure<\/label>\n\t\t\t\t<\/div>\n<div>\n\t\t\t\t\t<label for=\"secondary_reasons_for_visit_high_cholesterol\"><br \/>\n\t\t\t\t\t\t<input id=\"secondary_reasons_for_visit_high_cholesterol\" name=\"secondary_reasons_for_visit\" type=\"checkbox\" value=\"High cholesterol\" ><br \/>\n\t\t\t\t\t\tHigh cholesterol<\/label>\n\t\t\t\t<\/div>\n<div>\n\t\t\t\t\t<label for=\"secondary_reasons_for_visit_diabetes_prediabetes\"><br \/>\n\t\t\t\t\t\t<input id=\"secondary_reasons_for_visit_diabetes_prediabetes\" name=\"secondary_reasons_for_visit\" type=\"checkbox\" value=\"Diabetes\/Pre-diabetes\" ><br \/>\n\t\t\t\t\t\tDiabetes\/Pre-diabetes<\/label>\n\t\t\t\t<\/div>\n<div>\n\t\t\t\t\t<label for=\"secondary_reasons_for_visit_vegetarian_vegan\"><br \/>\n\t\t\t\t\t\t<input id=\"secondary_reasons_for_visit_vegetarian_vegan\" name=\"secondary_reasons_for_visit\" type=\"checkbox\" value=\"Vegetarian\/vegan\" ><br \/>\n\t\t\t\t\t\tVegetarian\/vegan<\/label>\n\t\t\t\t<\/div>\n<div>\n\t\t\t\t\t<label for=\"secondary_reasons_for_visit_iron_deficiency_anemia\"><br \/>\n\t\t\t\t\t\t<input id=\"secondary_reasons_for_visit_iron_deficiency_anemia\" name=\"secondary_reasons_for_visit\" type=\"checkbox\" value=\"Iron-deficiency anemia\" ><br \/>\n\t\t\t\t\t\tIron-deficiency anemia<\/label>\n\t\t\t\t<\/div>\n<div>\n\t\t\t\t\t<label for=\"secondary_reasons_for_visit_polycystic_ovary_syndrome\"><br \/>\n\t\t\t\t\t\t<input id=\"secondary_reasons_for_visit_polycystic_ovary_syndrome\" name=\"secondary_reasons_for_visit\" type=\"checkbox\" value=\"Polycystic ovary syndrome\" ><br \/>\n\t\t\t\t\t\tPolycystic ovary syndrome <\/label>\n\t\t\t\t<\/div>\n<div>\n\t\t\t\t\t<label for=\"secondary_reasons_for_visit_bariatric_surgery\"><br \/>\n\t\t\t\t\t\t<input id=\"secondary_reasons_for_visit_bariatric_surgery\" name=\"secondary_reasons_for_visit\" type=\"checkbox\" value=\"Bariatric surgery\" ><br \/>\n\t\t\t\t\t\tBariatric surgery<\/label>\n\t\t\t\t<\/div>\n<div>\n\t\t\t\t\t<label for=\"secondary_reasons_for_visit_other\"><br \/>\n\t\t\t\t\t\t<input id=\"secondary_reasons_for_visit_other\" name=\"secondary_reasons_for_visit_other\" type=\"checkbox\" value=\"Other Secondary Reason\" ><br \/>\n\t\t\t\t\t\tOther:<\/label><br \/>\n\t\t\t\t\t<label for=\"secondary_reasons_for_visit_other_text\">If other reason for visit, please describe:<\/label><br \/>\n\t\t\t\t\t<input type=\"text\" id=\"secondary_reasons_for_visit_other_text\" name=\"secondary_reasons_for_visit_other_text\" >\n\t\t\t\t<\/div>\n<div>\n\t\t\t\t\t<label for=\"secondary_reasons_for_visit_none\"><br \/>\n\t\t\t\t\t\t<input id=\"secondary_reasons_for_visit_none\" name=\"secondary_reasons_for_visit_none\" type=\"checkbox\" value=\"No secondary reason\" ><br \/>\n\t\t\t\t\t\tNo secondary reason<\/label>\n\t\t\t\t<\/div>\n<\/p><\/div>\n<\/fieldset>\n<div>\n\t\t\t<label for=\"additional_information\">Additional information you would like to share: <\/label><br \/>\n\t\t\t<textarea id=\"additional_information\" name=\"additional_information\" cols=\"5\" rows=\"5\"><\/textarea>\n\t\t<\/div>\n<div>\n<fieldset>\n<legend>Availability<\/legend>\n<div class=\"gfield_description\">\n<p><em>Please provide your general availability 8am-5pm Monday through Friday using the checkboxes below. Please use the text boxes to indicate times of day you are generally available for any days you select. We will use this availability to schedule you for the next available appointment. Appointments are scheduled as soon as we are able. Wait times vary depending on provider availability. We will send you a confirmation email with the date and time of your scheduled appointment. <\/em><\/p>\n<\/div>\n<div>\n\t\t\t\t<label for=\"monday\"><br \/>\n\t\t\t\t\t<input id=\"monday\" type=\"checkbox\" name=\"monday\" value=\"Monday:\" ><br \/>\n\t\t\t\t\t<strong>Monday:<\/strong><\/label><br \/>\n\t\t\t\t<label for=\"monday_availability\">If checked, enter the times you are available between 8am-5pm:<\/label><br \/>\n\t\t\t\t<input type=\"text\" id=\"monday_availability\" name=\"monday_availability\" aria-label=\"Time available between 8am-5pm on Monday\" placeholder=\" e.g. Mondays 8am-11am, 3pm-5pm\" >\n\t\t\t<\/div>\n<div>\n\t\t\t\t<label for=\"tuesday\"><br \/>\n\t\t\t\t\t<input id=\"tuesday\" type=\"checkbox\" name=\"tuesday\" value=\"Tuesday:\" ><br \/>\n\t\t\t\t\t<strong>Tuesday:<\/strong><\/label><br \/>\n\t\t\t\tIf checked, enter the times you are available between 8am-5pm:<br \/>\n\t\t\t\t<input type=\"text\" id=\"tuesday_availability\" name=\"tuesday_availability\" aria-label=\"Time available between 8am-5pm on Tuesday\" placeholder=\" e.g. Tuesdays 8am-11am, 3pm-5pm\" >\n\t\t\t<\/div>\n<div>\n\t\t\t\t<label for=\"wednesday\"><br \/>\n\t\t\t\t\t<input id=\"wednesday\" type=\"checkbox\" name=\"wednesday\" value=\"Wednesday:\" ><br \/>\n\t\t\t\t\t<strong>Wednesday:<\/strong><\/label><br \/>\n\t\t\t\tIf checked, enter the times you are available between 8am-5pm:<br \/>\n\t\t\t\t<input type=\"text\" id=\"wednesday_availability\" name=\"wednesday_availability\" aria-label=\"Time available between 8am-5pm on Wednesday\" placeholder=\" e.g. Wednesdays 8am-11am, 3pm-5pm\" >\n\t\t\t<\/div>\n<div>\n\t\t\t\t<label for=\"thursday\"><br \/>\n\t\t\t\t\t<input id=\"thursday\" type=\"checkbox\" name=\"thursday\" value=\"Thursday:\" ><br \/>\n\t\t\t\t\t<strong>Thursday:<\/strong><\/label><br \/>\n\t\t\t\tIf checked, enter the times you are available between 8am-5pm:<br \/>\n\t\t\t\t<input type=\"text\" id=\"thursday_availability\" name=\"thursday_availability\" aria-label=\"Time available between 8am-5pm on Thursday\" placeholder=\" e.g. Thursdays 8am-11am, 3pm-5pm\" >\n\t\t\t<\/div>\n<div>\n\t\t\t\t<label for=\"friday\"><br \/>\n\t\t\t\t\t<input id=\"friday\" type=\"checkbox\" name=\"friday\" value=\"Friday:\" ><br \/>\n\t\t\t\t\t<strong>Friday:<\/strong><\/label><br \/>\n\t\t\t\tIf checked, enter the times you are available between 8am-5pm:<br \/>\n\t\t\t\t<input type=\"text\" id=\"friday_availability\" name=\"friday_availability\" aria-label=\"Time available between 8am-5pm on Friday\" placeholder=\" e.g. Fridays 8am-11am, 3pm-5pm\" >\n\t\t\t<\/div>\n<\/fieldset>\n<\/div>\n<div>\n\t\t\t<input type=\"submit\" id=\"__btnSubmit\" name=\"__btnSubmit\" value=\"Submit\" ><br \/>\n\t\t\t<input type=\"reset\" id=\"__btnReset\" name=\"__btnReset\" value=\"Reset\" >\n\t\t<\/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 Student Counseling Registration Form * = mandatory field First Name: * &nbsp; Last Name: * &nbsp; Gender: Please selectMaleFemaleOther DOB: * &nbsp; Email: * &nbsp; Phone: * &nbsp; Current Address Street: * &nbsp; City: * &nbsp; State: * [&hellip;]<\/p>\n","protected":false},"author":1251,"featured_media":0,"parent":61,"menu_order":5,"comment_status":"closed","ping_status":"closed","template":"","meta":[],"_links":{"self":[{"href":"https:\/\/www.bu.edu\/scnc\/wp-json\/wp\/v2\/pages\/2343"}],"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=2343"}],"version-history":[{"count":31,"href":"https:\/\/www.bu.edu\/scnc\/wp-json\/wp\/v2\/pages\/2343\/revisions"}],"predecessor-version":[{"id":6061,"href":"https:\/\/www.bu.edu\/scnc\/wp-json\/wp\/v2\/pages\/2343\/revisions\/6061"}],"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=2343"}],"curies":[{"name":"wp","href":"https:\/\/api.w.org\/{rel}","templated":true}]}}