Form tester for Contact Form 7 - Conditional Fields for CF7

Form code

<h4> <b> Client Details </b> </h4>

<label> Client Name
[text* ClientName] </label>

<label> Date Of Birth
[date DateOfBirth] </label>

<label> Current Age
[number Age min:1 max:130 "25"] </label>

<label> Gender
[select Gender include_blank "Male" "Female" "Other"] </label>

<label> Pronouns 
[text PreferedPronouns placeholder "him, her, other"] </label>

<label> Address
[text* ClientAddress] </label>

<label> Email
[email* Clientemail] </label>

<label> Phone 
[tel* ClientPhoneNumber] </label>

<h4> <b> Key Contact/Primary Guardian </h4>

[radio TypeOfContact use_label_element "Key Contact" "Primary Guardian" "Self"]

<label> Name
[text* KeyName] </label>

<label> Phone 
[tel* KeyPhoneNumber] </label>

<br>
<h4> <b> Emergency Contact </b> </h4>

<label> Name
[text* EMName] </label>

<label> Relationship
[text* Relationship] </label>

<label> Phone 
[tel* EMPhoneNumber] </label>

<br>
<h4> <b> Referrer Details </b> </h4>

<label> Referral Date
[date ReferralDate] </label>

<label> Name and Title
[text* ReferrersNameandTitle] </label>

<label> Organisation
[text Organisation] </label>

<label> Address
[text ReferralAddress] </label>

<label> Email
[email* Referreremail] </label>

<label> Phone 
[tel* RefPhoneNumber] </label>

<br>
<h4> <b> Reason For Referral </b> </h4>

<b> Required Service </b>

[checkbox* RequiredService use_label_element "Speech" "Language" "Alternative Communication" "Voice" "Stuttering" "Literacy " "Mealtime Difficulties" "Swallowing" "Orofacial Myofunctional Assessment/Therapy" "Other(provide details below)"]

<label> Extra Referral Information
[textarea ExtraReferralInformation placeholder "If 'other' was selected please provide information about your key concerns so that we can determine how to best meet the needs of the client."] </label>

<label> Relevant History/Information
[textarea RelevantHistoryInformation placeholder "Include any past/current diagnoses and/or medical conditions and please advise if any asthma, epilepsy, anaphylactic/allergy plans are in place."] </label>

<label> Other Current Therapists / Services engaged with:
[textarea OtherCurrentTherapists placeholder "Please provide details and contact details if possible"] </label>

<label> Relevant reports or plans to be provided:
[textarea Relevantreportsorplanstobeprovided placeholder "Please attach to referral or provide details prior to service"] </label>

<br>
<h4> <b> Funding Type </b> - <i> some services may attract a gap fee, contact us to discuss if unsure </i> </h4>

[radio FundingType use_label_element "NDIS" "Home Care Package (HCP)" "Community Home Support Plan (CHSP)" "Home and Community Care (HACC)" "Motor Accidents Insurance Board (MAIB)" "Private" "Medicare/DVA" "Other"]

[group NDISFC]

<p> Participation Number
[number ParticipationNumber] </p>

<p> Plan Start Date
[date PlanStartDate] </p>

<p> Plan End Date
[date PlanEndDate] </p>

<p> How is plan managed? 
[checkbox* NDISPlanType exclusive use_label_element "NDIS" "Plan Managed" "Self-managed"] </p>

<p> Plan Manager <i> (if applicable) </i>
[text PlanManager] </p>

<p> Person/s Responsible for Billing
[text PersonResponsibleforBilling] </p>

<p>Available Funds/Hours for Speech Pathology 
[text AvailableFundsHoursforSpeechPathology] </p>

<p>NDIS Goals
[text NDISGoals] </p>

<br>

[/group]

[group HCPCF]
<h4> <b> Home Care Package (HCP) </b> </h4>

<p> Home Care Package Information
[textarea HCP placeholder "Add details"] </p>

[/group]

[group CHSPCF]
<h4> <b> Community Home Support Plan (CHSP) </b> </h4>

<p> Community Home Support Plan Information
[textarea CHSP placeholder "Add details"] </p>

[/group]

[group HACC]
<h4> <b> Home and Community Care (HACC) </b> </h4>

<p> Home and Community Care Information
[textarea HACC placeholder "Add details"] </p>

[/group]

[group MAIB]

<h4> <b> Motor Accidents Insurance Board (MAIB) </b> </h4>

<p> Motor Accidents Insurance Board Information
[textarea MAIB placeholder "Add details"] </p>

[/group]

[group PHFCF]

<br>
<h4> <b> Private Health Fund </b> </h4>

<p> Fund Name
[text FundName] </p>

<p> Fund Number
[number FundNumber] </p>
 
<p> Expiry Date
[date ExpiryDate] </p>

[/group]

[group OCF]
<h4> <b> Other Funding </b> </h4>

<p> Fund Information 
[textarea OtherFunding placeholder "add funding details"] </P>

[/group]

[group MC/DVA]
<h4> <b> Medicare </b> </h4>

<p> Card Number
[number MedicareCardNumber] </p>

<p> Individual Reference Number (IRN)
[number IRNNumber] </p>

<p> Expiry Date
[date MedicareExpiryDate] </p>

<p> Type Of Referral
[text TypeOfReferral placeholder "e.g. chronic disease management plan"]

<br>
<h4> <b> Dept Veteran Affairs Card </b> </h4>

<p> Card Number
[number CardNumber] </p>

<p> Expiry Date
[date ExpiryDate] </p>

[/group]

<br>
Please ensure all fields are have the correct information entered.

