{"id":3185,"date":"2025-02-06T10:14:03","date_gmt":"2025-02-06T15:14:03","guid":{"rendered":"https:\/\/yapp.scdmh.org\/?page_id=3185"},"modified":"2025-05-21T11:10:55","modified_gmt":"2025-05-21T15:10:55","slug":"consultation-line-pre-registration","status":"publish","type":"page","link":"https:\/\/yapp.scdmh.org\/?page_id=3185","title":{"rendered":"Consultation Line Pre-Registration"},"content":{"rendered":"\t\t<div data-elementor-type=\"wp-page\" data-elementor-id=\"3185\" class=\"elementor elementor-3185\" data-elementor-post-type=\"page\">\n\t\t\t\t\t\t<section class=\"elementor-section elementor-top-section elementor-element elementor-element-513c423 elementor-section-boxed elementor-section-height-default elementor-section-height-default\" data-id=\"513c423\" data-element_type=\"section\">\n\t\t\t\t\t\t<div class=\"elementor-container elementor-column-gap-default\">\n\t\t\t\t\t<div class=\"elementor-column elementor-col-100 elementor-top-column elementor-element elementor-element-064c2e8\" data-id=\"064c2e8\" data-element_type=\"column\">\n\t\t\t<div class=\"elementor-widget-wrap elementor-element-populated\">\n\t\t\t\t\t\t<div class=\"elementor-element elementor-element-17f93fd elementor-widget elementor-widget-heading\" data-id=\"17f93fd\" data-element_type=\"widget\" data-widget_type=\"heading.default\">\n\t\t\t\t<div class=\"elementor-widget-container\">\n\t\t\t\t\t<h3 class=\"elementor-heading-title elementor-size-default\">Consultation Line Pre-Registration Form<\/h3>\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t\t<\/div>\n\t\t<\/div>\n\t\t\t\t\t<\/div>\n\t\t<\/section>\n\t\t\t\t<section class=\"elementor-section elementor-top-section elementor-element elementor-element-c9c08d3 elementor-section-boxed elementor-section-height-default elementor-section-height-default\" data-id=\"c9c08d3\" data-element_type=\"section\">\n\t\t\t\t\t\t<div class=\"elementor-container elementor-column-gap-default\">\n\t\t\t\t\t<div class=\"elementor-column elementor-col-100 elementor-top-column elementor-element elementor-element-5763314\" data-id=\"5763314\" data-element_type=\"column\">\n\t\t\t<div class=\"elementor-widget-wrap elementor-element-populated\">\n\t\t\t\t\t\t<div class=\"elementor-element elementor-element-a02fa5b elementor-widget elementor-widget-text-editor\" data-id=\"a02fa5b\" data-element_type=\"widget\" data-widget_type=\"text-editor.default\">\n\t\t\t\t<div class=\"elementor-widget-container\">\n\t\t\t\t\t\t\t\t\t<div class=\"forminator-ui forminator-custom-form forminator-custom-form-3444 forminator-design--default  forminator_ajax\" data-forminator-render=\"0\" data-form=\"forminator-module-3444\" data-uid=\"6a968750c20d5\"><br\/><\/div><form\n\t\t\t\tid=\"forminator-module-3444\"\n\t\t\t\tclass=\"forminator-ui forminator-custom-form forminator-custom-form-3444 forminator-design--default  forminator_ajax\"\n\t\t\t\tmethod=\"post\"\n\t\t\t\tdata-forminator-render=\"0\"\n\t\t\t\tdata-form-id=\"3444\"\n\t\t\t\t data-color-option=\"theme\" data-design=\"default\" data-grid=\"open\" style=\"display: none;\"\n\t\t\t\tdata-uid=\"6a968750c20d5\"\n\t\t\t><div role=\"alert\" aria-live=\"polite\" class=\"forminator-response-message forminator-error\" aria-hidden=\"true\"><\/div><div class=\"forminator-row\"><div id=\"section-1\" class=\"forminator-field-section forminator-col forminator-col-12 \"><div class=\"forminator-field\"><h2 class=\"forminator-title\">Your Data<\/h2><h3 class=\"forminator-subtitle\">This data is collected for grant compliance purposes and will be used only for participation in YAP-P activities. YAP-P is supported by the Health Resources and Services Administration (HRSA) of the U.S. Dept. of Health and Human Services (HHS) as part of an award totaling $445,000 with 20% financed by SCDMH. The contents were developed by the YAP-P team and do not necessarily represent the official views of, nor an endorsement, by HRSA, HHS, or the U.S. Government.