document.write("    "+"\n");
document.write("    <style type=\"text/css\">"+"\n");
document.write("                    body {"+"\n");
document.write("                padding: 0;"+"\n");
document.write("                margin: 0;"+"\n");
document.write("            }"+"\n");
document.write("                    </style>"+"\n");
document.write("    <script type=\"text/javascript\">"+"\n");
document.write("        "+"\n");
document.write("    </script>"+"\n");
document.write("<div id=\"fsform-container-5655579\" class=\"fsform-container\" data-formid=\"5655579\"></div>"+"\n");
document.write("<script type=\"text/javascript\" src=\"https://static.formstack.com/forms/forms-renderer/builds/public/form_af54ff4c42.js\"></script>"+"\n");
document.write("<script type=\"text/javascript\" nonce=\"c26db180053d241d748d4c1086f57f0c802ce546fb63b1c59d185b856aa8e394\">"+"\n");
document.write("  FSForm.render({\"fullscreen\":false,\"id\":5655579,\"loggingConfig\":{\"disabled\":true,\"sessionSampleRate\":1},\"shouldAutofocusForm\":false,\"target\":\"fsform-container-5655579\",\"viewKey\":\"dzaHKPW7MI\"},"+"\n");
document.write("    {"+"\n");
document.write("      formResponse: {\"error\":null,\"form\":{\"analytics\":{\"baseUrl\":\"https:\\/\\/rehabcenter.formstack.com\\/forms-analytics\",\"isEnabled\":true,\"viewMethod\":\"embedded\"},\"id\":\"5655579\",\"isEncrypted\":false,\"language\":\"en\",\"meta\":{\"ctaParams\":\"utm_source=formstack&utm_medium=product&utm_campaign=build+your+own\",\"ctaType\":\"s-prod-form\",\"extra\":{\"columns\":2,\"customIdentifier\":null,\"discountCode\":null,\"fileUploadsPerSubmission\":20,\"invisibleCaptcha\":false,\"invisibleCaptchaPublicKey\":\"\",\"kioskMode\":false,\"labelPosition\":\"top\",\"oneQuestion\":false,\"progressIndicator\":false,\"promptForLocation\":false,\"saveAndResume\":false,\"shareButtons\":null,\"showReferralBadge\":false,\"showSecurityLogo\":false,\"skipValidationBetweenPages\":false},\"fileUploadActionsDto\":{\"baseUrl\":\"https:\\/\\/rehabcenter.formstack.com\",\"getUploadUrlAction\":\"\\/live-form\\/fileUpload\\/getUploadUrls\"},\"hasEncryptionPassword\":false,\"hiddenSubmitFields\":[{\"key\":\"displayTime\",\"value\":\"2025-09-02T20:03:59-04:00\"}],\"isWorkflowForm\":false,\"isWorkspaceSubmission\":null,\"optimizeFormPerformance\":false,\"redirectUrl\":null,\"shouldTrackPartialSubmission\":null,\"stylesheets\":null,\"submitButtonTitle\":\"Submit Your Inquiry Here\",\"timezone\":\"US\\/Eastern\",\"welcomeMessage\":null},\"name\":\"Conifer Park