{"id":474,"date":"2022-08-23T14:24:52","date_gmt":"2022-08-23T13:24:52","guid":{"rendered":"https:\/\/www.cipawales.org.uk\/?page_id=474"},"modified":"2022-08-23T14:28:03","modified_gmt":"2022-08-23T13:28:03","slug":"easy-read-self-referral-form","status":"publish","type":"page","link":"https:\/\/www.cipawales.org.uk\/?page_id=474","title":{"rendered":"Easy Read self referral form"},"content":{"rendered":"<div class=\"wpforms-container wpforms-container-full wpforms-block\" id=\"wpforms-466\"><form id=\"wpforms-form-466\" class=\"wpforms-validate wpforms-form wpforms-ajax-form\" data-formid=\"466\" method=\"post\" enctype=\"multipart\/form-data\" action=\"\/index.php?rest_route=%2Fwp%2Fv2%2Fpages%2F474\" data-token=\"6beb42822f86209677817b908c8b67f6\" data-token-time=\"1777043650\"><noscript class=\"wpforms-error-noscript\">Please enable JavaScript in your browser to complete this form.<\/noscript><div class=\"wpforms-field-container\"><div id=\"wpforms-466-field_1-container\" class=\"wpforms-field wpforms-field-name\" data-field-id=\"1\"><label class=\"wpforms-field-label\">Name <span class=\"wpforms-required-label\">*<\/span><\/label><div class=\"wpforms-field-row wpforms-field-medium\"><div class=\"wpforms-field-row-block wpforms-first wpforms-one-half\"><input type=\"text\" id=\"wpforms-466-field_1\" class=\"wpforms-field-name-first wpforms-field-required\" name=\"wpforms[fields][1][first]\" required><label for=\"wpforms-466-field_1\" class=\"wpforms-field-sublabel after\">First<\/label><\/div><div class=\"wpforms-field-row-block wpforms-one-half\"><input type=\"text\" id=\"wpforms-466-field_1-last\" class=\"wpforms-field-name-last wpforms-field-required\" name=\"wpforms[fields][1][last]\" required><label for=\"wpforms-466-field_1-last\" class=\"wpforms-field-sublabel after\">Last<\/label><\/div><\/div><\/div><div id=\"wpforms-466-field_2-container\" class=\"wpforms-field wpforms-field-text\" data-field-id=\"2\"><label class=\"wpforms-field-label\" for=\"wpforms-466-field_2\">Name you would like us to use<\/label><input type=\"text\" id=\"wpforms-466-field_2\" class=\"wpforms-field-medium\" name=\"wpforms[fields][2]\" ><\/div><div id=\"wpforms-466-field_3-container\" class=\"wpforms-field wpforms-field-number\" data-field-id=\"3\"><label class=\"wpforms-field-label\" for=\"wpforms-466-field_3\">Date of birth e.g. 01 12 1990<\/label><input type=\"number\" id=\"wpforms-466-field_3\" class=\"wpforms-field-medium\" name=\"wpforms[fields][3]\" step=\"any\" ><\/div><div id=\"wpforms-466-field_4-container\" class=\"wpforms-field wpforms-field-number\" data-field-id=\"4\"><label class=\"wpforms-field-label\" for=\"wpforms-466-field_4\">Landline number<\/label><input type=\"number\" id=\"wpforms-466-field_4\" class=\"wpforms-field-medium\" name=\"wpforms[fields][4]\" step=\"any\" ><\/div><div id=\"wpforms-466-field_5-container\" class=\"wpforms-field wpforms-field-number\" data-field-id=\"5\"><label class=\"wpforms-field-label\" for=\"wpforms-466-field_5\">Mobile number<\/label><input type=\"number\" id=\"wpforms-466-field_5\" class=\"wpforms-field-medium\" name=\"wpforms[fields][5]\" step=\"any\" ><\/div><div id=\"wpforms-466-field_6-container\" class=\"wpforms-field wpforms-field-email\" data-field-id=\"6\"><label class=\"wpforms-field-label\" for=\"wpforms-466-field_6\">Email <span class=\"wpforms-required-label\">*<\/span><\/label><input type=\"email\" id=\"wpforms-466-field_6\" class=\"wpforms-field-medium wpforms-field-required\" name=\"wpforms[fields][6]\" spellcheck=\"false\" required><\/div><div id=\"wpforms-466-field_22-container\" class=\"wpforms-field wpforms-field-textarea\" data-field-id=\"22\"><label class=\"wpforms-field-label\" for=\"wpforms-466-field_22\">Home Address<\/label><textarea id=\"wpforms-466-field_22\" class=\"wpforms-field-medium\" name=\"wpforms[fields][22]\" ><\/textarea><\/div><div id=\"wpforms-466-field_7-container\" class=\"wpforms-field wpforms-field-radio\" data-field-id=\"7\"><label class=\"wpforms-field-label\">How would you like us to contact you?