Autism Services Test 1

Form using just Conditional Fields PRO but
CF7 Smart Grid Design Extension is installed:

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Form using both Conditional Fields PRO &
CF7 Smart Grid Design Extension:

    Child's Information

    Child's Information

    General Information

    Last, First, Initial.

    Language(s) spoken by the child.


    Healthcare Information

    Example: 1234-567-890

    Parent/Guardian Identification

    Parent/Guardian Identification

    Parent/Guardian {{rep-pg_index}}

    Primary

    Other

    Services Requested

    Services Requested

    Select all that apply.

    Select all that apply.

    Health/Medical Concerns

    Health/Medical Concerns

    Please explain your reasons for referral and list any specific questions or issues that need to be addressed.

    Referral/Source Information

    Referral/Source Information

    Name of the person completing this referral.

    Your phone number.

    Please select today's date.


    "The personal information being collected on this form is collected under the authority of the Health Protection and Promotion Act, the Municipal Freedom of Information and Protection of Privacy Act & Personal Information & Electronic Documents Act.

    This information shall be used to ensure necessary health care measures are attained. Questions covering the collection of this information may be directed to One Kids Place 400 McKeown Ave. North Bay Ontario, P1B 0B2. Phone (705) 476-5437."

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