<\/h3><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"name-1\" class=\"forminator-field-name forminator-col forminator-col-12 \"><div class=\"forminator-row forminator-no-margin\" data-multiple=\"true\"><div class=\"forminator-col forminator-col-md-6\"><div class=\"forminator-field\"><label for=\"forminator-field-first-name-1_6a968750c20d5\" id=\"forminator-field-first-name-1_6a968750c20d5-label\" class=\"forminator-label\">First Name <span class=\"forminator-required\">*<\/span><\/label><input type=\"text\" name=\"name-1-first-name\" placeholder=\"\" id=\"forminator-field-first-name-1_6a968750c20d5\" class=\"forminator-input\" aria-required=\"true\" data-multi=\"1\" autocomplete=\"given-name\" value=\"\" \/><\/div><\/div><div class=\"forminator-col forminator-col-md-6\"><div class=\"forminator-field\"><label for=\"forminator-field-last-name-1_6a968750c20d5\" id=\"forminator-field-last-name-1_6a968750c20d5-label\" class=\"forminator-label\">Last Name<\/label><input type=\"text\" name=\"name-1-last-name\" placeholder=\"\" id=\"forminator-field-last-name-1_6a968750c20d5\" class=\"forminator-input\" aria-required=\"false\" data-multi=\"1\" autocomplete=\"family-name\" value=\"\" \/><\/div><\/div><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"checkbox-1\" class=\"forminator-field-checkbox forminator-col forminator-col-12 \"><div role=\"group\" class=\"forminator-field required\" aria-labelledby=\"forminator-checkbox-group-forminator-field-checkbox-1-6a968750c20d5-label\"><span id=\"forminator-checkbox-group-forminator-field-checkbox-1-6a968750c20d5-label\" class=\"forminator-label\">Your Credentials <span class=\"forminator-required\">*<\/span><\/span><label id=\"forminator-field-checkbox-1-1-6a968750c20d5-label\" for=\"forminator-field-checkbox-1-1-6a968750c20d5\" class=\"forminator-checkbox\" title=\"MD\"><input type=\"checkbox\" name=\"checkbox-1[]\" value=\"one\" id=\"forminator-field-checkbox-1-1-6a968750c20d5\" aria-labelledby=\"forminator-field-checkbox-1-1-6a968750c20d5-label\" data-calculation=\"0\"   data-hidden-behavior=\"zero\"\/><span class=\"forminator-checkbox-box\" aria-hidden=\"true\"><\/span><span class=\"forminator-checkbox-label\">MD<\/span><\/label><label id=\"forminator-field-checkbox-1-2-6a968750c20d5-label\" for=\"forminator-field-checkbox-1-2-6a968750c20d5\" class=\"forminator-checkbox\" title=\"DO\"><input type=\"checkbox\" name=\"checkbox-1[]\" value=\"two\" id=\"forminator-field-checkbox-1-2-6a968750c20d5\" aria-labelledby=\"forminator-field-checkbox-1-2-6a968750c20d5-label\" data-calculation=\"0\"   data-hidden-behavior=\"zero\"\/><span class=\"forminator-checkbox-box\" aria-hidden=\"true\"><\/span><span class=\"forminator-checkbox-label\">DO<\/span><\/label><label id=\"forminator-field-checkbox-1-3-6a968750c20d5-label\" for=\"forminator-field-checkbox-1-3-6a968750c20d5\" class=\"forminator-checkbox\" title=\"APRN\/NP\"><input type=\"checkbox\" name=\"checkbox-1[]\" value=\"APRN-NP\" id=\"forminator-field-checkbox-1-3-6a968750c20d5\" aria-labelledby=\"forminator-field-checkbox-1-3-6a968750c20d5-label\" data-calculation=\"0\"   data-hidden-behavior=\"zero\"\/><span class=\"forminator-checkbox-box\" aria-hidden=\"true\"><\/span><span class=\"forminator-checkbox-label\">APRN\/NP<\/span><\/label><label id=\"forminator-field-checkbox-1-4-6a968750c20d5-label\" for=\"forminator-field-checkbox-1-4-6a968750c20d5\" class=\"forminator-checkbox\" title=\"PA\"><input type=\"checkbox\" name=\"checkbox-1[]\" value=\"PA\" id=\"forminator-field-checkbox-1-4-6a968750c20d5\" aria-labelledby=\"forminator-field-checkbox-1-4-6a968750c20d5-label\" data-calculation=\"0\"   