<\/label><ul id=\"wpforms-466-field_7\"><li class=\"choice-1 depth-1\"><input type=\"radio\" id=\"wpforms-466-field_7_1\" name=\"wpforms[fields][7]\" value=\"Landline\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-466-field_7_1\">Landline<\/label><\/li><li class=\"choice-2 depth-1\"><input type=\"radio\" id=\"wpforms-466-field_7_2\" name=\"wpforms[fields][7]\" value=\"Mobile\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-466-field_7_2\">Mobile<\/label><\/li><li class=\"choice-3 depth-1\"><input type=\"radio\" id=\"wpforms-466-field_7_3\" name=\"wpforms[fields][7]\" value=\"email\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-466-field_7_3\">email<\/label><\/li><li class=\"choice-4 depth-1\"><input type=\"radio\" id=\"wpforms-466-field_7_4\" name=\"wpforms[fields][7]\" value=\"Text message\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-466-field_7_4\">Text message<\/label><\/li><li class=\"choice-5 depth-1\"><input type=\"radio\" id=\"wpforms-466-field_7_5\" name=\"wpforms[fields][7]\" value=\"Home Address\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-466-field_7_5\">Home Address<\/label><\/li><\/ul><\/div><div id=\"wpforms-466-field_8-container\" class=\"wpforms-field wpforms-field-radio\" data-field-id=\"8\"><label class=\"wpforms-field-label\">What language would you like us to use?<\/label><ul id=\"wpforms-466-field_8\"><li class=\"choice-1 depth-1\"><input type=\"radio\" id=\"wpforms-466-field_8_1\" name=\"wpforms[fields][8]\" value=\"Welsh\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-466-field_8_1\">Welsh<\/label><\/li><li class=\"choice-2 depth-1\"><input type=\"radio\" id=\"wpforms-466-field_8_2\" name=\"wpforms[fields][8]\" value=\"English\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-466-field_8_2\">English<\/label><\/li><li class=\"choice-3 depth-1\"><input type=\"radio\" id=\"wpforms-466-field_8_3\" name=\"wpforms[fields][8]\" value=\"British sign language (BSL)\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-466-field_8_3\">British sign language (BSL)<\/label><\/li><li class=\"choice-4 depth-1\"><input type=\"radio\" id=\"wpforms-466-field_8_4\" name=\"wpforms[fields][8]\" value=\"Non verbal\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-466-field_8_4\">Non verbal<\/label><\/li><li class=\"choice-5 depth-1\"><input type=\"radio\" id=\"wpforms-466-field_8_5\" name=\"wpforms[fields][8]\" value=\"Other (write in box below)\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-466-field_8_5\">Other (write in box below)<\/label><\/li><\/ul><\/div><div id=\"wpforms-466-field_9-container\" class=\"wpforms-field wpforms-field-text\" data-field-id=\"9\"><label class=\"wpforms-field-label\" for=\"wpforms-466-field_9\">Your other language choice<\/label><input type=\"text\" id=\"wpforms-466-field_9\" class=\"wpforms-field-medium\" name=\"wpforms[fields][9]\" ><\/div><div id=\"wpforms-466-field_10-container\" class=\"wpforms-field wpforms-field-checkbox\" data-field-id=\"10\"><label class=\"wpforms-field-label\">Do you need information in Easy Read?<\/label><ul id=\"wpforms-466-field_10\"><li class=\"choice-1 depth-1\"><input type=\"checkbox\" id=\"wpforms-466-field_10_1\" name=\"wpforms[fields][10][]\" value=\"Yes\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-466-field_10_1\">Yes<\/label><\/li><li class=\"choice-2 depth-1\"><input type=\"checkbox\" id=\"wpforms-466-field_10_2\" name=\"wpforms[fields][10][]\" value=\"No\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-466-field_10_2\">No<\/label><\/li><\/ul><\/div><div id=\"wpforms-466-field_11-container\" class=\"wpforms-field wpforms-field-textarea\" data-field-id=\"11\"><label class=\"wpforms-field-label\" for=\"wpforms-466-field_11\">Do you have other needs you would like to tell us about?