{"id":665,"date":"2026-03-13T18:27:59","date_gmt":"2026-03-13T18:27:59","guid":{"rendered":"https:\/\/hope-grp.com\/?page_id=665"},"modified":"2026-04-30T00:04:58","modified_gmt":"2026-04-30T07:04:58","slug":"questionnaire","status":"publish","type":"page","link":"https:\/\/hope-grp.com\/index.php\/questionnaire\/","title":{"rendered":"Questionnaire"},"content":{"rendered":"\t\t<div data-elementor-type=\"wp-page\" data-elementor-id=\"665\" class=\"elementor elementor-665\" data-elementor-post-type=\"page\">\n\t\t\t\t\t\t<section class=\"elementor-section elementor-top-section elementor-element elementor-element-57519693 elementor-section-height-min-height elementor-section-boxed elementor-section-height-default elementor-section-items-middle\" data-id=\"57519693\" data-element_type=\"section\" data-settings=\"{&quot;background_background&quot;:&quot;gradient&quot;,&quot;shape_divider_bottom&quot;:&quot;waves&quot;}\">\n\t\t\t\t\t\t\t<div class=\"elementor-background-overlay\"><\/div>\n\t\t\t\t\t\t<div class=\"elementor-shape elementor-shape-bottom\" aria-hidden=\"true\" data-negative=\"false\">\n\t\t\t<svg xmlns=\"http:\/\/www.w3.org\/2000\/svg\" viewBox=\"0 0 1000 100\" preserveAspectRatio=\"none\">\n\t<path class=\"elementor-shape-fill\" d=\"M421.9,6.5c22.6-2.5,51.5,0.4,75.5,5.3c23.6,4.9,70.9,23.5,100.5,35.7c75.8,32.2,133.7,44.5,192.6,49.7\n\tc23.6,2.1,48.7,3.5,103.4-2.5c54.7-6,106.2-25.6,106.2-25.6V0H0v30.3c0,0,72,32.6,158.4,30.5c39.2-0.7,92.8-6.7,134-22.4\n\tc21.2-8.1,52.2-18.2,79.7-24.2C399.3,7.9,411.6,7.5,421.9,6.5z\"\/>\n<\/svg>\t\t<\/div>\n\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-3e758828\" data-id=\"3e758828\" 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-226e92d7 elementor-widget elementor-widget-heading\" data-id=\"226e92d7\" data-element_type=\"widget\" data-widget_type=\"heading.default\">\n\t\t\t\t\t<h1 class=\"elementor-heading-title elementor-size-default\">Questionnaire<\/h1>\t\t\t\t<\/div>\n\t\t\t\t<div class=\"elementor-element elementor-element-68f9d01c elementor-widget elementor-widget-heading\" data-id=\"68f9d01c\" data-element_type=\"widget\" data-widget_type=\"heading.default\">\n\t\t\t\t\t<h3 class=\"elementor-heading-title elementor-size-default\">Guiding You Through Our Process<\/h3>\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<div class=\"elementor-element elementor-element-6aa7645 e-flex e-con-boxed e-con e-parent\" data-id=\"6aa7645\" data-element_type=\"container\">\n\t\t\t\t\t<div class=\"e-con-inner\">\n\t\t\t\t<div class=\"elementor-element elementor-element-073df05 elementor-button-align-stretch elementor-widget elementor-widget-form\" data-id=\"073df05\" data-element_type=\"widget\" data-settings=\"{&quot;step_next_label&quot;:&quot;Next&quot;,&quot;step_previous_label&quot;:&quot;Previous&quot;,&quot;button_width&quot;:&quot;100&quot;,&quot;step_type&quot;:&quot;number_text&quot;,&quot;step_icon_shape&quot;:&quot;circle&quot;}\" data-widget_type=\"form.default\">\n\t\t\t\t\t\t\t<form class=\"elementor-form\" method=\"post\" name=\"New Form\" aria-label=\"New Form\">\n\t\t\t<input type=\"hidden\" name=\"post_id\" value=\"665\"\/>\n\t\t\t<input type=\"hidden\" name=\"form_id\" value=\"073df05\"\/>\n\t\t\t<input type=\"hidden\" name=\"referer_title\" value=\"Questionnaire\" \/>\n\n\t\t\t\t\t\t\t<input type=\"hidden\" name=\"queried_id\" value=\"665\"\/>\n\t\t\t\n\t\t\t<div class=\"elementor-form-fields-wrapper elementor-labels-above\">\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-text elementor-field-group elementor-column elementor-field-group-field_d315b0a elementor-col-100 elementor-field-required\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_d315b0a\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\tParent Name<font color='red'><b>*<\/b><\/font>\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t<input size=\"1\" type=\"text\" name=\"form_fields[field_d315b0a]\" id=\"form-field-field_d315b0a\" class=\"elementor-field elementor-size-sm  elementor-field-textual\" required=\"required\">\n\t\t\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-email elementor-field-group elementor-column elementor-field-group-field_54577ff elementor-col-100 elementor-field-required\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_54577ff\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\tParent Email<font