Webform\",\"password\":null,\"paymentIntegrations\":[],\"plugins\":[],\"portal\":null,\"publicFileUrl\":\"https:\\/\\/static.formstack.com\\/forms\\/forms-renderer\",\"sections\":[{\"calculation\":null,\"defaultValue\":null,\"fieldTypeAttributes\":{\"dtoType\":\"FieldAttributesSectionDto\",\"content\":\"\",\"heading\":\"\",\"labelPosition\":\"\",\"languageFormat\":\"\",\"numColumns\":0,\"usePageBreak\":false},\"fields\":[{\"calculation\":{\"calculationAllowNegatives\":0,\"calculationCategory\":\"text\",\"calculationOperator\":\"\",\"calculationUnits\":\"\",\"fieldOneCalculation\":0,\"fieldTwoCalculation\":0,\"rules\":[]},\"defaultValue\":{\"dtoType\":\"DefaultValueStringDto\",\"confirmValue\":\"\",\"value\":\"\"},\"fieldTypeAttributes\":{\"dtoType\":\"FieldAttributesTextDto\",\"autocompleteOptions\":null,\"calculationAllowNegatives\":0,\"calculationCategory\":\"text\",\"calculationOperator\":\"\",\"calculationUnits\":\"\",\"charactersWide\":50,\"confirmationText\":\"\",\"defaultValue\":\"\",\"fieldOneCalculation\":0,\"fieldTwoCalculation\":0,\"maxLength\":0,\"minLength\":0,\"placeholderText\":\"\"},\"fields\":null,\"general\":{\"autofill\":null,\"columnSpan\":\"1\",\"hidden\":false,\"hideLabel\":false,\"id\":\"160609129\",\"internalLabel\":null,\"isRootSection\":false,\"label\":\"First Name\",\"language\":\"en\",\"options\":[],\"parentTableMetadata\":null,\"readOnly\":false,\"required\":true,\"searchConfig\":{\"canSearchOptions\":false,\"useRemoteSearch\":false},\"section\":\"0\",\"shouldForceSkipValidation\":false,\"supportingText\":null,\"type\":\"text\",\"unique\":false,\"useCallout\":false},\"logic\":null,\"secureSettings\":{\"hideInputCharacters\":false,\"removeDataFromEmailNotifications\":false,\"requireConfirmation\":false,\"restrictDataAccess\":false}},{\"calculation\":{\"calculationAllowNegatives\":0,\"calculationCategory\":\"text\",\"calculationOperator\":\"\",\"calculationUnits\":\"\",\"fieldOneCalculation\":0,\"fieldTwoCalculation\":0,\"rules\":[]},\"defaultValue\":{\"dtoType\":\"DefaultValueStringDto\",\"confirmValue\":\"\",\"value\":\"\"},\"fieldTypeAttributes\":{\"dtoType\":\"FieldAttributesTextDto\",\"autocompleteOptions\":null,\"calculationAllowNegatives\":0,\"calculationCategory\":\"text\",\"calculationOperator\":\"\",\"calculationUnits\":\"\",\"charactersWide\":50,\"confirmationText\":\"\",\"defaultValue\":\"\",\"fieldOneCalculation\":0,\"fieldTwoCalculation\":0,\"maxLength\":0,\"minLength\":0,\"placeholderText\":\"\"},\"fields\":null,\"general\":{\"autofill\":null,\"columnSpan\":\"1\",\"hidden\":false,\"hideLabel\":false,\"id\":\"160609130\",\"internalLabel\":null,\"isRootSection\":false,\"label\":\"Last Name\",\"language\":\"en\",\"options\":[],\"parentTableMetadata\":null,\"readOnly\":false,\"required\":true,\"searchConfig\":{\"canSearchOptions\":false,\"useRemoteSearch\":false},\"section\":\"0\",\"shouldForceSkipValidation\":false,\"supportingText\":null,\"type\":\"text\",\"unique\":false,\"useCallout\":false},\"logic\":null,\"secureSettings\":{\"hideInputCharacters\":false,\"removeDataFromEmailNotifications\":false,\"requireConfirmation\":false,\"restrictDataAccess\":false}},{\"calculation\":null,\"defaultValue\":{\"dtoType\":\"DefaultValueStringDto\",\"confirmValue\":\"\",\"value\":\"\"},\"fieldTypeAttributes\":{\"dtoType\":\"FieldAttributesPhoneDto\",\"charactersWide\":2,\"countryFormat\":\"US\",\"defaultValue\":\"\",\"phoneFormat\":\"national\",\"placeholderText\":\"\"},\"fields\":null,\"general\":{\"autofill\":null,\"columnSpan\":\"1\",\"hidden\":false,\"hideLabel\":false,\"id\":\"160609131\",\"internalLabel\":null,\"isRootSection\":false,\"label\":\"Phone\",\"language\":\"en\",\"options\":[],\"parentTableMetadata\":null,\"readOnly\":false,\"required\":true,\"searchConfig\":{\"canSearchOptions\":false,\"useRemoteSearch\":false},\"section\":\"0\",\"shouldForceSkipValidation\":false,\"supportingText\":null,\"type\":\"phone\",\"unique\":false,\"useCallout\":false},\"logic\":null,\"secureSettings\":null},{\"calculation\":null,\"defaultValue\":{\"dtoType\":\"DefaultValueStringDto\",\"confirmValue\":\"\",\"value\":\"\"},\"fieldTypeAttributes\":{\"dtoType\":\"FieldAttributesEmailDto\",\"charactersWide\":50,\"confirmationText\":\"\",\"defaultValue\":\"\",\"maxLength\":0,\"placeholderText\":\"\",\"useConfirmation\":false},\"fields\":null,\"general\":{\"autofill\":null,\"columnSpan\":\"1\",\"hidden\":false,\"hideLabel\":false,\"id\":\"160609132\",\"internalLabel\":null,\"isRootSection\":false,\"label\":\"Email\",\"language\":\"en\",\"options\":[],\"parentTableMetadata\":null,\"readOnly\":false,\"required\":true,\"searchConfig\":{\"canSearchOptions\":false,\"useRemoteSearch\":false},\"section\":\"0\",\"shouldForceSkipValidation\":false,\"supportingText\":null,\"type\":\"email\",\"unique\":false,\"useCallout\":false},\"logic\":null,\"secureSettings\":null},{\"calculation\":{\"calculationAllowNegatives\":0,\"calculationCategory\":\"text\",\"calculationOperator\":\"\",\"calculationUnits\":\"\",\"fieldOneCalculation\":0,\"fieldTwoCalculation\":0,\"rules\":[]},\"defaultValue\":{\"dtoType\":\"DefaultValueStringDto\",\"confirmValue\":\"\",\"value\":\"\"},\"fieldTypeAttributes\":{\"dtoType\":\"FieldAttributesTextDto\",\"autocompleteOptions\":null,\"calculationAllowNegatives\":0,\"calculationCategory\":\"text\",\"calculationOperator\":\"\",\"calculationUnits\":\"\",\"charactersWide\":50,\"confirmationText\":\"\",\"defaultValue\":\"\",\"fieldOneCalculation\":0,\"fieldTwoCalculation\":0,\"maxLength\":0,\"minLength\":0,\"placeholderText\":\"\"},\"fields\":null,\"general\":{\"autofill\":null,\"columnSpan\":\"1\",\"hidden\":false,\"hideLabel\":false,\"id\":\"160609133\",\"internalLabel\":null,\"isRootSection\":false,\"label\":\"City\",\"language\":\"en\",\"options\":[],\"parentTableMetadata\":null,\"readOnly\":false,\"required\":true,\"searchConfig\":{\"canSearchOptions\":false,\"useRemoteSearch\":false},\"section\":\"0\",\"shouldForceSkipValidation\":false,\"supportingText\":null,\"type\":\"text\",\"unique\":false,\"useCallout\":false},\"logic\":null,\"secureSettings\":{\"hideInputCharacters\":false,\"removeDataFromEmailNotifications\":false,\"requireConfirmation\":false,\"restrictDataAccess\":false}},{\"calculation\":{\"calculationAllowNegatives\":\"\",\"calculationCategory\":\"text\",\"calculationOperator\":\"\",\"calculationUnits\":\"\",\"fieldOneCalculation\":\"\",\"fieldTwoCalculation\":\"\",\"rules\":[]},\"defaultValue\":{\"dtoType\":\"DefaultValueStringDto\",\"confirmValue\":\"\",\"value\":\"\"},\"fieldTypeAttributes\":{\"dtoType\":\"FieldAttributesSelectDto\",\"defaultValue\":\"\",\"optionCount\":1,\"optionLayout\":\"vertical\",\"optionPartToStore\":\"value\",\"useLabelsAndValues\":false,\"useOtherOption\":false,\"useRandomOption\":false,\"useSearchableOptions\":null},\"fields\":null,\"general\":{\"autofill\":null,\"columnSpan\":\"1\",\"hidden\":false,\"hideLabel\":false,\"id\":\"160609134\",\"internalLabel\":null,\"isRootSection\":false,\"label\":\"State\",\"language\":\"en\",\"options\":[{\"label\":\"\",\"value\":\"\"},{\"label\":\"Alabama\",\"value\":\"Alabama\",\"imageUrl\":\"\"},{\"label\":\"Alaska\",\"value\":\"Alaska\",\"imageUrl\":\"\"},{\"label\":\"Arizona\",\"value\":\"Arizona\",\"imageUrl\":\"\"},{\"label\":\"Arkansas\",\"value\":\"Arkansas\",\"imageUrl\":\"\"},{\"label\":\"California\",\"value\":\"California\",\"imageUrl\":\"\"},{\"label\":\"Colorado\",\"value\":\"Colorado\",\"imageUrl\":\"\"},{\"label\":\"Connecticut\",\"value\":\"Connecticut\",\"imageUrl\":\"\"},{\"label\":\"Delaware\",\"value\":\"Delaware\",\"imageUrl\":\"\"},{\"label\":\"Florida\",\"value\":\"Florida\",\"imageUrl\":\"\"},{\"label\":\"Georgia\",\"value\":\"Georgia\",\"imageUrl\":\"\"},{\"label\":\"Hawaii\",\"value\":\"Hawaii\",\"imageUrl\":\"\"},{\"label\":\"Idaho\",\"value\":\"Idaho\",\"imageUrl\":\"\"},{\"label\":\"Illinois\",\"value\":\"Illinois\",\"imageUrl\":\"\"},{\"label\":\"Indiana\",\"value\":\"Indiana\",\"imageUrl\":\"\"},{\"label\":\"Iowa\",\"value\":\"Iowa\",\"imageUrl\":\"\"},{\"label\":\"Kansas\",\"value\":\"Kansas\",\"imageUrl\":\"\"},{\"label\":\"Kentucky\",\"value\":\"Kentucky\",\"imageUrl\":\"\"},{\"label\":\"Louisiana\",\"value\":\"Louisiana\",\"imageUrl\":\"\"},{\"label\":\"Maine\",\"value\":\"Maine\",\"imageUrl\":\"\"},{\"label\":\"Maryland\",\"value\":\"Maryland\",\"imageUrl\":\"\"},{\"label\":\"Massachusetts\",\"value\":\"Massachusetts\",\"imageUrl\":\"\"},{\"label\":\"Michigan\",\"value\":\"Michigan\",\"imageUrl\":\"\"},{\"label\":\"Minnesota\",\"value\":\"Minnesota\",\"imageUrl\":\"\"},{\"label\":\"Mississippi\",\"value\":\"Mississippi\",\"imageUrl\":\"\"},{\"label\":\"Missouri\",\"value\":\"Missouri\",\"imageUrl\":\"\"},{\"label\":\"Montana\",\"value\":\"Montana\",\"imageUrl\":\"\"},{\"label\":\"Nebraska\",\"value\":\"Nebraska\",\"imageUrl\":\"\"},{\"label\":\"Nevada\",\"value\":\"Nevada\",\"imageUrl\":\"\"},{\"label\":\"New Hampshire\",\"value\":\"New Hampshire\",\"imageUrl\":\"\"},{\"label\":\"New Jersey\",\"value\":\"New Jersey\",\"imageUrl\":\"\"},{\"label\":\"New Mexico\",\"value\":\"New