data-hidden-behavior=\"zero\"\/><span class=\"forminator-checkbox-box\" aria-hidden=\"true\"><\/span><span class=\"forminator-checkbox-label\">PA<\/span><\/label><label id=\"forminator-field-checkbox-1-5-6a968750c20d5-label\" for=\"forminator-field-checkbox-1-5-6a968750c20d5\" class=\"forminator-checkbox\" title=\"Other\"><input type=\"checkbox\" name=\"checkbox-1[]\" value=\"Other\" id=\"forminator-field-checkbox-1-5-6a968750c20d5\" aria-labelledby=\"forminator-field-checkbox-1-5-6a968750c20d5-label\" data-calculation=\"0\"   data-hidden-behavior=\"zero\"\/><span class=\"forminator-checkbox-box\" aria-hidden=\"true\"><\/span><span class=\"forminator-checkbox-label\">Other<\/span><\/label><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"text-1\" class=\"forminator-field-text forminator-col forminator-col-12 \"><div class=\"forminator-field\"><label for=\"forminator-field-text-1_6a968750c20d5\" id=\"forminator-field-text-1_6a968750c20d5-label\" class=\"forminator-label\">If Other, Please Specify<\/label><input type=\"text\" name=\"text-1\" value=\"\" placeholder=\"\" id=\"forminator-field-text-1_6a968750c20d5\" class=\"forminator-input forminator-name--field\" data-required=\"\" \/><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"text-2\" class=\"forminator-field-text forminator-col forminator-col-12 \"><div class=\"forminator-field\"><label for=\"forminator-field-text-2_6a968750c20d5\" id=\"forminator-field-text-2_6a968750c20d5-label\" class=\"forminator-label\">Your Email for consult calendar Invitations <span class=\"forminator-required\">*<\/span><\/label><input type=\"text\" name=\"text-2\" value=\"\" placeholder=\"\" id=\"forminator-field-text-2_6a968750c20d5\" class=\"forminator-input forminator-name--field\" data-required=\"1\" aria-describedby=\"forminator-field-text-2_6a968750c20d5-description\" \/><span id=\"forminator-field-text-2_6a968750c20d5-description\" class=\"forminator-description\">YAP-P will send you a calendar invitation for any scheduled consultations.<\/span><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"text-3\" class=\"forminator-field-text forminator-col forminator-col-12 \"><div class=\"forminator-field\"><label for=\"forminator-field-text-3_6a968750c20d5\" id=\"forminator-field-text-3_6a968750c20d5-label\" class=\"forminator-label\">Main Practice \/ Clinic Name <span class=\"forminator-required\">*<\/span><\/label><input type=\"text\" name=\"text-3\" value=\"\" placeholder=\"\" id=\"forminator-field-text-3_6a968750c20d5\" class=\"forminator-input forminator-name--field\" data-required=\"1\" \/><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"address-1\" class=\"forminator-field-address forminator-col forminator-col-12 \"><div class=\"forminator-row\"><div id=\"address-1-street_address\" class=\"forminator-col\"><div class=\"forminator-field\"><label for=\"forminator-field-address-1-street_address_6a968750c20d5\" id=\"forminator-field-address-1-street_address_6a968750c20d5-label\" class=\"forminator-label\">Main Practice Street Address <span class=\"forminator-required\">*<\/span><\/label><input type=\"text\" name=\"address-1-street_address\" placeholder=\"\" id=\"forminator-field-address-1-street_address_6a968750c20d5\" class=\"forminator-input\" data-required=\"1\" aria-required=\"true\" autocomplete=\"address-line1\" value=\"\" \/><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"address-1-address_line\" class=\"forminator-col\"><div class=\"forminator-field\"><label for=\"forminator-field-address-1-address_line_6a968750c20d5\" id=\"forminator-field-address-1-address_line_6a968750c20d5-label\" class=\"forminator-label\">Apartment, suite, etc<\/label><input