{"id":4231,"date":"2020-08-28T21:11:09","date_gmt":"2020-08-28T21:11:09","guid":{"rendered":"http:\/\/www.northcare.com\/?page_id=4231"},"modified":"2025-02-28T21:52:59","modified_gmt":"2025-02-28T21:52:59","slug":"contact-form","status":"publish","type":"page","link":"https:\/\/www.northcare.com\/index.php\/contact-form\/","title":{"rendered":"Contact Form"},"content":{"rendered":"<p>[vc_row top_margin=&#8221;page-margin-top&#8221; el_position=&#8221;first last&#8221;][vc_column width=&#8221;3\/4&#8243;]<div class=\"info-box\"><p><\/p>\n<h1>Request Services<\/h1>\n<ul>\n<li style=\"text-align: left;\">\n<h4>You can fill out the form and someone will call you back within the next business day.<\/h4>\n<\/li>\n<li style=\"text-align: left;\">\n<h4>You can give us a call at <a href=\"tel:(405)8582700\">(405)858-2700<\/a> and schedule an appointment.<\/h4>\n<\/li>\n<li style=\"text-align: left;\">\n<h4>You can Walk-In<\/h4>\n<\/li>\n<\/ul>\n<h4 style=\"text-align: center;\">Walk-Ins are taken anytime between the following days\/hours:<\/h4>\n<h4 style=\"text-align: center;\"><strong>Monday &#8211; Thursday<\/strong> 8:00am-3:00pm<\/h4>\n<h4 style=\"text-align: center;\"><strong>Friday<\/strong> 8:00am-12:00pm<\/h4>\n<h4 style=\"text-align: left;\"><\/h4>\n<p><\/p><\/div>[vc_column_text]<\/p>\n<h4 style=\"text-align: left;\"><img loading=\"lazy\" decoding=\"async\" class=\"size-medium wp-image-4937 alignleft\" src=\"http:\/\/www.northcare.com\/wp-content\/uploads\/2020\/11\/woman-on-smartphone-200x300.jpg\" alt=\"\" width=\"200\" height=\"300\" srcset=\"https:\/\/www.northcare.com\/wp-content\/uploads\/2020\/11\/woman-on-smartphone-200x300.jpg 200w, https:\/\/www.northcare.com\/wp-content\/uploads\/2020\/11\/woman-on-smartphone-683x1024.jpg 683w, https:\/\/www.northcare.com\/wp-content\/uploads\/2020\/11\/woman-on-smartphone-768x1152.jpg 768w, https:\/\/www.northcare.com\/wp-content\/uploads\/2020\/11\/woman-on-smartphone-1024x1536.jpg 1024w, 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Import<\\\/a>\",\"width\":\"full\",\"group\":\"\",\"value\":[{\"label\":\"One\",\"value\":\"one\",\"calc\":\"\",\"selected\":0,\"order\":0},{\"label\":\"Two\",\"value\":\"two\",\"calc\":\"\",\"selected\":0,\"order\":1},{\"label\":\"Three\",\"value\":\"three\",\"calc\":\"\",\"selected\":0,\"order\":2}],\"columns\":{\"label\":{\"header\":\"Label\",\"default\":\"\"},\"value\":{\"header\":\"Value\",\"default\":\"\"},\"calc\":{\"header\":\"Calc Value\",\"default\":\"\"},\"selected\":{\"header\":\"<span class=\\\"dashicons dashicons-yes\\\"><\\\/span>\",\"default\":0}}},\"manual_value\":true},{\"errors\":[],\"max_options\":0,\"label\":\"Edmond\",\"value\":\"Edmond\",\"calc\":\"\",\"selected\":0,\"order\":1,\"settingModel\":{\"settings\":false,\"hide_merge_tags\":false,\"error\":false,\"name\":\"options\",\"type\":\"option-repeater\",\"label\":\"Options <a href=\\\"#\\\" class=\\\"nf-add-new\\\">Add New<\\\/a> <a href=\\\"#\\\" class=\\\"extra nf-open-import-tooltip\\\"><i class=\\\"fa 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class=\\\"extra nf-open-import-tooltip\\\"><i class=\\\"fa