Mexico\",\"imageUrl\":\"\"},{\"label\":\"New York\",\"value\":\"New York\",\"imageUrl\":\"\"},{\"label\":\"North Carolina\",\"value\":\"North Carolina\",\"imageUrl\":\"\"},{\"label\":\"North Dakota\",\"value\":\"North Dakota\",\"imageUrl\":\"\"},{\"label\":\"Ohio\",\"value\":\"Ohio\",\"imageUrl\":\"\"},{\"label\":\"Oklahoma\",\"value\":\"Oklahoma\",\"imageUrl\":\"\"},{\"label\":\"Oregon\",\"value\":\"Oregon\",\"imageUrl\":\"\"},{\"label\":\"Pennsylvania\",\"value\":\"Pennsylvania\",\"imageUrl\":\"\"},{\"label\":\"Rhode Island\",\"value\":\"Rhode Island\",\"imageUrl\":\"\"},{\"label\":\"South Carolina\",\"value\":\"South Carolina\",\"imageUrl\":\"\"},{\"label\":\"South Dakota\",\"value\":\"South Dakota\",\"imageUrl\":\"\"},{\"label\":\"Tennessee\",\"value\":\"Tennessee\",\"imageUrl\":\"\"},{\"label\":\"Texas\",\"value\":\"Texas\",\"imageUrl\":\"\"},{\"label\":\"Utah\",\"value\":\"Utah\",\"imageUrl\":\"\"},{\"label\":\"Vermont\",\"value\":\"Vermont\",\"imageUrl\":\"\"},{\"label\":\"Virginia\",\"value\":\"Virginia\",\"imageUrl\":\"\"},{\"label\":\"Washington\",\"value\":\"Washington\",\"imageUrl\":\"\"},{\"label\":\"West Virginia\",\"value\":\"West Virginia\",\"imageUrl\":\"\"},{\"label\":\"Wisconsin\",\"value\":\"Wisconsin\",\"imageUrl\":\"\"},{\"label\":\"Wyoming\",\"value\":\"Wyoming\",\"imageUrl\":\"\"}],\"parentTableMetadata\":null,\"readOnly\":false,\"required\":true,\"searchConfig\":{\"canSearchOptions\":false,\"useRemoteSearch\":false},\"section\":\"0\",\"shouldForceSkipValidation\":false,\"supportingText\":null,\"type\":\"select\",\"unique\":false,\"useCallout\":false},\"logic\":null,\"secureSettings\":null},{\"calculation\":{\"calculationAllowNegatives\":\"\",\"calculationCategory\":\"text\",\"calculationOperator\":\"\",\"calculationUnits\":\"\",\"fieldOneCalculation\":\"\",\"fieldTwoCalculation\":\"\",\"rules\":[]},\"defaultValue\":{\"dtoType\":\"DefaultValueStringDto\",\"confirmValue\":\"\",\"value\":\"\"},\"fieldTypeAttributes\":{\"dtoType\":\"FieldAttributesSelectDto\",\"defaultValue\":\"\",\"optionCount\":1,\"optionLayout\":\"vertical\",\"optionPartToStore\":\"value\",\"useLabelsAndValues\":false,\"useOtherOption\":false,\"useRandomOption\":false,\"useSearchableOptions\":null},\"fields\":null,\"general\":{\"autofill\":null,\"columnSpan\":\"1\",\"hidden\":false,\"hideLabel\":false,\"id\":\"160609376\",\"internalLabel\":null,\"isRootSection\":false,\"label\":\"Inquiring Regarding\",\"language\":\"en\",\"options\":[{\"label\":\"\",\"value\":\"\"},{\"label\":\"Conifer Park - Inpatient Detox & Rehab\",\"value\":\"Conifer Park - Inpatient Detox & Rehab\",\"imageUrl\":null},{\"label\":\"Conifer Park - Outpatient (Glen Falls)\",\"value\":\"Conifer Park - Outpatient (Glen Falls)\",\"imageUrl\":null},{\"label\":\"Conifer Park - Outpatient OTP (Plattsburgh)\",\"value\":\"Conifer Park - Outpatient OTP (Plattsburgh)\",\"imageUrl\":null},{\"label\":\"Conifer