{"id":20,"date":"2016-03-19T01:59:27","date_gmt":"2016-03-19T01:59:27","guid":{"rendered":"http:\/\/worklinks.works\/?page_id=20"},"modified":"2016-03-19T02:51:56","modified_gmt":"2016-03-19T02:51:56","slug":"referral-form","status":"publish","type":"page","link":"http:\/\/worklinks.works\/index.php\/home\/referral-form\/","title":{"rendered":"Referral Form"},"content":{"rendered":"<div role=\"form\" class=\"wpcf7\" id=\"wpcf7-f19-o1\" lang=\"en-US\" dir=\"ltr\">\n<div class=\"screen-reader-response\"><p role=\"status\" aria-live=\"polite\" aria-atomic=\"true\"><\/p> <ul><\/ul><\/div>\n<form action=\"\/index.php\/wp-json\/wp\/v2\/pages\/20#wpcf7-f19-o1\" method=\"post\" class=\"wpcf7-form init\" novalidate=\"novalidate\" data-status=\"init\">\n<div style=\"display: none;\">\n<input type=\"hidden\" name=\"_wpcf7\" value=\"19\" \/>\n<input type=\"hidden\" name=\"_wpcf7_version\" value=\"5.3\" \/>\n<input type=\"hidden\" name=\"_wpcf7_locale\" value=\"en_US\" \/>\n<input type=\"hidden\" name=\"_wpcf7_unit_tag\" value=\"wpcf7-f19-o1\" \/>\n<input type=\"hidden\" name=\"_wpcf7_container_post\" value=\"0\" \/>\n<input type=\"hidden\" name=\"_wpcf7_posted_data_hash\" value=\"\" \/>\n<input type=\"hidden\" name=\"_wpcf7_recaptcha_response\" value=\"\" \/>\n<\/div>\n<div style=\"width: 100%;\">\n<p>Services Requested:<br \/>\n    <span class=\"wpcf7-form-control-wrap services-requested\"><select name=\"services-requested\" class=\"wpcf7-form-control wpcf7-select wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\"><option value=\"Return to Work (RTW)\">Return to Work (RTW)<\/option><option value=\"Re-employability Assessments (REA)\">Re-employability Assessments (REA)<\/option><option value=\"Job Search\">Job Search<\/option><option value=\"Functional Capacity Evaluation (FCE)\">Functional Capacity Evaluation (FCE)<\/option><option value=\"Labor Market Services (LMS)\">Labor Market Services (LMS)<\/option><\/select><\/span>\n<\/p>\n<\/div>\n<div style=\"float: left; width: 49%;\">\n<h1>Injured Worker Information<\/h1>\n<p>Referral Date:<br \/>\n    <span class=\"wpcf7-form-control-wrap referral-date\"><input type=\"text\" name=\"referral-date\" value=\"\" size=\"40\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" \/><\/span>\n<\/p>\n<p>Average Weekly Wage:<br \/>\n    <span class=\"wpcf7-form-control-wrap average-wage\"><input type=\"text\" name=\"average-wage\" value=\"\" size=\"40\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" \/><\/span>\n<\/p>\n<p>Claim Number:<br \/>\n    <span class=\"wpcf7-form-control-wrap claim-number\"><input type=\"text\" name=\"claim-number\" value=\"\" size=\"40\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" \/><\/span>\n<\/p>\n<p>Injured Workers Name:<br \/>\n    <span class=\"wpcf7-form-control-wrap iw-name\"><input type=\"text\" name=\"iw-name\" value=\"\" size=\"40\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" \/><\/span>\n<\/p>\n<p>Address:<br \/>\n    <span class=\"wpcf7-form-control-wrap iw-address\"><input type=\"text\" name=\"iw-address\" value=\"\" size=\"40\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" \/><\/span>\n<\/p>\n<p>Phone:<br \/>\n    <span class=\"wpcf7-form-control-wrap iw-phone\"><input type=\"text\" name=\"iw-phone\" value=\"\" size=\"40\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" \/><\/span>\n<\/p>\n<p>Date of Birth:<br \/>\n    <span class=\"wpcf7-form-control-wrap iw-dob\"><input type=\"text\" name=\"iw-dob\" value=\"\" size=\"40\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" \/><\/span>\n<\/p>\n<p>Date of Injury:<br \/>\n    <span class=\"wpcf7-form-control-wrap iw-doi\"><input type=\"text\" name=\"iw-doi\" value=\"\" size=\"40\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" \/><\/span>\n<\/p>\n<p>Occupation:<br \/>\n    <span class=\"wpcf7-form-control-wrap iw-occupation\"><input type=\"text\" name=\"iw-occupation\" value=\"\" size=\"40\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" \/><\/span>\n<\/p>\n<p>E-Mail:<br \/>\n    <span class=\"wpcf7-form-control-wrap iw-email\"><input type=\"text\" name=\"iw-email\" value=\"\" size=\"40\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" \/><\/span>\n<\/p>\n<p><br clear=\"all\" \/><\/p>\n<p>Injured Worker's Attorney:<br \/>\n    <span class=\"wpcf7-form-control-wrap iw-attorney\"><input type=\"text\" name=\"iw-attorney\" value=\"\" size=\"40\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" \/><\/span>\n<\/p>\n<p>Address:<br \/>\n    <span class=\"wpcf7-form-control-wrap iw-Attaddress\"><input type=\"text\" name=\"iw-Attaddress\" value=\"\" size=\"40\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" \/><\/span>\n<\/p>\n<p>Phone:<br \/>\n    <span class=\"wpcf7-form-control-wrap iw-Attphone\"><input type=\"text\" name=\"iw-Attphone\" value=\"\" size=\"40\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" \/><\/span>\n<\/p>\n<p>Fax:<br \/>\n    <span class=\"wpcf7-form-control-wrap iw-Attfax\"><input type=\"text\" name=\"iw-Attfax\" value=\"\" size=\"40\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" \/><\/span>\n<\/p>\n<p>Email:<br \/>\n    <span class=\"wpcf7-form-control-wrap iw-Attemail\"><input type=\"text\" name=\"iw-Attemail\" value=\"\" size=\"40\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" \/><\/span>\n<\/p>\n<p><br clear=\"all\" \/><\/p>\n<p>Physician:<br \/>\n    <span class=\"wpcf7-form-control-wrap iw-physician\"><input type=\"text\" name=\"iw-physician\" value=\"\" size=\"40\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" \/><\/span>\n<\/p>\n<p>Address:<br \/>\n    <span class=\"wpcf7-form-control-wrap iw-physicianAddress\"><input type=\"text\" name=\"iw-physicianAddress\" value=\"\" size=\"40\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" \/><\/span>\n<\/p>\n<p>Speciality:<br \/>\n    <span class=\"wpcf7-form-control-wrap iw-physicianSpeciality\"><input type=\"text\" name=\"iw-physicianSpeciality\" value=\"\" size=\"40\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" \/><\/span>\n<\/p>\n<p>Phone:<br \/>\n    <span class=\"wpcf7-form-control-wrap iw-physicianPhone\"><input type=\"text\" name=\"iw-physicianPhone\" value=\"\" size=\"40\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" \/><\/span>\n<\/p>\n<p>Fax:<br \/>\n    <span class=\"wpcf7-form-control-wrap iw-physicianFax\"><input type=\"text\" name=\"iw-physicianFax\" value=\"\" size=\"40\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" \/><\/span>\n<\/p>\n<p>Light Duty Release Date:<br \/>\n    <span class=\"wpcf7-form-control-wrap iw-ldReleaseDate\"><input type=\"text\" name=\"iw-ldReleaseDate\" value=\"\" size=\"40\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" \/><\/span>\n<\/p>\n<p>Work Level:<br \/>\n    <span class=\"wpcf7-form-control-wrap iw-workLevel\"><select name=\"iw-workLevel\" class=\"wpcf7-form-control wpcf7-select wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\"><option value=\"Sedentary\">Sedentary<\/option><option value=\"Light\">Light<\/option><option value=\"Medium\">Medium<\/option><option value=\"Heavy\">Heavy<\/option><\/select><\/span>\n<\/p>\n<p><br clear=\"all\" \/><\/p>\n<p>Primary Language:<br \/>\n    <span class=\"wpcf7-form-control-wrap iw-primaryLanguage\"><select name=\"iw-primaryLanguage\" class=\"wpcf7-form-control wpcf7-select wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\"><option value=\"English\">English<\/option><option value=\"Spanish\">Spanish<\/option><option value=\"Other\">Other<\/option><\/select><\/span>\n<\/p>\n<p><br clear=\"all\" \/><\/p>\n<p>Injury Description:<br \/>\n    <span class=\"wpcf7-form-control-wrap iw-injuryDescription\"><textarea name=\"iw-injuryDescription\" cols=\"40\" rows=\"10\" class=\"wpcf7-form-control wpcf7-textarea\" aria-invalid=\"false\"><\/textarea><\/span>\n<\/p>\n<\/div>\n<div style=\"float: right; width: 49%;\">\n<h1>Worker's Comp Information<\/h1>\n<p>Adjuster:<br \/>\n    <span class=\"wpcf7-form-control-wrap wrkComp-adjuster\"><input type=\"text\" name=\"wrkComp-adjuster\" value=\"\" size=\"40\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" \/><\/span>\n<\/p>\n<p>Carrier:<br \/>\n    <span class=\"wpcf7-form-control-wrap wrkComp-carrier\"><input type=\"text\" name=\"wrkComp-carrier\" value=\"\" size=\"40\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" \/><\/span>\n<\/p>\n<p>Address:<br \/>\n    <span class=\"wpcf7-form-control-wrap wrkComp-address\"><input type=\"text\" name=\"wrkComp-address\" value=\"\" size=\"40\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" \/><\/span>\n<\/p>\n<p>Phone:<br \/>\n    <span class=\"wpcf7-form-control-wrap wrkComp-phone\"><input type=\"text\" name=\"wrkComp-phone\" value=\"\" size=\"40\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" \/><\/span>\n<\/p>\n<p>Fax:<br \/>\n    <span class=\"wpcf7-form-control-wrap wrkComp-fax\"><input type=\"text\" name=\"wrkComp-fax\" value=\"\" size=\"40\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" \/><\/span>\n<\/p>\n<p>Email:<br \/>\n    <span class=\"wpcf7-form-control-wrap wrkComp-email\"><input type=\"email\" name=\"wrkComp-email\" value=\"\" size=\"40\" class=\"wpcf7-form-control wpcf7-text wpcf7-email wpcf7-validates-as-email\" aria-invalid=\"false\" \/><\/span>\n<\/p>\n<p><br clear=\"all\" \/><\/p>\n<p>Defense Attorney:<br \/>\n    <span class=\"wpcf7-form-control-wrap defense-attorney\"><input type=\"text\" name=\"defense-attorney\" value=\"\" size=\"40\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" \/><\/span>\n<\/p>\n<p>Address:<br \/>\n    <span class=\"wpcf7-form-control-wrap defense-attorneyAddress\"><input type=\"text\" name=\"defense-attorneyAddress\" value=\"\" size=\"40\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" \/><\/span>\n<\/p>\n<p>Phone:<br \/>\n    <span class=\"wpcf7-form-control-wrap defense-attorneyPhone\"><input type=\"text\" name=\"defense-attorneyPhone\" value=\"\" size=\"40\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" \/><\/span>\n<\/p>\n<p>Fax:<br \/>\n    <span class=\"wpcf7-form-control-wrap defense-attorneyFax\"><input type=\"text\" name=\"defense-attorneyFax\" value=\"\" size=\"40\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" \/><\/span>\n<\/p>\n<p>Email:<br \/>\n    <span class=\"wpcf7-form-control-wrap defense-attorneyEmail\"><input type=\"text\" name=\"defense-attorneyEmail\" value=\"\" size=\"40\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" \/><\/span>\n<\/p>\n<p><br clear=\"all\" \/><\/p>\n<h1>Employer Information<\/h1>\n<p>Employer:<br \/>\n    <span class=\"wpcf7-form-control-wrap employer-name\"><input type=\"text\" name=\"employer-name\" value=\"\" size=\"40\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" \/><\/span>\n<\/p>\n<p>Phone:<br \/>\n    <span class=\"wpcf7-form-control-wrap employer-phone\"><input type=\"text\" name=\"employer-phone\" value=\"\" size=\"40\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" \/><\/span>\n<\/p>\n<p>Fax:<br \/>\n    <span class=\"wpcf7-form-control-wrap employer-fax\"><input type=\"text\" name=\"employer-fax\" value=\"\" size=\"40\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" \/><\/span>\n<\/p>\n<p>E-Mail:<br \/>\n    <span class=\"wpcf7-form-control-wrap employer-email\"><input type=\"email\" name=\"employer-email\" value=\"\" size=\"40\" class=\"wpcf7-form-control wpcf7-text wpcf7-email wpcf7-validates-as-email\" aria-invalid=\"false\" \/><\/span>\n<\/p>\n<\/div>\n<p><input type=\"submit\" value=\"Send\" class=\"wpcf7-form-control wpcf7-submit\" \/><\/p>\n<div class=\"wpcf7-response-output\" aria-hidden=\"true\"><\/div><\/form><\/div>\n","protected":false},"excerpt":{"rendered":"","protected":false},"author":1,"featured_media":0,"parent":6,"menu_order":0,"comment_status":"closed","ping_status":"closed","template":"page-fullwidth.php","meta":[],"_links":{"self":[{"href":"http:\/\/worklinks.works\/index.php\/wp-json\/wp\/v2\/pages\/20"}],"collection":[{"href":"http:\/\/worklinks.works\/index.php\/wp-json\/wp\/v2\/pages"}],"about":[{"href":"http:\/\/worklinks.works\/index.php\/wp-json\/wp\/v2\/types\/page"}],"author":[{"embeddable":true,"href":"http:\/\/worklinks.works\/index.php\/wp-json\/wp\/v2\/users\/1"}],"replies":[{"embeddable":true,"href":"http:\/\/worklinks.works\/index.php\/wp-json\/wp\/v2\/comments?post=20"}],"version-history":[{"count":2,"href":"http:\/\/worklinks.works\/index.php\/wp-json\/wp\/v2\/pages\/20\/revisions"}],"predecessor-version":[{"id":23,"href":"http:\/\/worklinks.works\/index.php\/wp-json\/wp\/v2\/pages\/20\/revisions\/23"}],"up":[{"embeddable":true,"href":"http:\/\/worklinks.works\/index.php\/wp-json\/wp\/v2\/pages\/6"}],"wp:attachment":[{"href":"http:\/\/worklinks.works\/index.php\/wp-json\/wp\/v2\/media?parent=20"}],"curies":[{"name":"wp","href":"https:\/\/api.w.org\/{rel}","templated":true}]}}