color='red'><b>*<\/b><\/font>\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t<input size=\"1\" type=\"email\" name=\"form_fields[field_54577ff]\" id=\"form-field-field_54577ff\" class=\"elementor-field elementor-size-sm  elementor-field-textual\" required=\"required\">\n\t\t\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-text elementor-field-group elementor-column elementor-field-group-field_998d537 elementor-col-100 elementor-field-required\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_998d537\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\tChild Name<font color='red'><b>*<\/b><\/font>\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t<input size=\"1\" type=\"text\" name=\"form_fields[field_998d537]\" id=\"form-field-field_998d537\" class=\"elementor-field elementor-size-sm  elementor-field-textual\" required=\"required\">\n\t\t\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-number elementor-field-group elementor-column elementor-field-group-field_108103e elementor-col-100 elementor-field-required\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_108103e\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\tChild Age<font color='red'><b>*<\/b><\/font>\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t\t<input type=\"number\" name=\"form_fields[field_108103e]\" id=\"form-field-field_108103e\" class=\"elementor-field elementor-size-sm  elementor-field-textual\" placeholder=\"Year Old\" required=\"required\" min=\"1\" max=\"\" >\n\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-date elementor-field-group elementor-column elementor-field-group-field_27d9714 elementor-col-100 elementor-field-required\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_27d9714\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\tChild Birthdate<font color='red'><b>*<\/b><\/font>\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\n\t\t<input type=\"date\" name=\"form_fields[field_27d9714]\" id=\"form-field-field_27d9714\" class=\"elementor-field elementor-size-sm  elementor-field-textual elementor-date-field elementor-use-native\" required=\"required\" pattern=\"[0-9]{4}-[0-9]{2}-[0-9]{2}\">\n\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-text elementor-field-group elementor-column elementor-field-group-field_9593218 elementor-col-100 elementor-field-required\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_9593218\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\tHome Address<font color='red'><b>*<\/b><\/font>\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t<input size=\"1\" type=\"text\" name=\"form_fields[field_9593218]\" id=\"form-field-field_9593218\" class=\"elementor-field elementor-size-sm  elementor-field-textual\" placeholder=\"(Street, City, Zip Code &amp; County)\" required=\"required\">\n\t\t\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-radio elementor-field-group elementor-column elementor-field-group-field_0e13796 elementor-col-100 elementor-field-required\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_0e13796\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\tDoes your child have a formal diagnosis?<font color='red'><b>*<\/b><\/font>\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t<div class=\"elementor-field-subgroup  \"><span class=\"elementor-field-option\"><input type=\"radio\" value=\"Yes\" id=\"form-field-field_0e13796-0\" name=\"form_fields[field_0e13796]\" required=\"required\"> <label for=\"form-field-field_0e13796-0\">Yes<\/label><\/span><span class=\"elementor-field-option\"><input type=\"radio\" value=\"No\" id=\"form-field-field_0e13796-1\" name=\"form_fields[field_0e13796]\" required=\"required\"> <label for=\"form-field-field_0e13796-1\">No<\/label><\/span><\/div>\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-text elementor-field-group elementor-column elementor-field-group-field_7936525 elementor-col-100 elementor-field-required\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_7936525\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\tWhich days and times are you looking to receive services?