{"id":298,"date":"2025-03-25T17:37:45","date_gmt":"2025-03-25T17:37:45","guid":{"rendered":"https:\/\/empoweraballc.com\/?page_id=298"},"modified":"2025-12-26T15:47:31","modified_gmt":"2025-12-26T15:47:31","slug":"contactanos","status":"publish","type":"page","link":"https:\/\/amanipathaba.com\/en_us\/contactanos\/","title":{"rendered":"Cont\u00e1ctanos"},"content":{"rendered":"\t\t<div data-elementor-type=\"wp-page\" data-elementor-id=\"298\" class=\"elementor elementor-298\" data-elementor-post-type=\"page\">\n\t\t\t\t\t\t<section class=\"elementor-section elementor-top-section elementor-element elementor-element-2a409939 elementor-section-boxed elementor-section-height-default elementor-section-height-default\" data-id=\"2a409939\" data-element_type=\"section\" data-e-type=\"section\" data-settings=\"{&quot;background_background&quot;:&quot;gradient&quot;}\">\n\t\t\t\t\t\t\t<div class=\"elementor-background-overlay\"><\/div>\n\t\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-1e215ed8\" data-id=\"1e215ed8\" data-element_type=\"column\" data-e-type=\"column\">\n\t\t\t<div class=\"elementor-widget-wrap elementor-element-populated\">\n\t\t\t\t\t\t<section class=\"elementor-section elementor-inner-section elementor-element elementor-element-10ddbf77 elementor-section-content-middle elementor-section-boxed elementor-section-height-default elementor-section-height-default\" data-id=\"10ddbf77\" data-element_type=\"section\" data-e-type=\"section\">\n\t\t\t\t\t\t<div class=\"elementor-container elementor-column-gap-no\">\n\t\t\t\t\t<div class=\"elementor-column elementor-col-50 elementor-inner-column elementor-element elementor-element-2b7b2dd9\" data-id=\"2b7b2dd9\" data-element_type=\"column\" data-e-type=\"column\">\n\t\t\t<div class=\"elementor-widget-wrap\">\n\t\t\t\t\t\t\t<\/div>\n\t\t<\/div>\n\t\t\t\t<div class=\"elementor-column elementor-col-50 elementor-inner-column elementor-element elementor-element-218f6af8\" data-id=\"218f6af8\" data-element_type=\"column\" data-e-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-467f95c2 elementor-icon-list--layout-inline elementor-align-end elementor-mobile-align-center elementor-list-item-link-full_width elementor-widget elementor-widget-icon-list\" data-id=\"467f95c2\" data-element_type=\"widget\" data-e-type=\"widget\" data-widget_type=\"icon-list.default\">\n\t\t\t\t<div class=\"elementor-widget-container\">\n\t\t\t\t\t\t\t<ul class=\"elementor-icon-list-items elementor-inline-items\">\n\t\t\t\t\t\t\t<li class=\"elementor-icon-list-item elementor-inline-item\">\n\t\t\t\t\t\t\t\t\t\t<span class=\"elementor-icon-list-text\">Home<\/span>\n\t\t\t\t\t\t\t\t\t<\/li>\n\t\t\t\t\t\t\t\t<li class=\"elementor-icon-list-item elementor-inline-item\">\n\t\t\t\t\t\t\t\t\t\t\t<a href=\"https:\/\/amanipathaba.com\/contact\/\">\n\n\t\t\t\t\t\t\t\t\t\t\t\t<span class=\"elementor-icon-list-icon\">\n\t\t\t\t\t\t\t<svg aria-hidden=\"true\" class=\"e-font-icon-svg e-fas-chevron-right\" viewBox=\"0 0 320 512\" xmlns=\"http:\/\/www.w3.org\/2000\/svg\"><path d=\"M285.476 272.971L91.132 467.314c-9.373 9.373-24.569 9.373-33.941 0l-22.667-22.667c-9.357-9.357-9.375-24.522-.04-33.901L188.505 256 34.484 101.255c-9.335-9.379-9.317-24.544.04-33.901l22.667-22.667c9.373-9.373 24.569-9.373 33.941 0L285.475 239.03c9.373 9.372 9.373 24.568.001 33.941z\"><\/path><\/svg>\t\t\t\t\t\t<\/span>\n\t\t\t\t\t\t\t\t\t\t<span class=\"elementor-icon-list-text\">Cont\u00e1ctanos<\/span>\n\t\t\t\t\t\t\t\t\t\t\t<\/a>\n\t\t\t\t\t\t\t\t\t<\/li>\n\t\t\t\t\t\t<\/ul>\n\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<section class=\"elementor-section elementor-inner-section elementor-element elementor-element-015623e elementor-section-content-middle elementor-section-boxed elementor-section-height-default elementor-section-height-default\" data-id=\"015623e\" data-element_type=\"section\" data-e-type=\"section\">\n\t\t\t\t\t\t<div class=\"elementor-container elementor-column-gap-no\">\n\t\t\t\t\t<div class=\"elementor-column elementor-col-100 elementor-inner-column elementor-element elementor-element-1933d57\" data-id=\"1933d57\" data-element_type=\"column\" data-e-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-587b948 elementor-widget elementor-widget-heading\" data-id=\"587b948\" data-element_type=\"widget\" data-e-type=\"widget\" data-widget_type=\"heading.default\">\n\t\t\t\t<div class=\"elementor-widget-container\">\n\t\t\t\t\t<h2 class=\"elementor-heading-title elementor-size-default\">Contact us<\/h2>\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\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-2ab2f5e6 elementor-section-content-middle elementor-section-boxed elementor-section-height-default elementor-section-height-default\" data-id=\"2ab2f5e6\" data-element_type=\"section\" data-e-type=\"section\" data-settings=\"{&quot;background_background&quot;:&quot;classic&quot;}\">\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-4feeda04\" data-id=\"4feeda04\" data-element_type=\"column\" data-e-type=\"column\" data-settings=\"{&quot;background_background&quot;:&quot;classic&quot;}\">\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-654f5023 elementor-widget elementor-widget-metform\" data-id=\"654f5023\" data-element_type=\"widget\" data-e-type=\"widget\" data-widget_type=\"metform.default\">\n\t\t\t\t<div class=\"elementor-widget-container\">\n\t\t\t\t\t<div id=\"mf-response-props-id-304\" data-previous-steps-style=\"\" data-editswitchopen=\"\" data-response_type=\"alert\" data-erroricon=\"fas fa-exclamation-triangle\" data-successicon=\"fas fa-check\" data-messageposition=\"top\" class=\"   mf-scroll-top-no\">\n\t\t<div class=\"formpicker_warper formpicker_warper_editable\" data-metform-formpicker-key=\"304\" >\n\t\t\t\t\n\t\t\t<div class=\"mf-widget-container\">\n\t\t\t\t\r\n\t\t<div\r\n\t\t\tid=\"metform-wrap-654f5023-304\"\r\n\t\t\tclass=\"mf-form-wrapper\"\r\n\t\t\tdata-form-id=\"304\"\r\n\t\t\tdata-action=\"https:\/\/amanipathaba.com\/en_us\/wp-json\/metform\/v1\/entries\/insert\/304\"\r\n\t\t\tdata-wp-nonce=\"04d36feb54\"\r\n\t\t\tdata-form-nonce=\"a69a53bd21\"\r\n\t\t\tdata-quiz-summery = \"false\"\r\n\t\t\tdata-save-progress = \"false\"\r\n\t\t\tdata-form-type=\"general-form\"\r\n\t\t\tdata-stop-vertical-effect=\"\"\r\n\t\t\tdata-payment-submit-before=\"0\"\r\n\t\t\t><\/div>\r\n\r\n\r\n\t\t<!