{"id":2345,"date":"2016-03-04T17:15:55","date_gmt":"2016-03-04T22:15:55","guid":{"rendered":"https:\/\/www.bu.edu\/scnc\/?page_id=2345"},"modified":"2016-06-23T16:39:05","modified_gmt":"2016-06-23T20:39:05","slug":"general","status":"publish","type":"page","link":"https:\/\/www.bu.edu\/scnc\/forms\/general\/","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)\r\n\t\t\t&& isNotEmpty(last_name, \"Please enter your last name.\", elmlast_nameError)\r\n\t\t\t&& isNotEmpty(dob,\"Please enter your date of birth (MM\/DD\/YYYY format).\", elmdobError)\r\n\t\t\t&& isLengthMinMax(dob, 10, 10, \"Please use MM\/DD\/YYYY format.\", elmdobError)\r\n\t\t\t&& isValidEmail(email, \"Enter a valid email.\", elmemailError)\r\n\t\t\t&& isNotEmpty(phone, \"Please enter your phone.\", elmphoneError)\r\n\t\t\t&& isNotEmpty(street, \"Please enter your street address.\", elmstreetError)\r\n\t\t\t&& isNotEmpty(city, \"Please enter your city.\", elmcityError) \r\n\t\t\t&& isSelected(state, \"Please select your state.\", elmstateError)\r\n\t\t\t&& isNotEmpty(zip,\"Please enter your five-digit zip code.\", elmzipError)\r\n\t\t\t&& isLengthMinMax(zip, 5, 5, \"Please use five-digit format.\", elmzipError)\r\n\t\t\t&& isChecked(\"primary_reason_for_visit\", \"Please check your primary reason for visit.\", elmprimary_reason_for_visitError)\r\n\t\t\t&& isChecked(\"insurance_company\", \"Please select your insurance company.\", elminsurance_companyError) \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=\"General Public Registration\" \/><br \/>\n  <input type=\"hidden\" name=\"txtDone\" value=\"https:\/\/www.bu.edu\/scnc\/wp-assets\/general\/thanks\/index.html\" \/><\/p>\n<fieldset>\n<legend class=\"secure-lock\"> General Public 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=\"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=\"street\">Street: <em class=\"required\">*<\/em><\/label><br \/>\n        <input name=\"street\" id=\"street\" type=\"text\" \/>\n      <\/div>\n<div id=\"elmstreetError\" 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<fieldset>\n<legend>Who referred you to us?:<\/legend>\n<div>\n        <label for=\"self\"><br \/>\n          <input id=\"self\" name=\"who_referred_you\" type=\"radio\" value=\"Self\" \/><br \/>\n          Self<\/label>\n      <\/div>\n<div>\n        <label for=\"primary_care_physician\"><br \/>\n          <input id=\"primary_care_physician\" name=\"who_referred_you\" type=\"radio\" value=\"Primary Care Physician\" \/><br \/>\n          Primary Care Physician<\/label>\n      <\/div>\n<div>\n        <label for=\"behavioral_medicine\"><br \/>\n          <input id=\"behavioral_medicine\" name=\"who_referred_you\" type=\"radio\" value=\"Behavioral Medicine provider\" \/><br \/>\n          Behavioral Medicine provider<\/label>\n      <\/div>\n<div>\n        <label for=\"coach_athletic_trainer\"><br \/>\n          <input id=\"coach_athletic_trainer\" name=\"who_referred_you\" type=\"radio\" value=\"Coach\/Athletic Trainer\" \/><br \/>\n          Coach\/Athletic Trainer<\/label>\n      <\/div>\n<div>\n        <label for=\"friend\"><br \/>\n          <input id=\"friend\" type=\"radio\" name=\"who_referred_you\" value=\"Friend\" \/><br \/>\n          Friend <\/label>\n      <\/div>\n<div>\n        <label for=\"treatment_center\"><br \/>\n          <input id=\"treatment_center\" type=\"radio\" name=\"who_referred_you\" value=\"Treatment Center\" \/><br \/>\n          Treatment Center <\/label>\n      <\/div>\n<div>\n        <label for=\"other_referred\"><br \/>\n          <input id=\"other_referred\" type=\"radio\" name=\"who_referred_you\" value=\"Other:\" \/><br \/>\n          Other:<\/label><br \/>\n        <label for=\"referred_by_other\">If referred by other, who?:<\/label><br \/>\n        <input type=\"text\" id=\"referred_by_other\" name=\"referred_by_other\" \/>\n      <\/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        <label for=\"healthy_meal_planning\"><br \/>\n          <input id=\"healthy_meal_planning\" name=\"primary_reason_for_visit\" type=\"radio\" value=\"Healthy meal planning\" \/><br \/>\n          Healthy meal planning<\/label>\n      <\/div>\n<div>\n        <label for=\"concern_about_weight_gain_in_college\"><br \/>\n          <input id=\"concern_about_weight_gain_in_college\" name=\"primary_reason_for_visit\" type=\"radio\" value=\"Concern about weight gain in college\" \/><br \/>\n          Concern about weight gain in college<\/label>\n      <\/div>\n<div>\n        <label for=\"healthy_weight_loss\"><br \/>\n          <input id=\"healthy_weight_loss\" name=\"primary_reason_for_visit\" type=\"radio\" value=\"Healthy weight loss\" \/><br \/>\n          Healthy weight loss <\/label>\n      <\/div>\n<div>\n        <label for=\"sports_nutrition\"><br \/>\n          <input id=\"sports_nutrition\" name=\"primary_reason_for_visit\" type=\"radio\" value=\"Sports nutrition\" \/><br \/>\n          Sports nutrition<\/label>\n      <\/div>\n<div>\n        <label for=\"stress_over_undereating\"><br \/>\n          <input id=\"stress_over_undereating\" type=\"radio\" name=\"primary_reason_for_visit\" value=\"Stress over\/undereating\" \/><br \/>\n          Stress over\/undereating<\/label>\n      <\/div>\n<div>\n        <label for=\"emotional_over_undereating\"><br \/>\n          <input id=\"emotional_over_undereating\" type=\"radio\" name=\"primary_reason_for_visit\" value=\"Emotional over\/undereating\" \/><br \/>\n          Emotional over\/undereating<\/label>\n      <\/div>\n<div>\n        <label for=\"social_over_undereating\"><br \/>\n          <input id=\"social_over_undereating\" type=\"radio\" name=\"primary_reason_for_visit\" value=\"Social over\/undereating\" \/><br \/>\n          Social over\/undereating<\/label>\n      <\/div>\n<div>\n        <label for=\"dining_hall_over_undereating\"><br \/>\n          <input id=\"dining_hall_over_undereating\" type=\"radio\" name=\"primary_reason_for_visit\" value=\"Dining hall over\/undereating\" \/><br \/>\n          Dining hall over\/undereating<\/label>\n      <\/div>\n<div>\n        <label for=\"hunger_management\"><br \/>\n          <input id=\"hunger_management\" type=\"radio\" name=\"primary_reason_for_visit\" value=\"Hunger management\" \/><br \/>\n          Hunger management<\/label>\n      <\/div>\n<div>\n        <label for=\"unhealthy_weight_control_practices\"><br \/>\n          <input id=\"unhealthy_weight_control_practices\" type=\"radio\" name=\"primary_reason_for_visit\" value=\"Unhealthy weight control practices\" \/><br \/>\n          Unhealthy weight control practices<\/label>\n      <\/div>\n<div>\n        <input id=\"eating_disorder\" name=\"primary_reason_for_visit\" type=\"radio\" value=\"Eating disorder\" class=\"eating_disorder\" \/><br \/>\n        <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              <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=\"food_allergy_intolerances\" name=\"primary_reason_for_visit\" type=\"radio\" value=\"Food allergies or intolerances\" \/><br \/>\n        <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              <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=\"gastrointestinal_disorder\" name=\"primary_reason_for_visit\" type=\"radio\" value=\"Gastrointestinal disorder\" \/><br \/>\n        <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              <label for=\"gastrointestinal_disorders_ibs\"><br \/>\n                <input id=\"gastrointestinal_disorders_ibs\" name=\"gastrointestinal_disorders_ibs\" type=\"checkbox\" value=\"IBS\" \/><br \/>\n                IBS<\/label>\n            <\/div>\n<div>\n              <label for=\"gastrointestinal_disorders_crohns_disease\"><br \/>\n                <input id=\"gastrointestinal_disorders_crohns_disease\" name=\"gastrointestinal_disorders_crohns_disease\" type=\"checkbox\" value=\"Crohn's Disease\" \/><br \/>\n                Crohn&#8217;s Disease<\/label>\n            <\/div>\n<div>\n              <label for=\"gastrointestinal_disorders_ulcerative_colitis\"><br \/>\n                <input id=\"gastrointestinal_disorders_ulcerative_colitis\" name=\"gastrointestinal_disorders_ulcerative_colitis\" type=\"checkbox\" value=\"Ulcerative Colitis\" \/><br \/>\n                Ulcerative Colitis<\/label>\n            <\/div>\n<div>\n              <label for=\"gastrointestinal_disorders_gerd\"><br \/>\n                <input id=\"gastrointestinal_disorders_gerd\" type=\"checkbox\" name=\"gastrointestinal_disorders_gerd\" value=\"GERD\" \/><br \/>\n                GERD <\/label>\n            <\/div>\n<div>\n              <label for=\"gastrointestinal_disorders_celiac_disease\"><br \/>\n                <input id=\"gastrointestinal_disorders_celiac_disease\" name=\"gastrointestinal_disorders_celiac_disease\" type=\"checkbox\" value=\"Celiac Disease\" \/><br \/>\n                Celiac Disease<\/label>\n            <\/div>\n<div>\n              <label for=\"gastrointestinal_disorders_other\"><br \/>\n                <input id=\"gastrointestinal_disorders_other\" type=\"checkbox\" name=\"gastrointestinal_disorders_other\" value=\"Other Gastrointestinal disorder: \" \/><br \/>\n                Other:<\/label><br \/>\n              <label for=\"other_gastrointestinal_disorders_text\">If other gastrointestinal disorder, please describe:<\/label><br \/>\n              <input type=\"text\" id=\"other_gastrointestinal_disorders_text\" name=\"other_gastrointestinal_disorders_text\" \/>\n            <\/div>\n<\/fieldset><\/div>\n<\/p><\/div>\n<div>\n        <label for=\"high_blood_pressure\"><br \/>\n          <input id=\"high_blood_pressure\" name=\"primary_reason_for_visit\" type=\"radio\" value=\"High blood pressure\" \/><br \/>\n          High blood pressure<\/label>\n      <\/div>\n<div>\n        <label for=\"high_cholesterol\"><br \/>\n          <input id=\"high_cholesterol\" name=\"primary_reason_for_visit\" type=\"radio\" value=\"High cholesterol\" \/><br \/>\n          High cholesterol<\/label>\n      <\/div>\n<div>\n        <label for=\"diabetes_prediabetes\"><br \/>\n          <input id=\"diabetes_prediabetes\" name=\"primary_reason_for_visit\" type=\"radio\" value=\"Diabetes\/Pre-diabetes\" \/><br \/>\n          Diabetes\/Pre-diabetes<\/label>\n      <\/div>\n<div>\n        <label for=\"vegetarian_vegan\"><br \/>\n          <input id=\"vegetarian_vegan\" name=\"primary_reason_for_visit\" type=\"radio\" value=\"Vegetarian\/vegan\" \/><br \/>\n          Vegetarian\/vegan<\/label>\n      <\/div>\n<div>\n        <label for=\"iron_deficiency_anemia\"><br \/>\n          <input id=\"iron_deficiency_anemia\" name=\"primary_reason_for_visit\" type=\"radio\" value=\"Iron-deficiency anemia\" \/><br \/>\n          Iron-deficiency anemia<\/label>\n      <\/div>\n<div>\n        <label for=\"polycystic_ovary_syndrome\"><br \/>\n          <input id=\"polycystic_ovary_syndrome\" name=\"primary_reason_for_visit\" type=\"radio\" value=\"Polycystic ovary syndrome\" \/><br \/>\n          Polycystic ovary syndrome <\/label>\n      <\/div>\n<div>\n        <label for=\"bariatric_surgery\"><br \/>\n          <input id=\"bariatric_surgery\" name=\"primary_reason_for_visit\" type=\"radio\" value=\"Bariatric surgery\" \/><br \/>\n          Bariatric surgery<\/label>\n      <\/div>\n<div>\n        <label for=\"other_primary_reason_for_visit\"><br \/>\n          <input id=\"other_primary_reason_for_visit\" name=\"primary_reason_for_visit\" type=\"radio\" value=\"Other Primary Reason\" \/><br \/>\n          Other:<\/label><br \/>\n        <label for=\"other_primary_reason_for_visit_text\">If other primary reason for visit, please describe:<\/label><br \/>\n        <input type=\"text\" id=\"other_primary_reason_for_visit_text\" name=\"other_primary_reason_for_visit_text\" \/>\n      <\/div>\n<div id=\"elmprimary_reason_for_visitError\" class=\"errorMsg\">&nbsp;<\/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        <label for=\"secondary_reasons_for_visit_healthy_meal_planning\"><br \/>\n          <input id=\"secondary_reasons_for_visit_healthy_meal_planning\" name=\"secondary_reasons_for_visit_healthy_meal_planning\" type=\"checkbox\" value=\"Healthy meal planning\" \/><br \/>\n          Healthy meal planning<\/label>\n      <\/div>\n<div>\n        <label for=\"secondary_reasons_for_visit_concern_about_weight_gain_in_college\"><br \/>\n          <input id=\"secondary_reasons_for_visit_concern_about_weight_gain_in_college\" name=\"secondary_reasons_for_visit_concern_about_weight_gain_in_college\" type=\"checkbox\" value=\"Concern