{"id":2865,"date":"2021-02-11T14:43:56","date_gmt":"2021-02-11T19:43:56","guid":{"rendered":"https:\/\/wholelifecoachingenergytherapy.com\/?page_id=2865"},"modified":"2021-02-11T14:44:38","modified_gmt":"2021-02-11T19:44:38","slug":"form-test","status":"publish","type":"page","link":"https:\/\/wholelifecoachingenergytherapy.com\/form-test\/","title":{"rendered":"form test"},"content":{"rendered":"\t\t<div data-elementor-type=\"wp-page\" data-elementor-id=\"2865\" class=\"elementor elementor-2865\" data-elementor-post-type=\"page\">\n\t\t\t\t\t\t<section class=\"elementor-section elementor-top-section elementor-element elementor-element-e67500e elementor-section-boxed elementor-section-height-default elementor-section-height-default\" data-id=\"e67500e\" data-element_type=\"section\">\n\t\t\t\t\t\t<div class=\"elementor-container elementor-column-gap-default\">\n\t\t\t\t\t<div class=\"elementor-column elementor-col-100 elementor-top-column elementor-element elementor-element-ed2cc12\" data-id=\"ed2cc12\" data-element_type=\"column\">\n\t\t\t<div class=\"elementor-widget-wrap elementor-element-populated\">\n\t\t\t\t\t\t<div class=\"elementor-element elementor-element-be7b7ed elementor-widget elementor-widget-wp-widget-wpforms-widget\" data-id=\"be7b7ed\" data-element_type=\"widget\" data-widget_type=\"wp-widget-wpforms-widget.default\">\n\t\t\t\t<div class=\"elementor-widget-container\">\n\t\t\t<div class=\"wpforms-container wpforms-container-full\" id=\"wpforms-2864\"><form id=\"wpforms-form-2864\" class=\"wpforms-validate wpforms-form\" data-formid=\"2864\" method=\"post\" enctype=\"multipart\/form-data\" action=\"\/wp-json\/wp\/v2\/pages\/2865\" data-token=\"f57fab8fdd018bfa23dbd2763bdc9606\" data-token-time=\"1715725187\"><noscript class=\"wpforms-error-noscript\">Please enable JavaScript in your browser to complete this form.<\/noscript><div class=\"wpforms-field-container\"><div id=\"wpforms-2864-field_1-container\" class=\"wpforms-field wpforms-field-name\" data-field-id=\"1\"><label class=\"wpforms-field-label\" for=\"wpforms-2864-field_1\">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-2864-field_1\" class=\"wpforms-field-name-first wpforms-field-required\" name=\"wpforms[fields][1][first]\" required><label for=\"wpforms-2864-field_1\" class=\"wpforms-field-sublabel after \">First<\/label><\/div><div class=\"wpforms-field-row-block wpforms-one-half\"><input type=\"text\" id=\"wpforms-2864-field_1-last\" class=\"wpforms-field-name-last wpforms-field-required\" name=\"wpforms[fields][1][last]\" required><label for=\"wpforms-2864-field_1-last\" class=\"wpforms-field-sublabel after \">Last<\/label><\/div><\/div><\/div><div id=\"wpforms-2864-field_2-container\" class=\"wpforms-field wpforms-field-email\" data-field-id=\"2\"><label class=\"wpforms-field-label\" for=\"wpforms-2864-field_2\">Email <span class=\"wpforms-required-label\">*<\/span><\/label><input type=\"email\" id=\"wpforms-2864-field_2\" class=\"wpforms-field-medium wpforms-field-required\" name=\"wpforms[fields][2]\" spellcheck=\"false\" required><\/div><div id=\"wpforms-2864-field_8-container\" class=\"wpforms-field wpforms-field-phone\" data-field-id=\"8\"><label class=\"wpforms-field-label\" for=\"wpforms-2864-field_8\">Primary Phone <span class=\"wpforms-required-label\">*<\/span><\/label><input type=\"tel\" id=\"wpforms-2864-field_8\" class=\"wpforms-field-medium wpforms-field-required\" data-rule-int-phone-field=\"true\" name=\"wpforms[fields][8]\" required><\/div><div id=\"wpforms-2864-field_4-container\" class=\"wpforms-field wpforms-field-phone\" data-field-id=\"4\"><label class=\"wpforms-field-label\" for=\"wpforms-2864-field_4\">Alternate Phone<\/label><input type=\"tel\" id=\"wpforms-2864-field_4\" class=\"wpforms-field-medium\" data-rule-int-phone-field=\"true\" name=\"wpforms[fields][4]\" ><\/div><div id=\"wpforms-2864-field_5-container\" class=\"wpforms-field wpforms-field-address\" data-field-id=\"5\"><label class=\"wpforms-field-label\" for=\"wpforms-2864-field_5\">Address<\/label><div class=\"wpforms-field-row wpforms-field-medium\"><div ><input type=\"text\" id=\"wpforms-2864-field_5\" class=\"wpforms-field-address-address1\" name=\"wpforms[fields][5][address1]\" ><label for=\"wpforms-2864-field_5\" class=\"wpforms-field-sublabel after \">Address Line 1<\/label><\/div><\/div><div class=\"wpforms-field-row wpforms-field-medium\"><div ><input type=\"text\" id=\"wpforms-2864-field_5-address2\" class=\"wpforms-field-address-address2\" name=\"wpforms[fields][5][address2]\" ><label