----------------------------- \r\n\t\t\t* controls_data : find the the props passed indie of data attribute\r\n\t\t\t* props.SubmitResponseMarkup : contains the markup of error or success message\r\n\t\t\t* https:\/\/developer.mozilla.org\/en-US\/docs\/Web\/JavaScript\/Reference\/Template_literals\r\n\t\t--------------------------- -->\r\n\r\n\t\t\t\t<script type=\"text\/mf\" class=\"mf-template\">\r\n\t\t\tfunction controls_data (value){\r\n\t\t\t\tlet currentWrapper = \"mf-response-props-id-304\";\r\n\t\t\t\tlet currentEl = document.getElementById(currentWrapper);\r\n\t\t\t\t\r\n\t\t\t\treturn currentEl ? currentEl.dataset[value] : false\r\n\t\t\t}\r\n\r\n\r\n\t\t\tlet is_edit_mode = '' ? true : false;\r\n\t\t\tlet message_position = controls_data('messageposition') || 'top';\r\n\r\n\t\t\t\r\n\t\t\tlet message_successIcon = controls_data('successicon') || '';\r\n\t\t\tlet message_errorIcon = controls_data('erroricon') || '';\r\n\t\t\tlet message_editSwitch = controls_data('editswitchopen') === 'yes' ? true : false;\r\n\t\t\tlet message_proClass = controls_data('editswitchopen') === 'yes' ? 'mf_pro_activated' : '';\r\n\t\t\t\r\n\t\t\tlet is_dummy_markup = is_edit_mode && message_editSwitch ? true : false;\r\n\r\n\t\t\t\r\n\t\t\treturn html`\r\n\t\t\t\t<form\r\n\t\t\t\t\tclassName=\"metform-form-content\"\r\n\t\t\t\t\tref=${parent.formContainerRef}\r\n\t\t\t\t\tonSubmit=${ validation.handleSubmit( parent.handleFormSubmit ) }\r\n\t\t\t\t\r\n\t\t\t\t\t>\r\n\t\t\t\r\n\t\t\t\r\n\t\t\t\t\t${is_dummy_markup ? message_position === 'top' ?  props.ResponseDummyMarkup(message_successIcon, message_proClass) : '' : ''}\r\n\t\t\t\t\t${is_dummy_markup ? ' ' :  message_position === 'top' ? props.SubmitResponseMarkup`${parent}${state}${message_successIcon}${message_errorIcon}${message_proClass}` : ''}\r\n\r\n\t\t\t\t\t<!--------------------------------------------------------\r\n\t\t\t\t\t*** IMPORTANT \/ DANGEROUS ***\r\n\t\t\t\t\t${html``} must be used as in immediate child of \"metform-form-main-wrapper\"\r\n\t\t\t\t\tclass otherwise multistep form will not run at all\r\n\t\t\t\t\t---------------------------------------------------------->\r\n\r\n\t\t\t\t\t<div className=\"metform-form-main-wrapper\" key=${'hide-form-after-submit'} ref=${parent.formRef}>\r\n\t\t\t\t\t${html`\r\n\t\t\t\t\t\t\t\t<div data-elementor-type=\"wp-post\" key=\"2\" data-elementor-id=\"304\" className=\"elementor elementor-304\" data-elementor-post-type=\"metform-form\">\n\t\t\t\t\t\t<section className=\"elementor-section elementor-top-section elementor-element elementor-element-7eca56f6 elementor-section-full_width elementor-section-height-default elementor-section-height-default\" data-id=\"7eca56f6\" data-element_type=\"section\" data-e-type=\"section\">\n\t\t\t\t\t\t<div className=\"elementor-container elementor-column-gap-default\">\n\t\t\t\t\t<div className=\"elementor-column elementor-col-100 elementor-top-column elementor-element elementor-element-5539f7eb\" data-id=\"5539f7eb\" data-element_type=\"column\" data-e-type=\"column\">\n\t\t\t<div className=\"elementor-widget-wrap elementor-element-populated\">\n\t\t\t\t\t\t<section className=\"elementor-section elementor-inner-section elementor-element elementor-element-cc6be4 elementor-section-full_width elementor-section-height-default elementor-section-height-default\" data-id=\"cc6be4\" data-element_type=\"section\" data-e-type=\"section\">\n\t\t\t\t\t\t<div className=\"elementor-container elementor-column-gap-default\">\n\t\t\t\t\t<div className=\"elementor-column elementor-col-100 elementor-inner-column elementor-element elementor-element-8999f43\" data-id=\"8999f43\" data-element_type=\"column\" data-e-type=\"column\">\n\t\t\t<div className=\"elementor-widget-wrap elementor-element-populated\">\n\t\t\t\t\t\t<div className=\"elementor-element elementor-element-77426f75 elementor-widget elementor-widget-heading\" data-id=\"77426f75\" data-element_type=\"widget\" data-e-type=\"widget\" data-widget_type=\"heading.default\">\n\t\t\t\t<div className=\"elementor-widget-container\">\n\t\t\t\t\t<h3 className=\"elementor-heading-title elementor-size-default\">If you are a family member interested in ABA therapy:<\/h3>\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t<div className=\"elementor-element elementor-element-6ced8249 elementor-widget elementor-widget-heading\" data-id=\"6ced8249\" data-element_type=\"widget\" data-e-type=\"widget\" data-widget_type=\"heading.default\">\n\t\t\t\t<div className=\"elementor-widget-container\">\n\t\t\t\t\t<p className=\"elementor-heading-title elementor-size-default\">For any other questions, please complete the form below:<\/p>\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 className=\"elementor-element elementor-element-500b9439 elementor-widget-divider--view-line elementor-widget elementor-widget-divider\" data-id=\"500b9439\" data-element_type=\"widget\" data-e-type=\"widget\" data-widget_type=\"divider.default\">\n\t\t\t\t<div className=\"elementor-widget-container\">\n\t\t\t\t\t\t\t<div className=\"elementor-divider\">\n\t\t\t<span className=\"elementor-divider-separator\">\n\t\t\t\t\t\t<\/span>\n\t\t<\/div>\n\t\t\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t<section className=\"elementor-section elementor-inner-section elementor-element elementor-element-5b469eeb elementor-section-full_width elementor-section-height-default elementor-section-height-default\" data-id=\"5b469eeb\" data-element_type=\"section\" data-e-type=\"section\">\n\t\t\t\t\t\t<div className=\"elementor-container elementor-column-gap-default\">\n\t\t\t\t\t<div className=\"elementor-column elementor-col-50 elementor-inner-column elementor-element elementor-element-40819b95\" data-id=\"40819b95\" data-element_type=\"column\" data-e-type=\"column\">\n\t\t\t<div className=\"elementor-widget-wrap elementor-element-populated\">\n\t\t\t\t\t\t<div className=\"elementor-element elementor-element-4dc87cc4 elementor-widget elementor-widget-mf-text\" data-id=\"4dc87cc4\" data-element_type=\"widget\" data-e-type=\"widget\" data-settings=\"{&quot;mf_input_name&quot;:&quot;mf-first-name&quot;}\" data-widget_type=\"mf-text.default\">\n\t\t\t\t<div className=\"elementor-widget-container\">\n\t\t\t\t\t\r\n\t\t<div className=\"mf-input-wrapper\">\r\n\t\t\t\t\t\t\t<label className=\"mf-input-label\" htmlFor=\"mf-input-text-4dc87cc4\">\r\n\t\t\t\t\t${ parent.decodeEntities(`Name of the insured`) } \t\t\t\t\t<span className=\"mf-input-required-indicator\"><\/span>\r\n\t\t\t\t<\/label>\r\n\t\t\t\r\n\t\t\t<input\r\n\t\t\t\ttype=\"text\"\r\n\t\t\t\tclassName=\"mf-input mf-conditional-input\"\r\n\t\t\t\tid=\"mf-input-text-4dc87cc4\"\r\n\t\t\t\tname=\"mf-first-name\"\r\n\t\t\t\tplaceholder=\"${ parent.decodeEntities(`First name`) } \"\r\n\t\t\t\t\t\t\t\t\tonInput=${parent.handleChange}\r\n\t\t\t\t\tonBlur=${parent.handleChange}\r\n\t\t\t\t\taria-invalid=${validation.errors['mf-first-name'] ? 