hunterprimarycare.com.au
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urlscan Pro
101.0.104.206
Public Scan
Submitted URL: http://hunterpir.com.au/
Effective URL: https://hunterprimarycare.com.au/health-services/mental-health-services/commonwealth-psychosocial-support-program/
Submission: On November 17 via api from US — Scanned from AU
Effective URL: https://hunterprimarycare.com.au/health-services/mental-health-services/commonwealth-psychosocial-support-program/
Submission: On November 17 via api from US — Scanned from AU
Form analysis 8 forms found in the DOM
GET https://hunterprimarycare.com.au/
<form role="search" class="searchform fusion-search-form fusion-search-form-classic" method="get" action="https://hunterprimarycare.com.au/">
<div class="fusion-search-form-content">
<div class="fusion-search-field search-field">
<label><span class="screen-reader-text">Search for:</span>
<input type="search" value="" name="s" class="s" placeholder="Search..." required="" aria-required="true" aria-label="Search...">
</label>
</div>
<div class="fusion-search-button search-button">
<input type="submit" class="fusion-search-submit searchsubmit" aria-label="Search" value="">
</div>
</div>
</form>GET https://hunterprimarycare.com.au/
<form role="search" class="searchform fusion-search-form fusion-search-form-classic" method="get" action="https://hunterprimarycare.com.au/">
<div class="fusion-search-form-content">
<div class="fusion-search-field search-field">
<label><span class="screen-reader-text">Search for:</span>
<input type="search" value="" name="s" class="s" placeholder="Search..." required="" aria-required="true" aria-label="Search...">
</label>
</div>
<div class="fusion-search-button search-button">
<input type="submit" class="fusion-search-submit searchsubmit" aria-label="Search" value="">
</div>
</div>
</form>#
<form action="#" autocomplete="off" aria-label="Search form 1">
<input type="search" class="orig" tabindex="100" placeholder="Search here..." name="phrase" value="" aria-label="Search input 1" autocomplete="off">
<input type="text" class="autocomplete" name="phrase" value="" aria-label="Search autocomplete, ignore please" aria-hidden="true" autocomplete="off" disabled="">
<input type="submit" aria-hidden="true" aria-label="Hidden button" style="width:0; height: 0; visibility: hidden;">
</form>Name: options —
<form name="options" class="asp-fss-flex" autocomplete="off">
<input type="hidden" style="display:none;" name="current_page_id" value="1940">
<input type="hidden" name="qtranslate_lang" style="display:none;" value="0">
<input type="hidden" name="filters_changed" style="display:none;" value="0">
<input type="hidden" name="filters_initial" style="display:none;" value="1">
<fieldset class="asp_filter_generic asp_filter_id_1 asp_filter_n_0 hiddend">
<legend>Generic filters</legend>
<input type="checkbox" value="exact" id="set_exact1_1" style="display:none;" name="asp_gen[]">
<input type="checkbox" value="title" id="set_title1_1" style="display:none;" data-origvalue="1" name="asp_gen[]" checked="checked">
<input type="checkbox" value="content" id="set_content1_1" style="display:none;" data-origvalue="1" name="asp_gen[]" checked="checked">
<input type="checkbox" value="excerpt" id="set_excerpt1_1" style="display:none;" data-origvalue="1" name="asp_gen[]" checked="checked">
</fieldset> <input type="checkbox" style="display: none !important;" value="post" aria-label="Hidden label" aria-hidden="true" id="1_1customset_1_1100" name="customset[]" checked="checked">
<input type="checkbox" style="display: none !important;" value="page" aria-label="Hidden label" aria-hidden="true" id="1_1customset_1_1101" name="customset[]" checked="checked">
<input type="checkbox" style="display: none !important;" value="avada_portfolio" aria-label="Hidden label" aria-hidden="true" id="1_1customset_1_1102" name="customset[]" checked="checked">
<input type="checkbox" style="display: none !important;" value="avada_faq" aria-label="Hidden label" aria-hidden="true" id="1_1customset_1_1103" name="customset[]" checked="checked">
<div style="clear:both;"></div>
</form>#
<form action="#" autocomplete="off" aria-label="Search form 1">
<input type="search" class="orig" tabindex="100" placeholder="Search here..." name="phrase" value="" aria-label="Search input 1" autocomplete="off">
<input type="text" class="autocomplete" name="phrase" value="" aria-label="Search autocomplete, ignore please" aria-hidden="true" autocomplete="off" disabled="">
<input type="submit" aria-hidden="true" aria-label="Hidden button" style="width:0; height: 0; visibility: hidden;">
</form>Name: options —
<form name="options" class="asp-fss-flex" autocomplete="off">
<input type="hidden" style="display:none;" name="current_page_id" value="1940">
<input type="hidden" name="qtranslate_lang" style="display:none;" value="0">
<input type="hidden" name="filters_changed" style="display:none;" value="0">
<input type="hidden" name="filters_initial" style="display:none;" value="1">
<fieldset class="asp_filter_generic asp_filter_id_1 asp_filter_n_0 hiddend">
<legend>Generic filters</legend>
<input type="checkbox" value="exact" id="set_exact1_2" style="display:none;" name="asp_gen[]">
<input type="checkbox" value="title" id="set_title1_2" style="display:none;" data-origvalue="1" name="asp_gen[]" checked="checked">
<input type="checkbox" value="content" id="set_content1_2" style="display:none;" data-origvalue="1" name="asp_gen[]" checked="checked">
<input type="checkbox" value="excerpt" id="set_excerpt1_2" style="display:none;" data-origvalue="1" name="asp_gen[]" checked="checked">
</fieldset> <input type="checkbox" style="display: none !important;" value="post" aria-label="Hidden label" aria-hidden="true" id="1_2customset_1_2100" name="customset[]" checked="checked">
<input type="checkbox" style="display: none !important;" value="page" aria-label="Hidden label" aria-hidden="true" id="1_2customset_1_2101" name="customset[]" checked="checked">
<input type="checkbox" style="display: none !important;" value="avada_portfolio" aria-label="Hidden label" aria-hidden="true" id="1_2customset_1_2102" name="customset[]" checked="checked">
<input type="checkbox" style="display: none !important;" value="avada_faq" aria-label="Hidden label" aria-hidden="true" id="1_2customset_1_2103" name="customset[]" checked="checked">
<div style="clear:both;"></div>
</form><form>
<div>
<div class="nf-before-form-content"><nf-section>
<div class="nf-form-fields-required">Fields marked with an <span class="ninja-forms-req-symbol">*</span> are required</div>
</nf-section></div>
<div class="nf-form-content "><nf-rows-wrap>
<div class="nf-row">
<nf-cells>
<div class="nf-cell" style="width: 100%;">
<nf-fields><nf-field>
<div id="nf-field-340-container" class="nf-field-container date-container label-above ">
<div class="nf-before-field"><nf-section>
</nf-section></div>
<div class="nf-field">
<div id="nf-field-340-wrap" class="field-wrap date-wrap" data-field-id="340">
<div class="nf-field-label"><label for="nf-field-340" id="nf-label-field-340" class="">Referral Date </label></div>
<div class="nf-field-element">
<div class="pikaday__container"><!-- Pikaday mentions were added for backwards compatibility -->
<input id="nf-field-340" name="nf-field-340" aria-invalid="false" aria-describedby="nf-error-340" class="ninja-forms-field nf-element datepicker pikaday__display pikaday__display--pikaday flatpickr-input"
aria-labelledby="nf-label-field-340" type="hidden" value="17/11/2022"><input class="ninja-forms-field nf-element datepicker pikaday__display pikaday__display--pikaday form-control input" placeholder="" tabindex="0"
type="text">
</div>
</div>
</div>
</div>
<div class="nf-after-field"><nf-section>
<div class="nf-input-limit"></div>
<div id="nf-error-340" class="nf-error-wrap nf-error" role="alert"></div>
</nf-section></div>
</div>
</nf-field></nf-fields>
</div>
</nf-cells>
</div>
<div class="nf-row">
<nf-cells>
<div class="nf-cell" style="width: 100%;">
<nf-fields><nf-field>
<div id="nf-field-482-container" class="nf-field-container email-container label-above ">
<div class="nf-before-field"><nf-section>
</nf-section></div>
<div class="nf-field">
<div id="nf-field-482-wrap" class="field-wrap email-wrap" data-field-id="482">
<div class="nf-field-label"><label for="nf-field-482" id="nf-label-field-482" class="">Email </label></div>
<div class="nf-field-element">
<input type="email" value="" class="ninja-forms-field nf-element" id="nf-field-482" name="email" autocomplete="email" aria-invalid="false" aria-describedby="nf-error-482" aria-labelledby="nf-label-field-482">
</div>
</div>
</div>
<div class="nf-after-field"><nf-section>
<div class="nf-input-limit"></div>
<div id="nf-error-482" class="nf-error-wrap nf-error" role="alert"></div>
</nf-section></div>
</div>
</nf-field></nf-fields>
</div>
</nf-cells>
</div>
<div class="nf-row">
<nf-cells>
<div class="nf-cell" style="width: 100%;">
<nf-fields><nf-field>
<div id="nf-field-394-container" class="nf-field-container listradio-container label-above two-col-list list-container">
<div class="nf-before-field"><nf-section>
</nf-section></div>
<div class="nf-field">
<div id="nf-field-394-wrap" class="field-wrap listradio-wrap list-wrap list-radio-wrap" data-field-id="394">
<div class="nf-field-label"><label for="nf-field-394" id="nf-label-field-394" class="">Is this referral for yourself? </label></div>
<div class="nf-field-element">
<ul aria-describedby="nf-error-394">
<li>
<input type="radio" id="nf-field-394-0" name="nf-field-394" class="ninja-forms-field nf-element " value="yes" aria-labelledby="nf-label-class-field-394-0">
<label for="nf-field-394-0" id="nf-label-class-field-394-0" class="">Yes</label>
</li>
<li>
<input type="radio" id="nf-field-394-1" name="nf-field-394" class="ninja-forms-field nf-element " value="no" aria-labelledby="nf-label-class-field-394-1">
<label for="nf-field-394-1" id="nf-label-class-field-394-1" class="">No</label>
</li>
</ul>
</div>
</div>
</div>
<div class="nf-after-field"><nf-section>
<div class="nf-input-limit"></div>
<div id="nf-error-394" class="nf-error-wrap nf-error" role="alert"></div>
</nf-section></div>
</div>
</nf-field></nf-fields>
</div>
</nf-cells>
</div>
<div class="nf-row">
<nf-cells>
<div class="nf-cell" style="width: 100%;">
<nf-fields><nf-field>
<div id="nf-field-452-container" class="nf-field-container hr-container label-above ">
<div class="nf-before-field"><nf-section>
</nf-section></div>
<div class="nf-field">
<div id="nf-field-452-wrap" class="field-wrap hr-wrap" data-field-id="452">
<div class="nf-field-label"><label for="nf-field-452" id="nf-label-field-452" class="">Divider </label></div>
<div class="nf-field-element">
<hr class="ninja-forms-field">
</div>
</div>
</div>
<div class="nf-after-field"><nf-section>
<div class="nf-input-limit"></div>
<div id="nf-error-452" class="nf-error-wrap nf-error" role="alert"></div>
</nf-section></div>
</div>
</nf-field></nf-fields>
</div>
</nf-cells>
</div>
<div class="nf-row">
<nf-cells>
<div class="nf-cell" style="width: 100%;">
<nf-fields><nf-field>
<div id="nf-field-341-container" class="nf-field-container html-container label-above ">
<div class="nf-before-field"><nf-section>
</nf-section></div>
<div class="nf-field">
<div id="nf-field-341-wrap" class="field-wrap html-wrap" data-field-id="341">
<div class="nf-field-label"><label for="nf-field-341" id="nf-label-field-341" class="">Person Information </label></div>
<div class="nf-field-element">
<h2>Person Information</h2>
</div>
</div>
</div>
<div class="nf-after-field"><nf-section>
<div class="nf-input-limit"></div>
<div id="nf-error-341" class="nf-error-wrap nf-error" role="alert"></div>
</nf-section></div>
</div>
</nf-field></nf-fields>
</div>
</nf-cells>
</div>
<div class="nf-row">
<nf-cells>
<div class="nf-cell" style="width: 100%;">
<nf-fields><nf-field>
<div id="nf-field-346-container" class="nf-field-container firstname-container label-above one-half first ">
<div class="nf-before-field"><nf-section>
</nf-section></div>
<div class="nf-field">
<div id="nf-field-346-wrap" class="field-wrap firstname-wrap" data-field-id="346">
<div class="nf-field-label"><label for="nf-field-346" id="nf-label-field-346" class="">First Name <span class="ninja-forms-req-symbol">*</span> </label></div>
<div class="nf-field-element">
<input type="text" value="" class="ninja-forms-field nf-element" id="nf-field-346" name="fname" autocomplete="given-name" aria-invalid="false" aria-describedby="nf-error-346" aria-labelledby="nf-label-field-346" required="">
</div>
</div>
</div>
<div class="nf-after-field"><nf-section>
<div class="nf-input-limit"></div>
<div id="nf-error-346" class="nf-error-wrap nf-error" role="alert"></div>
</nf-section></div>
</div>
</nf-field></nf-fields>
</div>
</nf-cells>
</div>
<div class="nf-row">
<nf-cells>
<div class="nf-cell" style="width: 100%;">
<nf-fields><nf-field>
<div id="nf-field-345-container" class="nf-field-container lastname-container label-above one-half last ">
<div class="nf-before-field"><nf-section>
</nf-section></div>
<div class="nf-field">
<div id="nf-field-345-wrap" class="field-wrap lastname-wrap" data-field-id="345">
<div class="nf-field-label"><label for="nf-field-345" id="nf-label-field-345" class="">Last Name <span class="ninja-forms-req-symbol">*</span> </label></div>
<div class="nf-field-element">
<input type="text" value="" class="ninja-forms-field nf-element" id="nf-field-345" name="lname" autocomplete="family-name" aria-invalid="false" aria-describedby="nf-error-345" aria-labelledby="nf-label-field-345"