for=\"wpforms-2864-field_5-address2\" class=\"wpforms-field-sublabel after \">Address Line 2<\/label><\/div><\/div><div class=\"wpforms-field-row wpforms-field-medium\"><div class=\"wpforms-field-row-block wpforms-one-half wpforms-first\"><input type=\"text\" id=\"wpforms-2864-field_5-city\" class=\"wpforms-field-address-city\" name=\"wpforms[fields][5][city]\" ><label for=\"wpforms-2864-field_5-city\" class=\"wpforms-field-sublabel after \">City<\/label><\/div><div class=\"wpforms-field-row-block wpforms-one-half\"><select id=\"wpforms-2864-field_5-state\" class=\"wpforms-field-address-state\" name=\"wpforms[fields][5][state]\" value=\"North Carolina\" ><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\"  selected='selected'>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><label for=\"wpforms-2864-field_5-state\" class=\"wpforms-field-sublabel after \">State<\/label><\/div><\/div><div class=\"wpforms-field-row wpforms-field-medium\"><div class=\"wpforms-field-row-block wpforms-one-half wpforms-first\"><input type=\"text\" id=\"wpforms-2864-field_5-postal\" class=\"wpforms-field-address-postal wpforms-masked-input\" data-inputmask-mask=\"(99999)|(99999-9999)\" data-inputmask-keepstatic=\"true\" data-rule-inputmask-incomplete=\"1\" name=\"wpforms[fields][5][postal]\" ><label for=\"wpforms-2864-field_5-postal\" class=\"wpforms-field-sublabel after \">Zip Code<\/label><\/div><\/div><\/div><div id=\"wpforms-2864-field_6-container\" class=\"wpforms-field wpforms-field-text\" data-field-id=\"6\"><label class=\"wpforms-field-label\" for=\"wpforms-2864-field_6\">Birthdate <span class=\"wpforms-required-label\">*<\/span><\/label><input type=\"text\" id=\"wpforms-2864-field_6\" class=\"wpforms-field-medium wpforms-field-required\" name=\"wpforms[fields][6]\" required><\/div><div id=\"wpforms-2864-field_7-container\" class=\"wpforms-field wpforms-field-name\" data-field-id=\"7\"><label class=\"wpforms-field-label\" for=\"wpforms-2864-field_7\">Emergency contact <\/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-2864-field_7\" class=\"wpforms-field-name-first\" name=\"wpforms[fields][7][first]\" ><label for=\"wpforms-2864-field_7\" class=\"wpforms-field-sublabel after \">First<\/label><\/div><div class=\"wpforms-field-row-block wpforms-one-half\"><input type=\"text\" id=\"wpforms-2864-field_7-last\" class=\"wpforms-field-name-last\" name=\"wpforms[fields][7][last]\" ><label for=\"wpforms-2864-field_7-last\" class=\"wpforms-field-sublabel after \">Last<\/label><\/div><\/div><\/div><div id=\"wpforms-2864-field_3-container\" class=\"wpforms-field wpforms-field-phone\" data-field-id=\"3\"><label class=\"wpforms-field-label\" for=\"wpforms-2864-field_3\">Emergency contact phone<\/label><input type=\"tel\" id=\"wpforms-2864-field_3\" class=\"wpforms-field-medium\" data-rule-int-phone-field=\"true\" name=\"wpforms[fields][3]\" ><\/div><div id=\"wpforms-2864-field_9-container\" class=\"wpforms-field wpforms-field-text\" data-field-id=\"9\"><label class=\"wpforms-field-label\" for=\"wpforms-2864-field_9\">How did you find me?<\/label><input type=\"text\" id=\"wpforms-2864-field_9\" class=\"wpforms-field-medium\" name=\"wpforms[fields][9]\" ><\/div><div id=\"wpforms-2864-field_10-container\" class=\"wpforms-field wpforms-field-radio wpforms-conditional-trigger\" data-field-id=\"10\"><label class=\"wpforms-field-label\" for=\"wpforms-2864-field_10\">Are you currently seeing a medical practitioner or therapist?  <span class=\"wpforms-required-label\">*<\/span><\/label><ul id=\"wpforms-2864-field_10\" class=\"wpforms-field-required\"><li class=\"choice-1 depth-1\"><input type=\"radio\" id=\"wpforms-2864-field_10_1\" name=\"wpforms[fields][10]\" value=\"Yes\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-2864-field_10_1\">Yes<\/label><\/li><li class=\"choice-2 depth-1\"><input type=\"radio\" id=\"wpforms-2864-field_10_2\" name=\"wpforms[fields][10]\" value=\"No\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-2864-field_10_2\">No<\/label><\/li><\/ul><\/div><div id=\"wpforms-2864-field_11-container\" class=\"wpforms-field wpforms-field-textarea wpforms-conditional-field wpforms-conditional-show\" data-field-id=\"11\" style=\"display:none;\"><label class=\"wpforms-field-label\" for=\"wpforms-2864-field_11\">List the type of medical practitioner and\/or therapist(s) you are currently seeing <\/label><textarea id=\"wpforms-2864-field_11\" class=\"wpforms-field-medium\" name=\"wpforms[fields][11]\" ><\/textarea><div class=\"wpforms-field-description\">Example: Chiropractor, Acupuncturist, Osteopath<\/div><\/div><div