'true' : 'false'}\r\n\t\t\t\t\tref=${el =>{\r\n\t\t\t\t\t\t\t\t\t\t\t\tparent.activateValidation({\"message\":\"This field is required.\",\"minLength\":1,\"maxLength\":\"\",\"type\":\"none\",\"required\":false,\"expression\":\"null\"}, el)\r\n\t\t\t\t\t}}\r\n\t\t\t\t\t\t\t\t\/>\r\n\r\n\t\t\t\t\t\t\t<${validation.ErrorMessage}\r\n\t\t\t\t\terrors=${validation.errors}\r\n\t\t\t\t\tname=\"mf-first-name\"\r\n\t\t\t\t\tas=${html`<span className=\"mf-error-message\"><\/span>`}\r\n\t\t\t\t\t\/>\r\n\t\t\t\r\n\t\t\t\t\t<\/div>\r\n\r\n\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<div className=\"elementor-column elementor-col-50 elementor-inner-column elementor-element elementor-element-3b7b6da2\" data-id=\"3b7b6da2\" data-element_type=\"column\" data-e-type=\"column\">\n\t\t\t<div className=\"elementor-widget-wrap elementor-element-populated\">\n\t\t\t\t\t\t<div className=\"elementor-element elementor-element-37da684c elementor-widget elementor-widget-mf-text\" data-id=\"37da684c\" data-element_type=\"widget\" data-e-type=\"widget\" data-settings=\"{&quot;mf_input_name&quot;:&quot;mf-subject&quot;}\" data-widget_type=\"mf-text.default\">\n\t\t\t\t<div className=\"elementor-widget-container\">\n\t\t\t\t\t\r\n\t\t<div className=\"mf-input-wrapper\">\r\n\t\t\t\t\t\t\t<label className=\"mf-input-label\" htmlFor=\"mf-input-text-37da684c\">\r\n\t\t\t\t\t${ parent.decodeEntities(`Insured&#039;s last name`) } \t\t\t\t\t<span className=\"mf-input-required-indicator\"><\/span>\r\n\t\t\t\t<\/label>\r\n\t\t\t\r\n\t\t\t<input\r\n\t\t\t\ttype=\"text\"\r\n\t\t\t\tclassName=\"mf-input mf-conditional-input\"\r\n\t\t\t\tid=\"mf-input-text-37da684c\"\r\n\t\t\t\tname=\"mf-subject\"\r\n\t\t\t\tplaceholder=\"${ parent.decodeEntities(`Last name`) } \"\r\n\t\t\t\t\t\t\t\t\tonInput=${parent.handleChange}\r\n\t\t\t\t\tonBlur=${parent.handleChange}\r\n\t\t\t\t\taria-invalid=${validation.errors['mf-subject'] ? 'true' : 'false'}\r\n\t\t\t\t\tref=${el =>{\r\n\t\t\t\t\t\t\t\t\t\t\t\tparent.activateValidation({\"message\":\"This field is required.\",\"minLength\":1,\"maxLength\":\"\",\"type\":\"none\",\"required\":false,\"expression\":\"null\"}, el)\r\n\t\t\t\t\t}}\r\n\t\t\t\t\t\t\t\t\/>\r\n\r\n\t\t\t\t\t\t\t<${validation.ErrorMessage}\r\n\t\t\t\t\terrors=${validation.errors}\r\n\t\t\t\t\tname=\"mf-subject\"\r\n\t\t\t\t\tas=${html`<span className=\"mf-error-message\"><\/span>`}\r\n\t\t\t\t\t\/>\r\n\t\t\t\r\n\t\t\t\t\t<\/div>\r\n\r\n\t\t\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t\t<\/div>\n\t\t<\/div>\n\t\t\t\t\t<\/div>\n\t\t<\/section>\n\t\t\t\t<section className=\"elementor-section elementor-inner-section elementor-element elementor-element-3a34f48 elementor-section-full_width elementor-section-height-default elementor-section-height-default\" data-id=\"3a34f48\" data-element_type=\"section\" data-e-type=\"section\">\n\t\t\t\t\t\t<div className=\"elementor-container elementor-column-gap-default\">\n\t\t\t\t\t<div className=\"elementor-column elementor-col-50 elementor-inner-column elementor-element elementor-element-5b1958af\" data-id=\"5b1958af\" data-element_type=\"column\" data-e-type=\"column\">\n\t\t\t<div className=\"elementor-widget-wrap elementor-element-populated\">\n\t\t\t\t\t\t<div className=\"elementor-element elementor-element-1a0e467e elementor-widget elementor-widget-mf-email\" data-id=\"1a0e467e\" data-element_type=\"widget\" data-e-type=\"widget\" data-settings=\"{&quot;mf_input_name&quot;:&quot;nombre&quot;}\" data-widget_type=\"mf-email.default\">\n\t\t\t\t<div className=\"elementor-widget-container\">\n\t\t\t\t\t\r\n\t\t<div className=\"mf-input-wrapper\">\r\n\t\t\t\t\t\t\t<label className=\"mf-input-label\" htmlFor=\"mf-input-email-1a0e467e\">\r\n\t\t\t\t\t${ parent.decodeEntities(`Email address`) } \t\t\t\t\t<span className=\"mf-input-required-indicator\">*<\/span>\r\n\t\t\t\t<\/label>\r\n\t\t\t\r\n\t\t\t<input \r\n\t\t\t\ttype=\"email\" \r\n\t\t\t\t \r\n\t\t\t\tdefaultValue=\"\" \r\n\t\t\t\tclassName=\"mf-input mf-conditional-input\" \r\n\t\t\t\tid=\"mf-input-email-1a0e467e\" \r\n\t\t\t\tname=\"nombre\" \r\n\t\t\t\tplaceholder=\"${ parent.decodeEntities(`yourname&quot;email.com`) } \" \r\n\t\t\t\t \r\n\t\t\t\tonBlur=${parent.handleChange} onFocus=${parent.handleChange} aria-invalid=${validation.errors['nombre'] ? 'true' : 'false' } \r\n\t\t\t\tref=${el=> parent.activateValidation({\"message\":\"This field is required.\",\"emailMessage\":\"Please enter a valid Email address\",\"minLength\":1,\"maxLength\":\"\",\"type\":\"none\",\"required\":true,\"expression\":\"null\"}, el)}\r\n\t\t\t\t\t\t\t\/>\r\n\r\n\t\t\t\t\t\t<${validation.ErrorMessage} \r\n\t\t\t\terrors=${validation.errors} \r\n\t\t\t\tname=\"nombre\" \r\n\t\t\t\tas=${html`<span className=\"mf-error-message\"><\/span>`}\r\n\t\t\t\/>\r\n\t\t\t\r\n\t\t\t\t\t<\/div>\r\n\r\n\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<div className=\"elementor-column elementor-col-50 elementor-inner-column elementor-element elementor-element-41b886a1\" data-id=\"41b886a1\" data-element_type=\"column\" data-e-type=\"column\">\n\t\t\t<div className=\"elementor-widget-wrap elementor-element-populated\">\n\t\t\t\t\t\t<div className=\"elementor-element elementor-element-0440707 elementor-widget elementor-widget-mf-number\" data-id=\"0440707\" data-element_type=\"widget\" data-e-type=\"widget\" data-settings=\"{&quot;mf_input_name&quot;:&quot;mf-number&quot;}\" data-widget_type=\"mf-number.default\">\n\t\t\t\t<div className=\"elementor-widget-container\">\n\t\t\t\t\t\r\n\t\t<div className=\"mf-input-wrapper\">\r\n\t\t\t\t\t\t\t<label className=\"mf-input-label\" htmlFor=\"mf-input-number-0440707\">\r\n\t\t\t\t\t${ parent.decodeEntities(`Phone number`) } \t\t\t\t\t<span className=\"mf-input-required-indicator\"><\/span>\r\n\t\t\t\t<\/label>\r\n\t\t\t\r\n\t\t\t<input\r\n\t\t\t\ttype=\"number\"\r\n\t\t\t\tstep=\"any\"\r\n\t\t\t\tclassName=\"mf-input \"\r\n\t\t\t\tid=\"mf-input-mobile-0440707\"\r\n\t\t\t\t\t\t\t\tname=\"mf-number\"\r\n\t\t\t\tplaceholder=\"${ parent.decodeEntities(`555-555-555`) } \"\r\n\t\t\t\t\t\t\t\t\t\t\t\t\tonInput=${parent.handleChange}\r\n\t\t\t\t\taria-invalid=${validation.errors['mf-number'] ? 