about weight gain in college\" \/><br \/>\n          Concern about weight gain in college<\/label>\n      <\/div>\n<div>\n        <label for=\"secondary_reasons_for_visit_healthy_weight_loss\"><br \/>\n          <input id=\"secondary_reasons_for_visit_healthy_weight_loss\" name=\"secondary_reasons_for_visit_healthy_weight_loss\" type=\"checkbox\" value=\"Healthy weight loss\" \/><br \/>\n          Healthy weight loss <\/label>\n      <\/div>\n<div>\n        <label for=\"secondary_reasons_for_visit_sports_nutrition\"><br \/>\n          <input id=\"secondary_reasons_for_visit_sports_nutrition\" name=\"secondary_reasons_for_visit_sports_nutrition\" type=\"checkbox\" value=\"Sports nutrition\" \/><br \/>\n          Sports nutrition<\/label>\n      <\/div>\n<div>\n        <label for=\"secondary_reasons_for_visit_stress_over_undereating\"><br \/>\n          <input id=\"secondary_reasons_for_visit_stress_over_undereating\" type=\"checkbox\" name=\"secondary_reasons_for_visit_stress_over_undereating\" value=\"Stress over\/undereating\" \/><br \/>\n          Stress over\/undereating<\/label>\n      <\/div>\n<div>\n        <label for=\"secondary_reasons_for_visit_emotional_over_undereating\"><br \/>\n          <input id=\"secondary_reasons_for_visit_emotional_over_undereating\" type=\"checkbox\" name=\"secondary_reasons_for_visit_emotional_over_undereating\" value=\"Emotional over\/undereating\" \/><br \/>\n          Emotional over\/undereating<\/label>\n      <\/div>\n<div>\n        <label for=\"secondary_reasons_for_visit_social_over_undereating\"><br \/>\n          <input id=\"secondary_reasons_for_visit_social_over_undereating\" type=\"checkbox\" name=\"secondary_reasons_for_visit_social_over_undereating\" value=\"Social over\/undereating\" \/><br \/>\n          Social over\/undereating<\/label>\n      <\/div>\n<div>\n        <label for=\"secondary_reasons_for_visit_dining_hall_over_undereating\"><br \/>\n          <input id=\"secondary_reasons_for_visit_dining_hall_over_undereating\" type=\"checkbox\" name=\"secondary_reasons_for_visit_dining_hall_over_undereating\" value=\"Dining hall over\/undereating\" \/><br \/>\n          Dining hall over\/undereating<\/label>\n      <\/div>\n<div>\n        <label for=\"secondary_reasons_for_visit_hunger_management\"><br \/>\n          <input id=\"secondary_reasons_for_visit_hunger_management\" type=\"checkbox\" name=\"secondary_reasons_for_visit_hunger_management\" value=\"Hunger management\" \/><br \/>\n          Hunger management<\/label>\n      <\/div>\n<div>\n        <label for=\"secondary_reasons_for_visit_unhealthy_weight_control_practices\"><br \/>\n          <input id=\"secondary_reasons_for_visit_unhealthy_weight_control_practices\" type=\"checkbox\" name=\"secondary_reasons_for_visit_unhealthy_weight_control_practices\" value=\"Unhealthy weight control practices\" \/><br \/>\n          Unhealthy weight control practices<\/label>\n      <\/div>\n<div>\n        <input id=\"secondary_reasons_for_visit_eating_disorder\" name=\"secondary_reasons_for_visit\" type=\"checkbox\" value=\"Eating disorder\" \/><br \/>\n        <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              <label for=\"secondary_eating_disorder_anorexia_nervosa\"><br \/>\n                <input id=\"secondary_eating_disorder_anorexia_nervosa\" name=\"secondary_eating_disorder_anorexia_nervosa\" type=\"checkbox\" value=\"Anorexia Nervosa\" \/><br \/>\n                Anorexia Nervosa<\/label>\n            <\/div>\n<div>\n              <label for=\"secondary_eating_disorder_bulimia_nervosa\"><br \/>\n                <input id=\"secondary_eating_disorder_bulimia_nervosa\" name=\"secondary_eating_disorder_bulimia_nervosa\" type=\"checkbox\" value=\"Bulimia Nervosa\" \/><br \/>\n                Bulimia Nervosa<\/label>\n            <\/div>\n<div>\n              <label for=\"secondary_eating_disorder_binge_eating_disorder\"><br \/>\n                <input id=\"secondary_eating_disorder_binge_eating_disorder\" name=\"secondary_eating_disorder_binge_eating_disorder\" type=\"checkbox\" value=\"Binge Eating Disorder\" \/><br \/>\n                Binge eating