fa-sign-in\\\" aria-hidden=\\\"true\\\"><\\\/i> Import<\\\/a>\",\"width\":\"full\",\"group\":\"\",\"value\":[{\"label\":\"One\",\"value\":\"one\",\"calc\":\"\",\"selected\":0,\"order\":0},{\"label\":\"Two\",\"value\":\"two\",\"calc\":\"\",\"selected\":0,\"order\":1},{\"label\":\"Three\",\"value\":\"three\",\"calc\":\"\",\"selected\":0,\"order\":2}],\"columns\":{\"label\":{\"header\":\"Label\",\"default\":\"\"},\"value\":{\"header\":\"Value\",\"default\":\"\"},\"calc\":{\"header\":\"Calc Value\",\"default\":\"\"},\"selected\":{\"header\":\"<span class=\\\"dashicons dashicons-yes\\\"><\\\/span>\",\"default\":0}}},\"manual_value\":true},{\"errors\":[],\"max_options\":0,\"order\":3,\"new\":false,\"options\":[],\"label\":\"None\",\"value\":\"None\",\"calc\":\"\",\"selected\":0,\"settingModel\":{\"settings\":false,\"hide_merge_tags\":false,\"error\":false,\"name\":\"options\",\"type\":\"option-repeater\",\"label\":\"Options <a href=\\\"#\\\" class=\\\"nf-add-new\\\">Add New<\\\/a> <a href=\\\"#\\\" class=\\\"extra nf-open-import-tooltip\\\"><i class=\\\"fa fa-sign-in\\\" aria-hidden=\\\"true\\\"><\\\/i> Import<\\\/a>\",\"width\":\"full\",\"group\":\"\",\"value\":[{\"label\":\"One\",\"value\":\"one\",\"calc\":\"\",\"selected\":0,\"order\":0},{\"label\":\"Two\",\"value\":\"two\",\"calc\":\"\",\"selected\":0,\"order\":1},{\"label\":\"Three\",\"value\":\"three\",\"calc\":\"\",\"selected\":0,\"order\":2}],\"columns\":{\"label\":{\"header\":\"Label\",\"default\":\"\"},\"value\":{\"header\":\"Value\",\"default\":\"\"},\"calc\":{\"header\":\"Calc Value\",\"default\":\"\"},\"selected\":{\"header\":\"<span class=\\\"dashicons 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guidelines.&nbsp;<\\\/b><\\\/p>\",\"container_class\":\"\",\"element_class\":\"\",\"wrap_styles_border\":\"\",\"wrap_styles_width\":\"\",\"wrap_styles_margin\":\"\",\"wrap_styles_padding\":\"\",\"wrap_styles_float\":\"\",\"wrap_styles_show_advanced_css\":0,\"label_styles_border\":\"\",\"label_styles_width\":\"\",\"label_styles_font-size\":\"\",\"label_styles_margin\":\"\",\"label_styles_padding\":\"\",\"label_styles_float\":\"\",\"label_styles_show_advanced_css\":0,\"element_styles_border\":\"\",\"element_styles_width\":\"\",\"element_styles_font-size\":\"\",\"element_styles_margin\":\"\",\"element_styles_padding\":\"\",\"element_styles_float\":\"\",\"element_styles_show_advanced_css\":0,\"key\":\"html_1721682507342\",\"cellcid\":\"c4312\",\"drawerDisabled\":false,\"admin_label\":\"\",\"id\":73,\"beforeField\":\"\",\"afterField\":\"\",\"value\":\"<p><br><\\\/p><p><b>As a Certified Community Behavioral Health Center, we have funds to help cover costs for individuals 22 and over, whose income is at or below 200% or below the federal poverty guidelines.&nbsp;<\\\/b><\\\/p>\",\"label_pos\":\"above\",\"parentType\":\"html\",\"element_templates\":[\"html\",\"input\"],\"old_classname\":\"\",\"wrap_template\":\"wrap\"},{\"objectType\":\"Field\",\"objectDomain\":\"fields\",\"editActive\":false,\"order\":2,\"idAttribute\":\"id\",\"label\":\"My income is Above or Below based on the guidelines below.