'true' : 'false'}\r\n\t\t\t\t\tref=${el => parent.activateValidation({\"message\":\"This field is required.\",\"minLength\":1,\"maxLength\":\"\",\"type\":\"none\",\"required\":false,\"expression\":\"null\"}, el)}\r\n\t\t\t\t\t\t\t\t\/>\r\n\r\n\t\t\t\t\t\t\t<${validation.ErrorMessage}\r\n\t\t\t\t\terrors=${validation.errors}\r\n\t\t\t\t\tname=\"mf-number\"\r\n\t\t\t\t\tas=${html`<span className=\"mf-error-message\"><\/span>`}\r\n\t\t\t\t\t\/>\r\n\t\t\t\r\n\t\t\t\t\t<\/div>\r\n\r\n\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<section className=\"elementor-section elementor-inner-section elementor-element elementor-element-7790d60c elementor-section-full_width elementor-section-height-default elementor-section-height-default\" data-id=\"7790d60c\" data-element_type=\"section\" data-e-type=\"section\">\n\t\t\t\t\t\t<div className=\"elementor-container elementor-column-gap-default\">\n\t\t\t\t\t<div className=\"elementor-column elementor-col-33 elementor-inner-column elementor-element elementor-element-7ae5340f\" data-id=\"7ae5340f\" data-element_type=\"column\" data-e-type=\"column\">\n\t\t\t<div className=\"elementor-widget-wrap elementor-element-populated\">\n\t\t\t\t\t\t<div className=\"elementor-element elementor-element-3b876138 elementor-widget elementor-widget-mf-text\" data-id=\"3b876138\" data-element_type=\"widget\" data-e-type=\"widget\" data-settings=\"{&quot;mf_input_name&quot;:&quot;telephone&quot;}\" data-widget_type=\"mf-text.default\">\n\t\t\t\t<div className=\"elementor-widget-container\">\n\t\t\t\t\t\r\n\t\t<div className=\"mf-input-wrapper\">\r\n\t\t\t\t\t\t\t<label className=\"mf-input-label\" htmlFor=\"mf-input-text-3b876138\">\r\n\t\t\t\t\t${ parent.decodeEntities(`City`) } \t\t\t\t\t<span className=\"mf-input-required-indicator\"><\/span>\r\n\t\t\t\t<\/label>\r\n\t\t\t\r\n\t\t\t<input\r\n\t\t\t\ttype=\"text\"\r\n\t\t\t\tclassName=\"mf-input mf-conditional-input\"\r\n\t\t\t\tid=\"mf-input-text-3b876138\"\r\n\t\t\t\tname=\"telephone\"\r\n\t\t\t\tplaceholder=\"${ parent.decodeEntities(`Enter your city`) } \"\r\n\t\t\t\t\t\t\t\t\tonInput=${parent.handleChange}\r\n\t\t\t\t\tonBlur=${parent.handleChange}\r\n\t\t\t\t\taria-invalid=${validation.errors['telephone'] ? 'true' : 'false'}\r\n\t\t\t\t\tref=${el =>{\r\n\t\t\t\t\t\t\t\t\t\t\t\tparent.activateValidation({\"message\":\"This field is required.\",\"minLength\":1,\"maxLength\":\"\",\"type\":\"none\",\"required\":false,\"expression\":\"null\"}, el)\r\n\t\t\t\t\t}}\r\n\t\t\t\t\t\t\t\t\/>\r\n\r\n\t\t\t\t\t\t\t<${validation.ErrorMessage}\r\n\t\t\t\t\terrors=${validation.errors}\r\n\t\t\t\t\tname=\"telephone\"\r\n\t\t\t\t\tas=${html`<span className=\"mf-error-message\"><\/span>`}\r\n\t\t\t\t\t\/>\r\n\t\t\t\r\n\t\t\t\t\t<\/div>\r\n\r\n\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<div className=\"elementor-column elementor-col-33 elementor-inner-column elementor-element elementor-element-42596a0e\" data-id=\"42596a0e\" data-element_type=\"column\" data-e-type=\"column\">\n\t\t\t<div className=\"elementor-widget-wrap elementor-element-populated\">\n\t\t\t\t\t\t<div className=\"elementor-element elementor-element-6278fb6 elementor-widget elementor-widget-mf-select\" data-id=\"6278fb6\" data-element_type=\"widget\" data-e-type=\"widget\" data-settings=\"{&quot;mf_input_name&quot;:&quot;mf-select&quot;,&quot;mf_input_list&quot;:[{&quot;mf_input_option_text&quot;:&quot;Arizona&quot;,&quot;mf_input_option_value&quot;:&quot;value-1&quot;,&quot;_id&quot;:&quot;a41d300&quot;,&quot;mf_input_option_status&quot;:&quot;&quot;,&quot;mf_input_option_selected&quot;:&quot;&quot;},{&quot;_id&quot;:&quot;1dad9d7&quot;,&quot;mf_input_option_text&quot;:&quot;Alabama&quot;,&quot;mf_input_option_value&quot;:&quot;Input Value&quot;,&quot;mf_input_option_status&quot;:&quot;&quot;,&quot;mf_input_option_selected&quot;:&quot;&quot;},{&quot;_id&quot;:&quot;a1df2a6&quot;,&quot;mf_input_option_text&quot;:&quot;Alaska&quot;,&quot;mf_input_option_value&quot;:&quot;Input Value&quot;,&quot;mf_input_option_status&quot;:&quot;&quot;,&quot;mf_input_option_selected&quot;:&quot;&quot;},{&quot;_id&quot;:&quot;cd2630e&quot;,&quot;mf_input_option_text&quot;:&quot;Arkansas&quot;,&quot;mf_input_option_value&quot;:&quot;Input Value&quot;,&quot;mf_input_option_status&quot;:&quot;&quot;,&quot;mf_input_option_selected&quot;:&quot;&quot;},{&quot;mf_input_option_text&quot;:&quot;Connecticut&quot;,&quot;mf_input_option_value&quot;:&quot;Connecticut&quot;,&quot;_id&quot;:&quot;806f968&quot;,&quot;mf_input_option_status&quot;:&quot;&quot;,&quot;mf_input_option_selected&quot;:&quot;&quot;},{&quot;mf_input_option_text&quot;:&quot;California&quot;,&quot;mf_input_option_value&quot;:&quot;Connecticut&quot;,&quot;_id&quot;:&quot;cee4df4&quot;,&quot;mf_input_option_status&quot;:&quot;&quot;,&quot;mf_input_option_selected&quot;:&quot;&quot;},{&quot;mf_input_option_text&quot;:&quot;California del Norte&quot;,&quot;mf_input_option_value&quot;:&quot;Connecticut&quot;,&quot;_id&quot;:&quot;764002e&quot;,&quot;mf_input_option_status&quot;:&quot;&quot;,&quot;mf_input_option_selected&quot;:&quot;&quot;},{&quot;mf_input_option_text&quot;:&quot;California del Sur&quot;,&quot;mf_input_option_value&quot;:&quot;value-3&quot;,&quot;_id&quot;:&quot;0557d24&quot;,&quot;mf_input_option_status&quot;:&quot;&quot;,&quot;mf_input_option_selected&quot;:&quot;&quot;},{&quot;mf_input_option_text&quot;:&quot;Colorado&quot;,&quot;mf_input_option_value&quot;:&quot;value-3&quot;,&quot;_id&quot;:&quot;f176269&quot;,&quot;mf_input_option_status&quot;:&quot;&quot;,&quot;mf_input_option_selected&quot;:&quot;&quot;},{&quot;mf_input_option_text&quot;:&quot;Dakota del Norte&quot;,&quot;mf_input_option_value&quot;:&quot;value-3&quot;,&quot;_id&quot;:&quot;0e3c5f1&quot;,&quot;mf_input_option_status&quot;:&quot;&quot;,&quot;mf_input_option_selected&quot;:&quot;&quot;},{&quot;mf_input_option_text&quot;:&quot;Dakota del