id=\"wpforms-2864-field_12-container\" class=\"wpforms-field wpforms-field-radio wpforms-conditional-trigger\" data-field-id=\"12\"><label class=\"wpforms-field-label\" for=\"wpforms-2864-field_12\">Are you currently taking any medications or supplements? <span class=\"wpforms-required-label\">*<\/span><\/label><ul id=\"wpforms-2864-field_12\" class=\"wpforms-field-required\"><li class=\"choice-1 depth-1\"><input type=\"radio\" id=\"wpforms-2864-field_12_1\" name=\"wpforms[fields][12]\" value=\"Yes\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-2864-field_12_1\">Yes<\/label><\/li><li class=\"choice-2 depth-1\"><input type=\"radio\" id=\"wpforms-2864-field_12_2\" name=\"wpforms[fields][12]\" value=\"No\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-2864-field_12_2\">No<\/label><\/li><\/ul><\/div><div id=\"wpforms-2864-field_13-container\" class=\"wpforms-field wpforms-field-textarea wpforms-conditional-field wpforms-conditional-show\" data-field-id=\"13\" style=\"display:none;\"><label class=\"wpforms-field-label\" for=\"wpforms-2864-field_13\">List any medications and\/or supplements that you\u2019re taking.<\/label><textarea id=\"wpforms-2864-field_13\" class=\"wpforms-field-medium\" name=\"wpforms[fields][13]\" ><\/textarea><\/div><div id=\"wpforms-2864-field_14-container\" class=\"wpforms-field wpforms-field-textarea\" data-field-id=\"14\"><label class=\"wpforms-field-label\" for=\"wpforms-2864-field_14\">Past medical history. Please list all past injuries surgeries illnesses or accidents.<\/label><textarea id=\"wpforms-2864-field_14\" class=\"wpforms-field-medium\" name=\"wpforms[fields][14]\" ><\/textarea><\/div><div id=\"wpforms-2864-field_15-container\" class=\"wpforms-field wpforms-field-textarea\" data-field-id=\"15\"><label class=\"wpforms-field-label\" for=\"wpforms-2864-field_15\">Why are you coming to see a holistic life coach\/ energy therapist? <span class=\"wpforms-required-label\">*<\/span><\/label><textarea id=\"wpforms-2864-field_15\" class=\"wpforms-field-medium wpforms-field-required\" name=\"wpforms[fields][15]\" required><\/textarea><\/div><div id=\"wpforms-2864-field_16-container\" class=\"wpforms-field wpforms-field-textarea\" data-field-id=\"16\"><label class=\"wpforms-field-label\" for=\"wpforms-2864-field_16\">What are your current goals for our work together? <span class=\"wpforms-required-label\">*<\/span><\/label><textarea id=\"wpforms-2864-field_16\" class=\"wpforms-field-medium wpforms-field-required\" name=\"wpforms[fields][16]\" required><\/textarea><\/div><div id=\"wpforms-2864-field_17-container\" class=\"wpforms-field wpforms-field-checkbox wpforms-list-inline\" data-field-id=\"17\"><label class=\"wpforms-field-label\" for=\"wpforms-2864-field_17\">Emotional state.  Please check all of the following feelings you have experienced in the past few months <span class=\"wpforms-required-label\">*<\/span><\/label><ul id=\"wpforms-2864-field_17\" class=\"wpforms-field-required\"><li class=\"choice-1 depth-1\"><input type=\"checkbox\" id=\"wpforms-2864-field_17_1\" name=\"wpforms[fields][17][]\" value=\"Abuse\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-2864-field_17_1\">Abuse<\/label><\/li><li class=\"choice-2 depth-1\"><input type=\"checkbox\" id=\"wpforms-2864-field_17_2\" name=\"wpforms[fields][17][]\" value=\"Agitated\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-2864-field_17_2\">Agitated<\/label><\/li><li class=\"choice-3 depth-1\"><input type=\"checkbox\" id=\"wpforms-2864-field_17_3\" name=\"wpforms[fields][17][]\" value=\"Aggravated\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-2864-field_17_3\">Aggravated<\/label><\/li><li class=\"choice-4 depth-1\"><input type=\"checkbox\" id=\"wpforms-2864-field_17_4\" name=\"wpforms[fields][17][]\" value=\"Angry\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-2864-field_17_4\">Angry<\/label><\/li><li class=\"choice-5 depth-1\"><input type=\"checkbox\" id=\"wpforms-2864-field_17_5\" name=\"wpforms[fields][17][]\" value=\"Annoyed\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-2864-field_17_5\">Annoyed<\/label><\/li><li class=\"choice-6 depth-1\"><input type=\"checkbox\" id=\"wpforms-2864-field_17_6\" name=\"wpforms[fields][17][]\" value=\"Anxious\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-2864-field_17_6\">Anxious<\/label><\/li><li class=\"choice-7 depth-1\"><input type=\"checkbox\" id=\"wpforms-2864-field_17_7\" name=\"wpforms[fields][17][]\" value=\"Apathy\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-2864-field_17_7\">Apathy<\/label><\/li><li