\",\"type\":\"listradio\",\"key\":\"my_income_is_above_or_below_based_on_the_guidelines_below_1721682718900\",\"label_pos\":\"above\",\"required\":1,\"options\":[{\"errors\":[],\"max_options\":0,\"label\":\"Above\",\"value\":\"Above\",\"calc\":\"\",\"selected\":0,\"order\":0,\"settingModel\":{\"settings\":false,\"hide_merge_tags\":false,\"error\":false,\"name\":\"options\",\"type\":\"option-repeater\",\"label\":\"Options <a href=\\\"#\\\" class=\\\"nf-add-new\\\">Add New<\\\/a> <a href=\\\"#\\\" class=\\\"extra nf-open-import-tooltip\\\"><i class=\\\"fa fa-sign-in\\\" aria-hidden=\\\"true\\\"><\\\/i> Import<\\\/a>\",\"width\":\"full\",\"group\":\"\",\"value\":[{\"label\":\"One\",\"value\":\"one\",\"calc\":\"\",\"selected\":0,\"order\":0},{\"label\":\"Two\",\"value\":\"two\",\"calc\":\"\",\"selected\":0,\"order\":1},{\"label\":\"Three\",\"value\":\"three\",\"calc\":\"\",\"selected\":0,\"order\":2}],\"columns\":{\"label\":{\"header\":\"Label\",\"default\":\"\"},\"value\":{\"header\":\"Value\",\"default\":\"\"},\"calc\":{\"header\":\"Calc Value\",\"default\":\"\"},\"selected\":{\"header\":\"<span class=\\\"dashicons dashicons-yes\\\"><\\\/span>\",\"default\":0}}},\"manual_value\":true},{\"errors\":[],\"max_options\":0,\"label\":\"Below\",\"value\":\"Below\",\"calc\":\"\",\"selected\":0,\"order\":1,\"settingModel\":{\"settings\":false,\"hide_merge_tags\":false,\"error\":false,\"name\":\"options\",\"type\":\"option-repeater\",\"label\":\"Options <a href=\\\"#\\\" class=\\\"nf-add-new\\\">Add New<\\\/a> <a href=\\\"#\\\" class=\\\"extra nf-open-import-tooltip\\\"><i class=\\\"fa fa-sign-in\\\" aria-hidden=\\\"true\\\"><\\\/i> Import<\\\/a>\",\"width\":\"full\",\"group\":\"\",\"value\":[{\"label\":\"One\",\"value\":\"one\",\"calc\":\"\",\"selected\":0,\"order\":0},{\"label\":\"Two\",\"value\":\"two\",\"calc\":\"\",\"selected\":0,\"order\":1},{\"label\":\"Three\",\"value\":\"three\",\"calc\":\"\",\"selected\":0,\"order\":2}],\"columns\":{\"label\":{\"header\":\"Label\",\"default\":\"\"},\"value\":{\"header\":\"Value\",\"default\":\"\"},\"calc\":{\"header\":\"Calc Value\",\"default\":\"\"},\"selected\":{\"header\":\"<span class=\\\"dashicons dashicons-yes\\\"><\\\/span>\",\"default\":0}}},\"manual_value\":true}],\"container_class\":\"\",\"element_class\":\"\",\"admin_label\":\"\",\"help_text\":\"\",\"wrap_styles_border\":\"\",\"wrap_styles_width\":\"\",\"wrap_styles_margin\":\"\",\"wrap_styles_padding\":\"\",\"wrap_styles_float\":\"\",\"wrap_styles_show_advanced_css\":0,\"label_styles_border\":\"\",\"label_styles_width\":\"\",\"label_styles_font-size\":\"\",\"label_styles_margin\":\"\",\"label_styles_padding\":\"\",\"label_styles_float\":\"\",\"label_styles_show_advanced_css\":0,\"element_styles_border\":\"\",\"element_styles_width\":\"\",\"element_styles_font-size\":\"\",\"element_styles_margin\":\"\",\"element_styles_padding\":\"\",\"element_styles_float\":\"\",\"element_styles_show_advanced_css\":0,\"list_item_row_styles_border\":\"\",\"list_item_row_styles_height\":\"\",\"list_item_row_styles_width\":\"\",\"list_item_row_styles_font-size\":\"\",\"list_item_row_styles_margin\":\"\",\"list_item_row_styles_padding\":\"\",\"list_item_row_styles_float\":\"\",\"list_item_row_styles_show_advanced_css\":0,\"list_item_label_styles_border\":\"\",\"list_item_label_styles_height\":