Sur&quot;,&quot;mf_input_option_value&quot;:&quot;value-3&quot;,&quot;_id&quot;:&quot;251a1bb&quot;,&quot;mf_input_option_status&quot;:&quot;&quot;,&quot;mf_input_option_selected&quot;:&quot;&quot;},{&quot;mf_input_option_text&quot;:&quot;Delaware&quot;,&quot;mf_input_option_value&quot;:&quot;value-3&quot;,&quot;_id&quot;:&quot;3a68f82&quot;,&quot;mf_input_option_status&quot;:&quot;&quot;,&quot;mf_input_option_selected&quot;:&quot;&quot;},{&quot;mf_input_option_text&quot;:&quot;Florida&quot;,&quot;mf_input_option_value&quot;:&quot;value-3&quot;,&quot;_id&quot;:&quot;f1764fd&quot;,&quot;mf_input_option_status&quot;:&quot;&quot;,&quot;mf_input_option_selected&quot;:&quot;&quot;},{&quot;mf_input_option_text&quot;:&quot;Georgia&quot;,&quot;mf_input_option_value&quot;:&quot;value-3&quot;,&quot;_id&quot;:&quot;f920b70&quot;,&quot;mf_input_option_status&quot;:&quot;&quot;,&quot;mf_input_option_selected&quot;:&quot;&quot;},{&quot;mf_input_option_text&quot;:&quot;Hawai&quot;,&quot;mf_input_option_value&quot;:&quot;value-3&quot;,&quot;_id&quot;:&quot;a3a7bd0&quot;,&quot;mf_input_option_status&quot;:&quot;&quot;,&quot;mf_input_option_selected&quot;:&quot;&quot;},{&quot;mf_input_option_text&quot;:&quot;Idaho&quot;,&quot;mf_input_option_value&quot;:&quot;value-3&quot;,&quot;_id&quot;:&quot;8486c9e&quot;,&quot;mf_input_option_status&quot;:&quot;&quot;,&quot;mf_input_option_selected&quot;:&quot;&quot;},{&quot;mf_input_option_text&quot;:&quot;Illinois&quot;,&quot;mf_input_option_value&quot;:&quot;value-3&quot;,&quot;_id&quot;:&quot;fc6687b&quot;,&quot;mf_input_option_status&quot;:&quot;&quot;,&quot;mf_input_option_selected&quot;:&quot;&quot;},{&quot;mf_input_option_text&quot;:&quot;Indiana&quot;,&quot;mf_input_option_value&quot;:&quot;value-3&quot;,&quot;_id&quot;:&quot;10c508d&quot;,&quot;mf_input_option_status&quot;:&quot;&quot;,&quot;mf_input_option_selected&quot;:&quot;&quot;},{&quot;mf_input_option_text&quot;:&quot;Iowa&quot;,&quot;mf_input_option_value&quot;:&quot;value-3&quot;,&quot;_id&quot;:&quot;89468ec&quot;,&quot;mf_input_option_status&quot;:&quot;&quot;,&quot;mf_input_option_selected&quot;:&quot;&quot;},{&quot;mf_input_option_text&quot;:&quot;Kansas&quot;,&quot;mf_input_option_value&quot;:&quot;value-3&quot;,&quot;_id&quot;:&quot;95daa81&quot;,&quot;mf_input_option_status&quot;:&quot;&quot;,&quot;mf_input_option_selected&quot;:&quot;&quot;},{&quot;mf_input_option_text&quot;:&quot;Kentucky&quot;,&quot;mf_input_option_value&quot;:&quot;value-3&quot;,&quot;_id&quot;:&quot;4e63c6a&quot;,&quot;mf_input_option_status&quot;:&quot;&quot;,&quot;mf_input_option_selected&quot;:&quot;&quot;},{&quot;mf_input_option_text&quot;:&quot;Luisiana&quot;,&quot;mf_input_option_value&quot;:&quot;value-3&quot;,&quot;_id&quot;:&quot;9140a1c&quot;,&quot;mf_input_option_status&quot;:&quot;&quot;,&quot;mf_input_option_selected&quot;:&quot;&quot;},{&quot;mf_input_option_text&quot;:&quot;Maine&quot;,&quot;mf_input_option_value&quot;:&quot;value-3&quot;,&quot;_id&quot;:&quot;a873578&quot;,&quot;mf_input_option_status&quot;:&quot;&quot;,&quot;mf_input_option_selected&quot;:&quot;&quot;},{&quot;mf_input_option_text&quot;:&quot;Maryland&quot;,&quot;mf_input_option_value&quot;:&quot;value-3&quot;,&quot;_id&quot;:&quot;4b79f47&quot;,&quot;mf_input_option_status&quot;:&quot;&quot;,&quot;mf_input_option_selected&quot;:&quot;&quot;},{&quot;mf_input_option_text&quot;:&quot;Michigan&quot;,&quot;mf_input_option_value&quot;:&quot;value-3&quot;,&quot;_id&quot;:&quot;6d1e483&quot;,&quot;mf_input_option_status&quot;:&quot;&quot;,&quot;mf_input_option_selected&quot;:&quot;&quot;},{&quot;mf_input_option_text&quot;:&quot;Minnesota&quot;,&quot;mf_input_option_value&quot;:&quot;value-3&quot;,&quot;_id&quot;:&quot;3cf76bc&quot;,&quot;mf_input_option_status&quot;:&quot;&quot;,&quot;mf_input_option_selected&quot;:&quot;&quot;},{&quot;mf_input_option_text&quot;:&quot;Massachusetts&quot;,&quot;mf_input_option_value&quot;:&quot;value-3&quot;,&quot;_id&quot;:&quot;df7571f&quot;,&quot;mf_input_option_status&quot;:&quot;&quot;,&quot;mf_input_option_selected&quot;:&quot;&quot;},{&quot;mf_input_option_text&quot;:&quot;Misisipi&quot;,&quot;mf_input_option_value&quot;:&quot;value-3&quot;,&quot;_id&quot;:&quot;02044d6&quot;,&quot;mf_input_option_status&quot;:&quot;&quot;,&quot;mf_input_option_selected&quot;:&quot;&quot;},{&quot;mf_input_option_text&quot;:&quot;Misuri&quot;,&quot;mf_input_option_value&quot;:&quot;value-3&quot;,&quot;_id&quot;:&quot;d895a20&quot;,&quot;mf_input_option_status&quot;:&quot;&quot;,&quot;mf_input_option_selected&quot;:&quot;&quot;},{&quot;mf_input_option_text&quot;:&quot;Rhode Island&quot;,&quot;mf_input_option_value&quot;:&quot;value-3&quot;,&quot;_id&quot;:&quot;e56f720&quot;,&quot;mf_input_option_status&quot;:&quot;&quot;,&quot;mf_input_option_selected&quot;:&quot;&quot;},{&quot;mf_input_option_text&quot;:&quot;Montana&quot;,&quot;mf_input_option_value&quot;:&quot;value-3&quot;,&quot;_id&quot;:&quot;8cf96ea&quot;,&quot;mf_input_option_status&quot;:&quot;&quot;,&quot;mf_input_option_selected&quot;:&quot;&quot;},{&quot;mf_input_option_text&quot;:&quot;Nebraska&quot;,&quot;mf_input_option_value&quot;:&quot;value-3&quot;,&quot;_id&quot;:&quot;e1303b6&quot;,&quot;mf_input_option_status&quot;:&quot;&quot;,&quot;mf_input_option_selected&quot;:&quot;&quot;},{&quot;mf_input_option_text&quot;:&quot;Nevada&quot;,&quot;mf_input_option_value&quot;:&quot;value-3&quot;,&quot;_id&quot;:&quot;b47353b&quot;,&quot;mf_input_option_status&quot;:&quot;&quot;,&quot;mf_input_option_selected&quot;:&quot;&quot;},{&quot;mf_input_option_text&quot;:&quot;Nueva Jersey&quot;,&quot;mf_input_option_value&quot;:&quot;value-3&quot;,&quot;_id&quot;:&quot;524e100&quot;,&quot;mf_input_option_status&quot;:&quot;&quot;,&quot;mf_input_option_selected&quot;:&quot;&quot;},{&quot;mf_input_option_text&quot;:&quot;Nueva York&quot;,&quot;mf_input_option_value&quot;:&quot;value-3&quot;,&quot;_id&quot;:&quot;2888fd9&quot;,&quot;mf_input_option_status&quot;:&quot;&quot;,&quot;mf_input_option_selected&quot;:&quot;&quot;},{&quot;mf_input_option_text&quot;:&quot;Nuevo Hampshire&quot;,&quot;mf_input_option_value&quot;:&quot;value-3&quot;,&quot;_id&quot;:&quot;21d06eb&quot;,&quot;mf_input_option_status&quot;:&quot;&quot;,&quot;mf_input_option_selected&quot;:&quot;&quot;},{&quot;mf_input_option_text&quot;:&quot;Nuevo