Park - Outpatient OTP (Syracuse)\",\"value\":\"Conifer Park - Outpatient OTP (Syracuse)\",\"imageUrl\":\"\"},{\"label\":\"Conifer Park - Outpatient (Rochester)\",\"value\":\"Conifer Park - Outpatient (Rochester)\",\"imageUrl\":\"\"},{\"label\":\"Conifer Park - Outpatient OTP (Troy)\",\"value\":\"Conifer Park - Outpatient OTP (Troy)\",\"imageUrl\":\"\"},{\"label\":\"Conifer Park - Outpatient (Schenectady)\",\"value\":\"Conifer Park - Outpatient (Schenectady)\",\"imageUrl\":\"\"}],\"parentTableMetadata\":null,\"readOnly\":false,\"required\":false,\"searchConfig\":{\"canSearchOptions\":false,\"useRemoteSearch\":false},\"section\":\"0\",\"shouldForceSkipValidation\":false,\"supportingText\":null,\"type\":\"select\",\"unique\":false,\"useCallout\":false},\"logic\":null,\"secureSettings\":null},{\"calculation\":{\"calculationAllowNegatives\":\"\",\"calculationCategory\":\"text\",\"calculationOperator\":\"\",\"calculationUnits\":\"\",\"fieldOneCalculation\":\"\",\"fieldTwoCalculation\":\"\",\"rules\":[]},\"defaultValue\":{\"dtoType\":\"DefaultValueStringDto\",\"confirmValue\":\"\",\"value\":\"\"},\"fieldTypeAttributes\":{\"dtoType\":\"FieldAttributesSelectDto\",\"defaultValue\":\"\",\"optionCount\":1,\"optionLayout\":\"vertical\",\"optionPartToStore\":\"value\",\"useLabelsAndValues\":false,\"useOtherOption\":false,\"useRandomOption\":false,\"useSearchableOptions\":null},\"fields\":null,\"general\":{\"autofill\":null,\"columnSpan\":\"1\",\"hidden\":false,\"hideLabel\":false,\"id\":\"160609135\",\"internalLabel\":null,\"isRootSection\":false,\"label\":\"Insurance Type\",\"language\":\"en\",\"options\":[{\"label\":\"\",\"value\":\"\"},{\"label\":\"Medicaid\",\"value\":\"Medicaid\",\"imageUrl\":null},{\"label\":\"Medicare\",\"value\":\"Medicare\",\"imageUrl\":null},{\"label\":\"Commercial\",\"value\":\"Commercial\",\"imageUrl\":null}],\"parentTableMetadata\":null,\"readOnly\":false,\"required\":false,\"searchConfig\":{\"canSearchOptions\":false,\"useRemoteSearch\":false},\"section\":\"0\",\"shouldForceSkipValidation\":false,\"supportingText\":\"(optional)\",\"type\":\"select\",\"unique\":false,\"useCallout\":false},\"logic\":null,\"secureSettings\":null},{\"calculation\":{\"calculationAllowNegatives\":0,\"calculationCategory\":\"text\",\"calculationOperator\":\"\",\"calculationUnits\":\"\",\"fieldOneCalculation\":0,\"fieldTwoCalculation\":0,\"rules\":[]},\"defaultValue\":{\"dtoType\":\"DefaultValueStringDto\",\"confirmValue\":\"\",\"value\":\"\"},\"fieldTypeAttributes\":{\"dtoType\":\"FieldAttributesTextDto\",\"autocompleteOptions\":null,\"calculationAllowNegatives\":0,\"calculationCategory\":\"text\",\"calculationOperator\":\"\",\"calculationUnits\":\"\",\"charactersWide\":50,\"confirmationText\":\"\",\"defaultValue\":\"\",\"fieldOneCalculation\":0,\"fieldTwoCalculation\":0,\"maxLength\":0,\"minLength\":0,\"placeholderText\":\"\"},\"fields\":null,\"general\":{\"autofill\":null,\"columnSpan\":\"1\",\"hidden\":true,\"hideLabel\":false,\"id\":\"160609136\",\"internalLabel\":null,\"isRootSection\":false,\"label\":\"Insurance