type=\"text\" name=\"address-1-address_line\" placeholder=\"\" id=\"forminator-field-address-1-address_line_6a968750c20d5\" class=\"forminator-input\" data-required=\"\" aria-required=\"false\" autocomplete=\"address-line2\" value=\"\" \/><\/div><\/div><\/div><div class=\"forminator-row\" data-multiple=\"false\"><div id=\"address-1-city\" class=\"forminator-col forminator-col-12\"><div class=\"forminator-field\"><label for=\"forminator-field-address-1-city_6a968750c20d5\" id=\"forminator-field-address-1-city_6a968750c20d5-label\" class=\"forminator-label\">Main Practice City <span class=\"forminator-required\">*<\/span><\/label><input type=\"text\" name=\"address-1-city\" placeholder=\"\" id=\"forminator-field-address-1-city_6a968750c20d5\" class=\"forminator-input\" data-required=\"1\" aria-required=\"true\" autocomplete=\"address-level2\" value=\"\" \/><\/div><\/div><\/div><div class=\"forminator-row\" data-multiple=\"false\"><div id=\"address-1-zip\" class=\"forminator-col forminator-col-12\"><div class=\"forminator-field\"><label for=\"forminator-field-address-1-zip_6a968750c20d5\" id=\"forminator-field-address-1-zip_6a968750c20d5-label\" class=\"forminator-label\">Main Practice ZIP\/Postal Code <span class=\"forminator-required\">*<\/span><\/label><input type=\"text\" name=\"address-1-zip\" placeholder=\"\" id=\"forminator-field-address-1-zip_6a968750c20d5\" class=\"forminator-input\" autocomplete=\"postal-code\" value=\"\" \/><\/div><\/div><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"phone-1\" class=\"forminator-field-phone forminator-col forminator-col-12 \"><div class=\"forminator-field\"><label for=\"forminator-field-phone-1_6a968750c20d5\" id=\"forminator-field-phone-1_6a968750c20d5-label\" class=\"forminator-label\">Main Practice Phone Number <span class=\"forminator-required\">*<\/span><\/label><input type=\"text\" name=\"phone-1\" value=\"\" placeholder=\"\" id=\"forminator-field-phone-1_6a968750c20d5\" class=\"forminator-input forminator-field--phone\" data-required=\"1\" aria-required=\"true\" autocomplete=\"off\" \/><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"name-2\" class=\"forminator-field-name forminator-col forminator-col-12 \"><div class=\"forminator-field\"><label for=\"forminator-field-name-2_6a968750c20d5\" id=\"forminator-field-name-2_6a968750c20d5-label\" class=\"forminator-label\">Main Practice Manager \/ Administrator Name<\/label><input type=\"text\" name=\"name-2\" value=\"\" placeholder=\"\" id=\"forminator-field-name-2_6a968750c20d5\" class=\"forminator-input forminator-name--field\" aria-required=\"false\" autocomplete=\"name\" \/><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"email-1\" class=\"forminator-field-email forminator-col forminator-col-12 \"><div class=\"forminator-field\"><label for=\"forminator-field-email-1_6a968750c20d5\" id=\"forminator-field-email-1_6a968750c20d5-label\" class=\"forminator-label\">Main Practice Manager \/ Administrator Email Address<\/label><input type=\"email\" name=\"email-1\" value=\"\" placeholder=\"\" id=\"forminator-field-email-1_6a968750c20d5\" class=\"forminator-input forminator-email--field\" data-required=\"\" aria-required=\"false\" autocomplete=\"email\" \/><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"text-4\" class=\"forminator-field-text forminator-col forminator-col-12 \"><div class=\"forminator-field\"><label for=\"forminator-field-text-4_6a968750c20d5\" id=\"forminator-field-text-4_6a968750c20d5-label\" class=\"forminator-label\">Your NPI Number <span class=\"forminator-required\">*<\/span><\/label><input type=\"text\" name=\"text-4\" value=\"\" placeholder=\"\" id=\"forminator-field-text-4_6a968750c20d5\" class=\"forminator-input