required="">
</div>
</div>
</div>
<div class="nf-after-field"><nf-section>
<div class="nf-input-limit"></div>
<div id="nf-error-345" class="nf-error-wrap nf-error" role="alert"></div>
</nf-section></div>
</div>
</nf-field></nf-fields>
</div>
</nf-cells>
</div>
<div class="nf-row">
<nf-cells>
<div class="nf-cell" style="width: 100%;">
<nf-fields><nf-field>
<div id="nf-field-364-container" class="nf-field-container address-container label-above ">
<div class="nf-before-field"><nf-section>
</nf-section></div>
<div class="nf-field">
<div id="nf-field-364-wrap" class="field-wrap address-wrap" data-field-id="364">
<div class="nf-field-label"><label for="nf-field-364" id="nf-label-field-364" class="">Street Address <span class="ninja-forms-req-symbol">*</span> </label></div>
<div class="nf-field-element">
<input type="text" value="" class="ninja-forms-field nf-element" id="nf-field-364" name="address" autocomplete="address-line1" aria-invalid="false" aria-describedby="nf-error-364" aria-labelledby="nf-label-field-364"
required="">
</div>
</div>
</div>
<div class="nf-after-field"><nf-section>
<div class="nf-input-limit"></div>
<div id="nf-error-364" class="nf-error-wrap nf-error" role="alert"></div>
</nf-section></div>
</div>
</nf-field></nf-fields>
</div>
</nf-cells>
</div>
<div class="nf-row">
<nf-cells>
<div class="nf-cell" style="width: 100%;">
<nf-fields><nf-field>
<div id="nf-field-365-container" class="nf-field-container city-container label-above one-half first ">
<div class="nf-before-field"><nf-section>
</nf-section></div>
<div class="nf-field">
<div id="nf-field-365-wrap" class="field-wrap city-wrap" data-field-id="365">
<div class="nf-field-label"><label for="nf-field-365" id="nf-label-field-365" class="">Suburb <span class="ninja-forms-req-symbol">*</span> </label></div>
<div class="nf-field-element">
<input type="text" value="" class="ninja-forms-field nf-element" id="nf-field-365" name="city" autocomplete="address-level2" aria-invalid="false" aria-describedby="nf-error-365" aria-labelledby="nf-label-field-365"
required="">
</div>
</div>
</div>
<div class="nf-after-field"><nf-section>
<div class="nf-input-limit"></div>
<div id="nf-error-365" class="nf-error-wrap nf-error" role="alert"></div>
</nf-section></div>
</div>
</nf-field></nf-fields>
</div>
</nf-cells>
</div>
<div class="nf-row">
<nf-cells>
<div class="nf-cell" style="width: 100%;">
<nf-fields><nf-field>
<div id="nf-field-366-container" class="nf-field-container zip-container label-above one-half last ">
<div class="nf-before-field"><nf-section>
</nf-section></div>
<div class="nf-field">
<div id="nf-field-366-wrap" class="field-wrap zip-wrap" data-field-id="366">
<div class="nf-field-label"><label for="nf-field-366" id="nf-label-field-366" class="">Postcode <span class="ninja-forms-req-symbol">*</span> </label></div>
<div class="nf-field-element">
<input type="text" value="" class="ninja-forms-field nf-element" id="nf-field-366" name="zip" autocomplete="postal-code" aria-invalid="false" aria-describedby="nf-error-366" aria-labelledby="nf-label-field-366" required="">
</div>
</div>
</div>
<div class="nf-after-field"><nf-section>
<div class="nf-input-limit"></div>
<div id="nf-error-366" class="nf-error-wrap nf-error" role="alert"></div>
</nf-section></div>
</div>
</nf-field></nf-fields>
</div>
</nf-cells>
</div>
<div class="nf-row">
<nf-cells>
<div class="nf-cell" style="width: 100%;">
<nf-fields><nf-field>
<div id="nf-field-562-container" class="nf-field-container textbox-container label-above one-half first ">
<div class="nf-before-field"><nf-section>
</nf-section></div>
<div class="nf-field">
<div id="nf-field-562-wrap" class="field-wrap textbox-wrap" data-field-id="562">
<div class="nf-field-label"><label for="nf-field-562" id="nf-label-field-562" class="">Date of Birth <span class="ninja-forms-req-symbol">*</span> </label></div>
<div class="nf-field-element">
<input type="text" value="" class="ninja-forms-field nf-element" id="nf-field-562" name="nf-field-562" aria-invalid="false" aria-describedby="nf-error-562" aria-labelledby="nf-label-field-562" required="">
</div>
</div>
</div>
<div class="nf-after-field"><nf-section>
<div class="nf-input-limit"></div>
<div id="nf-error-562" class="nf-error-wrap nf-error" role="alert"></div>
</nf-section></div>
</div>
</nf-field></nf-fields>
</div>
</nf-cells>
</div>
<div class="nf-row">
<nf-cells>
<div class="nf-cell" style="width: 100%;">
<nf-fields><nf-field>
<div id="nf-field-367-container" class="nf-field-container number-container label-above one-half last ">
<div class="nf-before-field"><nf-section>
</nf-section></div>
<div class="nf-field">
<div id="nf-field-367-wrap" class="field-wrap number-wrap" data-field-id="367">
<div class="nf-field-label"><label for="nf-field-367" id="nf-label-field-367" class="">Age <span class="ninja-forms-req-symbol">*</span> </label></div>
<div class="nf-field-element">
<input id="nf-field-367" name="nf-field-367" aria-invalid="false" aria-describedby="nf-error-367" class="ninja-forms-field nf-element" aria-labelledby="nf-label-field-367" required="" type="number" value="" min="" max=""
step="1">
</div>
</div>
</div>
<div class="nf-after-field"><nf-section>
<div class="nf-input-limit"></div>
<div id="nf-error-367" class="nf-error-wrap nf-error" role="alert"></div>
</nf-section></div>
</div>
</nf-field></nf-fields>
</div>
</nf-cells>
</div>
<div class="nf-row">
<nf-cells>
<div class="nf-cell" style="width: 100%;">
<nf-fields><nf-field>
<div id="nf-field-368-container" class="nf-field-container phone-container label-above one-half first textbox-container">
<div class="nf-before-field"><nf-section>
</nf-section></div>
<div class="nf-field">
<div id="nf-field-368-wrap" class="field-wrap phone-wrap textbox-wrap" data-field-id="368">
<div class="nf-field-label"><label for="nf-field-368" id="nf-label-field-368" class="">Mobile Phone <span class="ninja-forms-req-symbol">*</span> </label></div>
<div class="nf-field-element">
<input type="tel" value="" class="ninja-forms-field nf-element" id="nf-field-368" name="phone" autocomplete="tel" aria-invalid="false" aria-describedby="nf-error-368" aria-labelledby="nf-label-field-368" required="">
</div>
</div>
</div>
<div class="nf-after-field"><nf-section>
<div class="nf-input-limit"></div>
<div id="nf-error-368" class="nf-error-wrap nf-error" role="alert"></div>
</nf-section></div>
</div>
</nf-field></nf-fields>
</div>
</nf-cells>
</div>
<div class="nf-row">
<nf-cells>
<div class="nf-cell" style="width: 100%;">
<nf-fields><nf-field>
<div id="nf-field-369-container" class="nf-field-container phone-container label-above one-half last textbox-container">
<div class="nf-before-field"><nf-section>
</nf-section></div>
<div class="nf-field">
<div id="nf-field-369-wrap" class="field-wrap phone-wrap textbox-wrap" data-field-id="369">
<div class="nf-field-label"><label for="nf-field-369" id="nf-label-field-369" class="">Landline Phone </label></div>
<div class="nf-field-element">
<input type="tel" value="" class="ninja-forms-field nf-element" id="nf-field-369" name="phone" autocomplete="tel" aria-invalid="false" aria-describedby="nf-error-369" aria-labelledby="nf-label-field-369">
</div>
</div>
</div>
<div class="nf-after-field"><nf-section>
<div class="nf-input-limit"></div>
<div id="nf-error-369" class="nf-error-wrap nf-error" role="alert"></div>
</nf-section></div>
</div>
</nf-field></nf-fields>
</div>
</nf-cells>
</div>
<div class="nf-row">
<nf-cells>
<div class="nf-cell" style="width: 100%;">
<nf-fields><nf-field>
<div id="nf-field-370-container" class="nf-field-container email-container label-above ">
<div class="nf-before-field"><nf-section>
</nf-section></div>
<div class="nf-field">
<div id="nf-field-370-wrap" class="field-wrap email-wrap" data-field-id="370">
<div class="nf-field-label"><label for="nf-field-370" id="nf-label-field-370" class="">Email </label></div>
<div class="nf-field-element">
<input type="email" value="" class="ninja-forms-field nf-element" id="nf-field-370" name="email" autocomplete="email" aria-invalid="false" aria-describedby="nf-error-370" aria-labelledby="nf-label-field-370">
</div>
</div>
</div>
<div class="nf-after-field"><nf-section>
<div class="nf-input-limit"></div>
<div id="nf-error-370" class="nf-error-wrap nf-error" role="alert"></div>
</nf-section></div>
</div>
</nf-field></nf-fields>
</div>
</nf-cells>
</div>
<div class="nf-row">
<nf-cells>
<div class="nf-cell" style="width: 100%;">
<nf-fields><nf-field>
<div id="nf-field-393-container" class="nf-field-container listradio-container label-above two-col-list list-container">
<div class="nf-before-field"><nf-section>
</nf-section></div>
<div class="nf-field">
<div id="nf-field-393-wrap" class="field-wrap listradio-wrap list-wrap list-radio-wrap" data-field-id="393">
<div class="nf-field-label"><label for="nf-field-393" id="nf-label-field-393" class="">Gender <span class="ninja-forms-req-symbol">*</span> </label></div>
<div class="nf-field-element">
<ul aria-describedby="nf-error-393">
<li>
<input type="radio" id="nf-field-393-0" name="nf-field-393" class="ninja-forms-field nf-element " value="male" aria-labelledby="nf-label-class-field-393-0" required="">
<label for="nf-field-393-0" id="nf-label-class-field-393-0" class="">Male</label>
</li>
<li>
<input type="radio" id="nf-field-393-1" name="nf-field-393" class="ninja-forms-field nf-element " value="female" aria-labelledby="nf-label-class-field-393-1" required="">
<label for="nf-field-393-1" id="nf-label-class-field-393-1" class="">Female</label>
</li>
<li>
<input type="radio" id="nf-field-393-2" name="nf-field-393" class="ninja-forms-field nf-element " value="non-binary-gender-fluid" aria-labelledby="nf-label-class-field-393-2" required="">
<label for="nf-field-393-2" id="nf-label-class-field-393-2" class="">Non-Binary/Gender Fluid</label>
</li>
<li>
<input type="radio" id="nf-field-393-3" name="nf-field-393" class="ninja-forms-field nf-element " value="different-identity-please-specify-below" aria-labelledby="nf-label-class-field-393-3" required="">
<label for="nf-field-393-3" id="nf-label-class-field-393-3" class="">Different Identity (please specify below)</label>
</li>
</ul>
</div>
</div>
</div>
<div class="nf-after-field"><nf-section>
<div class="nf-input-limit"></div>
<div id="nf-error-393" class="nf-error-wrap nf-error" role="alert"></div>
</nf-section></div>
</div>
</nf-field></nf-fields>
</div>
</nf-cells>
</div>
<div class="nf-row">
<nf-cells>
<div class="nf-cell" style="width: 100%;">
<nf-fields><nf-field>
<div id="nf-field-356-container" class="nf-field-container textbox-container label-hidden ">
<div class="nf-before-field"><nf-section>
</nf-section></div>
<div class="nf-field">
<div id="nf-field-356-wrap" class="field-wrap textbox-wrap" data-field-id="356">
<div class="nf-field-label"><label for="nf-field-356" id="nf-label-field-356" class="">Other Response </label></div>
<div class="nf-field-element">
<input type="text" value="" class="ninja-forms-field nf-element" id="nf-field-356" name="nf-field-356" aria-invalid="false" aria-describedby="nf-error-356" aria-labelledby="nf-label-field-356">
</div>
</div>
</div>
<div class="nf-after-field"><nf-section>
<div class="nf-input-limit"></div>
<div id="nf-error-356" class="nf-error-wrap nf-error" role="alert"></div>
</nf-section></div>
</div>
</nf-field></nf-fields>
</div>
</nf-cells>
</div>
<div class="nf-row">
<nf-cells>
<div class="nf-cell" style="width: 100%;">
<nf-fields><nf-field>
<div id="nf-field-387-container" class="nf-field-container listradio-container label-above two-col-list list-container">
<div class="nf-before-field"><nf-section>
</nf-section></div>
<div class="nf-field">
<div id="nf-field-387-wrap" class="field-wrap listradio-wrap list-wrap list-radio-wrap" data-field-id="387">
<div class="nf-field-label"><label for="nf-field-387" id="nf-label-field-387" class="">Identifies As <span class="ninja-forms-req-symbol">*</span> </label></div>
<div class="nf-field-element">
<ul aria-describedby="nf-error-387">
<li>
<input type="radio" id="nf-field-387-0" name="nf-field-387" class="ninja-forms-field nf-element " value="aboriginal-but-not-torres-strait-islander" aria-labelledby="nf-label-class-field-387-0" required="">
<label for="nf-field-387-0" id="nf-label-class-field-387-0" class="">Aboriginal but NOT Torres Strait Islander</label>
</li>
<li>
<input type="radio" id="nf-field-387-1" name="nf-field-387" class="ninja-forms-field nf-element " value="both-aboriginal-and-torres-strait-islander" aria-labelledby="nf-label-class-field-387-1" required="">
<label for="nf-field-387-1" id="nf-label-class-field-387-1" class="">BOTH Aboriginal & Torres Strait Islander</label>
</li>
<li>
<input type="radio" id="nf-field-387-2" name="nf-field-387" class="ninja-forms-field nf-element " value="neither-aboriginal-or-torres-strait-islander" aria-labelledby="nf-label-class-field-387-2" required="">
<label for="nf-field-387-2" id="nf-label-class-field-387-2" class="">NEITHER Aboriginal or Torres Strait Islander</label>
</li>
<li>
<input type="radio" id="nf-field-387-3" name="nf-field-387" class="ninja-forms-field nf-element " value="torres-strait-islander-but-not-origin" aria-labelledby="nf-label-class-field-387-3" required="">
<label for="nf-field-387-3" id="nf-label-class-field-387-3" class="">Torres Strait Islander but NOT origin</label>
</li>
<li>
<input type="radio" id="nf-field-387-4" name="nf-field-387" class="ninja-forms-field nf-element " value="not-stated-adequately-described" aria-labelledby="nf-label-class-field-387-4" required="">