<\/label><textarea id=\"wpforms-466-field_11\" class=\"wpforms-field-medium\" name=\"wpforms[fields][11]\" ><\/textarea><\/div><div id=\"wpforms-466-field_12-container\" class=\"wpforms-field wpforms-field-textarea\" data-field-id=\"12\"><label class=\"wpforms-field-label\" for=\"wpforms-466-field_12\">Reason for contacting us?<\/label><textarea id=\"wpforms-466-field_12\" class=\"wpforms-field-medium\" name=\"wpforms[fields][12]\" ><\/textarea><\/div><div id=\"wpforms-466-field_13-container\" class=\"wpforms-field wpforms-field-textarea\" data-field-id=\"13\"><label class=\"wpforms-field-label\" for=\"wpforms-466-field_13\">What do you need support with in your life and who supports you with these?<\/label><textarea id=\"wpforms-466-field_13\" class=\"wpforms-field-medium\" name=\"wpforms[fields][13]\" ><\/textarea><\/div><div id=\"wpforms-466-field_14-container\" class=\"wpforms-field wpforms-field-textarea\" data-field-id=\"14\"><label class=\"wpforms-field-label\" for=\"wpforms-466-field_14\">What would you like support with?<\/label><textarea id=\"wpforms-466-field_14\" class=\"wpforms-field-medium\" name=\"wpforms[fields][14]\" ><\/textarea><\/div><div id=\"wpforms-466-field_15-container\" class=\"wpforms-field wpforms-field-checkbox\" data-field-id=\"15\"><label class=\"wpforms-field-label\">Do you have a social worker?<\/label><ul id=\"wpforms-466-field_15\"><li class=\"choice-1 depth-1\"><input type=\"checkbox\" id=\"wpforms-466-field_15_1\" name=\"wpforms[fields][15][]\" value=\"Yes\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-466-field_15_1\">Yes<\/label><\/li><li class=\"choice-2 depth-1\"><input type=\"checkbox\" id=\"wpforms-466-field_15_2\" name=\"wpforms[fields][15][]\" value=\"No\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-466-field_15_2\">No<\/label><\/li><\/ul><\/div><div id=\"wpforms-466-field_16-container\" class=\"wpforms-field wpforms-field-textarea\" data-field-id=\"16\"><label class=\"wpforms-field-label\" for=\"wpforms-466-field_16\">If yes to last question, what do they help you with?<\/label><textarea id=\"wpforms-466-field_16\" class=\"wpforms-field-medium\" name=\"wpforms[fields][16]\" ><\/textarea><\/div><div id=\"wpforms-466-field_17-container\" class=\"wpforms-field wpforms-field-checkbox\" data-field-id=\"17\"><label class=\"wpforms-field-label\">Do you have meetings or appointments coming up?<\/label><ul id=\"wpforms-466-field_17\"><li class=\"choice-1 depth-1\"><input type=\"checkbox\" id=\"wpforms-466-field_17_1\" name=\"wpforms[fields][17][]\" value=\"Yes\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-466-field_17_1\">Yes<\/label><\/li><li class=\"choice-2 depth-1\"><input type=\"checkbox\" id=\"wpforms-466-field_17_2\" name=\"wpforms[fields][17][]\" value=\"No\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-466-field_17_2\">No<\/label><\/li><\/ul><\/div><div id=\"wpforms-466-field_18-container\" class=\"wpforms-field wpforms-field-textarea\" data-field-id=\"18\"><label class=\"wpforms-field-label\" for=\"wpforms-466-field_18\">If yes to last question, please give details<\/label><textarea id=\"wpforms-466-field_18\" class=\"wpforms-field-medium\" name=\"wpforms[fields][18]\" ><\/textarea><\/div><div id=\"wpforms-466-field_19-container\" class=\"wpforms-field wpforms-field-text\" data-field-id=\"19\"><label class=\"wpforms-field-label\" for=\"wpforms-466-field_19\">If you have filled this form on behalf of somebody please give your name<\/label><input type=\"text\" id=\"wpforms-466-field_19\" class=\"wpforms-field-medium\" name=\"wpforms[fields][19]\" ><\/div><div id=\"wpforms-466-field_20-container\" class=\"wpforms-field wpforms-field-checkbox\" data-field-id=\"20\"><label class=\"wpforms-field-label\">Is the person aware of the referral?