forminator-name--field\" data-required=\"1\" \/><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"checkbox-2\" class=\"forminator-field-checkbox forminator-col forminator-col-12 \"><div role=\"group\" class=\"forminator-field required\" aria-labelledby=\"forminator-checkbox-group-forminator-field-checkbox-2-6a968750c20d5-label\"><span id=\"forminator-checkbox-group-forminator-field-checkbox-2-6a968750c20d5-label\" class=\"forminator-label\">Provider Type <span class=\"forminator-required\">*<\/span><\/span><label id=\"forminator-field-checkbox-2-1-6a968750c20d5-label\" for=\"forminator-field-checkbox-2-1-6a968750c20d5\" class=\"forminator-checkbox\" title=\"Pediatrician\"><input type=\"checkbox\" name=\"checkbox-2[]\" value=\"one\" id=\"forminator-field-checkbox-2-1-6a968750c20d5\" aria-labelledby=\"forminator-field-checkbox-2-1-6a968750c20d5-label\" data-calculation=\"0\"   data-hidden-behavior=\"zero\"\/><span class=\"forminator-checkbox-box\" aria-hidden=\"true\"><\/span><span class=\"forminator-checkbox-label\">Pediatrician<\/span><\/label><label id=\"forminator-field-checkbox-2-2-6a968750c20d5-label\" for=\"forminator-field-checkbox-2-2-6a968750c20d5\" class=\"forminator-checkbox\" title=\"Family Medicine\"><input type=\"checkbox\" name=\"checkbox-2[]\" value=\"two\" id=\"forminator-field-checkbox-2-2-6a968750c20d5\" aria-labelledby=\"forminator-field-checkbox-2-2-6a968750c20d5-label\" data-calculation=\"0\"   data-hidden-behavior=\"zero\"\/><span class=\"forminator-checkbox-box\" aria-hidden=\"true\"><\/span><span class=\"forminator-checkbox-label\">Family Medicine<\/span><\/label><label id=\"forminator-field-checkbox-2-3-6a968750c20d5-label\" for=\"forminator-field-checkbox-2-3-6a968750c20d5\" class=\"forminator-checkbox\" title=\"OB\/GYN\"><input type=\"checkbox\" name=\"checkbox-2[]\" value=\"OB-GYN\" id=\"forminator-field-checkbox-2-3-6a968750c20d5\" aria-labelledby=\"forminator-field-checkbox-2-3-6a968750c20d5-label\" data-calculation=\"0\"   data-hidden-behavior=\"zero\"\/><span class=\"forminator-checkbox-box\" aria-hidden=\"true\"><\/span><span class=\"forminator-checkbox-label\">OB\/GYN<\/span><\/label><label id=\"forminator-field-checkbox-2-4-6a968750c20d5-label\" for=\"forminator-field-checkbox-2-4-6a968750c20d5\" class=\"forminator-checkbox\" title=\"Internal Medicine\"><input type=\"checkbox\" name=\"checkbox-2[]\" value=\"Internal-Medicine\" id=\"forminator-field-checkbox-2-4-6a968750c20d5\" aria-labelledby=\"forminator-field-checkbox-2-4-6a968750c20d5-label\" data-calculation=\"0\"   data-hidden-behavior=\"zero\"\/><span class=\"forminator-checkbox-box\" aria-hidden=\"true\"><\/span><span class=\"forminator-checkbox-label\">Internal Medicine<\/span><\/label><label id=\"forminator-field-checkbox-2-5-6a968750c20d5-label\" for=\"forminator-field-checkbox-2-5-6a968750c20d5\" class=\"forminator-checkbox\" title=\"Primary Care - Advance Practice Nurse \/ Nurse Practitioner (APN\/NP)\"><input type=\"checkbox\" name=\"checkbox-2[]\" value=\"Primary-Care---Advance-Practice-Nurse---Nurse-Practitioner-(APN-NP)\" id=\"forminator-field-checkbox-2-5-6a968750c20d5\" aria-labelledby=\"forminator-field-checkbox-2-5-6a968750c20d5-label\" data-calculation=\"0\"   data-hidden-behavior=\"zero\"\/><span class=\"forminator-checkbox-box\" aria-hidden=\"true\"><\/span><span class=\"forminator-checkbox-label\">Primary Care &#8211; Advance Practice Nurse \/ Nurse Practitioner (APN\/NP)<\/span><\/label><label id=\"forminator-field-checkbox-2-6-6a968750c20d5-label\" for=\"forminator-field-checkbox-2-6-6a968750c20d5\" class=\"forminator-checkbox\" title=\"Primary Care - Certified Nurse Midwife\"><input type=\"checkbox\" name=\"checkbox-2[]\" value=\"Primary-Care---Certified-Nurse-Midwife\" id=\"forminator-field-checkbox-2-6-6a968750c20d5\" aria-labelledby=\"forminator-field-checkbox-2-6-6a968750c20d5-label\" data-calculation=\"0\"   