M\\u00e9xico&quot;,&quot;mf_input_option_value&quot;:&quot;value-3&quot;,&quot;_id&quot;:&quot;79adcae&quot;,&quot;mf_input_option_status&quot;:&quot;&quot;,&quot;mf_input_option_selected&quot;:&quot;&quot;},{&quot;mf_input_option_text&quot;:&quot;Ohio&quot;,&quot;mf_input_option_value&quot;:&quot;value-3&quot;,&quot;_id&quot;:&quot;b1844fd&quot;,&quot;mf_input_option_status&quot;:&quot;&quot;,&quot;mf_input_option_selected&quot;:&quot;&quot;},{&quot;mf_input_option_text&quot;:&quot;Oklahoma&quot;,&quot;mf_input_option_value&quot;:&quot;value-3&quot;,&quot;_id&quot;:&quot;8442b09&quot;,&quot;mf_input_option_status&quot;:&quot;&quot;,&quot;mf_input_option_selected&quot;:&quot;&quot;},{&quot;mf_input_option_text&quot;:&quot;Oreg\\u00f3n&quot;,&quot;mf_input_option_value&quot;:&quot;value-3&quot;,&quot;_id&quot;:&quot;cb6207f&quot;,&quot;mf_input_option_status&quot;:&quot;&quot;,&quot;mf_input_option_selected&quot;:&quot;&quot;},{&quot;mf_input_option_text&quot;:&quot;Pensilvania&quot;,&quot;mf_input_option_value&quot;:&quot;value-3&quot;,&quot;_id&quot;:&quot;41ab121&quot;,&quot;mf_input_option_status&quot;:&quot;&quot;,&quot;mf_input_option_selected&quot;:&quot;&quot;},{&quot;mf_input_option_text&quot;:&quot;Rhode Island&quot;,&quot;mf_input_option_value&quot;:&quot;value-3&quot;,&quot;_id&quot;:&quot;25d4f75&quot;,&quot;mf_input_option_status&quot;:&quot;&quot;,&quot;mf_input_option_selected&quot;:&quot;&quot;},{&quot;mf_input_option_text&quot;:&quot;Tennessee&quot;,&quot;mf_input_option_value&quot;:&quot;value-3&quot;,&quot;_id&quot;:&quot;954371e&quot;,&quot;mf_input_option_status&quot;:&quot;&quot;,&quot;mf_input_option_selected&quot;:&quot;&quot;},{&quot;mf_input_option_text&quot;:&quot;Texas&quot;,&quot;mf_input_option_value&quot;:&quot;value-3&quot;,&quot;_id&quot;:&quot;3bdbaf4&quot;,&quot;mf_input_option_status&quot;:&quot;&quot;,&quot;mf_input_option_selected&quot;:&quot;&quot;},{&quot;mf_input_option_text&quot;:&quot;Utah&quot;,&quot;mf_input_option_value&quot;:&quot;value-3&quot;,&quot;_id&quot;:&quot;36ce050&quot;,&quot;mf_input_option_status&quot;:&quot;&quot;,&quot;mf_input_option_selected&quot;:&quot;&quot;},{&quot;mf_input_option_text&quot;:&quot;Vermont&quot;,&quot;mf_input_option_value&quot;:&quot;value-3&quot;,&quot;_id&quot;:&quot;780c11b&quot;,&quot;mf_input_option_status&quot;:&quot;&quot;,&quot;mf_input_option_selected&quot;:&quot;&quot;},{&quot;mf_input_option_text&quot;:&quot;Virginia&quot;,&quot;mf_input_option_value&quot;:&quot;value-3&quot;,&quot;_id&quot;:&quot;da437a6&quot;,&quot;mf_input_option_status&quot;:&quot;&quot;,&quot;mf_input_option_selected&quot;:&quot;&quot;},{&quot;mf_input_option_text&quot;:&quot;Virginia Occidental&quot;,&quot;mf_input_option_value&quot;:&quot;value-3&quot;,&quot;_id&quot;:&quot;84d36f9&quot;,&quot;mf_input_option_status&quot;:&quot;&quot;,&quot;mf_input_option_selected&quot;:&quot;&quot;},{&quot;mf_input_option_text&quot;:&quot;Washington&quot;,&quot;mf_input_option_value&quot;:&quot;value-3&quot;,&quot;_id&quot;:&quot;d042c92&quot;,&quot;mf_input_option_status&quot;:&quot;&quot;,&quot;mf_input_option_selected&quot;:&quot;&quot;},{&quot;mf_input_option_text&quot;:&quot;Wisconsin&quot;,&quot;mf_input_option_value&quot;:&quot;value-3&quot;,&quot;_id&quot;:&quot;e0e09e3&quot;,&quot;mf_input_option_status&quot;:&quot;&quot;,&quot;mf_input_option_selected&quot;:&quot;&quot;},{&quot;mf_input_option_text&quot;:&quot;Wyoming&quot;,&quot;mf_input_option_value&quot;:&quot;value-3&quot;,&quot;_id&quot;:&quot;f34bf12&quot;,&quot;mf_input_option_status&quot;:&quot;&quot;,&quot;mf_input_option_selected&quot;:&quot;&quot;}]}\" data-widget_type=\"mf-select.default\">\n\t\t\t\t<div className=\"elementor-widget-container\">\n\t\t\t\t\t\n\t\t\n\t\t<div className=\"mf-input-wrapper\">\n\t\t\t\t\t\t\t<label className=\"mf-input-label\" htmlFor=\"mf-input-select-6278fb6\">\n\t\t\t\t\t${ parent.decodeEntities(`State`) } \t\t\t\t\t<span className=\"mf-input-required-indicator\"><\/span>\n\t\t\t\t<\/label>\n            \n            <${props.Select}\n                className=${\"mf-input mf-input-select  \" + ( validation.errors['mf-select'] ? 'mf-invalid' : '' )}\n                classNamePrefix=\"mf_select\"\n                name=\"mf-select\"\n                placeholder=\"${ parent.decodeEntities(`Please select`) } \"\n                isSearchable=${false}\n                options=${[{\"label\":\"Arizona\",\"value\":\"value-1\",\"isDisabled\":false},{\"label\":\"Alabama\",\"value\":\"Input Value\",\"isDisabled\":false},{\"label\":\"Alaska\",\"value\":\"Input Value\",\"isDisabled\":false},{\"label\":\"Arkansas\",\"value\":\"Input Value\",\"isDisabled\":false},{\"label\":\"Connecticut\",\"value\":\"Connecticut\",\"isDisabled\":false},{\"label\":\"California\",\"value\":\"Connecticut\",\"isDisabled\":false},{\"label\":\"California del Norte\",\"value\":\"Connecticut\",\"isDisabled\":false},{\"label\":\"California del Sur\",\"value\":\"value-3\",\"isDisabled\":false},{\"label\":\"Colorado\",\"value\":\"value-3\",\"isDisabled\":false},{\"label\":\"Dakota del Norte\",\"value\":\"value-3\",\"isDisabled\":false},{\"label\":\"Dakota del Sur\",\"value\":\"value-3\",\"isDisabled\":false},{\"label\":\"Delaware\",\"value\":\"value-3\",\"isDisabled\":false},{\"label\":\"Florida\",\"value\":\"value-3\",\"isDisabled\":false},{\"label\":\"Georgia\",\"value\":\"value-3\",\"isDisabled\":false},{\"label\":\"Hawai\",\"value\":\"value-3\",\"isDisabled\":false},{\"label\":\"Idaho\",\"value\":\"value-3\",\"isDisabled\":false},{\"label\":\"Illinois\",\"value\":\"value-3\",\"isDisabled\":false},{\"label\":\"Indiana\",\"value\":\"value-3\",\"isDisabled\":false},{\"label\":\"Iowa\",\"value\":\"value-3\",\"isDisabled\":false},{\"label\":\"Kansas\",\"value\":\"value-3\",\"isDisabled\":false},{\"label\":\"Kentucky\",\"value\":\"value-3\",\"isDisabled\":false},{\"label\":\"Luisiana\",\"value\":\"value-3\",\"isDisabled\":false},{\"label\":\"Maine\",\"value\":\"value-3\",\"isDisabled\":false},{\"label\":\"Maryland\",\"value\":\"value-3\",\"isDisabled\":false},{\"label\":\"Michigan\",\"value\":\"value-3\",\"isDisabled\":false},{\"label\":\"Minnesota\",\"value\":\"value-3\",\"isDisabled\":false},{\"label\":\"Massachusetts\",\"value\":\"value-3\",\"isDisabled\":false},{\"label\":\"Misisipi\",\"value\":\"value-3\",\"isDisabled\":false},{\"label\":\"Misuri\",\"value\":\"value-3\",\"isDisabled\":false},{\"label\":\"Rhode Island\",\"value\":\"value-3\",\"isDisabled\":false},{\"label\":\"Montana\",\"value\":\"value-3\",\"isDisabled\":false},{\"label\":\"Nebraska\",\"value\":\"value-3\",\"isDisabled\":false},{\"label\":\"Nevada\",\"value\":\"value-3\",\"isDisabled\":false},{\"label\":\"Nueva Jersey\",\"value\":\"value-3\",\"isDisabled\":false},{\"label\":\"Nueva