Member ID\\/CIN #\",\"language\":\"en\",\"options\":[],\"parentTableMetadata\":null,\"readOnly\":false,\"required\":false,\"searchConfig\":{\"canSearchOptions\":false,\"useRemoteSearch\":false},\"section\":\"0\",\"shouldForceSkipValidation\":false,\"supportingText\":\"(optional)\",\"type\":\"text\",\"unique\":false,\"useCallout\":false},\"logic\":null,\"secureSettings\":{\"hideInputCharacters\":false,\"removeDataFromEmailNotifications\":false,\"requireConfirmation\":false,\"restrictDataAccess\":false}},{\"calculation\":null,\"defaultValue\":{\"dtoType\":\"DefaultValueStringDto\",\"confirmValue\":\"\",\"value\":\"\"},\"fieldTypeAttributes\":{\"dtoType\":\"FieldAttributesTextareaDto\",\"columnCount\":50,\"defaultValue\":\"\",\"maxLength\":0,\"minLength\":0,\"placeholderText\":\"\",\"rowCount\":10},\"fields\":null,\"general\":{\"autofill\":null,\"columnSpan\":\"1\",\"hidden\":true,\"hideLabel\":false,\"id\":\"160609137\",\"internalLabel\":null,\"isRootSection\":false,\"label\":\"Additional Info You Want To Share\",\"language\":\"en\",\"options\":[],\"parentTableMetadata\":null,\"readOnly\":false,\"required\":false,\"searchConfig\":{\"canSearchOptions\":false,\"useRemoteSearch\":false},\"section\":\"0\",\"shouldForceSkipValidation\":false,\"supportingText\":\"(optional)\",\"type\":\"textarea\",\"unique\":false,\"useCallout\":false},\"logic\":null,\"secureSettings\":null}],\"general\":{\"autofill\":null,\"columnSpan\":0,\"hidden\":false,\"hideLabel\":false,\"id\":\"0\",\"internalLabel\":null,\"isRootSection\":true,\"label\":\"\",\"language\":null,\"options\":[],\"parentTableMetadata\":null,\"readOnly\":false,\"required\":false,\"searchConfig\":null,\"section\":\"\",\"shouldForceSkipValidation\":null,\"supportingText\":null,\"type\":\"section\",\"unique\":false,\"useCallout\":null},\"logic\":null,\"secureSettings\":null}],\"shouldDisableSubmission\":null,\"submitUrl\":\"https:\\/\\/rehabcenter.formstack.com\\/forms\\/index.php\",\"theme\":{\"backgroundImage\":\"\",\"backgroundImageRepeat\":\"repeat\",\"bodyBgColor\":\"#ffffff\",\"buttonBgColor\":\"#333536\",\"buttonBorder\":\"1px\",\"buttonBorderColor\":\"transparent\",\"buttonColor\":\"#ffffff\",\"buttonFontSize\":\"18px\",\"buttonFontStyle\":\"normal\",\"buttonFontVariant\":\"\",\"buttonFontWeight\":\"700\",\"buttonPaddingLeftRight\":\"15px\",\"buttonPaddingTopBottom\":\"15px\",\"buttonRoundedCorners\":\"3px\",\"colorMain\":\"#595d64\",\"customCss\":\"\",\"errorBackgroundColor\":\"#fae9e9\",\"errorColorPrimary\":\"#ff3C3C\",\"errorColorSecondary\":\"#15232b\",\"extraneousPrimaryColor\":\"#595d64\",\"extraneousSecondaryColor\":\"#d4d4d4\",\"extraneousTertiaryColor\":\"#eaeaea\",\"fieldBgColor\":\"#ffffff\",\"fieldBorder\":