<label for="nf-field-387-4" id="nf-label-class-field-387-4" class="">NOT stated/adequately described</label>
</li>
</ul>
</div>
</div>
</div>
<div class="nf-after-field"><nf-section>
<div class="nf-input-limit"></div>
<div id="nf-error-387" class="nf-error-wrap nf-error" role="alert"></div>
</nf-section></div>
</div>
</nf-field></nf-fields>
</div>
</nf-cells>
</div>
<div class="nf-row">
<nf-cells>
<div class="nf-cell" style="width: 100%;">
<nf-fields><nf-field>
<div id="nf-field-371-container" class="nf-field-container textbox-container label-above one-half first ">
<div class="nf-before-field"><nf-section>
</nf-section></div>
<div class="nf-field">
<div id="nf-field-371-wrap" class="field-wrap textbox-wrap" data-field-id="371">
<div class="nf-field-label"><label for="nf-field-371" id="nf-label-field-371" class="">Mob or Country </label></div>
<div class="nf-field-element">
<input type="text" value="" class="ninja-forms-field nf-element" id="nf-field-371" name="nf-field-371" aria-invalid="false" aria-describedby="nf-error-371" aria-labelledby="nf-label-field-371">
</div>
</div>
</div>
<div class="nf-after-field"><nf-section>
<div class="nf-input-limit"></div>
<div id="nf-error-371" class="nf-error-wrap nf-error" role="alert"></div>
</nf-section></div>
</div>
</nf-field></nf-fields>
</div>
</nf-cells>
</div>
<div class="nf-row">
<nf-cells>
<div class="nf-cell" style="width: 100%;">
<nf-fields><nf-field>
<div id="nf-field-372-container" class="nf-field-container textbox-container label-above one-half last ">
<div class="nf-before-field"><nf-section>
</nf-section></div>
<div class="nf-field">
<div id="nf-field-372-wrap" class="field-wrap textbox-wrap" data-field-id="372">
<div class="nf-field-label"><label for="nf-field-372" id="nf-label-field-372" class="">Country of Birth </label></div>
<div class="nf-field-element">
<input type="text" value="" class="ninja-forms-field nf-element" id="nf-field-372" name="nf-field-372" aria-invalid="false" aria-describedby="nf-error-372" aria-labelledby="nf-label-field-372">
</div>
</div>
</div>
<div class="nf-after-field"><nf-section>
<div class="nf-input-limit"></div>
<div id="nf-error-372" class="nf-error-wrap nf-error" role="alert"></div>
</nf-section></div>
</div>
</nf-field></nf-fields>
</div>
</nf-cells>
</div>
<div class="nf-row">
<nf-cells>
<div class="nf-cell" style="width: 100%;">
<nf-fields><nf-field>
<div id="nf-field-373-container" class="nf-field-container listradio-container label-above two-col-list list-container">
<div class="nf-before-field"><nf-section>
</nf-section></div>
<div class="nf-field">
<div id="nf-field-373-wrap" class="field-wrap listradio-wrap list-wrap list-radio-wrap" data-field-id="373">
<div class="nf-field-label"><label for="nf-field-373" id="nf-label-field-373" class="">Is an Interpreter Required </label></div>
<div class="nf-field-element">
<ul aria-describedby="nf-error-373">
<li>
<input type="radio" id="nf-field-373-0" name="nf-field-373" class="ninja-forms-field nf-element " value="yes" aria-labelledby="nf-label-class-field-373-0">
<label for="nf-field-373-0" id="nf-label-class-field-373-0" class="">Yes</label>
</li>
<li>
<input type="radio" id="nf-field-373-1" name="nf-field-373" class="ninja-forms-field nf-element " value="no" aria-labelledby="nf-label-class-field-373-1">
<label for="nf-field-373-1" id="nf-label-class-field-373-1" class="">No</label>
</li>
</ul>
</div>
</div>
</div>
<div class="nf-after-field"><nf-section>
<div class="nf-input-limit"></div>
<div id="nf-error-373" class="nf-error-wrap nf-error" role="alert"></div>
</nf-section></div>
</div>
</nf-field></nf-fields>
</div>
</nf-cells>
</div>
<div class="nf-row">
<nf-cells>
<div class="nf-cell" style="width: 100%;">
<nf-fields><nf-field>
</nf-field></nf-fields>
</div>
</nf-cells>
</div>
<div class="nf-row">
<nf-cells>
<div class="nf-cell" style="width: 100%;">
<nf-fields><nf-field>
<div id="nf-field-375-container" class="nf-field-container listradio-container label-above two-col-list list-container">
<div class="nf-before-field"><nf-section>
</nf-section></div>
<div class="nf-field">
<div id="nf-field-375-wrap" class="field-wrap listradio-wrap list-wrap list-radio-wrap" data-field-id="375">
<div class="nf-field-label"><label for="nf-field-375" id="nf-label-field-375" class="">Resident of Australia </label></div>
<div class="nf-field-element">
<ul aria-describedby="nf-error-375">
<li>
<input type="radio" id="nf-field-375-0" name="nf-field-375" class="ninja-forms-field nf-element " value="yes" aria-labelledby="nf-label-class-field-375-0">
<label for="nf-field-375-0" id="nf-label-class-field-375-0" class="">Yes</label>
</li>
<li>
<input type="radio" id="nf-field-375-1" name="nf-field-375" class="ninja-forms-field nf-element " value="no" aria-labelledby="nf-label-class-field-375-1">
<label for="nf-field-375-1" id="nf-label-class-field-375-1" class="">No</label>
</li>
</ul>
</div>
</div>
</div>
<div class="nf-after-field"><nf-section>
<div class="nf-input-limit"></div>
<div id="nf-error-375" class="nf-error-wrap nf-error" role="alert"></div>
</nf-section></div>
</div>
</nf-field></nf-fields>
</div>
</nf-cells>
</div>
<div class="nf-row">
<nf-cells>
<div class="nf-cell" style="width: 100%;">
<nf-fields><nf-field>
<div id="nf-field-362-container" class="nf-field-container hr-container label-above ">
<div class="nf-before-field"><nf-section>
</nf-section></div>
<div class="nf-field">
<div id="nf-field-362-wrap" class="field-wrap hr-wrap" data-field-id="362">
<div class="nf-field-label"><label for="nf-field-362" id="nf-label-field-362" class="">Divider </label></div>
<div class="nf-field-element">
<hr class="ninja-forms-field">
</div>
</div>
</div>
<div class="nf-after-field"><nf-section>
<div class="nf-input-limit"></div>
<div id="nf-error-362" class="nf-error-wrap nf-error" role="alert"></div>
</nf-section></div>
</div>
</nf-field></nf-fields>
</div>
</nf-cells>
</div>
<div class="nf-row">
<nf-cells>
<div class="nf-cell" style="width: 100%;">
<nf-fields><nf-field>
<div id="nf-field-376-container" class="nf-field-container listradio-container label-above two-col-list list-container">
<div class="nf-before-field"><nf-section>
</nf-section></div>
<div class="nf-field">
<div id="nf-field-376-wrap" class="field-wrap listradio-wrap list-wrap list-radio-wrap" data-field-id="376">
<div class="nf-field-label"><label for="nf-field-376" id="nf-label-field-376" class="">The person has a diagnosed mental illness that is severe in degree <span class="ninja-forms-req-symbol">*</span> </label></div>
<div class="nf-field-element">
<ul aria-describedby="nf-error-376">
<li>
<input type="radio" id="nf-field-376-0" name="nf-field-376" class="ninja-forms-field nf-element " value="yes" aria-labelledby="nf-label-class-field-376-0" required="">
<label for="nf-field-376-0" id="nf-label-class-field-376-0" class="">Yes</label>
</li>
<li>
<input type="radio" id="nf-field-376-1" name="nf-field-376" class="ninja-forms-field nf-element " value="no" aria-labelledby="nf-label-class-field-376-1" required="">
<label for="nf-field-376-1" id="nf-label-class-field-376-1" class="">No</label>
</li>
</ul>
</div>
</div>
</div>
<div class="nf-after-field"><nf-section>
<div class="nf-input-limit"></div>
<div id="nf-error-376" class="nf-error-wrap nf-error" role="alert"></div>
</nf-section></div>
</div>
</nf-field></nf-fields>
</div>
</nf-cells>
</div>
<div class="nf-row">
<nf-cells>
<div class="nf-cell" style="width: 100%;">
<nf-fields><nf-field>
</nf-field></nf-fields>
</div>
</nf-cells>
</div>
<div class="nf-row">
<nf-cells>
<div class="nf-cell" style="width: 100%;">
<nf-fields><nf-field>
</nf-field></nf-fields>
</div>
</nf-cells>
</div>
<div class="nf-row">
<nf-cells>
<div class="nf-cell" style="width: 100%;">
<nf-fields><nf-field>
<div id="nf-field-363-container" class="nf-field-container listradio-container label-above two-col-list list-container">
<div class="nf-before-field"><nf-section>
</nf-section></div>
<div class="nf-field">
<div id="nf-field-363-wrap" class="field-wrap listradio-wrap list-wrap list-radio-wrap" data-field-id="363">
<div class="nf-field-label"><label for="nf-field-363" id="nf-label-field-363" class="">Is the person a participant of the NDIS? </label></div>
<div class="nf-field-element">
<ul aria-describedby="nf-error-363">
<li>
<input type="radio" id="nf-field-363-0" name="nf-field-363" class="ninja-forms-field nf-element " value="yes" aria-labelledby="nf-label-class-field-363-0">
<label for="nf-field-363-0" id="nf-label-class-field-363-0" class="">Yes</label>
</li>
<li>
<input type="radio" id="nf-field-363-1" name="nf-field-363" class="ninja-forms-field nf-element " value="no" aria-labelledby="nf-label-class-field-363-1">
<label for="nf-field-363-1" id="nf-label-class-field-363-1" class="">No</label>
</li>
</ul>
</div>
</div>
</div>
<div class="nf-after-field"><nf-section>
<div class="nf-input-limit"></div>
<div id="nf-error-363" class="nf-error-wrap nf-error" role="alert"></div>
</nf-section></div>
</div>
</nf-field></nf-fields>
</div>
</nf-cells>
</div>
<div class="nf-row">
<nf-cells>
<div class="nf-cell" style="width: 100%;">
<nf-fields><nf-field>
<div id="nf-field-358-container" class="nf-field-container listradio-container label-above two-col-list list-container">
<div class="nf-before-field"><nf-section>
</nf-section></div>
<div class="nf-field">
<div id="nf-field-358-wrap" class="field-wrap listradio-wrap list-wrap list-radio-wrap" data-field-id="358">
<div class="nf-field-label"><label for="nf-field-358" id="nf-label-field-358" class="">Is the person currently receiving support from NPS - Extension or Continuity of Supports? </label></div>
<div class="nf-field-element">
<ul aria-describedby="nf-error-358">
<li>
<input type="radio" id="nf-field-358-0" name="nf-field-358" class="ninja-forms-field nf-element " value="yes" aria-labelledby="nf-label-class-field-358-0">
<label for="nf-field-358-0" id="nf-label-class-field-358-0" class="">Yes</label>
</li>
<li>
<input type="radio" id="nf-field-358-1" name="nf-field-358" class="ninja-forms-field nf-element " value="no" aria-labelledby="nf-label-class-field-358-1">
<label for="nf-field-358-1" id="nf-label-class-field-358-1" class="">No</label>
</li>
</ul>
</div>
</div>
</div>
<div class="nf-after-field"><nf-section>
<div class="nf-input-limit"></div>
<div id="nf-error-358" class="nf-error-wrap nf-error" role="alert"></div>
</nf-section></div>
</div>
</nf-field></nf-fields>
</div>
</nf-cells>
</div>
<div class="nf-row">
<nf-cells>
<div class="nf-cell" style="width: 100%;">
<nf-fields><nf-field>
<div id="nf-field-357-container" class="nf-field-container listradio-container label-above two-col-list list-container">
<div class="nf-before-field"><nf-section>
</nf-section></div>
<div class="nf-field">
<div id="nf-field-357-wrap" class="field-wrap listradio-wrap list-wrap list-radio-wrap" data-field-id="357">
<div class="nf-field-label"><label for="nf-field-357" id="nf-label-field-357" class="">Is the person currently a client of Community Living Support (CLS) or Housing and Support Initiative (HASI)? </label></div>
<div class="nf-field-element">
<ul aria-describedby="nf-error-357">
<li>
<input type="radio" id="nf-field-357-0" name="nf-field-357" class="ninja-forms-field nf-element " value="yes" aria-labelledby="nf-label-class-field-357-0">
<label for="nf-field-357-0" id="nf-label-class-field-357-0" class="">Yes</label>
</li>
<li>
<input type="radio" id="nf-field-357-1" name="nf-field-357" class="ninja-forms-field nf-element " value="no" aria-labelledby="nf-label-class-field-357-1">
<label for="nf-field-357-1" id="nf-label-class-field-357-1" class="">No</label>
</li>
</ul>
</div>
</div>
</div>
<div class="nf-after-field"><nf-section>
<div class="nf-input-limit"></div>
<div id="nf-error-357" class="nf-error-wrap nf-error" role="alert"></div>
</nf-section></div>
</div>
</nf-field></nf-fields>
</div>
</nf-cells>
</div>
<div class="nf-row">
<nf-cells>
<div class="nf-cell" style="width: 100%;">
<nf-fields><nf-field>
<div id="nf-field-389-container" class="nf-field-container listcheckbox-container label-above two-col-list list-container">
<div class="nf-before-field"><nf-section>
</nf-section></div>
<div class="nf-field">
<div id="nf-field-389-wrap" class="field-wrap listcheckbox-wrap list-wrap list-checkbox-wrap" data-field-id="389">
<div class="nf-field-label"><label for="nf-field-389" id="nf-label-field-389" class="">What psychosocial areas are significantly impacted by their mental illness? (select all that apply) <span
class="ninja-forms-req-symbol">*</span> </label></div>
<div class="nf-field-element">
<ul aria-describedby="nf-error-389">
<li>
<input type="checkbox" id="nf-field-389-0" name="nf-field-389" class="ninja-forms-field nf-element " value="social-skills-and-friendships" aria-labelledby="nf-label-field-389-0" required="">
<label for="nf-field-389-0" id="nf-label-field-389-0" class="">Social skills and friendships</label>
</li>
<li>
<input type="checkbox" id="nf-field-389-1" name="nf-field-389" class="ninja-forms-field nf-element " value="vocational-skills-and-goals" aria-labelledby="nf-label-field-389-1" required="">
<label for="nf-field-389-1" id="nf-label-field-389-1" class="">Vocational skills and goals</label>
</li>
<li>
<input type="checkbox" id="nf-field-389-2" name="nf-field-389" class="ninja-forms-field nf-element " value="education-and-training" aria-labelledby="nf-label-field-389-2" required="">
<label for="nf-field-389-2" id="nf-label-field-389-2" class="">Education and training</label>
</li>
<li>