class=\"choice-8 depth-1\"><input type=\"checkbox\" id=\"wpforms-2864-field_17_8\" name=\"wpforms[fields][17][]\" value=\"Apprehensive\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-2864-field_17_8\">Apprehensive<\/label><\/li><li class=\"choice-9 depth-1\"><input type=\"checkbox\" id=\"wpforms-2864-field_17_9\" name=\"wpforms[fields][17][]\" value=\"Beautiful\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-2864-field_17_9\">Beautiful<\/label><\/li><li class=\"choice-10 depth-1\"><input type=\"checkbox\" id=\"wpforms-2864-field_17_10\" name=\"wpforms[fields][17][]\" value=\"Criticized\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-2864-field_17_10\">Criticized<\/label><\/li><li class=\"choice-11 depth-1\"><input type=\"checkbox\" id=\"wpforms-2864-field_17_11\" name=\"wpforms[fields][17][]\" value=\"Depressed\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-2864-field_17_11\">Depressed<\/label><\/li><li class=\"choice-12 depth-1\"><input type=\"checkbox\" id=\"wpforms-2864-field_17_12\" name=\"wpforms[fields][17][]\" value=\"Despair\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-2864-field_17_12\">Despair<\/label><\/li><li class=\"choice-13 depth-1\"><input type=\"checkbox\" id=\"wpforms-2864-field_17_13\" name=\"wpforms[fields][17][]\" value=\"Distressed\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-2864-field_17_13\">Distressed<\/label><\/li><li class=\"choice-14 depth-1\"><input type=\"checkbox\" id=\"wpforms-2864-field_17_14\" name=\"wpforms[fields][17][]\" value=\"Easily distracted\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-2864-field_17_14\">Easily distracted<\/label><\/li><li class=\"choice-15 depth-1\"><input type=\"checkbox\" id=\"wpforms-2864-field_17_15\" name=\"wpforms[fields][17][]\" value=\"Easily irritated\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-2864-field_17_15\">Easily irritated<\/label><\/li><li class=\"choice-16 depth-1\"><input type=\"checkbox\" id=\"wpforms-2864-field_17_16\" name=\"wpforms[fields][17][]\" value=\"Grieving\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-2864-field_17_16\">Grieving<\/label><\/li><li class=\"choice-17 depth-1\"><input type=\"checkbox\" id=\"wpforms-2864-field_17_17\" name=\"wpforms[fields][17][]\" value=\"Guilty\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-2864-field_17_17\">Guilty<\/label><\/li><li class=\"choice-18 depth-1\"><input type=\"checkbox\" id=\"wpforms-2864-field_17_18\" name=\"wpforms[fields][17][]\" value=\"Helpless\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-2864-field_17_18\">Helpless<\/label><\/li><li class=\"choice-19 depth-1\"><input type=\"checkbox\" id=\"wpforms-2864-field_17_19\" name=\"wpforms[fields][17][]\" value=\"Hopeless\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-2864-field_17_19\">Hopeless<\/label><\/li><li class=\"choice-20 depth-1\"><input type=\"checkbox\" id=\"wpforms-2864-field_17_20\" name=\"wpforms[fields][17][]\" value=\"Impatient\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-2864-field_17_20\">Impatient<\/label><\/li><li class=\"choice-21 depth-1\"><input type=\"checkbox\" id=\"wpforms-2864-field_17_21\" name=\"wpforms[fields][17][]\" value=\"Intimidated\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-2864-field_17_21\">Intimidated<\/label><\/li><li class=\"choice-22 depth-1\"><input type=\"checkbox\" id=\"wpforms-2864-field_17_22\" name=\"wpforms[fields][17][]\" value=\"Intolerant\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-2864-field_17_22\">Intolerant<\/label><\/li><li class=\"choice-23 depth-1\"><input type=\"checkbox\" id=\"wpforms-2864-field_17_23\" name=\"wpforms[fields][17][]\" value=\"Muddled\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-2864-field_17_23\">Muddled<\/label><\/li><li class=\"choice-24 depth-1\"><input type=\"checkbox\" id=\"wpforms-2864-field_17_24\" name=\"wpforms[fields][17][]\" value=\"Nervous\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-2864-field_17_24\">Nervous<\/label><\/li><li class=\"choice-29 depth-1\"><input type=\"checkbox\" id=\"wpforms-2864-field_17_29\" name=\"wpforms[fields][17][]\" value=\"Outraged\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-2864-field_17_29\">Outraged<\/label><\/li><li class=\"choice-28 depth-1\"><input type=\"checkbox\" id=\"wpforms-2864-field_17_28\" name=\"wpforms[fields][17][]\" value=\"Overwhelmed\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-2864-field_17_28\">Overwhelmed<\/label><\/li><li class=\"choice-27 depth-1\"><input