\"1px\",\"fieldBorderColor\":\"#cfd4d8\",\"fieldColor\":\"#595d64\",\"fieldFontStyle\":\"normal\",\"fieldFontVariant\":\"\",\"fieldFontWeight\":\"400\",\"fieldRequiredBgColor\":\"#ffffff\",\"fieldRequiredBorder\":\"1px\",\"fieldRequiredBorderColor\":\"#cfd4d8\",\"fieldRoundedCorners\":\"3px\",\"focusHighlightColor\":\"transparent\",\"focusHighlightOpacity\":0,\"fontService\":\"google\",\"fontWeights\":\"700,400\",\"footerImageAlignment\":\"\",\"footerImageHeight\":\"\",\"footerImageUrl\":\"\",\"footerImageWidth\":\"\",\"formAlignment\":\"center\",\"formBgColor\":\"#ffffff\",\"formBgColorOpacity\":1,\"formBorder\":\"1px\",\"formBorderColor\":\"transparent\",\"formBorderRoundedCorners\":\"6px\",\"globalFont\":\"Dosis\",\"globalFontSize\":1,\"globalRoundedCorners\":\"3px\",\"globalSpacing\":2,\"headerImageAlignment\":\"\",\"headerImageHeight\":\"\",\"headerImageUrl\":\"\",\"headerImageWidth\":\"\",\"inputFocusHighlightColor\":\"#0197EC\",\"isNoStyleStrict\":false,\"labelRequiredColor\":\"#595d64\",\"labelRequiredFontSize\":\"16px\",\"matrixLabelColumnPosition\":\"center\",\"matrixLabelRowPosition\":\"right\",\"placeholderTextColor\":\"\",\"productPriceColor\":\"#595d64\",\"ratingIconColor\":\"#595d64\",\"ratingIconSize\":\"25px\",\"readOnlyFieldBgColor\":\"#edeff0\",\"saveAndResumeButtonBackgroundColor\":\"#eaeaea\",\"saveAndResumeButtonTextColor\":\"#595d64\",\"sectionBgColor\":\"#edeff0\",\"sectionColor\":\"#595d64\",\"sectionHeadingAlignment\":\"center\",\"sectionHeadingColor\":\"#595d64\",\"sectionHeadingFontStyle\":\"normal\",\"sectionHeadingFontVariant\":\"\",\"sectionHeadingFontWeight\":\"400\",\"sectionHeadingSize\":\"28px\",\"sectionRoundedCorners\":\"3px\",\"sizeField\":\"14px\",\"sizeLabel\":\"16px\",\"spacing\":\"10px\",\"successBackgroundColor\":\"#eefaf5\",\"successColorPrimary\":\"#21B573\",\"successColorSecondary\":\"#eefaf5\",\"supportingTextColor\":\"#595d64\",\"supportingTextFontSize\":\"12px\",\"supportingTextFontStyle\":\"normal\",\"supportingTextFontVariant\":\"\",\"supportingTextFontWeight\":\"\",\"tableCellEvenBgColor\":\"#eaeaea33\",\"tableCellOddBgColor\":\"#d4d4d433\",\"transitionDuration\":\"0s\",\"transitionSpacingRightLeft\":\"10px\",\"transitionSpacingTopBottom\":\"10px\"},\"url\":\"https:\\/\\/rehabcenter.formstack.com\",\"version\":\"4\",\"viewKey\":\"dzaHKPW7MI\",\"workflows\":null},\"isCached\":true,\"success\":true},"+"\n");
document.write("    }"+"\n");
document.write("  );"+"\n");
document.write("    (function(){"+"\n");
document.write("    var link = document.createElement(\'link\');"+"\n");
document.write("    link.rel = \'stylesheet\';"+"\n");
document.write("    link.href = \'https://fonts.googleapis.com/css?family=Dosis:700,400\';"+"\n");
document.write("    document.querySelector(\'head\').appendChild(link);"+"\n");
document.write("  })();"+"\n");
document.write("  </script>"+"\n");
document.write(""+"\n");