<input type="checkbox" id="nf-field-389-3" name="nf-field-389" class="ninja-forms-field nf-element " value="maintaining-physical-wellbeing" aria-labelledby="nf-label-field-389-3" required="">
<label for="nf-field-389-3" id="nf-label-field-389-3" class="">Maintaining physical wellbeing</label>
</li>
<li>
<input type="checkbox" id="nf-field-389-4" name="nf-field-389" class="ninja-forms-field nf-element " value="daily-living-needs" aria-labelledby="nf-label-field-389-4" required="">
<label for="nf-field-389-4" id="nf-label-field-389-4" class="">Daily living needs</label>
</li>
<li>
<input type="checkbox" id="nf-field-389-5" name="nf-field-389" class="ninja-forms-field nf-element " value="building-broader-life-skills" aria-labelledby="nf-label-field-389-5" required="">
<label for="nf-field-389-5" id="nf-label-field-389-5" class="">Building broader life skills</label>
</li>
<li>
<input type="checkbox" id="nf-field-389-6" name="nf-field-389" class="ninja-forms-field nf-element " value="family-connections" aria-labelledby="nf-label-field-389-6" required="">
<label for="nf-field-389-6" id="nf-label-field-389-6" class="">Family connections</label>
</li>
<li>
<input type="checkbox" id="nf-field-389-7" name="nf-field-389" class="ninja-forms-field nf-element " value="financial-management-and-budgeting" aria-labelledby="nf-label-field-389-7" required="">
<label for="nf-field-389-7" id="nf-label-field-389-7" class="">Financial management and budgeting</label>
</li>
<li>
<input type="checkbox" id="nf-field-389-8" name="nf-field-389" class="ninja-forms-field nf-element " value="finding-and-managing-a-home" aria-labelledby="nf-label-field-389-8" required="">
<label for="nf-field-389-8" id="nf-label-field-389-8" class="">Finding and managing a home</label>
</li>
<li>
<input type="checkbox" id="nf-field-389-9" name="nf-field-389" class="ninja-forms-field nf-element " value="managing-drug-and-alcohol-addiction-including-tobacco" aria-labelledby="nf-label-field-389-9" required="">
<label for="nf-field-389-9" id="nf-label-field-389-9" class="">Managing drug and alcohol addiction, including tobacco</label>
</li>
</ul>
</div>
</div>
</div>
<div class="nf-after-field"><nf-section>
<div class="nf-input-limit"></div>
<div id="nf-error-389" class="nf-error-wrap nf-error" role="alert"></div>
</nf-section></div>
</div>
</nf-field></nf-fields>
</div>
</nf-cells>
</div>
<div class="nf-row">
<nf-cells>
<div class="nf-cell" style="width: 100%;">
<nf-fields><nf-field>
<div id="nf-field-360-container" class="nf-field-container listradio-container label-above two-col-list list-container">
<div class="nf-before-field"><nf-section>
</nf-section></div>
<div class="nf-field">
<div id="nf-field-360-wrap" class="field-wrap listradio-wrap list-wrap list-radio-wrap" data-field-id="360">
<div class="nf-field-label"><label for="nf-field-360" id="nf-label-field-360" class="">Does the person have barriers to engaging with services at this time? </label></div>
<div class="nf-field-element">
<ul aria-describedby="nf-error-360">
<li>
<input type="radio" id="nf-field-360-0" name="nf-field-360" class="ninja-forms-field nf-element " value="yes" aria-labelledby="nf-label-class-field-360-0">
<label for="nf-field-360-0" id="nf-label-class-field-360-0" class="">Yes</label>
</li>
<li>
<input type="radio" id="nf-field-360-1" name="nf-field-360" class="ninja-forms-field nf-element " value="no" aria-labelledby="nf-label-class-field-360-1">
<label for="nf-field-360-1" id="nf-label-class-field-360-1" class="">No</label>
</li>
</ul>
</div>
</div>
</div>
<div class="nf-after-field"><nf-section>
<div class="nf-input-limit"></div>
<div id="nf-error-360" class="nf-error-wrap nf-error" role="alert"></div>
</nf-section></div>
</div>
</nf-field></nf-fields>
</div>
</nf-cells>
</div>
<div class="nf-row">
<nf-cells>
<div class="nf-cell" style="width: 100%;">
<nf-fields><nf-field>
<div id="nf-field-352-container" class="nf-field-container listradio-container label-above two-col-list list-container">
<div class="nf-before-field"><nf-section>
</nf-section></div>
<div class="nf-field">
<div id="nf-field-352-wrap" class="field-wrap listradio-wrap list-wrap list-radio-wrap" data-field-id="352">
<div class="nf-field-label"><label for="nf-field-352" id="nf-label-field-352" class="">Person (or Guardian) has consented to be involved with CPS <span class="ninja-forms-req-symbol">*</span> </label></div>
<div class="nf-field-element">
<ul aria-describedby="nf-error-352">
<li>
<input type="radio" id="nf-field-352-0" name="nf-field-352" class="ninja-forms-field nf-element " value="yes" aria-labelledby="nf-label-class-field-352-0" required="">
<label for="nf-field-352-0" id="nf-label-class-field-352-0" class="">Yes</label>
</li>
<li>
<input type="radio" id="nf-field-352-1" name="nf-field-352" class="ninja-forms-field nf-element " value="no" aria-labelledby="nf-label-class-field-352-1" required="">
<label for="nf-field-352-1" id="nf-label-class-field-352-1" class="">No</label>
</li>
</ul>
</div>
</div>
</div>
<div class="nf-after-field"><nf-section>
<div class="nf-input-limit"></div>
<div id="nf-error-352" class="nf-error-wrap nf-error" role="alert"></div>
</nf-section></div>
</div>
</nf-field></nf-fields>
</div>
</nf-cells>
</div>
<div class="nf-row">
<nf-cells>
<div class="nf-cell" style="width: 100%;">
<nf-fields><nf-field>
<div id="nf-field-454-container" class="nf-field-container textarea-container label-above ">
<div class="nf-before-field"><nf-section>
</nf-section></div>
<div class="nf-field">
<div id="nf-field-454-wrap" class="field-wrap textarea-wrap" data-field-id="454">
<div class="nf-field-label"><label for="nf-field-454" id="nf-label-field-454" class="">How would the person benefit from a referral to CPS? <span class="ninja-forms-req-symbol">*</span> </label></div>
<div class="nf-field-element">
<textarea id="nf-field-454" name="nf-field-454" aria-invalid="false" aria-describedby="nf-error-454" class="ninja-forms-field nf-element" aria-labelledby="nf-label-field-454" required=""></textarea>
</div>
</div>
</div>
<div class="nf-after-field"><nf-section>
<div class="nf-input-limit"></div>
<div id="nf-error-454" class="nf-error-wrap nf-error" role="alert"></div>
</nf-section></div>
</div>
</nf-field></nf-fields>
</div>
</nf-cells>
</div>
<div class="nf-row">
<nf-cells>
<div class="nf-cell" style="width: 100%;">
<nf-fields><nf-field>
<div id="nf-field-585-container" class="nf-field-container listradio-container label-above two-col-list list-container">
<div class="nf-before-field"><nf-section>
</nf-section></div>
<div class="nf-field">
<div id="nf-field-585-wrap" class="field-wrap listradio-wrap list-wrap list-radio-wrap" data-field-id="585">
<div class="nf-field-label"><label for="nf-field-585" id="nf-label-field-585" class="">Is the person in hospital at the time of referral? </label></div>
<div class="nf-field-element">
<ul aria-describedby="nf-error-585">
<li>
<input type="radio" id="nf-field-585-0" name="nf-field-585" class="ninja-forms-field nf-element " value="yes" aria-labelledby="nf-label-class-field-585-0">
<label for="nf-field-585-0" id="nf-label-class-field-585-0" class="">Yes</label>
</li>
<li>
<input type="radio" id="nf-field-585-1" name="nf-field-585" class="ninja-forms-field nf-element " value="no" aria-labelledby="nf-label-class-field-585-1">
<label for="nf-field-585-1" id="nf-label-class-field-585-1" class="">No</label>
</li>
</ul>
</div>
</div>
</div>
<div class="nf-after-field"><nf-section>
<div class="nf-input-limit"></div>
<div id="nf-error-585" class="nf-error-wrap nf-error" role="alert"></div>
</nf-section></div>
</div>
</nf-field></nf-fields>
</div>
</nf-cells>
</div>
<div class="nf-row">
<nf-cells>
<div class="nf-cell" style="width: 100%;">
<nf-fields><nf-field>
</nf-field></nf-fields>
</div>
</nf-cells>
</div>
<div class="nf-row">
<nf-cells>
<div class="nf-cell" style="width: 100%;">
<nf-fields><nf-field>
<div id="nf-field-361-container" class="nf-field-container hr-container label-above ">
<div class="nf-before-field"><nf-section>
</nf-section></div>
<div class="nf-field">
<div id="nf-field-361-wrap" class="field-wrap hr-wrap" data-field-id="361">
<div class="nf-field-label"><label for="nf-field-361" id="nf-label-field-361" class="">Divider </label></div>
<div class="nf-field-element">
<hr class="ninja-forms-field">
</div>
</div>
</div>
<div class="nf-after-field"><nf-section>
<div class="nf-input-limit"></div>
<div id="nf-error-361" class="nf-error-wrap nf-error" role="alert"></div>
</nf-section></div>
</div>
</nf-field></nf-fields>
</div>
</nf-cells>
</div>
<div class="nf-row">
<nf-cells>
<div class="nf-cell" style="width: 100%;">
<nf-fields><nf-field>
<div id="nf-field-351-container" class="nf-field-container html-container label-above ">
<div class="nf-before-field"><nf-section>
</nf-section></div>
<div class="nf-field">
<div id="nf-field-351-wrap" class="field-wrap html-wrap" data-field-id="351">
<div class="nf-field-label"><label for="nf-field-351" id="nf-label-field-351" class="">Referrer's Details </label></div>
<div class="nf-field-element">
<h2 style="text-align: left;">Referrer's Details</h2>
</div>
</div>
</div>
<div class="nf-after-field"><nf-section>
<div class="nf-input-limit"></div>
<div id="nf-error-351" class="nf-error-wrap nf-error" role="alert"></div>
</nf-section></div>
</div>
</nf-field></nf-fields>
</div>
</nf-cells>
</div>
<div class="nf-row">
<nf-cells>
<div class="nf-cell" style="width: 100%;">
<nf-fields><nf-field>
<div id="nf-field-350-container" class="nf-field-container textbox-container label-above one-half first ">
<div class="nf-before-field"><nf-section>
</nf-section></div>
<div class="nf-field">
<div id="nf-field-350-wrap" class="field-wrap textbox-wrap" data-field-id="350">
<div class="nf-field-label"><label for="nf-field-350" id="nf-label-field-350" class="">Name </label></div>
<div class="nf-field-element">
<input type="text" value="" class="ninja-forms-field nf-element" id="nf-field-350" name="nf-field-350" aria-invalid="false" aria-describedby="nf-error-350" aria-labelledby="nf-label-field-350">
</div>
</div>
</div>
<div class="nf-after-field"><nf-section>
<div class="nf-input-limit"></div>
<div id="nf-error-350" class="nf-error-wrap nf-error" role="alert"></div>
</nf-section></div>
</div>
</nf-field></nf-fields>
</div>
</nf-cells>
</div>
<div class="nf-row">
<nf-cells>
<div class="nf-cell" style="width: 100%;">
<nf-fields><nf-field>
<div id="nf-field-349-container" class="nf-field-container textbox-container label-above one-half last ">
<div class="nf-before-field"><nf-section>
</nf-section></div>
<div class="nf-field">
<div id="nf-field-349-wrap" class="field-wrap textbox-wrap" data-field-id="349">
<div class="nf-field-label"><label for="nf-field-349" id="nf-label-field-349" class="">Organisation </label></div>
<div class="nf-field-element">
<input type="text" value="" class="ninja-forms-field nf-element" id="nf-field-349" name="nf-field-349" aria-invalid="false" aria-describedby="nf-error-349" aria-labelledby="nf-label-field-349">
</div>
</div>
</div>
<div class="nf-after-field"><nf-section>
<div class="nf-input-limit"></div>
<div id="nf-error-349" class="nf-error-wrap nf-error" role="alert"></div>
</nf-section></div>
</div>
</nf-field></nf-fields>
</div>
</nf-cells>
</div>
<div class="nf-row">
<nf-cells>
<div class="nf-cell" style="width: 100%;">
<nf-fields><nf-field>
<div id="nf-field-344-container" class="nf-field-container address-container label-above ">
<div class="nf-before-field"><nf-section>
</nf-section></div>
<div class="nf-field">
<div id="nf-field-344-wrap" class="field-wrap address-wrap" data-field-id="344">
<div class="nf-field-label"><label for="nf-field-344" id="nf-label-field-344" class="">Street Address </label></div>
<div class="nf-field-element">
<input type="text" value="" class="ninja-forms-field nf-element" id="nf-field-344" name="address" autocomplete="address-line1" aria-invalid="false" aria-describedby="nf-error-344" aria-labelledby="nf-label-field-344">
</div>
</div>
</div>
<div class="nf-after-field"><nf-section>
<div class="nf-input-limit"></div>
<div id="nf-error-344" class="nf-error-wrap nf-error" role="alert"></div>
</nf-section></div>
</div>
</nf-field></nf-fields>
</div>
</nf-cells>
</div>
<div class="nf-row">
<nf-cells>
<div class="nf-cell" style="width: 100%;">
<nf-fields><nf-field>
<div id="nf-field-342-container" class="nf-field-container city-container label-above one-half first ">
<div class="nf-before-field"><nf-section>
</nf-section></div>
<div class="nf-field">
<div id="nf-field-342-wrap" class="field-wrap city-wrap" data-field-id="342">
<div class="nf-field-label"><label for="nf-field-342" id="nf-label-field-342" class="">Suburb </label></div>
<div class="nf-field-element">
<input type="text" value="" class="ninja-forms-field nf-element" id="nf-field-342" name="city" autocomplete="address-level2" aria-invalid="false" aria-describedby="nf-error-342" aria-labelledby="nf-label-field-342">
</div>
</div>
</div>
<div class="nf-after-field"><nf-section>
<div class="nf-input-limit"></div>
<div id="nf-error-342" class="nf-error-wrap nf-error" role="alert"></div>
</nf-section></div>
</div>
</nf-field></nf-fields>
</div>
</nf-cells>
</div>
<div class="nf-row">
<nf-cells>
<div class="nf-cell" style="width: 100%;">
<nf-fields><nf-field>
<div id="nf-field-343-container" class="nf-field-container zip-container label-above one-half last ">
<div class="nf-before-field"><nf-section>
</nf-section></div>
<div class="nf-field">
<div id="nf-field-343-wrap" class="field-wrap zip-wrap" data-field-id="343">
