#intakeForm {
max-width: 600px;
margin: 0 auto;
padding: 20px;
font-family: Arial, sans-serif;
}
.form-group {
margin-bottom: 20px;
}
label {
display: block;
margin-bottom: 5px;
font-weight: bold;
}
input[type="text"],
input[type="email"],
input[type="tel"],
input[type="date"],
input[type="number"],
select,
textarea {
width: 100%;
padding: 8px;
border: 1px solid #ccc;
border-radius: 4px;
}
textarea {
height: 100px;
}
.time-inputs {
display: flex;
gap: 10px;
}
.time-inputs input {
flex: 1;
}
table {
width: 100%;
border-collapse: collapse;
}
th, td {
padding: 8px;
border: 1px solid #ccc;
text-align: left;
}
button {
background-color: #4CAF50;
color: white;
padding: 10px 20px;
border: none;
border-radius: 4px;
cursor: pointer;
font-size: 16px;
}
button:hover {
background-color: #45a049;
}
.intake-form-success-message {
background-color: #dff0d8;
color: #3c763d;
padding: 10px;
margin-bottom: 20px;
border: 1px solid #d6e9c6;
border-radius: 4px;
}
document.addEventListener('DOMContentLoaded', function() {
var form = document.getElementById('intakeForm');
var nonceContainer = document.getElementById('nonceContainer');
// Add nonce field dynamically
var nonceField = document.createElement('input');
nonceField.type = 'hidden';
nonceField.name = 'intake_form_nonce';
nonceField.value = 'c5a4dade6c'; // This will be replaced by the actual nonce
nonceContainer.appendChild(nonceField);
if (form) {
form.addEventListener('submit', function(event) {
// Form validation can be added here if needed
console.log('Form submitted');
});
}
});
Intake Form
| Day | Start Time | End Time |
|---|---|---|
| Monday | ||
| Tuesday | ||
| Wednesday | ||
| Thursday | ||
| Friday | ||
| Saturday | ||
| Sunday |
Select a range
$5,000 - $10,000
$10,001 - $15,000
Important Information:
- All payments are in advance pending the interview process.
- All clients must be clean for 72 hours to 30 days depending on the situation before entering the property.
- We are not affiliated with Insurance companies or OHIP because they typically only help for 28 days. In our experience, that is not enough time to heal to the point that is sufficient to bring about lasting recovery.