<font color='red'><b>*<\/b><\/font>\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t<input size=\"1\" type=\"text\" name=\"form_fields[field_7936525]\" id=\"form-field-field_7936525\" class=\"elementor-field elementor-size-sm  elementor-field-textual\" placeholder=\"List Days and Times\" required=\"required\">\n\t\t\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-radio elementor-field-group elementor-column elementor-field-group-field_95cdbd8 elementor-col-100 elementor-field-required\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_95cdbd8\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\tDo you intend on using Insurance, or private pay?<font color='red'><b>*<\/b><\/font>\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t<div class=\"elementor-field-subgroup  \"><span class=\"elementor-field-option\"><input type=\"radio\" value=\"Insurance\" id=\"form-field-field_95cdbd8-0\" name=\"form_fields[field_95cdbd8]\" required=\"required\"> <label for=\"form-field-field_95cdbd8-0\">Insurance<\/label><\/span><span class=\"elementor-field-option\"><input type=\"radio\" value=\"Private Pay\" id=\"form-field-field_95cdbd8-1\" name=\"form_fields[field_95cdbd8]\" required=\"required\"> <label for=\"form-field-field_95cdbd8-1\">Private Pay<\/label><\/span><\/div>\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-text elementor-field-group elementor-column elementor-field-group-field_607ae5d elementor-col-100\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_607ae5d\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\tIf using insurance, please list your provider<font color='red'><b>*<\/b><\/font>\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t<input size=\"1\" type=\"text\" name=\"form_fields[field_607ae5d]\" id=\"form-field-field_607ae5d\" class=\"elementor-field elementor-size-sm  elementor-field-textual\" placeholder=\"Provider Name\">\n\t\t\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-checkbox elementor-field-group elementor-column elementor-field-group-field_4abc6bd elementor-col-100\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_4abc6bd\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\tCurrent Services<font color='red'><b>*<\/b><\/font>\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t<div class=\"elementor-field-subgroup  \"><span class=\"elementor-field-option\"><input type=\"checkbox\" value=\"ABA Therapy\" id=\"form-field-field_4abc6bd-0\" name=\"form_fields[field_4abc6bd][]\"> <label for=\"form-field-field_4abc6bd-0\">ABA Therapy<\/label><\/span><span class=\"elementor-field-option\"><input type=\"checkbox\" value=\"Speech Therapy\" id=\"form-field-field_4abc6bd-1\" name=\"form_fields[field_4abc6bd][]\"> <label for=\"form-field-field_4abc6bd-1\">Speech Therapy<\/label><\/span><span class=\"elementor-field-option\"><input type=\"checkbox\" value=\"Occupational Therapy\" id=\"form-field-field_4abc6bd-2\" name=\"form_fields[field_4abc6bd][]\"> <label for=\"form-field-field_4abc6bd-2\">Occupational Therapy<\/label><\/span><span class=\"elementor-field-option\"><input type=\"checkbox\" value=\"Physical Therapy\" id=\"form-field-field_4abc6bd-3\" name=\"form_fields[field_4abc6bd][]\"> <label for=\"form-field-field_4abc6bd-3\">Physical Therapy<\/label><\/span><span class=\"elementor-field-option\"><input type=\"checkbox\" value=\"School Services\" id=\"form-field-field_4abc6bd-4\" name=\"form_fields[field_4abc6bd][]\"> <label for=\"form-field-field_4abc6bd-4\">School Services<\/label><\/span><span class=\"elementor-field-option\"><input type=\"checkbox\" value=\"None\" id=\"form-field-field_4abc6bd-5\" name=\"form_fields[field_4abc6bd][]\"> <label for=\"form-field-field_4abc6bd-5\">None<\/label><\/span><span class=\"elementor-field-option\"><input type=\"checkbox\" value=\"Other\" id=\"form-field-field_4abc6bd-6\" name=\"form_fields[field_4abc6bd][]\"> <label for=\"form-field-field_4abc6bd-6\">Other<\/label><\/span><\/div>\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-checkbox elementor-field-group elementor-column elementor-field-group-field_49f1926 elementor-col-100\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_49f1926\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\tBehavior Concerns?