<div class="nf-field-label"><label for="nf-field-343" id="nf-label-field-343" class="">Postcode </label></div>
<div class="nf-field-element">
<input type="text" value="" class="ninja-forms-field nf-element" id="nf-field-343" name="zip" autocomplete="postal-code" aria-invalid="false" aria-describedby="nf-error-343" aria-labelledby="nf-label-field-343">
</div>
</div>
</div>
<div class="nf-after-field"><nf-section>
<div class="nf-input-limit"></div>
<div id="nf-error-343" class="nf-error-wrap nf-error" role="alert"></div>
</nf-section></div>
</div>
</nf-field></nf-fields>
</div>
</nf-cells>
</div>
<div class="nf-row">
<nf-cells>
<div class="nf-cell" style="width: 100%;">
<nf-fields><nf-field>
<div id="nf-field-339-container" class="nf-field-container phone-container label-above one-half first textbox-container">
<div class="nf-before-field"><nf-section>
</nf-section></div>
<div class="nf-field">
<div id="nf-field-339-wrap" class="field-wrap phone-wrap textbox-wrap" data-field-id="339">
<div class="nf-field-label"><label for="nf-field-339" id="nf-label-field-339" class="">Direct Phone </label></div>
<div class="nf-field-element">
<input type="tel" value="" class="ninja-forms-field nf-element" id="nf-field-339" name="phone" autocomplete="tel" aria-invalid="false" aria-describedby="nf-error-339" aria-labelledby="nf-label-field-339">
</div>
</div>
</div>
<div class="nf-after-field"><nf-section>
<div class="nf-input-limit"></div>
<div id="nf-error-339" class="nf-error-wrap nf-error" role="alert"></div>
</nf-section></div>
</div>
</nf-field></nf-fields>
</div>
</nf-cells>
</div>
<div class="nf-row">
<nf-cells>
<div class="nf-cell" style="width: 100%;">
<nf-fields><nf-field>
<div id="nf-field-337-container" class="nf-field-container phone-container label-above one-half last textbox-container">
<div class="nf-before-field"><nf-section>
</nf-section></div>
<div class="nf-field">
<div id="nf-field-337-wrap" class="field-wrap phone-wrap textbox-wrap" data-field-id="337">
<div class="nf-field-label"><label for="nf-field-337" id="nf-label-field-337" class="">Mobile Phone </label></div>
<div class="nf-field-element">
<input type="tel" value="" class="ninja-forms-field nf-element" id="nf-field-337" name="phone" autocomplete="tel" aria-invalid="false" aria-describedby="nf-error-337" aria-labelledby="nf-label-field-337">
</div>
</div>
</div>
<div class="nf-after-field"><nf-section>
<div class="nf-input-limit"></div>
<div id="nf-error-337" class="nf-error-wrap nf-error" role="alert"></div>
</nf-section></div>
</div>
</nf-field></nf-fields>
</div>
</nf-cells>
</div>
<div class="nf-row">
<nf-cells>
<div class="nf-cell" style="width: 100%;">
<nf-fields><nf-field>
<div id="nf-field-336-container" class="nf-field-container email-container label-above ">
<div class="nf-before-field"><nf-section>
</nf-section></div>
<div class="nf-field">
<div id="nf-field-336-wrap" class="field-wrap email-wrap" data-field-id="336">
<div class="nf-field-label"><label for="nf-field-336" id="nf-label-field-336" class="">Email </label></div>
<div class="nf-field-element">
<input type="email" value="" class="ninja-forms-field nf-element" id="nf-field-336" name="email" autocomplete="email" aria-invalid="false" aria-describedby="nf-error-336" aria-labelledby="nf-label-field-336">
</div>
</div>
</div>
<div class="nf-after-field"><nf-section>
<div class="nf-input-limit"></div>
<div id="nf-error-336" class="nf-error-wrap nf-error" role="alert"></div>
</nf-section></div>
</div>
</nf-field></nf-fields>
</div>
</nf-cells>
</div>
<div class="nf-row">
<nf-cells>
<div class="nf-cell" style="width: 100%;">
<nf-fields><nf-field>
<div id="nf-field-377-container" class="nf-field-container textbox-container label-above ">
<div class="nf-before-field"><nf-section>
</nf-section></div>
<div class="nf-field">
<div id="nf-field-377-wrap" class="field-wrap textbox-wrap" data-field-id="377">
<div class="nf-field-label"><label for="nf-field-377" id="nf-label-field-377" class="">Referrer Type (eg. self, GP, Social Worker etc.) </label></div>
<div class="nf-field-element">
<input type="text" value="" class="ninja-forms-field nf-element" id="nf-field-377" name="nf-field-377" aria-invalid="false" aria-describedby="nf-error-377" aria-labelledby="nf-label-field-377">
</div>
</div>
</div>
<div class="nf-after-field"><nf-section>
<div class="nf-input-limit"></div>
<div id="nf-error-377" class="nf-error-wrap nf-error" role="alert"></div>
</nf-section></div>
</div>
</nf-field></nf-fields>
</div>
</nf-cells>
</div>
<div class="nf-row">
<nf-cells>
<div class="nf-cell" style="width: 100%;">
<nf-fields><nf-field>
<div id="nf-field-392-container" class="nf-field-container textarea-container label-above ">
<div class="nf-before-field"><nf-section>
</nf-section></div>
<div class="nf-field">
<div id="nf-field-392-wrap" class="field-wrap textarea-wrap" data-field-id="392">
<div class="nf-field-label"><label for="nf-field-392" id="nf-label-field-392" class="">Recent history of service engagement </label></div>
<div class="nf-field-element">
<textarea id="nf-field-392" name="nf-field-392" aria-invalid="false" aria-describedby="nf-error-392" class="ninja-forms-field nf-element" aria-labelledby="nf-label-field-392"></textarea>
</div>
</div>
</div>
<div class="nf-after-field"><nf-section>
<div class="nf-input-limit"></div>
<div id="nf-error-392" class="nf-error-wrap nf-error" role="alert"></div>
</nf-section></div>
</div>
</nf-field></nf-fields>
</div>
</nf-cells>
</div>
<div class="nf-row">
<nf-cells>
<div class="nf-cell" style="width: 100%;">
<nf-fields><nf-field>
<div id="nf-field-391-container" class="nf-field-container textarea-container label-above ">
<div class="nf-before-field"><nf-section>
</nf-section></div>
<div class="nf-field">
<div id="nf-field-391-wrap" class="field-wrap textarea-wrap" data-field-id="391">
<div class="nf-field-label"><label for="nf-field-391" id="nf-label-field-391" class="">Other services person is currently linked with (100 word limit) </label></div>
<div class="nf-field-element">
<textarea id="nf-field-391" name="nf-field-391" aria-invalid="false" aria-describedby="nf-error-391" class="ninja-forms-field nf-element" aria-labelledby="nf-label-field-391"></textarea>
</div>
</div>
</div>
<div class="nf-after-field"><nf-section>
<div class="nf-input-limit"> 100 of 100 Character(s) left </div>
<div id="nf-error-391" class="nf-error-wrap nf-error" role="alert"></div>
</nf-section></div>
</div>
</nf-field></nf-fields>
</div>
</nf-cells>
</div>
<div class="nf-row">
<nf-cells>
<div class="nf-cell" style="width: 100%;">
<nf-fields><nf-field>
<div id="nf-field-378-container" class="nf-field-container hr-container label-above ">
<div class="nf-before-field"><nf-section>
</nf-section></div>
<div class="nf-field">
<div id="nf-field-378-wrap" class="field-wrap hr-wrap" data-field-id="378">
<div class="nf-field-label"><label for="nf-field-378" id="nf-label-field-378" class="">Divider </label></div>
<div class="nf-field-element">
<hr class="ninja-forms-field">
</div>
</div>
</div>
<div class="nf-after-field"><nf-section>
<div class="nf-input-limit"></div>
<div id="nf-error-378" class="nf-error-wrap nf-error" role="alert"></div>
</nf-section></div>
</div>
</nf-field></nf-fields>
</div>
</nf-cells>
</div>
<div class="nf-row">
<nf-cells>
<div class="nf-cell" style="width: 100%;">
<nf-fields><nf-field>
<div id="nf-field-379-container" class="nf-field-container listradio-container label-above four-col-list list-container">
<div class="nf-before-field"><nf-section>
</nf-section></div>
<div class="nf-field">
<div id="nf-field-379-wrap" class="field-wrap listradio-wrap list-wrap list-radio-wrap" data-field-id="379">
<div class="nf-field-label"><label for="nf-field-379" id="nf-label-field-379" class="">Apparent co-existing factors that impact on mental illness </label></div>
<div class="nf-field-element">
<ul aria-describedby="nf-error-379">
<li>
<input type="radio" id="nf-field-379-0" name="nf-field-379" class="ninja-forms-field nf-element " value="no" aria-labelledby="nf-label-class-field-379-0">
<label for="nf-field-379-0" id="nf-label-class-field-379-0" class="">No</label>
</li>
<li>
<input type="radio" id="nf-field-379-1" name="nf-field-379" class="ninja-forms-field nf-element " value="not-reported" aria-labelledby="nf-label-class-field-379-1">
<label for="nf-field-379-1" id="nf-label-class-field-379-1" class="">Not Reported</label>
</li>
<li>
<input type="radio" id="nf-field-379-2" name="nf-field-379" class="ninja-forms-field nf-element " value="unknown" aria-labelledby="nf-label-class-field-379-2">
<label for="nf-field-379-2" id="nf-label-class-field-379-2" class="">Unknown</label>
</li>
<li>
<input type="radio" id="nf-field-379-3" name="nf-field-379" class="ninja-forms-field nf-element " value="yes" aria-labelledby="nf-label-class-field-379-3">
<label for="nf-field-379-3" id="nf-label-class-field-379-3" class="">Yes</label>
</li>
</ul>
</div>
</div>
</div>
<div class="nf-after-field"><nf-section>
<div class="nf-input-limit"></div>
<div id="nf-error-379" class="nf-error-wrap nf-error" role="alert"></div>
</nf-section></div>
</div>
</nf-field></nf-fields>
</div>
</nf-cells>
</div>
<div class="nf-row">
<nf-cells>
<div class="nf-cell" style="width: 100%;">
<nf-fields><nf-field>
<div id="nf-field-380-container" class="nf-field-container listradio-container label-above four-col-list list-container">
<div class="nf-before-field"><nf-section>
</nf-section></div>
<div class="nf-field">
<div id="nf-field-380-wrap" class="field-wrap listradio-wrap list-wrap list-radio-wrap" data-field-id="380">
<div class="nf-field-label"><label for="nf-field-380" id="nf-label-field-380" class="">Drug or Alcohol Abuse </label></div>
<div class="nf-field-element">
<ul aria-describedby="nf-error-380">
<li>
<input type="radio" id="nf-field-380-0" name="nf-field-380" class="ninja-forms-field nf-element " value="no" aria-labelledby="nf-label-class-field-380-0">
<label for="nf-field-380-0" id="nf-label-class-field-380-0" class="">No</label>
</li>
<li>
<input type="radio" id="nf-field-380-1" name="nf-field-380" class="ninja-forms-field nf-element " value="not-reported" aria-labelledby="nf-label-class-field-380-1">
<label for="nf-field-380-1" id="nf-label-class-field-380-1" class="">Not Reported</label>
</li>
<li>
<input type="radio" id="nf-field-380-2" name="nf-field-380" class="ninja-forms-field nf-element " value="unknown" aria-labelledby="nf-label-class-field-380-2">
<label for="nf-field-380-2" id="nf-label-class-field-380-2" class="">Unknown</label>
</li>
<li>
<input type="radio" id="nf-field-380-3" name="nf-field-380" class="ninja-forms-field nf-element " value="yes" aria-labelledby="nf-label-class-field-380-3">
<label for="nf-field-380-3" id="nf-label-class-field-380-3" class="">Yes</label>
</li>
</ul>
</div>
</div>
</div>
<div class="nf-after-field"><nf-section>
<div class="nf-input-limit"></div>
<div id="nf-error-380" class="nf-error-wrap nf-error" role="alert"></div>
</nf-section></div>
</div>
</nf-field></nf-fields>
</div>
</nf-cells>
</div>
<div class="nf-row">
<nf-cells>
<div class="nf-cell" style="width: 100%;">
<nf-fields><nf-field>
<div id="nf-field-381-container" class="nf-field-container listradio-container label-above four-col-list list-container">
<div class="nf-before-field"><nf-section>
</nf-section></div>
<div class="nf-field">
<div id="nf-field-381-wrap" class="field-wrap listradio-wrap list-wrap list-radio-wrap" data-field-id="381">
<div class="nf-field-label"><label for="nf-field-381" id="nf-label-field-381" class="">Intellectual / Cognitive Disability </label></div>
<div class="nf-field-element">
<ul aria-describedby="nf-error-381">
<li>
<input type="radio" id="nf-field-381-0" name="nf-field-381" class="ninja-forms-field nf-element " value="no" aria-labelledby="nf-label-class-field-381-0">
<label for="nf-field-381-0" id="nf-label-class-field-381-0" class="">No</label>
</li>
<li>
<input type="radio" id="nf-field-381-1" name="nf-field-381" class="ninja-forms-field nf-element " value="not-reported" aria-labelledby="nf-label-class-field-381-1">
<label for="nf-field-381-1" id="nf-label-class-field-381-1" class="">Not Reported</label>
</li>
<li>
<input type="radio" id="nf-field-381-2" name="nf-field-381" class="ninja-forms-field nf-element " value="unknown" aria-labelledby="nf-label-class-field-381-2">
<label for="nf-field-381-2" id="nf-label-class-field-381-2" class="">Unknown</label>
</li>
<li>
<input type="radio" id="nf-field-381-3" name="nf-field-381" class="ninja-forms-field nf-element " value="yes" aria-labelledby="nf-label-class-field-381-3">
<label for="nf-field-381-3" id="nf-label-class-field-381-3" class="">Yes</label>
</li>
</ul>
</div>
</div>
</div>
<div class="nf-after-field"><nf-section>
<div class="nf-input-limit"></div>
<div id="nf-error-381" class="nf-error-wrap nf-error" role="alert"></div>
</nf-section></div>
</div>
</nf-field></nf-fields>
</div>
</nf-cells>
</div>
<div class="nf-row">
<nf-cells>
<div class="nf-cell" style="width: 100%;">
<nf-fields><nf-field>
<div id="nf-field-382-container" class="nf-field-container listradio-container label-above four-col-list list-container">
<div class="nf-before-field"><nf-section>
</nf-section></div>
<div class="nf-field">
<div id="nf-field-382-wrap" class="field-wrap listradio-wrap list-wrap list-radio-wrap" data-field-id="382">
<div class="nf-field-label"><label for="nf-field-382" id="nf-label-field-382" class="">Physical Disability </label></div>
<div class="nf-field-element">
<ul aria-describedby="nf-error-382">
<li>