\"\",\"list_item_label_styles_width\":\"\",\"list_item_label_styles_font-size\":\"\",\"list_item_label_styles_margin\":\"\",\"list_item_label_styles_padding\":\"\",\"list_item_label_styles_float\":\"\",\"list_item_label_styles_show_advanced_css\":0,\"list_item_element_styles_border\":\"\",\"list_item_element_styles_height\":\"\",\"list_item_element_styles_width\":\"\",\"list_item_element_styles_font-size\":\"\",\"list_item_element_styles_margin\":\"\",\"list_item_element_styles_padding\":\"\",\"list_item_element_styles_float\":\"\",\"list_item_element_styles_show_advanced_css\":0,\"cellcid\":\"c4315\",\"drawerDisabled\":false,\"id\":77,\"beforeField\":\"\",\"afterField\":\"\",\"value\":\"\",\"parentType\":\"list\",\"element_templates\":[\"listradio\",\"input\"],\"old_classname\":\"list-radio\",\"wrap_template\":\"wrap\"},{\"objectType\":\"Field\",\"objectDomain\":\"fields\",\"editActive\":false,\"order\":3,\"idAttribute\":\"id\",\"label\":\"\",\"type\":\"html\",\"default\":\"<p style=\\\"text-align: left;\\\"><b><u>Persons in Household<\\\/u>&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; &nbsp; <u>Household Gross Annual Income<\\\/u><\\\/b><\\\/p><p style=\\\"text-align: left;\\\">&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;1&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; &nbsp; &nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;30,120<\\\/p><p style=\\\"text-align: left;\\\">&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;2&nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; 40,880<\\\/p><p style=\\\"text-align: left;\\\">&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;3&nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; 51,640<\\\/p><p style=\\\"text-align: left;\\\">&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;4&nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; 62,400<\\\/p><p style=\\\"text-align: left;\\\">&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;5&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; &nbsp; &nbsp;&nbsp;&nbsp;&nbsp;73,160<\\\/p><p style=\\\"text-align: left;\\\">&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;6&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; &nbsp; &nbsp;&nbsp;&nbsp;&nbsp;83,920<\\\/p><p style=\\\"text-align: left;\\\">&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;7&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; &nbsp; &nbsp;&nbsp;&nbsp;&nbsp;94,680<\\\/p><p style=\\\"text-align: left;\\\">&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;8&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; &nbsp; &nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;105,440<\\\/p><p style=\\\"text-align: left;\\\"><br><\\\/p><p><br><\\\/p>\",\"container_class\":\"\",\"element_class\":\"\",\"wrap_styles_border\":\"\",\"wrap_styles_width\":\"\",\"wrap_styles_margin\":\"\",\"wrap_styles_padding\":\"\",\"wrap_styles_float\":\"\",\"wrap_styles_show_advanced_css\":0,\"label_styles_border\":\"\",\"label_styles_width\":\"\",\"label_styles_font-size\":\"\",\"label_styles_margin\":\"\",\"label_styles_padding\":\"\",\"label_styles_float\":\"\",\"label_styles_show_advanced_css\":0,\"element_styles_border\":\"\",\"element_styles_width\":\"\",\"element_styles_font-size\":\"\",\"element_styles_margin\":\"\",\"element_styles_padding\":\"\",\"element_styles_float\":\"\",\"element_styles_show_advanced_css\":0,\"key\":\"html_1721682766580\",\"cellcid\":\"c4318\",\"drawerDisabled\":false,\"admin_label\":\"\",\"id\":82,\"beforeField\":\"\",\"afterField\":\"\",\"value\":\"<p