<\/label><ul id=\"wpforms-466-field_20\"><li class=\"choice-1 depth-1\"><input type=\"checkbox\" id=\"wpforms-466-field_20_1\" name=\"wpforms[fields][20][]\" value=\"Yes\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-466-field_20_1\">Yes<\/label><\/li><li class=\"choice-2 depth-1\"><input type=\"checkbox\" id=\"wpforms-466-field_20_2\" name=\"wpforms[fields][20][]\" value=\"No\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-466-field_20_2\">No<\/label><\/li><\/ul><\/div><div id=\"wpforms-466-field_21-container\" class=\"wpforms-field wpforms-field-textarea\" data-field-id=\"21\"><label class=\"wpforms-field-label\" for=\"wpforms-466-field_21\">Any other information you would like us to know?<\/label><textarea id=\"wpforms-466-field_21\" class=\"wpforms-field-medium\" name=\"wpforms[fields][21]\" ><\/textarea><\/div><\/div><!-- .wpforms-field-container --><div class=\"wpforms-recaptcha-container wpforms-is-recaptcha wpforms-is-recaptcha-type-v2\" ><div class=\"g-recaptcha\" data-sitekey=\"6Lc3zoIkAAAAAGJIc4QJCcoF1DlRPEt9Nm_e88Tt\"><\/div><input type=\"text\" name=\"g-recaptcha-hidden\" class=\"wpforms-recaptcha-hidden\" style=\"position:absolute!important;clip:rect(0,0,0,0)!important;height:1px!important;width:1px!important;border:0!important;overflow:hidden!important;padding:0!important;margin:0!important;\" data-rule-recaptcha=\"1\"><\/div><div class=\"wpforms-submit-container\" ><input type=\"hidden\" name=\"wpforms[id]\" value=\"466\"><input type=\"hidden\" name=\"page_title\" value=\"\"><input type=\"hidden\" name=\"page_url\" value=\"https:\/\/www.cipawales.org.uk\/index.php?rest_route=\/wp\/v2\/pages\/474\"><input type=\"hidden\" name=\"url_referer\" value=\"\"><button type=\"submit\" name=\"wpforms[submit]\" id=\"wpforms-submit-466\" class=\"wpforms-submit\" data-alt-text=\"Sending\u2026\" data-submit-text=\"Submit\" aria-live=\"assertive\" value=\"wpforms-submit\">Submit<\/button><img loading=\"lazy\" decoding=\"async\" src=\"https:\/\/www.cipawales.org.uk\/wp-content\/plugins\/wpforms-lite\/assets\/images\/submit-spin.svg\" class=\"wpforms-submit-spinner\" style=\"display: none;\" width=\"26\" height=\"26\" alt=\"Loading\"><\/div><\/form><\/div>  <!-- .wpforms-container -->","protected":false},"excerpt":{"rendered":"","protected":false},"author":1,"featured_media":0,"parent":0,"menu_order":0,"comment_status":"closed","ping_status":"closed","template":"","meta":{"_monsterinsights_skip_tracking":false,"_monsterinsights_sitenote_active":false,"_monsterinsights_sitenote_note":"","_monsterinsights_sitenote_category":0,"footnotes":""},"class_list":["post-474","page","type-page","status-publish"],"aioseo_notices":[],"_links":{"self":[{"href":"https:\/\/www.cipawales.org.uk\/index.php?rest_route=\/wp\/v2\/pages\/474","targetHints":{"allow":["GET"]}}],"collection":[{"href":"https:\/\/www.cipawales.org.uk\/index.php?rest_route=\/wp\/v2\/pages"}],"about":[{"href":"https:\/\/www.cipawales.org.uk\/index.php?rest_route=\/wp\/v2\/types\/page"}],"author":[{"embeddable":true,"href":"https:\/\/www.cipawales.org.uk\/index.php?rest_route=\/wp\/v2\/users\/1"}],"replies":[{"embeddable":true,"href":"https:\/\/www.cipawales.org.uk\/index.php?rest_route=%2Fwp%2Fv2%2Fcomments&post=474"}],"version-history":[{"count":3,"href":"https:\/\/www.cipawales.org.uk\/index.php?rest_route=\/wp\/v2\/pages\/474\/revisions"}],"predecessor-version":[{"id":479,"href":"https:\/\/www.cipawales.org.uk\/index.php?rest_route=\/wp\/v2\/pages\/474\/revisions\/479"}],"wp:attachment":[{"href":"https:\/\/www.cipawales.org.uk\/index.php?rest_route=%2Fwp%2Fv2%2Fmedia&parent=474"}],"curies":[{"name":"wp","href":"https:\/\/api.w.org\/{rel}","templated":true}]}}