York\",\"value\":\"value-3\",\"isDisabled\":false},{\"label\":\"Nuevo Hampshire\",\"value\":\"value-3\",\"isDisabled\":false},{\"label\":\"Nuevo M\\u00e9xico\",\"value\":\"value-3\",\"isDisabled\":false},{\"label\":\"Ohio\",\"value\":\"value-3\",\"isDisabled\":false},{\"label\":\"Oklahoma\",\"value\":\"value-3\",\"isDisabled\":false},{\"label\":\"Oreg\\u00f3n\",\"value\":\"value-3\",\"isDisabled\":false},{\"label\":\"Pensilvania\",\"value\":\"value-3\",\"isDisabled\":false},{\"label\":\"Rhode Island\",\"value\":\"value-3\",\"isDisabled\":false},{\"label\":\"Tennessee\",\"value\":\"value-3\",\"isDisabled\":false},{\"label\":\"Texas\",\"value\":\"value-3\",\"isDisabled\":false},{\"label\":\"Utah\",\"value\":\"value-3\",\"isDisabled\":false},{\"label\":\"Vermont\",\"value\":\"value-3\",\"isDisabled\":false},{\"label\":\"Virginia\",\"value\":\"value-3\",\"isDisabled\":false},{\"label\":\"Virginia Occidental\",\"value\":\"value-3\",\"isDisabled\":false},{\"label\":\"Washington\",\"value\":\"value-3\",\"isDisabled\":false},{\"label\":\"Wisconsin\",\"value\":\"value-3\",\"isDisabled\":false},{\"label\":\"Wyoming\",\"value\":\"value-3\",\"isDisabled\":false}]}\n                value=${parent.getValue(\"mf-select\") ? [{\"label\":\"Arizona\",\"value\":\"value-1\",\"isDisabled\":false},{\"label\":\"Alabama\",\"value\":\"Input Value\",\"isDisabled\":false},{\"label\":\"Alaska\",\"value\":\"Input Value\",\"isDisabled\":false},{\"label\":\"Arkansas\",\"value\":\"Input Value\",\"isDisabled\":false},{\"label\":\"Connecticut\",\"value\":\"Connecticut\",\"isDisabled\":false},{\"label\":\"California\",\"value\":\"Connecticut\",\"isDisabled\":false},{\"label\":\"California del Norte\",\"value\":\"Connecticut\",\"isDisabled\":false},{\"label\":\"California del Sur\",\"value\":\"value-3\",\"isDisabled\":false},{\"label\":\"Colorado\",\"value\":\"value-3\",\"isDisabled\":false},{\"label\":\"Dakota del Norte\",\"value\":\"value-3\",\"isDisabled\":false},{\"label\":\"Dakota del Sur\",\"value\":\"value-3\",\"isDisabled\":false},{\"label\":\"Delaware\",\"value\":\"value-3\",\"isDisabled\":false},{\"label\":\"Florida\",\"value\":\"value-3\",\"isDisabled\":false},{\"label\":\"Georgia\",\"value\":\"value-3\",\"isDisabled\":false},{\"label\":\"Hawai\",\"value\":\"value-3\",\"isDisabled\":false},{\"label\":\"Idaho\",\"value\":\"value-3\",\"isDisabled\":false},{\"label\":\"Illinois\",\"value\":\"value-3\",\"isDisabled\":false},{\"label\":\"Indiana\",\"value\":\"value-3\",\"isDisabled\":false},{\"label\":\"Iowa\",\"value\":\"value-3\",\"isDisabled\":false},{\"label\":\"Kansas\",\"value\":\"value-3\",\"isDisabled\":false},{\"label\":\"Kentucky\",\"value\":\"value-3\",\"isDisabled\":false},{\"label\":\"Luisiana\",\"value\":\"value-3\",\"isDisabled\":false},{\"label\":\"Maine\",\"value\":\"value-3\",\"isDisabled\":false},{\"label\":\"Maryland\",\"value\":\"value-3\",\"isDisabled\":false},{\"label\":\"Michigan\",\"value\":\"value-3\",\"isDisabled\":false},{\"label\":\"Minnesota\",\"value\":\"value-3\",\"isDisabled\":false},{\"label\":\"Massachusetts\",\"value\":\"value-3\",\"isDisabled\":false},{\"label\":\"Misisipi\",\"value\":\"value-3\",\"isDisabled\":false},{\"label\":\"Misuri\",\"value\":\"value-3\",\"isDisabled\":false},{\"label\":\"Rhode Island\",\"value\":\"value-3\",\"isDisabled\":false},{\"label\":\"Montana\",\"value\":\"value-3\",\"isDisabled\":false},{\"label\":\"Nebraska\",\"value\":\"value-3\",\"isDisabled\":false},{\"label\":\"Nevada\",\"value\":\"value-3\",\"isDisabled\":false},{\"label\":\"Nueva Jersey\",\"value\":\"value-3\",\"isDisabled\":false},{\"label\":\"Nueva York\",\"value\":\"value-3\",\"isDisabled\":false},{\"label\":\"Nuevo Hampshire\",\"value\":\"value-3\",\"isDisabled\":false},{\"label\":\"Nuevo M\\u00e9xico\",\"value\":\"value-3\",\"isDisabled\":false},{\"label\":\"Ohio\",\"value\":\"value-3\",\"isDisabled\":false},{\"label\":\"Oklahoma\",\"value\":\"value-3\",\"isDisabled\":false},{\"label\":\"Oreg\\u00f3n\",\"value\":\"value-3\",\"isDisabled\":false},{\"label\":\"Pensilvania\",\"value\":\"value-3\",\"isDisabled\":false},{\"label\":\"Rhode Island\",\"value\":\"value-3\",\"isDisabled\":false},{\"label\":\"Tennessee\",\"value\":\"value-3\",\"isDisabled\":false},{\"label\":\"Texas\",\"value\":\"value-3\",\"isDisabled\":false},{\"label\":\"Utah\",\"value\":\"value-3\",\"isDisabled\":false},{\"label\":\"Vermont\",\"value\":\"value-3\",\"isDisabled\":false},{\"label\":\"Virginia\",\"value\":\"value-3\",\"isDisabled\":false},{\"label\":\"Virginia Occidental\",\"value\":\"value-3\",\"isDisabled\":false},{\"label\":\"Washington\",\"value\":\"value-3\",\"isDisabled\":false},{\"label\":\"Wisconsin\",\"value\":\"value-3\",\"isDisabled\":false},{\"label\":\"Wyoming\",\"value\":\"value-3\",\"isDisabled\":false}].filter(item => item.value === parent.getValue(\"mf-select\"))[0] : []}\n                onChange=${(e)=> parent.handleSelect(e, \"mf-select\")}\n                ref=${() => {\n\t\t\t\t                    register({ name: \"mf-select\" }, parent.activateValidation({\"message\":\"This field is required.\",\"minLength\":1,\"maxLength\":\"\",\"type\":\"none\",\"required\":false}));\n                    if ( parent.getValue(\"mf-select\") === '' && false ) {\n\t\t\t\t    parent.setValue( 'mf-select', '', true );\n                        parent.handleChange({\n                            target: {\n                                name: 'mf-select',\n                                value: ''\n                            }\n                        });\n                    }\n                }}\n                \/>\n\n            \t\t\t\t<${validation.ErrorMessage}\n\t\t\t\t\terrors=${validation.errors}\n\t\t\t\t\tname=\"mf-select\"\n\t\t\t\t\tas=${html`<span className=\"mf-error-message\"><\/span>`}\n\t\t\t\t\t\/>\n\t\t\t\t\t\t\t\t<\/div>\n\n\t\t\n\t\t\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t\t<\/div>\n\t\t<\/div>\n\t\t\t\t<div className=\"elementor-column elementor-col-33 elementor-inner-column elementor-element elementor-element-1b005c0\" data-id=\"1b005c0\" data-element_type=\"column\" data-e-type=\"column\">\n\t\t\t<div className=\"elementor-widget-wrap elementor-element-populated\">\n\t\t\t\t\t\t<div className=\"elementor-element elementor-element-0e3d3e1 elementor-widget elementor-widget-mf-text\" data-id=\"0e3d3e1\" data-element_type=\"widget\" data-e-type=\"widget\" data-settings=\"{&quot;mf_input_name&quot;:&quot;postal-code&quot;}\" data-widget_type=\"mf-text.default\">\n\t\t\t\t<div className=\"elementor-widget-container\">\n\t\t\t\t\t\r\n\t\t<div className=\"mf-input-wrapper\">\r\n\t\t\t\t\t\t\t<label className=\"mf-input-label\" htmlFor=\"mf-input-text-0e3d3e1\">\r\n\t\t\t\t\t${ parent.decodeEntities(`Zip code`) } \t\t\t\t\t<span className=\"mf-input-required-indicator\"><\/span>\r\n\t\t\t\t<\/label>\r\n\t\t\t\r\n\t\t\t<input\r\n\t\t\t\ttype=\"text\"\r\n\t\t\t\tclassName=\"mf-input mf-conditional-input\"\r\n\t\t\t\tid=\"mf-input-text-0e3d3e1\"\r\n\t\t\t\tname=\"postal-code\"\r\n\t\t\t\tplaceholder=\"${ parent.decodeEntities(`12345`) } \"\r\n\t\t\t\t\t\t\t\t\tonInput=${parent.handleChange}\r\n\t\t\t\t\tonBlur=${parent.handleChange}\r\n\t\t\t\t\taria-invalid=${validation.errors['postal-code'] ? 