style=\\\"text-align: left;\\\"><b><u>Persons in Household<\\\/u>&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; &nbsp; <u>Household Gross Annual Income<\\\/u><\\\/b><\\\/p><p style=\\\"text-align: left;\\\">&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;1&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; &nbsp; &nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;30,120<\\\/p><p style=\\\"text-align: left;\\\">&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;2&nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; 40,880<\\\/p><p style=\\\"text-align: left;\\\">&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;3&nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; 51,640<\\\/p><p style=\\\"text-align: left;\\\">&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;4&nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; 62,400<\\\/p><p style=\\\"text-align: left;\\\">&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;5&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; &nbsp; &nbsp;&nbsp;&nbsp;&nbsp;73,160<\\\/p><p style=\\\"text-align: left;\\\">&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;6&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; &nbsp; &nbsp;&nbsp;&nbsp;&nbsp;83,920<\\\/p><p style=\\\"text-align: left;\\\">&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;7&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; &nbsp; &nbsp;&nbsp;&nbsp;&nbsp;94,680<\\\/p><p style=\\\"text-align: left;\\\">&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;8&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; &nbsp; &nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;105,440<\\\/p><p style=\\\"text-align: left;\\\"><br><\\\/p><p><br><\\\/p>\",\"label_pos\":\"above\",\"parentType\":\"html\",\"element_templates\":[\"html\",\"input\"],\"old_classname\":\"\",\"wrap_template\":\"wrap\"},{\"objectType\":\"Field\",\"objectDomain\":\"fields\",\"editActive\":false,\"order\":1,\"idAttribute\":\"id\",\"label\":\"\",\"type\":\"html\",\"default\":\"\",\"container_class\":\"\",\"element_class\":\"\",\"wrap_styles_border\":\"\",\"wrap_styles_width\":\"\",\"wrap_styles_margin\":\"\",\"wrap_styles_padding\":\"\",\"wrap_styles_float\":\"\",\"wrap_styles_show_advanced_css\":0,\"label_styles_border\":\"\",\"label_styles_width\":\"\",\"label_styles_font-size\":\"\",\"label_styles_margin\":\"\",\"label_styles_padding\":\"\",\"label_styles_float\":\"\",\"label_styles_show_advanced_css\":0,\"element_styles_border\":\"\",\"element_styles_width\":\"\",\"element_styles_font-size\":\"\",\"element_styles_margin\":\"\",\"element_styles_padding\":\"\",\"element_styles_float\":\"\",\"element_styles_show_advanced_css\":0,\"key\":\"html_1721766293171\",\"cellcid\":\"c4324\",\"drawerDisabled\":false,\"admin_label\":\"\",\"id\":109,\"beforeField\":\"\",\"afterField\":\"\",\"value\":\"\",\"label_pos\":\"above\",\"parentType\":\"html\",\"element_templates\":[\"html\",\"input\"],\"old_classname\":\"\",\"wrap_template\":\"wrap\"},{\"objectType\":\"Field\",\"objectDomain\":\"fields\",\"editActive\":false,\"order\":2,\"idAttribute\":\"id\",\"type\":\"listradio\",\"label\":\"Is the referred individual interested or in need of mental health treatment?