data-hidden-behavior=\"zero\"\/><span class=\"forminator-checkbox-box\" aria-hidden=\"true\"><\/span><span class=\"forminator-checkbox-label\">Primary Care &#8211; Certified Nurse Midwife<\/span><\/label><label id=\"forminator-field-checkbox-2-7-6a968750c20d5-label\" for=\"forminator-field-checkbox-2-7-6a968750c20d5\" class=\"forminator-checkbox\" title=\"Primary Care - Physician Assistant (PA)\"><input type=\"checkbox\" name=\"checkbox-2[]\" value=\"Primary-Care---Physician-Assistant-(PA)\" id=\"forminator-field-checkbox-2-7-6a968750c20d5\" aria-labelledby=\"forminator-field-checkbox-2-7-6a968750c20d5-label\" data-calculation=\"0\"   data-hidden-behavior=\"zero\"\/><span class=\"forminator-checkbox-box\" aria-hidden=\"true\"><\/span><span class=\"forminator-checkbox-label\">Primary Care &#8211; Physician Assistant (PA)<\/span><\/label><label id=\"forminator-field-checkbox-2-8-6a968750c20d5-label\" for=\"forminator-field-checkbox-2-8-6a968750c20d5\" class=\"forminator-checkbox\" title=\"Psychiatrist\"><input type=\"checkbox\" name=\"checkbox-2[]\" value=\"Psychiatrist\" id=\"forminator-field-checkbox-2-8-6a968750c20d5\" aria-labelledby=\"forminator-field-checkbox-2-8-6a968750c20d5-label\" data-calculation=\"0\"   data-hidden-behavior=\"zero\"\/><span class=\"forminator-checkbox-box\" aria-hidden=\"true\"><\/span><span class=\"forminator-checkbox-label\">Psychiatrist<\/span><\/label><label id=\"forminator-field-checkbox-2-9-6a968750c20d5-label\" for=\"forminator-field-checkbox-2-9-6a968750c20d5\" class=\"forminator-checkbox\" title=\"Developmental-Behavioral Pediatrician\"><input type=\"checkbox\" name=\"checkbox-2[]\" value=\"Developmental-Behavioral-Pediatrician\" id=\"forminator-field-checkbox-2-9-6a968750c20d5\" aria-labelledby=\"forminator-field-checkbox-2-9-6a968750c20d5-label\" data-calculation=\"0\"   data-hidden-behavior=\"zero\"\/><span class=\"forminator-checkbox-box\" aria-hidden=\"true\"><\/span><span class=\"forminator-checkbox-label\">Developmental-Behavioral Pediatrician<\/span><\/label><label id=\"forminator-field-checkbox-2-10-6a968750c20d5-label\" for=\"forminator-field-checkbox-2-10-6a968750c20d5\" class=\"forminator-checkbox\" title=\"Nurse\"><input type=\"checkbox\" name=\"checkbox-2[]\" value=\"Nurse\" id=\"forminator-field-checkbox-2-10-6a968750c20d5\" aria-labelledby=\"forminator-field-checkbox-2-10-6a968750c20d5-label\" data-calculation=\"0\"   data-hidden-behavior=\"zero\"\/><span class=\"forminator-checkbox-box\" aria-hidden=\"true\"><\/span><span class=\"forminator-checkbox-label\">Nurse<\/span><\/label><label id=\"forminator-field-checkbox-2-11-6a968750c20d5-label\" for=\"forminator-field-checkbox-2-11-6a968750c20d5\" class=\"forminator-checkbox\" title=\"Behavioral Health Clinician (e.g., psychologist, therapist, counselor)\"><input type=\"checkbox\" name=\"checkbox-2[]\" value=\"Behavioral-Health-Clinician-(e.g.,-psychologist,-therapist,-counselor)\" id=\"forminator-field-checkbox-2-11-6a968750c20d5\" aria-labelledby=\"forminator-field-checkbox-2-11-6a968750c20d5-label\" data-calculation=\"0\"   data-hidden-behavior=\"zero\"\/><span class=\"forminator-checkbox-box\" aria-hidden=\"true\"><\/span><span class=\"forminator-checkbox-label\">Behavioral Health Clinician (e.g., psychologist, therapist, counselor)<\/span><\/label><label id=\"forminator-field-checkbox-2-12-6a968750c20d5-label\" for=\"forminator-field-checkbox-2-12-6a968750c20d5\" class=\"forminator-checkbox\" title=\"Care Coordinator\/ Patient Navigator\"><input type=\"checkbox\" name=\"checkbox-2[]\" value=\"Care-Coordinator--Patient-Navigator\" id=\"forminator-field-checkbox-2-12-6a968750c20d5\" aria-labelledby=\"forminator-field-checkbox-2-12-6a968750c20d5-label\" data-calculation=\"0\"   