<input type="radio" id="nf-field-382-0" name="nf-field-382" class="ninja-forms-field nf-element " value="no" aria-labelledby="nf-label-class-field-382-0">
<label for="nf-field-382-0" id="nf-label-class-field-382-0" class="">No</label>
</li>
<li>
<input type="radio" id="nf-field-382-1" name="nf-field-382" class="ninja-forms-field nf-element " value="not-reported" aria-labelledby="nf-label-class-field-382-1">
<label for="nf-field-382-1" id="nf-label-class-field-382-1" class="">Not Reported</label>
</li>
<li>
<input type="radio" id="nf-field-382-2" name="nf-field-382" class="ninja-forms-field nf-element " value="unknown" aria-labelledby="nf-label-class-field-382-2">
<label for="nf-field-382-2" id="nf-label-class-field-382-2" class="">Unknown</label>
</li>
<li>
<input type="radio" id="nf-field-382-3" name="nf-field-382" class="ninja-forms-field nf-element " value="yes" aria-labelledby="nf-label-class-field-382-3">
<label for="nf-field-382-3" id="nf-label-class-field-382-3" class="">Yes</label>
</li>
</ul>
</div>
</div>
</div>
<div class="nf-after-field"><nf-section>
<div class="nf-input-limit"></div>
<div id="nf-error-382" class="nf-error-wrap nf-error" role="alert"></div>
</nf-section></div>
</div>
</nf-field></nf-fields>
</div>
</nf-cells>
</div>
<div class="nf-row">
<nf-cells>
<div class="nf-cell" style="width: 100%;">
<nf-fields><nf-field>
<div id="nf-field-383-container" class="nf-field-container listradio-container label-above four-col-list list-container">
<div class="nf-before-field"><nf-section>
</nf-section></div>
<div class="nf-field">
<div id="nf-field-383-wrap" class="field-wrap listradio-wrap list-wrap list-radio-wrap" data-field-id="383">
<div class="nf-field-label"><label for="nf-field-383" id="nf-label-field-383" class="">Sensory or Speech </label></div>
<div class="nf-field-element">
<ul aria-describedby="nf-error-383">
<li>
<input type="radio" id="nf-field-383-0" name="nf-field-383" class="ninja-forms-field nf-element " value="no" aria-labelledby="nf-label-class-field-383-0">
<label for="nf-field-383-0" id="nf-label-class-field-383-0" class="">No</label>
</li>
<li>
<input type="radio" id="nf-field-383-1" name="nf-field-383" class="ninja-forms-field nf-element " value="not-reported" aria-labelledby="nf-label-class-field-383-1">
<label for="nf-field-383-1" id="nf-label-class-field-383-1" class="">Not Reported</label>
</li>
<li>
<input type="radio" id="nf-field-383-2" name="nf-field-383" class="ninja-forms-field nf-element " value="unknown" aria-labelledby="nf-label-class-field-383-2">
<label for="nf-field-383-2" id="nf-label-class-field-383-2" class="">Unknown</label>
</li>
<li>
<input type="radio" id="nf-field-383-3" name="nf-field-383" class="ninja-forms-field nf-element " value="yes" aria-labelledby="nf-label-class-field-383-3">
<label for="nf-field-383-3" id="nf-label-class-field-383-3" class="">Yes</label>
</li>
</ul>
</div>
</div>
</div>
<div class="nf-after-field"><nf-section>
<div class="nf-input-limit"></div>
<div id="nf-error-383" class="nf-error-wrap nf-error" role="alert"></div>
</nf-section></div>
</div>
</nf-field></nf-fields>
</div>
</nf-cells>
</div>
<div class="nf-row">
<nf-cells>
<div class="nf-cell" style="width: 100%;">
<nf-fields><nf-field>
<div id="nf-field-384-container" class="nf-field-container listradio-container label-above four-col-list list-container">
<div class="nf-before-field"><nf-section>
</nf-section></div>
<div class="nf-field">
<div id="nf-field-384-wrap" class="field-wrap listradio-wrap list-wrap list-radio-wrap" data-field-id="384">
<div class="nf-field-label"><label for="nf-field-384" id="nf-label-field-384" class="">Significant Physical Issues </label></div>
<div class="nf-field-element">
<ul aria-describedby="nf-error-384">
<li>
<input type="radio" id="nf-field-384-0" name="nf-field-384" class="ninja-forms-field nf-element " value="no" aria-labelledby="nf-label-class-field-384-0">
<label for="nf-field-384-0" id="nf-label-class-field-384-0" class="">No</label>
</li>
<li>
<input type="radio" id="nf-field-384-1" name="nf-field-384" class="ninja-forms-field nf-element " value="not-reported" aria-labelledby="nf-label-class-field-384-1">
<label for="nf-field-384-1" id="nf-label-class-field-384-1" class="">Not Reported</label>
</li>
<li>
<input type="radio" id="nf-field-384-2" name="nf-field-384" class="ninja-forms-field nf-element " value="unknown" aria-labelledby="nf-label-class-field-384-2">
<label for="nf-field-384-2" id="nf-label-class-field-384-2" class="">Unknown</label>
</li>
<li>
<input type="radio" id="nf-field-384-3" name="nf-field-384" class="ninja-forms-field nf-element " value="yes" aria-labelledby="nf-label-class-field-384-3">
<label for="nf-field-384-3" id="nf-label-class-field-384-3" class="">Yes</label>
</li>
</ul>
</div>
</div>
</div>
<div class="nf-after-field"><nf-section>
<div class="nf-input-limit"></div>
<div id="nf-error-384" class="nf-error-wrap nf-error" role="alert"></div>
</nf-section></div>
</div>
</nf-field></nf-fields>
</div>
</nf-cells>
</div>
<div class="nf-row">
<nf-cells>
<div class="nf-cell" style="width: 100%;">
<nf-fields><nf-field>
<div id="nf-field-385-container" class="nf-field-container listradio-container label-above four-col-list list-container">
<div class="nf-before-field"><nf-section>
</nf-section></div>
<div class="nf-field">
<div id="nf-field-385-wrap" class="field-wrap listradio-wrap list-wrap list-radio-wrap" data-field-id="385">
<div class="nf-field-label"><label for="nf-field-385" id="nf-label-field-385" class="">Acquired Brain Injury </label></div>
<div class="nf-field-element">
<ul aria-describedby="nf-error-385">
<li>
<input type="radio" id="nf-field-385-0" name="nf-field-385" class="ninja-forms-field nf-element " value="no" aria-labelledby="nf-label-class-field-385-0">
<label for="nf-field-385-0" id="nf-label-class-field-385-0" class="">No</label>
</li>
<li>
<input type="radio" id="nf-field-385-1" name="nf-field-385" class="ninja-forms-field nf-element " value="not-reported" aria-labelledby="nf-label-class-field-385-1">
<label for="nf-field-385-1" id="nf-label-class-field-385-1" class="">Not Reported</label>
</li>
<li>
<input type="radio" id="nf-field-385-2" name="nf-field-385" class="ninja-forms-field nf-element " value="unknown" aria-labelledby="nf-label-class-field-385-2">
<label for="nf-field-385-2" id="nf-label-class-field-385-2" class="">Unknown</label>
</li>
<li>
<input type="radio" id="nf-field-385-3" name="nf-field-385" class="ninja-forms-field nf-element " value="yes" aria-labelledby="nf-label-class-field-385-3">
<label for="nf-field-385-3" id="nf-label-class-field-385-3" class="">Yes</label>
</li>
</ul>
</div>
</div>
</div>
<div class="nf-after-field"><nf-section>
<div class="nf-input-limit"></div>
<div id="nf-error-385" class="nf-error-wrap nf-error" role="alert"></div>
</nf-section></div>
</div>
</nf-field></nf-fields>
</div>
</nf-cells>
</div>
<div class="nf-row">
<nf-cells>
<div class="nf-cell" style="width: 100%;">
<nf-fields><nf-field>
<div id="nf-field-386-container" class="nf-field-container listradio-container label-above four-col-list list-container">
<div class="nf-before-field"><nf-section>
</nf-section></div>
<div class="nf-field">
<div id="nf-field-386-wrap" class="field-wrap listradio-wrap list-wrap list-radio-wrap" data-field-id="386">
<div class="nf-field-label"><label for="nf-field-386" id="nf-label-field-386" class="">Dementia </label></div>
<div class="nf-field-element">
<ul aria-describedby="nf-error-386">
<li>
<input type="radio" id="nf-field-386-0" name="nf-field-386" class="ninja-forms-field nf-element " value="no" aria-labelledby="nf-label-class-field-386-0">
<label for="nf-field-386-0" id="nf-label-class-field-386-0" class="">No</label>
</li>
<li>
<input type="radio" id="nf-field-386-1" name="nf-field-386" class="ninja-forms-field nf-element " value="not-reported" aria-labelledby="nf-label-class-field-386-1">
<label for="nf-field-386-1" id="nf-label-class-field-386-1" class="">Not Reported</label>
</li>
<li>
<input type="radio" id="nf-field-386-2" name="nf-field-386" class="ninja-forms-field nf-element " value="unknown" aria-labelledby="nf-label-class-field-386-2">
<label for="nf-field-386-2" id="nf-label-class-field-386-2" class="">Unknown</label>
</li>
<li>
<input type="radio" id="nf-field-386-3" name="nf-field-386" class="ninja-forms-field nf-element " value="yes" aria-labelledby="nf-label-class-field-386-3">
<label for="nf-field-386-3" id="nf-label-class-field-386-3" class="">Yes</label>
</li>
</ul>
</div>
</div>
</div>
<div class="nf-after-field"><nf-section>
<div class="nf-input-limit"></div>
<div id="nf-error-386" class="nf-error-wrap nf-error" role="alert"></div>
</nf-section></div>
</div>
</nf-field></nf-fields>
</div>
</nf-cells>
</div>
<div class="nf-row">
<nf-cells>
<div class="nf-cell" style="width: 100%;">
<nf-fields><nf-field>
<div id="nf-field-388-container" class="nf-field-container listcheckbox-container label-above three-col-list list-container">
<div class="nf-before-field"><nf-section>
</nf-section></div>
<div class="nf-field">
<div id="nf-field-388-wrap" class="field-wrap listcheckbox-wrap list-wrap list-checkbox-wrap" data-field-id="388">
<div class="nf-field-label"><label for="nf-field-388" id="nf-label-field-388" class="">ALERTS OR RISKS WE NEED TO BE AWARE OF <span class="ninja-forms-req-symbol">*</span> </label></div>
<div class="nf-field-element">
<ul aria-describedby="nf-error-388">
<li>
<input type="checkbox" id="nf-field-388-0" name="nf-field-388" class="ninja-forms-field nf-element " value="vicious-animal-s" aria-labelledby="nf-label-field-388-0" required="">
<label for="nf-field-388-0" id="nf-label-field-388-0" class="">Vicious Animal/s</label>
</li>
<li>
<input type="checkbox" id="nf-field-388-1" name="nf-field-388" class="ninja-forms-field nf-element " value="firearms-weapons" aria-labelledby="nf-label-field-388-1" required="">
<label for="nf-field-388-1" id="nf-label-field-388-1" class="">Firearms/Weapons</label>
</li>
<li>
<input type="checkbox" id="nf-field-388-2" name="nf-field-388" class="ninja-forms-field nf-element " value="self-harm" aria-labelledby="nf-label-field-388-2" required="">
<label for="nf-field-388-2" id="nf-label-field-388-2" class="">Self Harm</label>
</li>
<li>
<input type="checkbox" id="nf-field-388-3" name="nf-field-388" class="ninja-forms-field nf-element " value="suicidal-ideation" aria-labelledby="nf-label-field-388-3" required="">
<label for="nf-field-388-3" id="nf-label-field-388-3" class="">Suicidal Ideation</label>
</li>
<li>
<input type="checkbox" id="nf-field-388-4" name="nf-field-388" class="ninja-forms-field nf-element " value="domestic-violence" aria-labelledby="nf-label-field-388-4" required="">
<label for="nf-field-388-4" id="nf-label-field-388-4" class="">Domestic Violence</label>
</li>
<li>
<input type="checkbox" id="nf-field-388-5" name="nf-field-388" class="ninja-forms-field nf-element " value="harm-to-others" aria-labelledby="nf-label-field-388-5" required="">
<label for="nf-field-388-5" id="nf-label-field-388-5" class="">Harm to Others</label>
</li>
<li>
<input type="checkbox" id="nf-field-388-6" name="nf-field-388" class="ninja-forms-field nf-element " value="house-in-poor-condition" aria-labelledby="nf-label-field-388-6" required="">
<label for="nf-field-388-6" id="nf-label-field-388-6" class="">House in Poor Condition</label>
</li>
<li>
<input type="checkbox" id="nf-field-388-7" name="nf-field-388" class="ninja-forms-field nf-element " value="no-risks-identified" aria-labelledby="nf-label-field-388-7" required="">
<label for="nf-field-388-7" id="nf-label-field-388-7" class="">No Risks Identified</label>
</li>
</ul>
</div>
</div>
</div>
<div class="nf-after-field"><nf-section>
<div class="nf-input-limit"></div>
<div id="nf-error-388" class="nf-error-wrap nf-error" role="alert"></div>
</nf-section></div>
</div>
</nf-field></nf-fields>
</div>
</nf-cells>
</div>
<div class="nf-row">
<nf-cells>
<div class="nf-cell" style="width: 100%;">
<nf-fields><nf-field>
<div id="nf-field-390-container" class="nf-field-container hr-container label-above ">
<div class="nf-before-field"><nf-section>
</nf-section></div>
<div class="nf-field">
<div id="nf-field-390-wrap" class="field-wrap hr-wrap" data-field-id="390">
<div class="nf-field-label"><label for="nf-field-390" id="nf-label-field-390" class="">Divider </label></div>
<div class="nf-field-element">
<hr class="ninja-forms-field">
</div>
</div>
</div>
<div class="nf-after-field"><nf-section>
<div class="nf-input-limit"></div>
<div id="nf-error-390" class="nf-error-wrap nf-error" role="alert"></div>
</nf-section></div>
</div>
</nf-field></nf-fields>
</div>
</nf-cells>
</div>
<div class="nf-row">
<nf-cells>
<div class="nf-cell" style="width: 100%;">
<nf-fields><nf-field>
<div id="nf-field-353-container" class="nf-field-container listcheckbox-container label-above two-col-list list-container">
<div class="nf-before-field"><nf-section>
</nf-section></div>
<div class="nf-field">
<div id="nf-field-353-wrap" class="field-wrap listcheckbox-wrap list-wrap list-checkbox-wrap" data-field-id="353">
<div class="nf-field-label"><label for="nf-field-353" id="nf-label-field-353" class="">Where did you hear about Hunter Primary Care CPS Support? <span class="ninja-forms-req-symbol">*</span> </label></div>
<div class="nf-field-element">
<ul aria-describedby="nf-error-353">
<li>
<input type="checkbox" id="nf-field-353-0" name="nf-field-353" class="ninja-forms-field nf-element " value="emergency-department" aria-labelledby="nf-label-field-353-0" required="">
<label for="nf-field-353-0" id="nf-label-field-353-0" class="">Emergency Department</label>