disorder<\/label>\n            <\/div>\n<div>\n              <label for=\"secondary_eating_disorder_other\"><br \/>\n                <input id=\"secondary_eating_disorder_other\" type=\"checkbox\" name=\"secondary_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=\"secondary_reasons_for_visit_food_allergy_intolerances\" name=\"secondary_reasons_for_visit\" type=\"checkbox\" value=\"Food allergies or intolerances\" \/><br \/>\n        <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              <label for=\"secondary_food_allergy_intolerance_wheat\"><br \/>\n                <input id=\"secondary_food_allergy_intolerance_wheat\" name=\"secondary_food_allergy_intolerance_wheat\" type=\"checkbox\" value=\"Wheat\" \/><br \/>\n                Wheat<\/label>\n            <\/div>\n<div>\n              <label for=\"secondary_food_allergy_intolerance_milk\"><br \/>\n                <input id=\"secondary_food_allergy_intolerance_milk\" name=\"secondary_food_allergy_intolerance_milk\" type=\"checkbox\" value=\"Milk\" \/><br \/>\n                Milk<\/label>\n            <\/div>\n<div>\n              <label for=\"secondary_food_allergy_intolerance_peanuts\"><br \/>\n                <input id=\"secondary_food_allergy_intolerance_peanuts\" name=\"secondary_food_allergy_intolerance_peanuts\" type=\"checkbox\" value=\"Peanuts\" \/><br \/>\n                Peanuts<\/label>\n            <\/div>\n<div>\n              <label for=\"secondary_food_allergy_intolerance_tree_nuts\"><br \/>\n                <input id=\"secondary_food_allergy_intolerance_tree_nuts\" type=\"checkbox\" name=\"secondary_food_allergy_intolerance_tree_nuts\" value=\"Tree nuts\" \/><br \/>\n                Tree nuts<\/label>\n            <\/div>\n<div>\n              <label for=\"secondary_food_allergy_intolerance_eggs\"><br \/>\n                <input id=\"secondary_food_allergy_intolerance_eggs\" name=\"secondary_food_allergy_intolerance_eggs\" type=\"checkbox\" value=\"Eggs\" \/><br \/>\n                Eggs<\/label>\n            <\/div>\n<div>\n              <label for=\"secondary_food_allergy_intolerance_shellfish\"><br \/>\n                <input id=\"secondary_food_allergy_intolerance_shellfish\" name=\"secondary_food_allergy_intolerance_shellfish\" type=\"checkbox\" value=\"Shellfish\" \/><br \/>\n                Shellfish<\/label>\n            <\/div>\n<div>\n              <label for=\"secondary_food_allergy_intolerance_soy\"><br \/>\n                <input id=\"secondary_food_allergy_intolerance_soy\" name=\"secondary_food_allergy_intolerance_soy\" type=\"checkbox\" value=\"Soy\" \/><br \/>\n                Soy<\/label>\n            <\/div>\n<div>\n              <label for=\"secondary_food_allergy_intolerance_fish\"><br \/>\n                <input id=\"secondary_food_allergy_intolerance_fish\" type=\"checkbox\" name=\"secondary_food_allergy_intolerance_fish\" value=\"Fish\" \/><br \/>\n                Fish<\/label>\n            <\/div>\n<div>\n              <label for=\"secondary_food_allergy_intolerance_lactose_intolerance\"><br \/>\n                <input id=\"secondary_food_allergy_intolerance_lactose_intolerance\" name=\"secondary_food_allergy_intolerance_lactose_intolerance\" type=\"checkbox\" value=\"Lactose intolerance\" \/><br \/>\n                Lactose intolerance<\/label>\n            <\/div>\n<div>\n              <label for=\"secondary_food_allergy_intolerance_gluten_intolerance\"><br \/>\n                <input id=\"secondary_food_allergy_intolerance_gluten_intolerance\" name=\"secondary_food_allergy_intolerance_gluten_intolerance\" type=\"checkbox\" value=\"Gluten intolerance\" \/><br \/>\n                Gluten intolerance<\/label>\n            <\/div>\n<div>\n              <label for=\"secondary_food_allergy_intolerance_fodmaps\"><br \/>\n                <input id=\"secondary_food_allergy_intolerance_fodmaps\" name=\"secondary_food_allergy_intolerance_fodmaps\" type=\"checkbox\" value=\"FODMAPs\" \/><br \/>\n                FODMAPs<\/label>\n            <\/div>\n<div>\n              <label for=\"secondary_food_allergy_intolerance_other\"><br \/>\n                <input