data-hidden-behavior=\"zero\"\/><span class=\"forminator-checkbox-box\" aria-hidden=\"true\"><\/span><span class=\"forminator-checkbox-label\">Care Coordinator\/ Patient Navigator<\/span><\/label><label id=\"forminator-field-checkbox-2-13-6a968750c20d5-label\" for=\"forminator-field-checkbox-2-13-6a968750c20d5\" class=\"forminator-checkbox\" title=\"Other\"><input type=\"checkbox\" name=\"checkbox-2[]\" value=\"Other\" id=\"forminator-field-checkbox-2-13-6a968750c20d5\" aria-labelledby=\"forminator-field-checkbox-2-13-6a968750c20d5-label\" data-calculation=\"0\"   data-hidden-behavior=\"zero\"\/><span class=\"forminator-checkbox-box\" aria-hidden=\"true\"><\/span><span class=\"forminator-checkbox-label\">Other<\/span><\/label><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"text-5\" class=\"forminator-field-text forminator-col forminator-col-12 \"><div class=\"forminator-field\"><label for=\"forminator-field-text-5_6a968750c20d5\" id=\"forminator-field-text-5_6a968750c20d5-label\" class=\"forminator-label\">If Other, Please Specify<\/label><input type=\"text\" name=\"text-5\" value=\"\" placeholder=\"\" id=\"forminator-field-text-5_6a968750c20d5\" class=\"forminator-input forminator-name--field\" data-required=\"\" \/><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"phone-2\" class=\"forminator-field-phone forminator-col forminator-col-12 \"><div class=\"forminator-field\"><label for=\"forminator-field-phone-2_6a968750c20d5\" id=\"forminator-field-phone-2_6a968750c20d5-label\" class=\"forminator-label\">Your direct phone number for consultations <span class=\"forminator-required\">*<\/span><\/label><input type=\"text\" name=\"phone-2\" value=\"\" placeholder=\"\" id=\"forminator-field-phone-2_6a968750c20d5\" class=\"forminator-input forminator-field--phone\" data-required=\"1\" aria-required=\"true\" autocomplete=\"off\" aria-describedby=\"forminator-field-phone-2_6a968750c20d5-description\" \/><span id=\"forminator-field-phone-2_6a968750c20d5-description\" class=\"forminator-description\" id=\"forminator-field-phone-2_6a968750c20d5-description\">This is the number that will be called by our child &amp; adolescent psychiatrist for scheduled consultation.<\/span><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"radio-1\" class=\"forminator-field-radio forminator-col forminator-col-12 \"><div role=\"radiogroup\" class=\"forminator-field\" aria-labelledby=\"forminator-radiogroup-radio-1-6a968750c20d5-label\"><span id=\"forminator-radiogroup-radio-1-6a968750c20d5-label\" class=\"forminator-label\">Would you like to receive the YAP-P monthly newsletter to your email? <span class=\"forminator-required\">*<\/span><\/span><label id=\"forminator-field-radio-1-label-1\" for=\"forminator-field-radio-1-1-6a968750c20d5\" class=\"forminator-radio\" title=\"Yes\"><input type=\"radio\" name=\"radio-1\" value=\"one\" id=\"forminator-field-radio-1-1-6a968750c20d5\" aria-labelledby=\"forminator-field-radio-1-label-1\" data-calculation=\"0\"   data-hidden-behavior=\"zero\"\/><span class=\"forminator-radio-bullet\" aria-hidden=\"true\"><\/span><span class=\"forminator-radio-label\">Yes<\/span><\/label><label id=\"forminator-field-radio-1-label-2\" for=\"forminator-field-radio-1-2-6a968750c20d5\" class=\"forminator-radio\" title=\"No\"><input type=\"radio\" name=\"radio-1\" value=\"two\" id=\"forminator-field-radio-1-2-6a968750c20d5\" aria-labelledby=\"forminator-field-radio-1-label-2\" data-calculation=\"0\"   data-hidden-behavior=\"zero\"\/><span class=\"forminator-radio-bullet\" aria-hidden=\"true\"><\/span><span class=\"forminator-radio-label\">No<\/span><\/label><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"consent-1\" class=\"forminator-field-consent