{"id":11880,"date":"2024-07-19T15:53:14","date_gmt":"2024-07-19T22:53:14","guid":{"rendered":"https:\/\/ucpofcentralaz.org\/?page_id=11880"},"modified":"2025-09-24T12:26:58","modified_gmt":"2025-09-24T19:26:58","slug":"pediatric-therapy-referral-form","status":"publish","type":"page","link":"https:\/\/ucpofcentralaz.org\/es\/services\/pediatric-therapy-referral-form\/","title":{"rendered":"Therapy Program Form"},"content":{"rendered":"<div class=\"wpb-content-wrapper\"><div data-vc-full-width=\"true\" data-vc-full-width-init=\"false\" data-vc-stretch-content=\"true\" class=\"vc_row wpb_row vc_row-fluid headerPosition vc_custom_1721435104957 vc_row-has-fill vc_row-o-content-bottom vc_row-flex\"><div class=\"wpb_column vc_column_container vc_col-sm-12 vc_col-has-fill\"><div class=\"vc_column-inner vc_custom_1677175038488\"><div class=\"wpb_wrapper\"><div class=\"vc_empty_space\"   style=\"height: 50vh\"><span class=\"vc_empty_space_inner\"><\/span><\/div>\n\t<div class=\"wpb_text_column wpb_content_element\" >\n\t\t<div class=\"wpb_wrapper\">\n\t\t\t<div style=\"color: white;\">\n<h1 style=\"text-align: center; color: white; text-transform: uppercase;\"><strong>\u00a0Therapy Program Form<\/strong><\/h1>\n<p style=\"text-align: center;\"><strong>Located in North Phoenix at the Laura Dozer Center and in the East Valley at Ability 360<\/strong><\/p>\n<\/div>\n\n\t\t<\/div>\n\t<\/div>\n<div class=\"vc_empty_space\"   style=\"height: 15vh\"><span class=\"vc_empty_space_inner\"><\/span><\/div><\/div><\/div><\/div><\/div><div class=\"vc_row-full-width vc_clearfix\"><\/div><div class=\"qodef-content-grid\"><div class=\"vc_row wpb_row vc_row-fluid qodef-row-over vc_custom_1677180947186 vc_row-has-fill\"><div class=\"wpb_column vc_column_container vc_col-sm-12\"><div class=\"vc_column-inner\"><div class=\"wpb_wrapper\"><div class=\"vc_row wpb_row vc_inner vc_row-fluid\"><div class=\"wpb_column vc_column_container vc_col-sm-12\"><div class=\"vc_column-inner\"><div class=\"wpb_wrapper\"><div class=\"qodef-shortcode qodef-m  qodef-section-title qodef-alignment--center \">\n\t\t<h5 class=\"qodef-m-subtitle\" >\n\t\tLet us help you find the right services\t<\/h5>\n\t\t\t<h2 class=\"qodef-m-title\" >\n\t\t\t\t\tCAREGIVER STARTING POINT\t\t\t<\/h2>\n\t<\/div><\/div><\/div><\/div><\/div><\/div><\/div><\/div><\/div><\/div><div class=\"qodef-content-grid\"><div id=\"therapy-contact\" class=\"vc_row wpb_row vc_row-fluid vc_custom_1614379716148 vc_row-has-fill\"><div class=\"wpb_column vc_column_container vc_col-sm-4\"><div class=\"vc_column-inner\"><div class=\"wpb_wrapper\"><div class=\"vc_empty_space\"   style=\"height: 36px\"><span class=\"vc_empty_space_inner\"><\/span><\/div>\n\t<div class=\"wpb_text_column wpb_content_element\" >\n\t\t<div class=\"wpb_wrapper\">\n\t\t\t<h3 style=\"text-align: center;\">My child is ready for therapy, please contact me!<\/h3>\n\n\t\t<\/div>\n\t<\/div>\n<div class=\"vc_empty_space\"   style=\"height: 36px\"><span class=\"vc_empty_space_inner\"><\/span><\/div>\n\t<div  class=\"wpb_single_image wpb_content_element vc_align_center wpb_content_element\">\n\t\t\n\t\t<figure class=\"wpb_wrapper vc_figure\">\n\t\t\t<div class=\"vc_single_image-wrapper   vc_box_border_grey\"><img loading=\"lazy\" decoding=\"async\" width=\"671\" height=\"880\" src=\"https:\/\/ucpofcentralaz.org\/wp-content\/uploads\/therapy-at-ucp-831x1024-1-jpg.webp\" class=\"vc_single_image-img attachment-full\" alt=\"A young girl with cerebral palsy is playing with a toy dinosaur during a pediatric therapy session at home.\" title=\"A young girl with cerebral palsy is playing with a toy dinosaur during a pediatric therapy session at home.\" srcset=\"https:\/\/ucpofcentralaz.org\/wp-content\/uploads\/therapy-at-ucp-831x1024-1-jpg.webp 671w, https:\/\/ucpofcentralaz.org\/wp-content\/uploads\/therapy-at-ucp-831x1024-1-600x787.jpg 600w, https:\/\/ucpofcentralaz.org\/wp-content\/uploads\/therapy-at-ucp-831x1024-1-229x300.jpg 229w, 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Referral Team<\/h2>\n                            <p class='gform_description'><\/p>\n\t\t\t\t\t\t\t<p class='gform_required_legend'>&quot;<span class=\"gfield_required gfield_required_asterisk\">*<\/span>&quot; indicates required fields<\/p>\n                        <\/div><form method='post' enctype='multipart\/form-data'  id='gform_17'  action='\/es\/wp-json\/wp\/v2\/pages\/11880' data-formid='17' novalidate>\t\t\t\t\t<div style=\"display: none !important;\" class=\"akismet-fields-container gf_invisible\" data-prefix=\"ak_\">\n\t\t\t\t\t\t<label>&#916;<textarea name=\"ak_hp_textarea\" cols=\"45\" rows=\"8\" maxlength=\"100\"><\/textarea><\/label>\n\t\t\t\t\t\t<input type=\"hidden\" id=\"ak_js_1\" name=\"ak_js\" value=\"112\" \/>\n\t\t\t\t\t\t<script type=\"text\/javascript\">\n\/* <![CDATA[ *\/\ndocument.getElementById( \"ak_js_1\" ).setAttribute( \"value\", ( new Date() ).getTime() );\n\/* ]]> *\/\n<\/script>\n\n\t\t\t\t\t<\/div>\n                        <div class='gform-body gform_body'><div id='gform_fields_17' class='gform_fields top_label form_sublabel_below description_below validation_below'><div id=\"field_17_16\" class=\"gfield gfield--type-honeypot gform_validation_container field_sublabel_below gfield--has-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_17_16'>Instagram<\/label><div class='ginput_container'><input name='input_16' id='input_17_16' type='text' value='' autocomplete='new-password'\/><\/div><div class='gfield_description' id='gfield_description_17_16'>This field is for validation purposes and should be left unchanged.<\/div><\/div><fieldset id=\"field_17_1\" class=\"gfield gfield--type-name gfield--input-type-name gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Name<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class='ginput_complex ginput_container ginput_container--name no_prefix has_first_name no_middle_name has_last_name no_suffix gf_name_has_2 ginput_container_name gform-grid-row' id='input_17_1'>\n                            \n                            <span id='input_17_1_3_container' class='name_first gform-grid-col gform-grid-col--size-auto' >\n                                                    <input type='text' name='input_1.3' id='input_17_1_3' value=''   aria-required='true'     \/>\n                                                    <label for='input_17_1_3' class='gform-field-label gform-field-label--type-sub '>First<\/label>\n                                                <\/span>\n                            \n                            <span id='input_17_1_6_container' class='name_last gform-grid-col gform-grid-col--size-auto' >\n                                                    <input type='text' name='input_1.6' id='input_17_1_6' value=''   aria-required='true'     \/>\n                                                    <label for='input_17_1_6' class='gform-field-label gform-field-label--type-sub '>Last<\/label>\n                                                <\/span>\n                            \n                        <\/div><\/fieldset><div id=\"field_17_2\" class=\"gfield gfield--type-email gfield--input-type-email gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_17_2'>Email<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_email'>\n                            <input name='input_2' id='input_17_2' type='email' value='' class='medium'    aria-required=\"true\" aria-invalid=\"false\"  \/>\n                        <\/div><\/div><div id=\"field_17_5\" class=\"gfield gfield--type-phone gfield--input-type-phone gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_17_5'>Phone<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_phone'><input name='input_5' id='input_17_5' type='tel' value='' class='medium'   aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><fieldset id=\"field_17_9\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield--input-type-checkbox gfield_contains_required field_sublabel_below gfield--has-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' >I am interested in the following:<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox ' id='input_17_9'><div class='gchoice gchoice_17_9_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_9.1' type='checkbox'  value='Speech Therapy'  id='choice_17_9_1'   aria-describedby=\"gfield_description_17_9\"\/>\n\t\t\t\t\t\t\t\t<label for='choice_17_9_1' id='label_17_9_1' class='gform-field-label gform-field-label--type-inline'>Speech Therapy<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_17_9_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_9.2' type='checkbox'  value='Feeding Therapy'  id='choice_17_9_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_17_9_2' id='label_17_9_2' class='gform-field-label gform-field-label--type-inline'>Feeding Therapy<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_17_9_3'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_9.3' type='checkbox'  value='Occupational Therapy'  id='choice_17_9_3'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_17_9_3' id='label_17_9_3' class='gform-field-label gform-field-label--type-inline'>Occupational Therapy<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_17_9_4'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_9.4' type='checkbox'  value='Physical Therapy'  id='choice_17_9_4'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_17_9_4' id='label_17_9_4' class='gform-field-label gform-field-label--type-inline'>Physical Therapy<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_17_9_5'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_9.5' type='checkbox'  value='Augmentative &amp; Alternative Communication'  