type=\"checkbox\" id=\"wpforms-2864-field_17_27\" name=\"wpforms[fields][17][]\" value=\"Overworked\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-2864-field_17_27\">Overworked<\/label><\/li><li class=\"choice-26 depth-1\"><input type=\"checkbox\" id=\"wpforms-2864-field_17_26\" name=\"wpforms[fields][17][]\" value=\"Panicked\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-2864-field_17_26\">Panicked<\/label><\/li><li class=\"choice-25 depth-1\"><input type=\"checkbox\" id=\"wpforms-2864-field_17_25\" name=\"wpforms[fields][17][]\" value=\"Paralyzed\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-2864-field_17_25\">Paralyzed<\/label><\/li><li class=\"choice-32 depth-1\"><input type=\"checkbox\" id=\"wpforms-2864-field_17_32\" name=\"wpforms[fields][17][]\" value=\"Paranoid\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-2864-field_17_32\">Paranoid<\/label><\/li><li class=\"choice-31 depth-1\"><input type=\"checkbox\" id=\"wpforms-2864-field_17_31\" name=\"wpforms[fields][17][]\" value=\"Persecuted\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-2864-field_17_31\">Persecuted<\/label><\/li><li class=\"choice-30 depth-1\"><input type=\"checkbox\" id=\"wpforms-2864-field_17_30\" name=\"wpforms[fields][17][]\" value=\"Rejected\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-2864-field_17_30\">Rejected<\/label><\/li><li class=\"choice-36 depth-1\"><input type=\"checkbox\" id=\"wpforms-2864-field_17_36\" name=\"wpforms[fields][17][]\" value=\"Resentful\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-2864-field_17_36\">Resentful<\/label><\/li><li class=\"choice-35 depth-1\"><input type=\"checkbox\" id=\"wpforms-2864-field_17_35\" name=\"wpforms[fields][17][]\" value=\"Restless\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-2864-field_17_35\">Restless<\/label><\/li><li class=\"choice-34 depth-1\"><input type=\"checkbox\" id=\"wpforms-2864-field_17_34\" name=\"wpforms[fields][17][]\" value=\"Sad\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-2864-field_17_34\">Sad<\/label><\/li><li class=\"choice-33 depth-1\"><input type=\"checkbox\" id=\"wpforms-2864-field_17_33\" name=\"wpforms[fields][17][]\" value=\"Terrified\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-2864-field_17_33\">Terrified<\/label><\/li><li class=\"choice-38 depth-1\"><input type=\"checkbox\" id=\"wpforms-2864-field_17_38\" name=\"wpforms[fields][17][]\" value=\" Unable to grieve\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-2864-field_17_38\">Unable to grieve<\/label><\/li><li class=\"choice-37 depth-1\"><input type=\"checkbox\" id=\"wpforms-2864-field_17_37\" name=\"wpforms[fields][17][]\" value=\"Uncertain\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-2864-field_17_37\">Uncertain<\/label><\/li><li class=\"choice-39 depth-1\"><input type=\"checkbox\" id=\"wpforms-2864-field_17_39\" name=\"wpforms[fields][17][]\" value=\"Worried\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-2864-field_17_39\">Worried<\/label><\/li><\/ul><\/div><div id=\"wpforms-2864-field_18-container\" class=\"wpforms-field wpforms-field-radio\" data-field-id=\"18\"><label class=\"wpforms-field-label\" for=\"wpforms-2864-field_18\">Please rate your level of family stress.  <span class=\"wpforms-required-label\">*<\/span><\/label><ul id=\"wpforms-2864-field_18\" class=\"wpforms-field-required\"><li class=\"choice-1 depth-1\"><input type=\"radio\" id=\"wpforms-2864-field_18_1\" name=\"wpforms[fields][18]\" value=\"None\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-2864-field_18_1\">None<\/label><\/li><li class=\"choice-2 depth-1\"><input type=\"radio\" id=\"wpforms-2864-field_18_2\" name=\"wpforms[fields][18]\" value=\"Minimal\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-2864-field_18_2\">Minimal<\/label><\/li><li class=\"choice-3 depth-1\"><input type=\"radio\" id=\"wpforms-2864-field_18_3\" name=\"wpforms[fields][18]\" value=\"Moderate\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-2864-field_18_3\">Moderate<\/label><\/li><li class=\"choice-4 depth-1\"><input type=\"radio\" id=\"wpforms-2864-field_18_4\" name=\"wpforms[fields][18]\" value=\"Severe\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-2864-field_18_4\">Severe<\/label><\/li><\/ul><\/div><div id=\"wpforms-2864-field_19-container\" class=\"wpforms-field wpforms-field-radio\" data-field-id=\"19\"><label class=\"wpforms-field-label\" for=\"wpforms-2864-field_19\">Please rate your level of work stress. <span class=\"wpforms-required-label\">*<\/span><\/label><ul