[submit "Submit Form"]

Conditions (Text View)

Email / Summary code

<h1>Referral Form - [ClientName], [ReferralDate] </h1>
<H2>Service Request: <u>[RequiredService]</u></H2>
------------------------------------------------------------------------------------------------------------------
<u><h3>Client Details</h3></u>

<b>Client Name:</b> [ClientName]
<b>Date Of Birth:</b> [DateOfBirth]
<b>Age:</b> [Age]
<b>Gender:</b> [Gender]
<b>Prefered Pronouns:</b> [PreferedPronouns]
<b>Client Address:</b> [ClientAddress]
<b>Client Email:</b> [Clientemail]
<b>Client Phone Number:</b> [ClientPhoneNumber]
------------------------------------------------------------------------------------------------------------------
<u><h3>Key Contact/Primary Contact</h3></u>
<b> Type Of Contact:</b> [TypeOfContact]
<b>Key Contact Name:</b> [KeyName]
<b>Key Contact Phone Number:</b> [KeyPhoneNumber]
------------------------------------------------------------------------------------------------------------------
<u><h3 style="font-family:verdana;">Emergency Contact Details</h3></u>

<b>Emergency Contact Name:</b> [EMName]
<b>Relationship:</b> [Relationship]
<b>Phone Number:</b> [EMPhoneNumber]
------------------------------------------------------------------------------------------------------------------
<u><h3>Referrer Details</h3></u>

<b>Referral Date:</b> [ReferralDate]
<b>Referrer's Name and Title:</b> [ReferrersNameandTitle]
<b>Organisation:</b> [Organisation]
<b>Referral Address:</b> [ReferralAddress]
<b>Referrer's Email:</b> [Referreremail]
<b>Referrer's Phone Number:</b> [RefPhoneNumber]
------------------------------------------------------------------------------------------------------------------
<u><h3>Reason For Referral</h3></u>

<b>Required Service:</b> [RequiredService]

<b>Extra Referral Information:</b> [ExtraReferralInformation]

<b>Relevant History Information:</b> [RelevantHistoryInformation]

<b>Other Current Therapists Services Engaged With:</b> [OtherCurrentTherapists]

<b>Relevant reports or plans to be provided:</b> [Relevantreportsorplanstobeprovided]
------------------------------------------------------------------------------------------------------------------
<h2>Funding Type: <u>[FundingType]</h2></u>

<b>Participation Number:</b> [ParticipationNumber]  
<b>Plan Start Date:</b> [PlanStartDate] 
<b>Plan End Date:</b> [PlanEndDate]
<b>Type of Plan:</B> [NDISPlanType]
<b>PlanManager:</b> [PlanManager]
<b>Person Responsible for Billing:</b> [PersonResponsibleforBilling]
<b>Available Funds/Hours for Speech Pathology:</b> [AvailableFundsHoursforSpeechPathology]
<b>NDIS Goals: [NDISGoals] </b> 
------------------------------------------------------------------------------------------------------------------
<u><h3>Medicare</h3></u>

<b>Medicare Card Number:</b> [MedicareCardNumber]
<b>IRN Number:</b> [IRNNumber]
<b>Medicare Expiry Date:</b> [MedicareExpiryDate]
<b>Type Of Referral: [TypeOfReferral]</b>
------------------------------------------------------------------------------------------------------------------
<u><h3>Private Health Fund</h3></u>

<b>Fund Name:</b> [FundName]
<b>Fund Number:</b> [FundNumber]
<b>Fund Expiry Date:</b> [FundExpiryDate]
------------------------------------------------------------------------------------------------------------------
<u><h3>Dept Veteran Affairs Card</h3></u>
<b>Card Number:</b> [CardNumber]
<b>Card Expiry Date:</b> [ExpiryDate]
------------------------------------------------------------------------------------------------------------------
<b>Home Care Package:</b> [HCP]
<b>Community Home Support Plan:</b> [CHSP]
<b>Home and Community Care:</b> [HACC]
<b>Motor Accidents Insurance Board:</b> [MAIB]
------------------------------------------------------------------------------------------------------------------
<u><h3>Other Funding</h3></u>
<b>Fund Information:</b> [OtherFunding]
------------------------------------------------------------------------------------------------------------------
<i>This email was sent from My Speech Pathology Online Referral Form </i>

Attachments

Additional settings

Client Details

Key Contact/Primary Guardian

Emergency Contact

Referrer Details

Reason For Referral

Funding Type - some services may attract a gap fee, contact us to discuss if unsure

NDIS

Home Care Package (HCP)

Community Home Support Plan (CHSP)

Home and Community Care (HACC)

Motor Accidents Insurance Board (MAIB)

Private Health Fund

Other Funding

Medicare

Dept Veteran Affairs Card

Form Tester for Contact Form 7
powered by Conditional Fields for Contact Form 7

Client Details

Key Contact/Primary Guardian

Emergency Contact

Referrer Details

Reason For Referral

Funding Type - some services may attract a gap fee, contact us to discuss if unsure

NDIS

Home Care Package (HCP)

Community Home Support Plan (CHSP)

Home and Community Care (HACC)

Motor Accidents Insurance Board (MAIB)

Private Health Fund

Other Funding

Medicare

Dept Veteran Affairs Card

Form Tester for Contact Form 7powered by Conditional Fields for Contact Form 7

Form Tester for Contact Form 7
powered by Conditional Fields for Contact Form 7