forminator-col forminator-col-12 \"><div class=\"forminator-field\"><label for=\"forminator-field-consent-1_6a968750c20d5\" id=\"forminator-field-consent-1_6a968750c20d5-label\" class=\"forminator-label\">YAP-P Participation Agreement <span class=\"forminator-required\">*<\/span><\/label><div class=\"forminator-checkbox__wrapper\"><label id=\"forminator-field-consent-1_6a968750c20d5__label\" class=\"forminator-checkbox forminator-consent\" aria-labelledby=\"forminator-field-consent-1_6a968750c20d5-label\"><input type=\"checkbox\" name=\"consent-1\" id=\"forminator-field-consent-1_6a968750c20d5\" value=\"checked\" aria-labelledby=\"forminator-field-consent-1_6a968750c20d5-label\" aria-describedby=\"forminator-field-consent-1_6a968750c20d5__description\" data-required=\"true\" aria-required=\"true\" \/><span class=\"forminator-checkbox-box\" aria-hidden=\"true\"><\/span><\/label><div id=\"forminator-field-consent-1_6a968750c20d5__description\" class=\"forminator-checkbox__label forminator-consent__label\"><div>The overall goal of YAP-P is to support the provision of behavioral and mental health care in primary care settings through a continuum of supports including a rapid access child and adolescent psychiatry consultation line for community providers.<\/div>\n<p><br>Clinical practices and providers who care for patients ages 0 to 21 years are eligible to participate in YAP-P. To participate in YAP-P we ask that you agree to the following:<\/p>\n<ul>\n<li>The goal of YAP-P is to support the management of mental and behavioral health disorders in primary care settings and that YAP-P&nbsp;doesn\u2019t provide direct care to patients.<\/li>\n<li>Any recommendations given by YAP-P are for general guidance and are at the discretion of the community clinician to<i>&nbsp;<\/i>be considered in the context of the patient&#8217;s relevant prior history and current clinical status.<\/li>\n<li>The YAP-P consultation line is to be used for non-emergent clinical questions and not to be used for patients in crisis.<\/li>\n<li>Participants agree to complete periodic satisfactions surveys about YAP-P.<\/li>\n<\/ul><\/div><\/div><\/div><\/div><\/div><input type=\"hidden\" name=\"referer_url\" value=\"\" \/><div class=\"forminator-row forminator-row-last\"><div class=\"forminator-col\"><div class=\"forminator-field\"><button class=\"forminator-button forminator-button-submit\">Submit<\/button><\/div><\/div><\/div><input type=\"hidden\" id=\"forminator_nonce\" name=\"forminator_nonce\" value=\"d9bfdc3398\" \/><input type=\"hidden\" name=\"_wp_http_referer\" value=\"\/index.php?rest_route=%2Fwp%2Fv2%2Fpages%2F3185\" \/><input type=\"hidden\" name=\"form_id\" value=\"3444\"><input type=\"hidden\" name=\"page_id\" value=\"3185\"><input type=\"hidden\" name=\"form_type\" value=\"default\"><input type=\"hidden\" name=\"current_url\" value=\"https:\/\/yapp.scdmh.org\/?page_id=3185\"><input type=\"hidden\" name=\"render_id\" value=\"0\"><input type=\"hidden\" name=\"action\" value=\"forminator_submit_form_custom-forms\"><\/form>\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t\t<\/div>\n\t\t<\/div>\n\t\t\t\t\t<\/div>\n\t\t<\/section>\n\t\t\t\t<\/div>\n\t\t","protected":false},"excerpt":{"rendered":"<p>Consultation Line Pre-Registration Form<\/p>\n","protected":false},"author":5,"featured_media":0,"parent":0,"menu_order":0,"comment_status":"closed","ping_status":"closed","template":"elementor_header_footer","meta":{"iawp_total_views":24,"footnotes":""},"class_list":["post-3185","page","type-page","status-publish","hentry"],"yoast_head":"<!-- This site is optimized with the Yoast SEO plugin v26.7 - 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