id=\"wpforms-2864-field_19\" class=\"wpforms-field-required\"><li class=\"choice-1 depth-1\"><input type=\"radio\" id=\"wpforms-2864-field_19_1\" name=\"wpforms[fields][19]\" value=\"None\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-2864-field_19_1\">None<\/label><\/li><li class=\"choice-2 depth-1\"><input type=\"radio\" id=\"wpforms-2864-field_19_2\" name=\"wpforms[fields][19]\" value=\"Minimal\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-2864-field_19_2\">Minimal<\/label><\/li><li class=\"choice-3 depth-1\"><input type=\"radio\" id=\"wpforms-2864-field_19_3\" name=\"wpforms[fields][19]\" value=\"Moderate\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-2864-field_19_3\">Moderate<\/label><\/li><li class=\"choice-4 depth-1\"><input type=\"radio\" id=\"wpforms-2864-field_19_4\" name=\"wpforms[fields][19]\" value=\"Severe\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-2864-field_19_4\">Severe<\/label><\/li><\/ul><\/div><div id=\"wpforms-2864-field_29-container\" class=\"wpforms-field wpforms-field-radio\" data-field-id=\"29\"><label class=\"wpforms-field-label\" for=\"wpforms-2864-field_29\">Please rate your level of financial stress. <span class=\"wpforms-required-label\">*<\/span><\/label><ul id=\"wpforms-2864-field_29\" class=\"wpforms-field-required\"><li class=\"choice-1 depth-1\"><input type=\"radio\" id=\"wpforms-2864-field_29_1\" name=\"wpforms[fields][29]\" value=\"None\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-2864-field_29_1\">None<\/label><\/li><li class=\"choice-2 depth-1\"><input type=\"radio\" id=\"wpforms-2864-field_29_2\" name=\"wpforms[fields][29]\" value=\"Minimal\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-2864-field_29_2\">Minimal<\/label><\/li><li class=\"choice-3 depth-1\"><input type=\"radio\" id=\"wpforms-2864-field_29_3\" name=\"wpforms[fields][29]\" value=\"Moderate\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-2864-field_29_3\">Moderate<\/label><\/li><li class=\"choice-4 depth-1\"><input type=\"radio\" id=\"wpforms-2864-field_29_4\" name=\"wpforms[fields][29]\" value=\"Severe\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-2864-field_29_4\">Severe<\/label><\/li><\/ul><\/div><div id=\"wpforms-2864-field_20-container\" class=\"wpforms-field wpforms-field-radio\" data-field-id=\"20\"><label class=\"wpforms-field-label\" for=\"wpforms-2864-field_20\">Please rate your level of health stress. <span class=\"wpforms-required-label\">*<\/span><\/label><ul id=\"wpforms-2864-field_20\" class=\"wpforms-field-required\"><li class=\"choice-1 depth-1\"><input type=\"radio\" id=\"wpforms-2864-field_20_1\" name=\"wpforms[fields][20]\" value=\"None\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-2864-field_20_1\">None<\/label><\/li><li class=\"choice-2 depth-1\"><input type=\"radio\" id=\"wpforms-2864-field_20_2\" name=\"wpforms[fields][20]\" value=\"Minimal\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-2864-field_20_2\">Minimal<\/label><\/li><li class=\"choice-3 depth-1\"><input type=\"radio\" id=\"wpforms-2864-field_20_3\" name=\"wpforms[fields][20]\" value=\"Moderate\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-2864-field_20_3\">Moderate<\/label><\/li><li class=\"choice-4 depth-1\"><input type=\"radio\" id=\"wpforms-2864-field_20_4\" name=\"wpforms[fields][20]\" value=\"Severe\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-2864-field_20_4\">Severe<\/label><\/li><\/ul><\/div><div id=\"wpforms-2864-field_21-container\" class=\"wpforms-field wpforms-field-radio\" data-field-id=\"21\"><label class=\"wpforms-field-label\" for=\"wpforms-2864-field_21\">Approximately how much time do you spend each week to relax? <span class=\"wpforms-required-label\">*<\/span><\/label><ul id=\"wpforms-2864-field_21\" class=\"wpforms-field-required\"><li class=\"choice-1 depth-1\"><input type=\"radio\" id=\"wpforms-2864-field_21_1\" name=\"wpforms[fields][21]\" value=\"None\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-2864-field_21_1\">None<\/label><\/li><li class=\"choice-2 depth-1\"><input type=\"radio\" id=\"wpforms-2864-field_21_2\" name=\"wpforms[fields][21]\" value=\"1-2 hours\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-2864-field_21_2\">1-2 hours<\/label><\/li><li class=\"choice-3 depth-1\"><input type=\"radio\" id=\"wpforms-2864-field_21_3\" name=\"wpforms[fields][21]\" value=\"3-5 hours\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-2864-field_21_3\">3-5 hours<\/label><\/li><li class=\"choice-4 depth-1\"><input type=\"radio\" id=\"wpforms-2864-field_21_4\" name=\"wpforms[fields][21]\" value=\"5+ hours\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-2864-field_21_4\">5+ hours<\/label><\/li><\/ul><\/div><div id=\"wpforms-2864-field_22-container\" class=\"wpforms-field wpforms-field-textarea\" data-field-id=\"22\"><label class=\"wpforms-field-label\" for=\"wpforms-2864-field_22\">Please list any activities you do to relax.