id='choice_17_9_5'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_17_9_5' id='label_17_9_5' class='gform-field-label gform-field-label--type-inline'>Augmentative &amp; Alternative Communication<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_17_9_6'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_9.6' type='checkbox'  value='Infant Motor Evaluations'  id='choice_17_9_6'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_17_9_6' id='label_17_9_6' class='gform-field-label gform-field-label--type-inline'>Infant Motor Evaluations<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_17_9_7'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_9.7' type='checkbox'  value='Upper-Extremity Splinting'  id='choice_17_9_7'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_17_9_7' id='label_17_9_7' class='gform-field-label gform-field-label--type-inline'>Upper-Extremity Splinting<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_17_9_8'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_9.8' type='checkbox'  value='DME or Wheelchair Evaluation'  id='choice_17_9_8'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_17_9_8' id='label_17_9_8' class='gform-field-label gform-field-label--type-inline'>DME or Wheelchair Evaluation<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><div class='gfield_description' id='gfield_description_17_9'>\n<\/div><\/fieldset><fieldset id=\"field_17_15\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield--input-type-checkbox gfield--width-full gfield_contains_required field_sublabel_below gfield--has-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' >I am interested in this location:<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox ' id='input_17_15'><div class='gchoice gchoice_17_15_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_15.1' type='checkbox'  value='Laura Dozer Center- 1802 W. Parkside Ln, Phoenix, AZ 85027'  id='choice_17_15_1'   aria-describedby=\"gfield_description_17_15\"\/>\n\t\t\t\t\t\t\t\t<label for='choice_17_15_1' id='label_17_15_1' class='gform-field-label gform-field-label--type-inline'>Laura Dozer Center- 1802 W. 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Email Us Here!<\/h3>\n\n\t\t<\/div>\n\t<\/div>\n<div class=\"vc_empty_space\"   style=\"height: 32px\"><span class=\"vc_empty_space_inner\"><\/span><\/div><div class=\"vc_btn3-container  email-our-referral-team-btn vc_btn3-center vc_custom_1695165138021 vc_do_btn\" ><a style=\"background-color:#ef4e37; color:#ffffff;\" class=\"vc_general vc_btn3 vc_btn3-size-sm vc_btn3-shape-round vc_btn3-style-custom vc_btn3-icon-left\" href=\"mailto:Therapyreferrals@ucpofcentralaz.org\" title=\"\"><i class=\"vc_btn3-icon fas fa-envelope\"><\/i> Learn More Here<\/a><\/div><\/div><\/div><\/div><\/div><div class=\"vc_empty_space\"   style=\"height: 32px\"><span class=\"vc_empty_space_inner\"><\/span><\/div><div class=\"vc_empty_space\"   style=\"height: 32px\"><span class=\"vc_empty_space_inner\"><\/span><\/div><div class=\"vc_empty_space\"   style=\"height: 32px\"><span class=\"vc_empty_space_inner\"><\/span><\/div><\/div><\/div><\/div><\/div><\/div>\n<\/div>","protected":false},"excerpt":{"rendered":"\u00a0Therapy Program Form Located in North Phoenix at the Laura Dozer Center and in the East Valley at Ability 360 Let us help you find the right services CAREGIVER STARTING POINT My child is ready for therapy, please contact me! Message our Therapy Referral Team &quot;*&quot; indicates required fields &#916; NameThis field is for validation [...]","protected":false},"author":15,"featured_media":0,"parent":299,"menu_order":0,"comment_status":"closed","ping_status":"closed","template":"page-full-width.php","meta":{"nf_dc_page":"","footnotes":""},"class_list":["post-11880","page","type-page","status-publish","hentry"],"_links":{"self":[{"href":"https:\/\/ucpofcentralaz.org\/es\/wp-json\/wp\/v2\/pages\/11880","targetHints":{"allow":["GET"]}}],"collection":[{"href":"https:\/\/ucpofcentralaz.org\/es\/wp-json\/wp\/v2\/pages"}],"about":[{"href":"https:\/\/ucpofcentralaz.org\/es\/wp-json\/wp\/v2\/types\/page"}],"author":[{"embeddable":true,"href":"https:\/\/ucpofcentralaz.org\/es\/wp-json\/wp\/v2\/users\/15"}],"replies":[{"embeddable":true,"href":"https:\/\/ucpofcentralaz.org\/es\/wp-json\/wp\/v2\/comments?post=11880"}],"version-history":[{"count":5,"href":"https:\/\/ucpofcentralaz.org\/es\/wp-json\/wp\/v2\/pages\/11880\/revisions"}],"predecessor-version":[{"id":12032,"href":"https:\/\/ucpofcentralaz.org\/es\/wp-json\/wp\/v2\/pages\/11880\/revisions\/12032"}],"up":[{"embeddable":true,"href":"https:\/\/ucpofcentralaz.org\/es\/wp-json\/wp\/v2\/pages\/299"}],"wp:attachment":[{"href":"https:\/\/ucpofcentralaz.org\/es\/wp-json\/wp\/v2\/media?parent=11880"}],"curies":[{"name":"wp","href":"https:\/\/api.w.org\/{rel}","templated":true}]}}