<font color='red'><b>*<\/b><\/font>\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t<div class=\"elementor-field-subgroup  \"><span class=\"elementor-field-option\"><input type=\"checkbox\" value=\"Aggression\" id=\"form-field-field_49f1926-0\" name=\"form_fields[field_49f1926][]\"> <label for=\"form-field-field_49f1926-0\">Aggression<\/label><\/span><span class=\"elementor-field-option\"><input type=\"checkbox\" value=\"Tantrums\" id=\"form-field-field_49f1926-1\" name=\"form_fields[field_49f1926][]\"> <label for=\"form-field-field_49f1926-1\">Tantrums<\/label><\/span><span class=\"elementor-field-option\"><input type=\"checkbox\" value=\"Self-injury\" id=\"form-field-field_49f1926-2\" name=\"form_fields[field_49f1926][]\"> <label for=\"form-field-field_49f1926-2\">Self-injury<\/label><\/span><span class=\"elementor-field-option\"><input type=\"checkbox\" value=\"Elopement\" id=\"form-field-field_49f1926-3\" name=\"form_fields[field_49f1926][]\"> <label for=\"form-field-field_49f1926-3\">Elopement<\/label><\/span><span class=\"elementor-field-option\"><input type=\"checkbox\" value=\"Noncompliance\" id=\"form-field-field_49f1926-4\" name=\"form_fields[field_49f1926][]\"> <label for=\"form-field-field_49f1926-4\">Noncompliance<\/label><\/span><span class=\"elementor-field-option\"><input type=\"checkbox\" value=\"Communication delays\" id=\"form-field-field_49f1926-5\" name=\"form_fields[field_49f1926][]\"> <label for=\"form-field-field_49f1926-5\">Communication delays<\/label><\/span><span class=\"elementor-field-option\"><input type=\"checkbox\" value=\"Social skill difficulties\" id=\"form-field-field_49f1926-6\" name=\"form_fields[field_49f1926][]\"> <label for=\"form-field-field_49f1926-6\">Social skill difficulties<\/label><\/span><span class=\"elementor-field-option\"><input type=\"checkbox\" value=\"Please describe concerns in more detail\" id=\"form-field-field_49f1926-7\" name=\"form_fields[field_49f1926][]\"> <label for=\"form-field-field_49f1926-7\">Please describe concerns in more detail<\/label><\/span><span class=\"elementor-field-option\"><input type=\"checkbox\" value=\"Other:\" id=\"form-field-field_49f1926-8\" name=\"form_fields[field_49f1926][]\"> <label for=\"form-field-field_49f1926-8\">Other:<\/label><\/span><\/div>\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-text elementor-field-group elementor-column elementor-field-group-field_4e8575c elementor-col-100 elementor-field-required\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_4e8575c\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\tParent \/ Guardian Contact Information<font color='red'><b>*<\/b><\/font>\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t<input size=\"1\" type=\"text\" name=\"form_fields[field_4e8575c]\" id=\"form-field-field_4e8575c\" class=\"elementor-field elementor-size-sm  elementor-field-textual\" placeholder=\"Contact Information\" required=\"required\">\n\t\t\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-group elementor-column elementor-field-type-submit elementor-col-100 e-form__buttons\">\n\t\t\t\t\t<button class=\"elementor-button elementor-size-sm\" type=\"submit\">\n\t\t\t\t\t\t<span class=\"elementor-button-content-wrapper\">\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<span class=\"elementor-button-text\">Send<\/span>\n\t\t\t\t\t\t\t\t\t\t\t\t\t<\/span>\n\t\t\t\t\t<\/button>\n\t\t\t\t<\/div>\n\t\t\t<\/div>\n\t\t<\/form>\n\t\t\t\t\t\t<\/div>\n\t\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t","protected":false},"excerpt":{"rendered":"<p>Questionnaire Guiding You Through Our Process<\/p>\n","protected":false},"author":1,"featured_media":0,"parent":0,"menu_order":0,"comment_status":"closed","ping_status":"closed","template":"","meta":{"footnotes":""},"class_list":["post-665","page","type-page","status-publish","hentry"],"_links":{"self":[{"href":"https:\/\/hope-grp.com\/index.php\/wp-json\/wp\/v2\/pages\/665","targetHints":{"allow":["GET"]}}],"collection":[{"href":"https:\/\/hope-grp.com\/index.php\/wp-json\/wp\/v2\/pages"}],"about":[{"href":"https:\/\/hope-grp.com\/index.php\/wp-json\/wp\/v2\/types\/page"}],"author":[{"embeddable":true,"href":"https:\/\/hope-grp.com\/index.php\/wp-json\/wp\/v2\/users\/1"}],"replies":[{"embeddable":true,"href":"https:\/\/hope-grp.com\/index.php\/wp-json\/wp\/v2\/comments?post=665"}],"version-history":[{"count":109,"href":"https:\/\/hope-grp.com\/index.php\/wp-json\/wp\/v2\/pages\/665\/revisions"}],"predecessor-version":[{"id":1110,"href":"https:\/\/hope-grp.com\/index.php\/wp-json\/wp\/v2\/pages\/665\/revisions\/1110"}],"wp:attachment":[{"href":"https:\/\/hope-grp.com\/index.php\/wp-json\/wp\/v2\/media?parent=665"}],"curies":[{"name":"wp","href":"https:\/\/api.w.org\/{rel}","templated":true}]}}