<\/label><textarea id=\"wpforms-2864-field_22\" class=\"wpforms-field-medium\" name=\"wpforms[fields][22]\" ><\/textarea><\/div><div id=\"wpforms-2864-field_23-container\" class=\"wpforms-field wpforms-field-text\" data-field-id=\"23\"><label class=\"wpforms-field-label\" for=\"wpforms-2864-field_23\">How many hours a night do you sleep? <span class=\"wpforms-required-label\">*<\/span><\/label><input type=\"text\" id=\"wpforms-2864-field_23\" class=\"wpforms-field-medium wpforms-field-required\" name=\"wpforms[fields][23]\" required><\/div><div id=\"wpforms-2864-field_24-container\" class=\"wpforms-field wpforms-field-radio\" data-field-id=\"24\"><label class=\"wpforms-field-label\" for=\"wpforms-2864-field_24\">Is your sleep restful? <span class=\"wpforms-required-label\">*<\/span><\/label><ul id=\"wpforms-2864-field_24\" class=\"wpforms-field-required\"><li class=\"choice-1 depth-1\"><input type=\"radio\" id=\"wpforms-2864-field_24_1\" name=\"wpforms[fields][24]\" value=\"Yes\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-2864-field_24_1\">Yes<\/label><\/li><li class=\"choice-2 depth-1\"><input type=\"radio\" id=\"wpforms-2864-field_24_2\" name=\"wpforms[fields][24]\" value=\"No\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-2864-field_24_2\">No<\/label><\/li><\/ul><\/div><div id=\"wpforms-2864-field_25-container\" class=\"wpforms-field wpforms-field-textarea\" data-field-id=\"25\"><label class=\"wpforms-field-label\" for=\"wpforms-2864-field_25\">If you have physical discomfort, please share where your aches and pains are. List area and indicate the severity of the pain with 1 being slight and 10 being very severe.<\/label><textarea id=\"wpforms-2864-field_25\" class=\"wpforms-field-medium\" name=\"wpforms[fields][25]\" ><\/textarea><\/div><div id=\"wpforms-2864-field_26-container\" class=\"wpforms-field wpforms-field-checkbox\" data-field-id=\"26\"><label class=\"wpforms-field-label wpforms-label-hide\" for=\"wpforms-2864-field_26\">Agreement to Terms of Service <span class=\"wpforms-required-label\">*<\/span><\/label><ul id=\"wpforms-2864-field_26\" class=\"wpforms-field-required\"><li class=\"choice-1 depth-1\"><input type=\"checkbox\" id=\"wpforms-2864-field_26_1\" name=\"wpforms[fields][26][]\" value=\"I have read and agree to the following Terms of Service.\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-2864-field_26_1\">I have read and agree to the following Terms of Service. <span class=\"wpforms-required-label\">*<\/span><\/label><\/li><\/ul><div class=\"wpforms-field-description wpforms-disclaimer-description\">It is my choice to receive holistic life coaching\/energy therapy sessions with Donna Burick. I understand that this is not a substitute for medical treatment or medications. I am aware that Donna does not diagnose illness or disease nor did she prescribe medicine. I understand that my participation in these sessions is voluntary and that at any time I may choose to end my participation. I acknowledge my responsibility for exercising my judgment and initiative and choosing to receive these sessions. I also acknowledge that all information given to Donna Burick is 100% confidential.<\/br><br \/>\r\nSessions must be canceled 24-hours in advance to avoid paying for your scheduled session.<\/br><br \/>\r\nBy this consent, I knowingly and voluntarily assume responsibility for my healing process.<\/div><\/div><div id=\"wpforms-2864-field_27-container\" class=\"wpforms-field wpforms-field-html\" data-field-id=\"27\"><div id=\"wpforms-2864-field_27\"><b>Please Note: 24-hour cancellation notice required.<\/b>\r\nSessions must be canceled 24-hours in advance to avoid paying for your scheduled session.<\/div><\/div><div id=\"wpforms-2864-field_28-container\" class=\"wpforms-field wpforms-field-html\" data-field-id=\"28\"><div id=\"wpforms-2864-field_28\"><b>Please ensure you see the message \"Thanks for completing this form\" After you hit the submit form.<\/b>\r\n<b>If you do not see the message you have missed some information in the form above. Look for the <em>\"This field is required\"<\/em> message for where information is required.<\/b>\r\nPlease review the form and enter the missing information and then press the \"submit\" button again.