id=\"secondary_food_allergy_intolerance_other\" type=\"checkbox\" name=\"secondary_food_allergy_intolerance_other\" value=\"Other Allergy\/Intolerance: \" \/><br \/>\n                Other:<\/label><br \/>\n              <label for=\"secondary_other_allergy_intolerance_text\">If other allegy or intolerance, please describe:<\/label><br \/>\n              <input type=\"text\" id=\"secondary_other_allergy_intolerance_text\" name=\"secondary_other_allergy_intolerance_text\" \/>\n            <\/div>\n<\/fieldset><\/div>\n<\/p><\/div>\n<div>\n        <input id=\"secondary_reasons_for_visit_gastrointestinal_disorder\" name=\"secondary_reasons_for_visit\" type=\"checkbox\" value=\"Gastrointestinal disorder\" \/><br \/>\n        <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              <label for=\"secondary_reasons_for_visit_ibs\"><br \/>\n                <input id=\"secondary_reasons_for_visit_ibs\" name=\"secondary_gastrointestinal_disorders\" type=\"checkbox\" value=\"IBS\" \/><br \/>\n                IBS<\/label>\n            <\/div>\n<div>\n              <label for=\"secondary_reasons_for_visit_crohns_disease\"><br \/>\n                <input id=\"secondary_reasons_for_visit_crohns_disease\" name=\"secondary_gastrointestinal_disorders\" type=\"checkbox\" value=\"Crohn's Disease\" \/><br \/>\n                Crohn&#8217;s Disease<\/label>\n            <\/div>\n<div>\n              <label for=\"secondary_reasons_for_visit_ulcerative_colitis\"><br \/>\n                <input id=\"secondary_reasons_for_visit_ulcerative_colitis\" name=\"secondary_gastrointestinal_disorders\" type=\"checkbox\" value=\"Ulcerative Colitis\" \/><br \/>\n                Ulcerative Colitis<\/label>\n            <\/div>\n<div>\n              <label for=\"secondary_reasons_for_visit_gerd\"><br \/>\n                <input id=\"secondary_reasons_for_visit_gerd\" type=\"checkbox\" name=\"secondary_gastrointestinal_disorders\" value=\"GERD\" \/><br \/>\n                GERD <\/label>\n            <\/div>\n<div>\n              <label for=\"secondary_reasons_for_visit_celiac_disease\"><br \/>\n                <input id=\"secondary_reasons_for_visit_celiac_disease\" name=\"secondary_gastrointestinal_disorders\" type=\"checkbox\" value=\"Celiac Disease\" \/><br \/>\n                Celiac Disease<\/label>\n            <\/div>\n<div>\n              <label for=\"secondary_gastrointestinal_disorder_other\"><br \/>\n                <input id=\"secondary_gastrointestinal_disorder_other\" type=\"checkbox\" name=\"secondary_gastrointestinal_disorder_other\" value=\"Other Gastrointestinal disorder: \" \/><br \/>\n                Other:<\/label><br \/>\n              <label for=\"secondary_gastrointestinal_disorder_other_text\">If other gastrointestinal disorder, please describe:<\/label><br \/>\n              <input type=\"text\" id=\"secondary_gastrointestinal_disorder_other_text\" name=\"secondary_gastrointestinal_disorder_other_text\" \/>\n            <\/div>\n<\/fieldset><\/div>\n<\/p><\/div>\n<div>\n        <label for=\"secondary_reasons_for_visit_high_blood_pressure\"><br \/>\n          <input id=\"secondary_reasons_for_visit_high_blood_pressure\" name=\"secondary_reasons_for_visit_high_blood_pressure\" type=\"checkbox\" value=\"High blood pressure\" \/><br \/>\n          High blood pressure<\/label>\n      <\/div>\n<div>\n        <label for=\"secondary_reasons_for_visit_high_cholesterol\"><br \/>\n          <input id=\"secondary_reasons_for_visit_high_cholesterol\" name=\"secondary_reasons_for_visit_high_cholesterol\" type=\"checkbox\" value=\"High cholesterol\" \/><br \/>\n          High cholesterol<\/label>\n      <\/div>\n<div>\n        <label for=\"secondary_reasons_for_visit_diabetes_prediabetes\"><br \/>\n          <input id=\"secondary_reasons_for_visit_diabetes_prediabetes\" name=\"secondary_reasons_for_visit_diabetes_prediabetes\" type=\"checkbox\" value=\"Diabetes\/Pre-diabetes\" \/><br \/>\n          Diabetes\/Pre-diabetes<\/label>\n      <\/div>\n<div>\n        <label for=\"secondary_reasons_for_visit_vegetarian_vegan\"><br \/>\n          <input id=\"secondary_reasons_for_visit_vegetarian_vegan\" name=\"secondary_reasons_for_visit_vegetarian_vegan\" type=\"checkbox\" value=\"Vegetarian\/vegan\" \/><br \/>\n          Vegetarian\/vegan<\/label>\n      <\/div>\n<div>\n        <label for=\"secondary_reasons_for_visit_iron_deficiency_anemia\"><br \/>\n          <input id=\"secondary_reasons_for_visit_iron_deficiency_anemia\" name=\"secondary_reasons_for_visit_iron_deficiency_anemia\" type=\"checkbox\" value=\"Iron-deficiency anemia\" \/><br \/>\n          Iron-deficiency anemia<\/label>\n      <\/div>\n<div>\n        <label for=\"secondary_reasons_for_visit_polycystic_ovary_syndrome\"><br \/>\n          <input id=\"secondary_reasons_for_visit_polycystic_ovary_syndrome\" name=\"secondary_reasons_for_visit_polycystic_ovary_syndrome\" type=\"checkbox\" value=\"Polycystic ovary syndrome\" \/><br \/>\n          Polycystic ovary syndrome <\/label>\n      <\/div>\n<div>\n        <label for=\"secondary_reasons_for_visit_bariatric_surgery\"><br \/>\n          <input id=\"secondary_reasons_for_visit_bariatric_surgery\" name=\"secondary_reasons_for_visit_bariatric_surgery\" type=\"checkbox\" value=\"Bariatric surgery\" \/><br \/>\n          Bariatric surgery<\/label>\n      <\/div>\n<div>\n        <label for=\"secondary_reasons_for_visit_other_secondary_reasons_for_visit\"><br \/>\n          <input id=\"secondary_reasons_for_visit_other_secondary_reasons_for_visit\" name=\"secondary_reasons_for_visit_other_secondary_reasons_for_visit\" type=\"checkbox\" value=\"Other Secondary Reason\" \/><br \/>\n          Other:<\/label><br \/>\n        <label for=\"other_secondary_reasons_for_visit_text\">If other reason for visit, please describe:<\/label><br \/>\n        <input type=\"text\" id=\"other_secondary_reasons_for_visit_text\" name=\"other_secondary_reasons_for_visit_text\" \/>\n      <\/div>\n<div>\n        <label for=\"secondary_reasons_for_visit_none\"><br \/>\n          <input id=\"secondary_reasons_for_visit_none\" name=\"secondary_reasons_for_visit_none\" type=\"checkbox\" value=\"No secondary reason\" \/><br \/>\n          No secondary reason<\/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<fieldset>\n<legend>Primary Insurance<\/legend>\n<p><em>The SCNC Registered Dietitian Nutritionists are providers for many of the major insurance companies, however insurance coverage for nutrition services varies greatly depending on policy type and medical diagnosis. Please check with your insurance company to determine if Medical Nutrition Therapy is a covered health benefit for you. <strong>You will be responsible for any balance not covered by insurance.<\/strong> <\/em><\/p>\n<fieldset>\n<legend>Insurance Company <em class=\"required\">*<\/em><\/legend>\n<div>\n          <label for=\"aetna\"><br \/>\n            <input id=\"aetna\" name=\"insurance_company\" type=\"radio\" value=\"Aetna\" \/><br \/>\n            Aetna<\/label>\n        <\/div>\n<div>\n          <label for=\"aetna_student_health\"><br \/>\n            <input id=\"aetna_student_health\" name=\"insurance_company\" type=\"radio\" value=\"Aetna Student Health\" \/><br \/>\n            Aetna Student Health<\/label>\n        <\/div>\n<div>\n          <label for=\"harvard_pilgrim_health_care\"><br \/>\n            <input id=\"harvard_pilgrim_health_care\" name=\"insurance_company\" type=\"radio\" value=\"Harvard Pilgrim Health Care\" \/><br \/>\n            Harvard Pilgrim Health Care<\/label>\n        <\/div>\n<div>\n          <label for=\"blue_cross_blue_shield_of_ma\"><br \/>\n            <input id=\"blue_cross_blue_shield_of_ma\" name=\"insurance_company\" type=\"radio\" value=\"Blue Cross Blue Shield of Massachusetts\" \/><br \/>\n            Blue Cross Blue Shield of Massachusetts<\/label>\n        <\/div>\n<div>\n          <label for=\"tufts_health_plan\"><br \/>\n            <input id=\"tufts_health_plan\" type=\"radio\" name=\"insurance_company\" value=\"Tufts Health Plan\" \/><br \/>\n            Tufts Health Plan<\/label>\n        <\/div>\n<div>\n          <label for=\"united_healthcare\"><br \/>\n            <input id=\"united_healthcare\" type=\"radio\" name=\"insurance_company\" value=\"United Healthcare\" \/><br \/>\n            United Healthcare<\/label>\n        <\/div>\n<div>\n          <label for=\"other_insurance_company\"><br \/>\n            <input id=\"other_insurance_company\" type=\"radio\" name=\"insurance_company\" value=\"Other:\" \/><br \/>\n            Other:<\/label><br \/>\n          <label for=\"other_insurance_company_text\">Name of Insurance:<\/label><br \/>\n          <input type=\"text\" id=\"other_insurance_company_text\" name=\"other_insurance_company_text\" \/>\n        <\/div>\n<div>\n          <label for=\"self_pay\"><br \/>\n            <input id=\"self_pay\" type=\"radio\" name=\"insurance_company\" value=\"Self Pay\" \/><br \/>\n            Self Pay<\/label>\n        <\/div>\n<div id=\"elminsurance_companyError\" class=\"errorMsg\">&nbsp;<\/div>\n<\/fieldset>\n<div>\n        <label for=\"insurance_id\">Insurance ID#: <\/label><br \/>\n        <input id=\"insurance_id\" name=\"insurance_id\" type=\"text\"\/>\n      <\/div>\n<div>\n        <label for=\"insurance_group\">Group#: <\/label><br \/>\n        <input id=\"insurance_group\" name=\"insurance_group\" type=\"text\"\/>\n      <\/div>\n<fieldset>\n<legend>Primary Insured:<\/legend>\n<div>\n          <label for=\"primary_insured_self\"><br \/>\n            <input name=\"primary_insured\" type=\"radio\" id=\"primary_insured_self\" value=\"Self\" \/><br \/>\n            Self<\/label>\n        <\/div>\n<div>\n          <label for=\"primary_insured_spouse\"><br \/>\n            <input name=\"primary_insured\" type=\"radio\" id=\"primary_insured_spouse\" value=\"Spouse\" \/><br \/>\n            Spouse<\/label>\n        <\/div>\n<div>\n          <label for=\"primary_insured_parent\"><br \/>\n            <input name=\"primary_insured\" type=\"radio\" id=\"primary_insured_parent\" value=\"Parent\" \/><br \/>\n            Parent<\/label>\n        <\/div>\n<div>\n          <label for=\"primary_insured_other\"><br \/>\n            <input name=\"primary_insured\" type=\"radio\" id=\"primary_insured_other\" value=\"Other\" \/><br \/>\n            Other<\/label>\n        <\/div>\n<\/fieldset>\n<fieldset>\n<legend>Information of Primary Insured (if not self)<\/legend>\n<div>\n          <label for=\"insured_name\"> Name:<\/label><br \/>\n          <input name=\"insured_name\" id=\"insured_name\" type=\"text\" \/>\n        <\/div>\n<div>\n          <label for=\"insured_dob\"> Date of Birth:<\/label><br \/>\n          <input name=\"insured_dob\" id=\"insured_dob\" type=\"text\" \/>\n        <\/div>\n<div>\n          <label for=\"insured_address\"> Street Address:<\/label><br \/>\n          <input name=\"insured_address\" id=\"insured_address\" type=\"text\" \/>\n        <\/div>\n<div>\n          <label for=\"insured_address_city\"> City:<\/label><br \/>\n          <input name=\"insured_address_city\" id=\"insured_address_city\" type=\"text\" \/>\n        <\/div>\n<div>\n          <label for=\"insured_address_state\">State:<\/label><br \/>\n          <select name=\"insured_address_state\" id=\"insured_address_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>\n          <label for=\"insured_address_zip\">Zip Code:<\/label><br \/>\n          <input name=\"insured_address_zip\" type=\"text\" id=\"insured_address_zip\" maxlength=\"5\" \/>\n        <\/div>\n<\/fieldset>\n<\/fieldset>\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. General Public Counseling Registration Form * = mandatory field First Name: * &nbsp; Last Name: * &nbsp; Gender: Please selectMaleFemaleOther DOB: * &nbsp; Email: * &nbsp; Primary Phone: * &nbsp; Secondary Phone: Current Address Street: * &nbsp; City: * [&hellip;]<\/p>\n","protected":false},"author":1251,"featured_media":0,"parent":61,"menu_order":6,"comment_status":"closed","ping_status":"closed","template":"","meta":[],"_links":{"self":[{"href":"https:\/\/www.bu.edu\/scnc\/wp-json\/wp\/v2\/pages\/2345"}],"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=2345"}],"version-history":[{"count":20,"href":"https:\/\/www.bu.edu\/scnc\/wp-json\/wp\/v2\/pages\/2345\/revisions"}],"predecessor-version":[{"id":3436,"href":"https:\/\/www.bu.edu\/scnc\/wp-json\/wp\/v2\/pages\/2345\/revisions\/3436"}],"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=2345"}],"curies":[{"name":"wp","href":"https:\/\/api.w.org\/{rel}","templated":true}]}}