\",\"key\":\"is_the_referred_individual_interested_or_in_need_of_mental_health_treatment_1753907844783\",\"label_pos\":\"above\",\"required\":1,\"options\":[{\"errors\":[],\"max_options\":0,\"label\":\"Yes\",\"value\":\"Yes\",\"calc\":\"\",\"selected\":0,\"order\":0,\"settingModel\":{\"settings\":false,\"hide_merge_tags\":false,\"error\":false,\"name\":\"options\",\"type\":\"option-repeater\",\"label\":\"Options <a href=\\\"#\\\" class=\\\"nf-add-new\\\">Add New<\\\/a> <a href=\\\"#\\\" class=\\\"extra nf-open-import-tooltip\\\"><i class=\\\"fa fa-sign-in\\\" aria-hidden=\\\"true\\\"><\\\/i> Import<\\\/a>\",\"width\":\"full\",\"group\":\"\",\"value\":[{\"label\":\"One\",\"value\":\"one\",\"calc\":\"\",\"selected\":0,\"order\":0},{\"label\":\"Two\",\"value\":\"two\",\"calc\":\"\",\"selected\":0,\"order\":1},{\"label\":\"Three\",\"value\":\"three\",\"calc\":\"\",\"selected\":0,\"order\":2}],\"columns\":{\"label\":{\"header\":\"Label\",\"default\":\"\"},\"value\":{\"header\":\"Value\",\"default\":\"\"},\"calc\":{\"header\":\"Calc Value\",\"default\":\"\"},\"selected\":{\"header\":\"<span class=\\\"dashicons dashicons-yes\\\"><\\\/span>\",\"default\":0}}},\"manual_value\":true},{\"errors\":[],\"max_options\":0,\"label\":\"No\",\"value\":\"No\",\"calc\":\"\",\"selected\":0,\"order\":1,\"settingModel\":{\"settings\":false,\"hide_merge_tags\":false,\"error\":false,\"name\":\"options\",\"type\":\"option-repeater\",\"label\":\"Options <a href=\\\"#\\\" class=\\\"nf-add-new\\\">Add New<\\\/a> <a href=\\\"#\\\" class=\\\"extra nf-open-import-tooltip\\\"><i class=\\\"fa fa-sign-in\\\" aria-hidden=\\\"true\\\"><\\\/i> Import<\\\/a>\",\"width\":\"full\",\"group\":\"\",\"value\":[{\"label\":\"One\",\"value\":\"one\",\"calc\":\"\",\"selected\":0,\"order\":0},{\"label\":\"Two\",\"value\":\"two\",\"calc\":\"\",\"selected\":0,\"order\":1},{\"label\":\"Three\",\"value\":\"three\",\"calc\":\"\",\"selected\":0,\"order\":2}],\"columns\":{\"label\":{\"header\":\"Label\",\"default\":\"\"},\"value\":{\"header\":\"Value\",\"default\":\"\"},\"calc\":{\"header\":\"Calc Value\",\"default\":\"\"},\"selected\":{\"header\":\"<span class=\\\"dashicons dashicons-yes\\\"><\\\/span>\",\"default\":0}}},\"manual_value\":true}],\"container_class\":\"\",\"element_class\":\"\",\"admin_label\":\"\",\"help_text\":\"\",\"wrap_styles_border\":\"\",\"wrap_styles_width\":\"\",\"wrap_styles_margin\":\"\",\"wrap_styles_padding\":\"\",\"wrap_styles_float\":\"\",\"wrap_styles_show_advanced_css\":0,\"label_styles_border\":\"\",\"label_styles_width\":\"\",\"label_styles_font-size\":\"\",\"label_styles_margin\":\"\",\"label_styles_padding\":\"\",\"label_styles_float\":\"\",\"label_styles_show_advanced_css\":0,\"element_styles_border\":\"\",\"element_styles_width\":\"\",\"element_styles_font-size\":\"\",\"element_styles_margin\":\"\",\"element_styles_padding\":\"\",\"element_styles_float\":\"\",\"element_styles_show_advanced_css\":0,\"list_item_row_styles_border\":\"\",\"list_item_row_styles_height\":\"\",\"list_item_row_styles_width\":\"\",\"list_item_row_styles_font-size\":\"\",\"list_item_row_styles_margin\":\"\",\"list_item_row_styles_padding\":\"\",\"list_item_row_styles_float\":\"\",\"list_item_row_styles_show_advanced_css\":0,\"list_item_label_styles_border\":\"\",\"list_item_label_styles_height\":\"\",\"list_item_label_styles_width\":\"\",\"list_item_label_styles_font-size\":\"\",\"list_item_label_styles_margin\":\"\",\"list_item_label_styles_padding\":\"\",\"list_item_label_styles_float\":\"\",\"list_item_label_styles_show_advanced_css\":0,\"list_item_element_styles_border\":\"\",\"list_item_element_styles_height\":\"\",\"list_item_element_styles_width\":\"\",\"list_item_element_styles_font-size\":\"\",\"list_item_element_styles_margin\":\"\",\"list_item_element_styles_padding\":\"\",\"list_item_element_styles_float\":\"\",\"list_item_element_styles_show_advanced_css\":0,\"cellcid\":\"c4327\",\"drawerDisabled\":false,\"id\":139,\"beforeField\":\"\",\"afterField\":\"\",\"value\":\"\",\"parentType\":\"list\",\"element_templates\":[\"listradio\",\"input\"],\"old_classname\":\"list-radio\",\"wrap_template\":\"wrap\"},{\"objectType\":\"Field\",\"objectDomain\":\"fields\",\"editActive\":false,\"order\":3,\"idAttribute\":\"id\",\"label\":\"Is 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Import<\\\/a>\",\"width\":\"full\",\"group\":\"\",\"value\":[{\"label\":\"One\",\"value\":\"one\",\"calc\":\"\",\"selected\":0,\"order\":0},{\"label\":\"Two\",\"value\":\"two\",\"calc\":\"\",\"selected\":0,\"order\":1},{\"label\":\"Three\",\"value\":\"three\",\"calc\":\"\",\"selected\":0,\"order\":2}],\"columns\":{\"label\":{\"header\":\"Label\",\"default\":\"\"},\"value\":{\"header\":\"Value\",\"default\":\"\"},\"calc\":{\"header\":\"Calc Value\",\"default\":\"\"},\"selected\":{\"header\":\"<span class=\\\"dashicons dashicons-yes\\\"><\\\/span>\",\"default\":0}}},\"manual_value\":true},{\"errors\":[],\"max_options\":0,\"label\":\"No\",\"value\":\"No\",\"calc\":\"\",\"selected\":0,\"order\":1,\"settingModel\":{\"settings\":false,\"hide_merge_tags\":false,\"error\":false,\"name\":\"options\",\"type\":\"option-repeater\",\"label\":\"Options <a href=\\\"#\\\" class=\\\"nf-add-new\\\">Add New<\\\/a> <a href=\\\"#\\\" class=\\\"extra nf-open-import-tooltip\\\"><i class=\\\"fa fa-sign-in\\\" aria-hidden=\\\"true\\\"><\\\/i> Import<\\\/a>\",\"width\":\"full\",\"group\":\"\",\"value\":[{\"label\":\"One\",\"value\":\"one\",\"calc\":\"\",\"selected\":0,\"order\":0},{\"label\":\"Two\",\"value\":\"two\",\"calc\":\"\",\"selected\":0,\"order\":1},{\"label\":\"Three\",\"value\":\"three\",\"calc\":\"\",\"selected\":0,\"order\":2}],\"columns\":{\"label\":{\"header\":\"Label\",\"default\":\"\"},\"value\":{\"header\":\"Value\",\"default\":\"\"},\"calc\":{\"header\":\"Calc Value\",\"default\":\"\"},\"selected\":{\"header\":\"<span class=\\\"dashicons 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