\r\n<\/div><\/div><\/div><!-- .wpforms-field-container --><div class=\"wpforms-submit-container\" ><input type=\"hidden\" name=\"wpforms[id]\" value=\"2864\"><input type=\"hidden\" name=\"page_title\" value=\"\"><input type=\"hidden\" name=\"page_url\" value=\"https:\/\/wholelifecoachingenergytherapy.com\/wp-json\/wp\/v2\/pages\/2865\"><button type=\"submit\" name=\"wpforms[submit]\" id=\"wpforms-submit-2864\" class=\"wpforms-submit\" data-alt-text=\"Sending...\" data-submit-text=\"Submit\" aria-live=\"assertive\" value=\"wpforms-submit\">Submit<\/button><\/div><\/form><\/div>  <!-- .wpforms-container -->\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t\t<\/div>\n\t\t<\/div>\n\t\t\t\t\t<\/div>\n\t\t<\/section>\n\t\t\t\t<\/div>\n\t\t","protected":false},"excerpt":{"rendered":"","protected":false},"author":1,"featured_media":0,"parent":0,"menu_order":0,"comment_status":"closed","ping_status":"closed","template":"","meta":{"_mo_disable_npp":"","_monsterinsights_skip_tracking":false,"_monsterinsights_sitenote_active":false,"_monsterinsights_sitenote_note":"","_monsterinsights_sitenote_category":0,"site-sidebar-layout":"no-sidebar","site-content-layout":"page-builder","ast-site-content-layout":"","site-content-style":"default","site-sidebar-style":"default","ast-global-header-display":"","ast-banner-title-visibility":"","ast-main-header-display":"","ast-hfb-above-header-display":"","ast-hfb-below-header-display":"","ast-hfb-mobile-header-display":"","site-post-title":"disabled","ast-breadcrumbs-content":"","ast-featured-img":"disabled","footer-sml-layout":"","theme-transparent-header-meta":"default","adv-header-id-meta":"","stick-header-meta":"","header-above-stick-meta":"","header-main-stick-meta":"","header-below-stick-meta":"","astra-migrate-meta-layouts":"default","ast-page-background-enabled":"default","ast-page-background-meta":{"desktop":{"background-color":"","background-image":"","background-repeat":"repeat","background-position":"center center","background-size":"auto","background-attachment":"scroll","background-type":"","background-media":"","overlay-type":"","overlay-color":"","overlay-gradient":""},"tablet":{"background-color":"","background-image":"","background-repeat":"repeat","background-position":"center center","background-size":"auto","background-attachment":"scroll","background-type":"","background-media":"","overlay-type":"","overlay-color":"","overlay-gradient":""},"mobile":{"background-color":"","background-image":"","background-repeat":"repeat","background-position":"center center","background-size":"auto","background-attachment":"scroll","background-type":"","background-media":"","overlay-type":"","overlay-color":"","overlay-gradient":""}},"ast-content-background-meta":{"desktop":{"background-color":"var(--ast-global-color-5)","background-image":"","background-repeat":"repeat","background-position":"center center","background-size":"auto","background-attachment":"scroll","background-type":"","background-media":"","overlay-type":"","overlay-color":"","overlay-gradient":""},"tablet":{"background-color":"var(--ast-global-color-5)","background-image":"","background-repeat":"repeat","background-position":"center center","background-size":"auto","background-attachment":"scroll","background-type":"","background-media":"","overlay-type":"","overlay-color":"","overlay-gradient":""},"mobile":{"background-color":"var(--ast-global-color-5)","background-image":"","background-repeat":"repeat","background-position":"center center","background-size":"auto","background-attachment":"scroll","background-type":"","background-media":"","overlay-type":"","overlay-color":"","overlay-gradient":""}},"footnotes":""},"_links":{"self":[{"href":"https:\/\/wholelifecoachingenergytherapy.com\/wp-json\/wp\/v2\/pages\/2865"}],"collection":[{"href":"https:\/\/wholelifecoachingenergytherapy.com\/wp-json\/wp\/v2\/pages"}],"about":[{"href":"https:\/\/wholelifecoachingenergytherapy.com\/wp-json\/wp\/v2\/types\/page"}],"author":[{"embeddable":true,"href":"https:\/\/wholelifecoachingenergytherapy.com\/wp-json\/wp\/v2\/users\/1"}],"replies":[{"embeddable":true,"href":"https:\/\/wholelifecoachingenergytherapy.com\/wp-json\/wp\/v2\/comments?post=2865"}],"version-history":[{"count":0,"href":"https:\/\/wholelifecoachingenergytherapy.com\/wp-json\/wp\/v2\/pages\/2865\/revisions"}],"wp:attachment":[{"href":"https:\/\/wholelifecoachingenergytherapy.com\/wp-json\/wp\/v2\/media?parent=2865"}],"curies":[{"name":"wp","href":"https:\/\/api.w.org\/{rel}","templated":true}]}}