</li>
<li>
<input type="checkbox" id="nf-field-353-1" name="nf-field-353" class="ninja-forms-field nf-element " value="friend-family-member" aria-labelledby="nf-label-field-353-1" required="">
<label for="nf-field-353-1" id="nf-label-field-353-1" class="">Friend/Family Member</label>
</li>
<li>
<input type="checkbox" id="nf-field-353-2" name="nf-field-353" class="ninja-forms-field nf-element " value="google-search" aria-labelledby="nf-label-field-353-2" required="">
<label for="nf-field-353-2" id="nf-label-field-353-2" class="">Google Search</label>
</li>
<li>
<input type="checkbox" id="nf-field-353-3" name="nf-field-353" class="ninja-forms-field nf-element " value="government-agency" aria-labelledby="nf-label-field-353-3" required="">
<label for="nf-field-353-3" id="nf-label-field-353-3" class="">Government Agency</label>
</li>
<li>
<input type="checkbox" id="nf-field-353-4" name="nf-field-353" class="ninja-forms-field nf-element " value="gp-or-health-professional" aria-labelledby="nf-label-field-353-4" required="">
<label for="nf-field-353-4" id="nf-label-field-353-4" class="">GP or Health Professional</label>
</li>
<li>
<input type="checkbox" id="nf-field-353-5" name="nf-field-353" class="ninja-forms-field nf-element " value="hunter-primary-care-staff" aria-labelledby="nf-label-field-353-5" required="">
<label for="nf-field-353-5" id="nf-label-field-353-5" class="">Hunter Primary Care Staff</label>
</li>
<li>
<input type="checkbox" id="nf-field-353-6" name="nf-field-353" class="ninja-forms-field nf-element " value="ndia" aria-labelledby="nf-label-field-353-6" required="">
<label for="nf-field-353-6" id="nf-label-field-353-6" class="">NDIA</label>
</li>
<li>
<input type="checkbox" id="nf-field-353-7" name="nf-field-353" class="ninja-forms-field nf-element " value="newspaper" aria-labelledby="nf-label-field-353-7" required="">
<label for="nf-field-353-7" id="nf-label-field-353-7" class="">Newspaper</label>
</li>
<li>
<input type="checkbox" id="nf-field-353-8" name="nf-field-353" class="ninja-forms-field nf-element " value="online-advertising" aria-labelledby="nf-label-field-353-8" required="">
<label for="nf-field-353-8" id="nf-label-field-353-8" class="">Online Advertising</label>
</li>
<li>
<input type="checkbox" id="nf-field-353-9" name="nf-field-353" class="ninja-forms-field nf-element " value="public-guardian" aria-labelledby="nf-label-field-353-9" required="">
<label for="nf-field-353-9" id="nf-label-field-353-9" class="">Public Guardian</label>
</li>
<li>
<input type="checkbox" id="nf-field-353-10" name="nf-field-353" class="ninja-forms-field nf-element " value="radio" aria-labelledby="nf-label-field-353-10" required="">
<label for="nf-field-353-10" id="nf-label-field-353-10" class="">Radio </label>
</li>
<li>
<input type="checkbox" id="nf-field-353-11" name="nf-field-353" class="ninja-forms-field nf-element " value="social-media" aria-labelledby="nf-label-field-353-11" required="">
<label for="nf-field-353-11" id="nf-label-field-353-11" class="">Social Media</label>
</li>
<li>
<input type="checkbox" id="nf-field-353-12" name="nf-field-353" class="ninja-forms-field nf-element " value="service-provider" aria-labelledby="nf-label-field-353-12" required="">
<label for="nf-field-353-12" id="nf-label-field-353-12" class="">Service Provider</label>
</li>
<li>
<input type="checkbox" id="nf-field-353-13" name="nf-field-353" class="ninja-forms-field nf-element " value="television" aria-labelledby="nf-label-field-353-13" required="">
<label for="nf-field-353-13" id="nf-label-field-353-13" class="">Television</label>
</li>
<li>
<input type="checkbox" id="nf-field-353-14" name="nf-field-353" class="ninja-forms-field nf-element " value="other-please-provide-details-below" aria-labelledby="nf-label-field-353-14" required="">
<label for="nf-field-353-14" id="nf-label-field-353-14" class="">Other (please provide details below)</label>
</li>
</ul>
</div>
</div>
</div>
<div class="nf-after-field"><nf-section>
<div class="nf-input-limit"></div>
<div id="nf-error-353" class="nf-error-wrap nf-error" role="alert"></div>
</nf-section></div>
</div>
</nf-field></nf-fields>
</div>
</nf-cells>
</div>
<div class="nf-row">
<nf-cells>
<div class="nf-cell" style="width: 100%;">
<nf-fields><nf-field>
<div id="nf-field-354-container" class="nf-field-container textbox-container label-hidden ">
<div class="nf-before-field"><nf-section>
</nf-section></div>
<div class="nf-field">
<div id="nf-field-354-wrap" class="field-wrap textbox-wrap" data-field-id="354">
<div class="nf-field-label"><label for="nf-field-354" id="nf-label-field-354" class="">Other Response </label></div>
<div class="nf-field-element">
<input type="text" value="" class="ninja-forms-field nf-element" id="nf-field-354" name="nf-field-354" aria-invalid="false" aria-describedby="nf-error-354" aria-labelledby="nf-label-field-354">
</div>
</div>
</div>
<div class="nf-after-field"><nf-section>
<div class="nf-input-limit"></div>
<div id="nf-error-354" class="nf-error-wrap nf-error" role="alert"></div>
</nf-section></div>
</div>
</nf-field></nf-fields>
</div>
</nf-cells>
</div>
<div class="nf-row">
<nf-cells>
<div class="nf-cell" style="width: 100%;">
<nf-fields><nf-field>
<div id="nf-field-338-container" class="nf-field-container submit-container label-above textbox-container">
<div class="nf-before-field"><nf-section>
</nf-section></div>
<div class="nf-field">
<div id="nf-field-338-wrap" class="field-wrap submit-wrap textbox-wrap" data-field-id="338">
<div class="nf-field-label"></div>
<div class="nf-field-element">
<input id="nf-field-338" class="ninja-forms-field nf-element " type="button" value="Submit">
</div>
<div class="nf-error-wrap"></div>
</div>
</div>
<div class="nf-after-field"><nf-section>
<div class="nf-input-limit"></div>
<div id="nf-error-338" class="nf-error-wrap nf-error" role="alert"></div>
</nf-section></div>
</div>
</nf-field></nf-fields>
</div>
</nf-cells>
</div>
</nf-rows-wrap></div>
<div class="nf-after-form-content"><nf-section>
<div id="nf-form-errors-12" class="nf-form-errors" role="alert"><nf-errors></nf-errors></div>
<div class="nf-form-hp"><nf-section>
<label for="nf-field-hp-12" aria-hidden="true"> If you are a human seeing this field, please leave it empty. <input id="nf-field-hp-12" name="nf-field-hp" class="nf-element nf-field-hp" type="text" value="">
</label>
</nf-section></div>
</nf-section></div>
</div>
</form><form>
<div>
<div class="nf-before-form-content"><nf-section>
<div class="nf-form-fields-required">Fields marked with an <span class="ninja-forms-req-symbol">*</span> are required</div>
</nf-section></div>
<div class="nf-form-content "><nf-rows-wrap>
<div class="nf-row">
<nf-cells>
<div class="nf-cell" style="width: 50%;">
<nf-fields><nf-field>
<div id="nf-field-595-container" class="nf-field-container firstname-container label-above ">
<div class="nf-before-field"><nf-section>
</nf-section></div>
<div class="nf-field">
<div id="nf-field-595-wrap" class="field-wrap firstname-wrap" data-field-id="595">
<div class="nf-field-label"><label for="nf-field-595" id="nf-label-field-595" class="">First Name <span class="ninja-forms-req-symbol">*</span> </label></div>
<div class="nf-field-element">
<input type="text" value="" class="ninja-forms-field nf-element" id="nf-field-595" name="fname" autocomplete="given-name" aria-invalid="false" aria-describedby="nf-error-595" aria-labelledby="nf-label-field-595" required="">
</div>
</div>
</div>
<div class="nf-after-field"><nf-section>
<div class="nf-input-limit"></div>
<div id="nf-error-595" class="nf-error-wrap nf-error" role="alert"></div>
</nf-section></div>
</div>
</nf-field></nf-fields>
</div>
<div class="nf-cell" style="width: 50%;">
<nf-fields><nf-field>
<div id="nf-field-596-container" class="nf-field-container lastname-container label-above field--half ">
<div class="nf-before-field"><nf-section>
</nf-section></div>
<div class="nf-field">
<div id="nf-field-596-wrap" class="field-wrap lastname-wrap" data-field-id="596">
<div class="nf-field-label"><label for="nf-field-596" id="nf-label-field-596" class="">Last Name <span class="ninja-forms-req-symbol">*</span> </label></div>
<div class="nf-field-element">
<input type="text" value="" class="ninja-forms-field nf-element" id="nf-field-596" name="lname" autocomplete="family-name" aria-invalid="false" aria-describedby="nf-error-596" aria-labelledby="nf-label-field-596"
required="">
</div>
</div>
</div>
<div class="nf-after-field"><nf-section>
<div class="nf-input-limit"></div>
<div id="nf-error-596" class="nf-error-wrap nf-error" role="alert"></div>
</nf-section></div>
</div>
</nf-field></nf-fields>
</div>
</nf-cells>
</div>
<div class="nf-row">
<nf-cells>
<div class="nf-cell" style="width: 50%;">
<nf-fields><nf-field>
<div id="nf-field-597-container" class="nf-field-container phone-container label-above textbox-container">
<div class="nf-before-field"><nf-section>
</nf-section></div>
<div class="nf-field">
<div id="nf-field-597-wrap" class="field-wrap phone-wrap textbox-wrap" data-field-id="597">
<div class="nf-field-label"><label for="nf-field-597" id="nf-label-field-597" class="">Phone </label></div>
<div class="nf-field-element">
<input type="tel" value="" class="ninja-forms-field nf-element" id="nf-field-597" name="phone" autocomplete="tel" aria-invalid="false" aria-describedby="nf-error-597" aria-labelledby="nf-label-field-597">
</div>
</div>
</div>
<div class="nf-after-field"><nf-section>
<div class="nf-input-limit"></div>
<div id="nf-error-597" class="nf-error-wrap nf-error" role="alert"></div>
</nf-section></div>
</div>
</nf-field></nf-fields>
</div>
<div class="nf-cell" style="width: 50%;">
<nf-fields><nf-field>
<div id="nf-field-598-container" class="nf-field-container email-container label-above ">
<div class="nf-before-field"><nf-section>
</nf-section></div>
<div class="nf-field">
<div id="nf-field-598-wrap" class="field-wrap email-wrap" data-field-id="598">
<div class="nf-field-label"><label for="nf-field-598" id="nf-label-field-598" class="">Email <span class="ninja-forms-req-symbol">*</span> </label></div>
<div class="nf-field-element">
<input type="email" value="" class="ninja-forms-field nf-element" id="nf-field-598" name="email" autocomplete="email" aria-invalid="false" aria-describedby="nf-error-598" aria-labelledby="nf-label-field-598" required="">
</div>
</div>
</div>
<div class="nf-after-field"><nf-section>
<div class="nf-input-limit"></div>
<div id="nf-error-598" class="nf-error-wrap nf-error" role="alert"></div>
</nf-section></div>
</div>
</nf-field></nf-fields>
</div>
</nf-cells>
</div>
<div class="nf-row">
<nf-cells>
<div class="nf-cell" style="width: 100%;">
<nf-fields><nf-field>
<div id="nf-field-605-container" class="nf-field-container listcheckbox-container label-above two-col-list list-container">
<div class="nf-before-field"><nf-section>
</nf-section></div>
<div class="nf-field">
<div id="nf-field-605-wrap" class="field-wrap listcheckbox-wrap list-wrap list-checkbox-wrap" data-field-id="605">
<div class="nf-field-label"><label for="nf-field-605" id="nf-label-field-605" class="">Preferred Contact Method </label></div>
<div class="nf-field-element">
<ul aria-describedby="nf-error-605">
<li>
<input type="checkbox" id="nf-field-605-0" name="nf-field-605" class="ninja-forms-field nf-element " value="sms" aria-labelledby="nf-label-field-605-0">
<label for="nf-field-605-0" id="nf-label-field-605-0" class="">SMS</label>
</li>
<li>
<input type="checkbox" id="nf-field-605-1" name="nf-field-605" class="ninja-forms-field nf-element " value="phone" aria-labelledby="nf-label-field-605-1">
<label for="nf-field-605-1" id="nf-label-field-605-1" class="">Phone Call</label>
</li>
<li>
<input type="checkbox" id="nf-field-605-2" name="nf-field-605" class="ninja-forms-field nf-element " value="email" aria-labelledby="nf-label-field-605-2">
<label for="nf-field-605-2" id="nf-label-field-605-2" class="">Email</label>
</li>
</ul>
</div>
</div>
</div>
<div class="nf-after-field"><nf-section>
<div class="nf-input-limit"></div>
<div id="nf-error-605" class="nf-error-wrap nf-error" role="alert"></div>
</nf-section></div>
</div>
</nf-field></nf-fields>
</div>
</nf-cells>
</div>
<div class="nf-row">
<nf-cells>
<div class="nf-cell" style="width: 100%;">
<nf-fields><nf-field>
<div id="nf-field-599-container" class="nf-field-container zip-container label-above ">
<div class="nf-before-field"><nf-section>
</nf-section></div>
<div class="nf-field">
<div id="nf-field-599-wrap" class="field-wrap zip-wrap" data-field-id="599">
<div class="nf-field-label"><label for="nf-field-599" id="nf-label-field-599" class="">Zip/Postcode <span class="ninja-forms-req-symbol">*</span> </label></div>
<div class="nf-field-element">
<input type="text" value="" class="ninja-forms-field nf-element" id="nf-field-599" name="zip" autocomplete="postal-code" aria-invalid="false" aria-describedby="nf-error-599" aria-labelledby="nf-label-field-599" required="">
</div>
</div>
</div>
<div class="nf-after-field"><nf-section>
<div class="nf-input-limit"></div>
<div id="nf-error-599" class="nf-error-wrap nf-error" role="alert"></div>
</nf-section></div>
</div>
</nf-field></nf-fields>
</div>
</nf-cells>
</div>
<div class="nf-row">
<nf-cells>
<div class="nf-cell" style="width: 100%;">
<nf-fields><nf-field>
<div id="nf-field-602-container" class="nf-field-container listradio-container label-above list-container">
<div class="nf-before-field"><nf-section>
</nf-section></div>
<div class="nf-field">
<div id="nf-field-602-wrap" class="field-wrap listradio-wrap list-wrap list-radio-wrap" data-field-id="602">
<div class="nf-field-label"><label for="nf-field-602" id="nf-label-field-602" class="">Do you identify as Aboriginal or Torres Strait Islander? <span class="ninja-forms-req-symbol">*</span> </label></div>
<div class="nf-field-element">
<ul aria-describedby="nf-error-602">
<li>
<input type="radio" id="nf-field-602-0" name="nf-field-602" class="ninja-forms-field nf-element " value="Yes" aria-labelledby="nf-label-class-field-602-0" required="">
<label for="nf-field-602-0" id="nf-label-class-field-602-0" class="">Yes</label>
</li>
<li>
<input type="radio" id="nf-field-602-1" name="nf-field-602" class="ninja-forms-field nf-element " value="No" aria-labelledby="nf-label-class-field-602-1" required="">
<label for="nf-field-602-1" id="nf-label-class-field-602-1" class="">No</label>
</li>
<li>
<input type="radio" id="nf-field-602-2" name="nf-field-602" class="ninja-forms-field nf-element " value="Prefer not to disclose" aria-labelledby="nf-label-class-field-602-2" required="">
<label for="nf-field-602-2" id="nf-label-class-field-602-2" class="">Prefer not to disclose</label>
</li>
</ul>
</div>
</div>
</div>
<div class="nf-after-field"><nf-section>
<div class="nf-input-limit"></div>
<div id="nf-error-602" class="nf-error-wrap nf-error" role="alert"></div>
</nf-section></div>
</div>
</nf-field></nf-fields>
</div>
</nf-cells>
</div>
<div class="nf-row">
<nf-cells>
<div class="nf-cell" style="width: 100%;">
<nf-fields><nf-field>
<div id="nf-field-603-container" class="nf-field-container listselect-container label-above list-container">
<div class="nf-before-field"><nf-section>
</nf-section></div>
<div class="nf-field">
<div id="nf-field-603-wrap" class="field-wrap listselect-wrap list-wrap list-select-wrap" data-field-id="603">
<div class="nf-field-label"><label for="nf-field-603" id="nf-label-field-603" class="">I am enquiring about: <span class="ninja-forms-req-symbol">*</span> </label></div>
<div class="nf-field-element">
<select id="nf-field-603" name="nf-field-603" aria-invalid="false" aria-describedby="nf-error-603" class="ninja-forms-field nf-element" aria-labelledby="nf-label-field-603" required="">
<option value="" selected="selected"></option>
<option value="Aboriginal Torres Strait Islander Heath Worker Services">Aboriginal & Torres Strait Islander Heath Worker Services</option>
<option value="Commonwealth Psychosocial Support CPS">Commonwealth Psychosocial Support (CPS)</option>
<option value="Drug Alcohol Counselling">Drug & Alcohol Counselling</option>
<option value="headspace Newcastle">headspace Newcastle</option>
<option value="Mindreach - Telephone Supported Self-Help Program for Drug Alcohol Use">Mindreach - Telephone Supported Self-Help Program for Drug & Alcohol Use</option>
<option value="NDIS Allied Health">NDIS Allied Health</option>
<option value="NDIS Positive Behaviour Support">NDIS Positive Behaviour Support</option>
<option value="NDIS Specialist Support Coordination">NDIS Specialist Support Coordination</option>
<option value="NDIS Support Coordination">NDIS Support Coordination</option>
<option value="Yudhilidin First Nations Care Coordination">Yudhilidin First Nations Care Coordination</option>
<option value="Not sure">Not sure</option>
</select>
<div for="nf-field-603"></div>
</div>
</div>
</div>
<div class="nf-after-field"><nf-section>
<div class="nf-input-limit"></div>
<div id="nf-error-603" class="nf-error-wrap nf-error" role="alert"></div>
</nf-section></div>
</div>
</nf-field></nf-fields>
</div>
</nf-cells>
</div>
<div class="nf-row">
<nf-cells>
<div class="nf-cell" style="width: 100%;">
<nf-fields><nf-field>
<div id="nf-field-606-container" class="nf-field-container textarea-container label-above ">
<div class="nf-before-field"><nf-section>
</nf-section></div>
<div class="nf-field">
<div id="nf-field-606-wrap" class="field-wrap textarea-wrap" data-field-id="606">
<div class="nf-field-label"><label for="nf-field-606" id="nf-label-field-606" class="">Message </label></div>
<div class="nf-field-element">
<textarea id="nf-field-606" name="nf-field-606" aria-invalid="false" aria-describedby="nf-error-606" class="ninja-forms-field nf-element"
placeholder="Tell us any additional information you would like us to know regarding your self-referral to the service you're interest in" aria-labelledby="nf-label-field-606"></textarea>
</div>
</div>
</div>
<div class="nf-after-field"><nf-section>
<div class="nf-input-limit"></div>
<div id="nf-error-606" class="nf-error-wrap nf-error" role="alert"></div>
</nf-section></div>
</div>
</nf-field></nf-fields>
</div>
</nf-cells>
</div>
<div class="nf-row">
<nf-cells>
<div class="nf-cell" style="width: 100%;">
<nf-fields><nf-field>
<div id="nf-field-604-container" class="nf-field-container submit-container label-above textbox-container">
<div class="nf-before-field"><nf-section>
</nf-section></div>
<div class="nf-field">
<div id="nf-field-604-wrap" class="field-wrap submit-wrap textbox-wrap" data-field-id="604">
<div class="nf-field-label"></div>
<div class="nf-field-element">
<input id="nf-field-604" class="ninja-forms-field nf-element " type="button" value="Submit">
</div>
<div class="nf-error-wrap"></div>
</div>
</div>
<div class="nf-after-field"><nf-section>
<div class="nf-input-limit"></div>
<div id="nf-error-604" class="nf-error-wrap nf-error" role="alert"></div>
</nf-section></div>
</div>
</nf-field></nf-fields>
</div>
</nf-cells>
</div>
</nf-rows-wrap></div>
<div class="nf-after-form-content"><nf-section>
<div id="nf-form-errors-26" class="nf-form-errors" role="alert"><nf-errors></nf-errors></div>
<div class="nf-form-hp"><nf-section>
<label for="nf-field-hp-26" aria-hidden="true"> If you are a human seeing this field, please leave it empty. <input id="nf-field-hp-26" name="nf-field-hp" class="nf-element nf-field-hp" type="text" value="">
</label>
</nf-section></div>
</nf-section></div>
</div>
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Home » For Individuals & Carers » Mental Health and Wellbeing Services »
Commonwealth Psychosocial Support Program (CPS)
Commonwealth Psychosocial Support Program (CPS)Abby
Richards2022-08-25T10:12:00+10:00
COMMONWEALTH PSYCHOSOCIAL SUPPORT PROGRAM (CPS)
ASSISTING PEOPLE WITH SEVERE MENTAL ILLNESS BUILD DAILY LIVING SKILLS AND
CONNECT WITH SERVICES
The Commonwealth Psychosocial Support Program (CPS) aims to assist people with
severe mental illness, who have reduced psychosocial function and are not
eligible for assistance through the NDIS to build daily living skills and
connect with services based on their goals.
While the NDIS provides comprehensive support for the majority of people with
severe mental illness, you might not meet the NDIS criteria but may still
benefit from specialised psychosocial support at certain times.
HOW WILL CPS HELP ME?
Our Skills Facilitators can help you identify and work towards your goals in one
of the following key areas:
* Social skills, friendships and family connections
* Day to day living skills
* Financial management and budgeting
* Finding and maintaining a home
* Vocational skills and goals
* Maintaining physical wellbeing, including exercise
* Managing substance use issues
* Building broader life skills, including confidence and resilience
* Building capacity to live independently in the community
Your Skills Facilitator will work with you to develop a Individualised Support
Plan which will include your goals, strategies and support systems. A Mentor or
Peer Worker will assist you to implement your plan by working alongside you to
build your skills and community connections.
AM I ELIGIBLE?
Our CPS Service is available to people with a severe mental illness who:
* Live or work in the Newcastle, and Port Stephens regions
* Have needs that can be appropriately met through short term low intensity
support
* Aged 16 years and over
* Have an associated level of reduced psychosocial functional capacity
* Are not eligible for assistance through the NDIS
* Are not a client of Community Living Support (CLS) or Housing and Support
Initiative (HASI)
HOW TO REFER
Referrals to our Commonwealth Commonwealth Psychosocial Support Program can be
made completing our online referral form.
If referrals are received for Lake Macquarie, Mid Coast and Hunter regions, our
intake team will contact you and direct you to the appropriate service provider
in that area.
For more information about our Commonwealth Psychosocial Support Program,
contact the CPS team on (02) 4925 2259 or email mhcc@hunterprimarycare.com.au
Complete CPS Online Referral
HUNTER PSYCHOSOCIAL SUPPORT SERVICE (HPSS)
REFERRAL AND INTAKE FORM
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Fields marked with an * are required
Referral Date
Email
Is this referral for yourself?
* Yes
* No
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Person Information
PERSON INFORMATION
First Name *
Last Name *
Street Address *
Suburb *
Postcode *
Date of Birth *
Age *
Mobile Phone *
Landline Phone
Email
Gender *
* Male
* Female
* Non-Binary/Gender Fluid
* Different Identity (please specify below)
Other Response
Identifies As *
* Aboriginal but NOT Torres Strait Islander
* BOTH Aboriginal & Torres Strait Islander
* NEITHER Aboriginal or Torres Strait Islander
* Torres Strait Islander but NOT origin
* NOT stated/adequately described
Mob or Country
Country of Birth
Is an Interpreter Required
* Yes
* No
Resident of Australia
* Yes
* No
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The person has a diagnosed mental illness that is severe in degree *
* Yes
* No
Is the person a participant of the NDIS?
* Yes
* No
Is the person currently receiving support from NPS - Extension or Continuity of
Supports?
* Yes
* No
Is the person currently a client of Community Living Support (CLS) or Housing
and Support Initiative (HASI)?
* Yes
* No
What psychosocial areas are significantly impacted by their mental illness?
(select all that apply) *
* Social skills and friendships
* Vocational skills and goals
* Education and training
* Maintaining physical wellbeing
* Daily living needs
* Building broader life skills
* Family connections
* Financial management and budgeting
* Finding and managing a home
* Managing drug and alcohol addiction, including tobacco
Does the person have barriers to engaging with services at this time?
* Yes
* No
Person (or Guardian) has consented to be involved with CPS *
* Yes
* No
How would the person benefit from a referral to CPS? *
Is the person in hospital at the time of referral?
* Yes
* No
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Referrer's Details
REFERRER'S DETAILS
Name
Organisation
Street Address
Suburb
Postcode
Direct Phone
Mobile Phone
Email
Referrer Type (eg. self, GP, Social Worker etc.)
Recent history of service engagement
Other services person is currently linked with (100 word limit)
100 of 100 Character(s) left
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Apparent co-existing factors that impact on mental illness
* No
* Not Reported
* Unknown
* Yes
Drug or Alcohol Abuse
* No
* Not Reported
* Unknown
* Yes
Intellectual / Cognitive Disability
* No
* Not Reported
* Unknown
* Yes
Physical Disability
* No
* Not Reported
* Unknown
* Yes
Sensory or Speech
* No
* Not Reported
* Unknown
* Yes
Significant Physical Issues
* No
* Not Reported
* Unknown
* Yes
Acquired Brain Injury
* No
* Not Reported
* Unknown
* Yes
Dementia
* No
* Not Reported
* Unknown
* Yes
ALERTS OR RISKS WE NEED TO BE AWARE OF *
* Vicious Animal/s
* Firearms/Weapons
* Self Harm
* Suicidal Ideation
* Domestic Violence
* Harm to Others
* House in Poor Condition
* No Risks Identified
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Where did you hear about Hunter Primary Care CPS Support? *
* Emergency Department
* Friend/Family Member
* Google Search
* Government Agency
* GP or Health Professional
* Hunter Primary Care Staff
* NDIA
* Newspaper
* Online Advertising
* Public Guardian
* Radio
* Social Media
* Service Provider
* Television
* Other (please provide details below)
Other Response
If you are a human seeing this field, please leave it empty.
INTERESTED IN OUR SERVICES?
Our friendly team are ready to answer your questions. Complete this form and we
will come back to you as soon as possible.
You can also get in touch with us over the telephone or by email
(02) 4925 2259
info@hunterprimarycare.com.au
Notice: JavaScript is required for this content.
Fields marked with an * are required
First Name *
Last Name *
Phone
Email *
Preferred Contact Method
* SMS
* Phone Call
* Email
Zip/Postcode *
Do you identify as Aboriginal or Torres Strait Islander? *
* Yes
* No
* Prefer not to disclose
I am enquiring about: *
Aboriginal & Torres Strait Islander Heath Worker Services Commonwealth
Psychosocial Support (CPS) Drug & Alcohol Counselling headspace Newcastle
Mindreach - Telephone Supported Self-Help Program for Drug & Alcohol Use NDIS
Allied Health NDIS Positive Behaviour Support NDIS Specialist Support
Coordination NDIS Support Coordination Yudhilidin First Nations Care
Coordination Not sure
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If you are a human seeing this field, please leave it empty.
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Hunter Primary Care acknowledges Aboriginal and Torres Strait Islander peoples
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present and future who we share this great region with.
DIVERSITY COMMITMENT
Hunter Primary Care is committed to embracing diversity and eliminating all
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