'true' : 'false'}\r\n\t\t\t\t\tref=${el =>{\r\n\t\t\t\t\t\t\t\t\t\t\t\tparent.activateValidation({\"message\":\"This field is required.\",\"minLength\":1,\"maxLength\":\"\",\"type\":\"none\",\"required\":false,\"expression\":\"null\"}, el)\r\n\t\t\t\t\t}}\r\n\t\t\t\t\t\t\t\t\/>\r\n\r\n\t\t\t\t\t\t\t<${validation.ErrorMessage}\r\n\t\t\t\t\terrors=${validation.errors}\r\n\t\t\t\t\tname=\"postal-code\"\r\n\t\t\t\t\tas=${html`<span className=\"mf-error-message\"><\/span>`}\r\n\t\t\t\t\t\/>\r\n\t\t\t\r\n\t\t\t\t\t<\/div>\r\n\r\n\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<section className=\"elementor-section elementor-inner-section elementor-element elementor-element-b47b0a7 elementor-section-full_width elementor-section-height-default elementor-section-height-default\" data-id=\"b47b0a7\" data-element_type=\"section\" data-e-type=\"section\">\n\t\t\t\t\t\t<div className=\"elementor-container elementor-column-gap-default\">\n\t\t\t\t\t<div className=\"elementor-column elementor-col-50 elementor-inner-column elementor-element elementor-element-36fec03\" data-id=\"36fec03\" data-element_type=\"column\" data-e-type=\"column\">\n\t\t\t<div className=\"elementor-widget-wrap elementor-element-populated\">\n\t\t\t\t\t\t<div className=\"elementor-element elementor-element-578ccda elementor-widget elementor-widget-mf-text\" data-id=\"578ccda\" data-element_type=\"widget\" data-e-type=\"widget\" data-settings=\"{&quot;mf_input_name&quot;:&quot;mf-first-name&quot;}\" data-widget_type=\"mf-text.default\">\n\t\t\t\t<div className=\"elementor-widget-container\">\n\t\t\t\t\t\r\n\t\t<div className=\"mf-input-wrapper\">\r\n\t\t\t\t\t\t\t<label className=\"mf-input-label\" htmlFor=\"mf-input-text-578ccda\">\r\n\t\t\t\t\t${ parent.decodeEntities(`guardian&#039;s name`) } \t\t\t\t\t<span className=\"mf-input-required-indicator\">*<\/span>\r\n\t\t\t\t<\/label>\r\n\t\t\t\r\n\t\t\t<input\r\n\t\t\t\ttype=\"text\"\r\n\t\t\t\tclassName=\"mf-input mf-conditional-input\"\r\n\t\t\t\tid=\"mf-input-text-578ccda\"\r\n\t\t\t\tname=\"mf-first-name\"\r\n\t\t\t\tplaceholder=\"${ parent.decodeEntities(`First name`) } \"\r\n\t\t\t\t\t\t\t\t\tonInput=${parent.handleChange}\r\n\t\t\t\t\tonBlur=${parent.handleChange}\r\n\t\t\t\t\taria-invalid=${validation.errors['mf-first-name'] ? 'true' : 'false'}\r\n\t\t\t\t\tref=${el =>{\r\n\t\t\t\t\t\t\t\t\t\t\t\tparent.activateValidation({\"message\":\"This field is required.\",\"minLength\":1,\"maxLength\":\"\",\"type\":\"none\",\"required\":true,\"expression\":\"null\"}, el)\r\n\t\t\t\t\t}}\r\n\t\t\t\t\t\t\t\t\/>\r\n\r\n\t\t\t\t\t\t\t<${validation.ErrorMessage}\r\n\t\t\t\t\terrors=${validation.errors}\r\n\t\t\t\t\tname=\"mf-first-name\"\r\n\t\t\t\t\tas=${html`<span className=\"mf-error-message\"><\/span>`}\r\n\t\t\t\t\t\/>\r\n\t\t\t\r\n\t\t\t\t\t<\/div>\r\n\r\n\t\t\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t\t<\/div>\n\t\t<\/div>\n\t\t\t\t<div className=\"elementor-column elementor-col-50 elementor-inner-column elementor-element elementor-element-11f612e\" data-id=\"11f612e\" data-element_type=\"column\" data-e-type=\"column\">\n\t\t\t<div className=\"elementor-widget-wrap elementor-element-populated\">\n\t\t\t\t\t\t<div className=\"elementor-element elementor-element-a9c7cbd elementor-widget elementor-widget-mf-text\" data-id=\"a9c7cbd\" data-element_type=\"widget\" data-e-type=\"widget\" data-settings=\"{&quot;mf_input_name&quot;:&quot;mf-subject&quot;}\" data-widget_type=\"mf-text.default\">\n\t\t\t\t<div className=\"elementor-widget-container\">\n\t\t\t\t\t\r\n\t\t<div className=\"mf-input-wrapper\">\r\n\t\t\t\t\t\t\t<label className=\"mf-input-label\" htmlFor=\"mf-input-text-a9c7cbd\">\r\n\t\t\t\t\t${ parent.decodeEntities(`Guardian&#039;s surname`) } \t\t\t\t\t<span className=\"mf-input-required-indicator\">*<\/span>\r\n\t\t\t\t<\/label>\r\n\t\t\t\r\n\t\t\t<input\r\n\t\t\t\ttype=\"text\"\r\n\t\t\t\tclassName=\"mf-input mf-conditional-input\"\r\n\t\t\t\tid=\"mf-input-text-a9c7cbd\"\r\n\t\t\t\tname=\"mf-subject\"\r\n\t\t\t\tplaceholder=\"${ parent.decodeEntities(`Last name`) } \"\r\n\t\t\t\t\t\t\t\t\tonInput=${parent.handleChange}\r\n\t\t\t\t\tonBlur=${parent.handleChange}\r\n\t\t\t\t\taria-invalid=${validation.errors['mf-subject'] ? 'true' : 'false'}\r\n\t\t\t\t\tref=${el =>{\r\n\t\t\t\t\t\t\t\t\t\t\t\tparent.activateValidation({\"message\":\"This field is required.\",\"minLength\":1,\"maxLength\":\"\",\"type\":\"none\",\"required\":true,\"expression\":\"null\"}, el)\r\n\t\t\t\t\t}}\r\n\t\t\t\t\t\t\t\t\/>\r\n\r\n\t\t\t\t\t\t\t<${validation.ErrorMessage}\r\n\t\t\t\t\terrors=${validation.errors}\r\n\t\t\t\t\tname=\"mf-subject\"\r\n\t\t\t\t\tas=${html`<span className=\"mf-error-message\"><\/span>`}\r\n\t\t\t\t\t\/>\r\n\t\t\t\r\n\t\t\t\t\t<\/div>\r\n\r\n\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<section className=\"elementor-section elementor-inner-section elementor-element elementor-element-65239fef elementor-section-full_width elementor-section-height-default elementor-section-height-default\" data-id=\"65239fef\" data-element_type=\"section\" data-e-type=\"section\">\n\t\t\t\t\t\t<div className=\"elementor-container elementor-column-gap-default\">\n\t\t\t\t\t<div className=\"elementor-column elementor-col-100 elementor-inner-column elementor-element elementor-element-259e03ce\" data-id=\"259e03ce\" data-element_type=\"column\" data-e-type=\"column\">\n\t\t\t<div className=\"elementor-widget-wrap elementor-element-populated\">\n\t\t\t\t\t\t<div className=\"elementor-element elementor-element-f2601c2 elementor-widget elementor-widget-mf-text\" data-id=\"f2601c2\" data-element_type=\"widget\" data-e-type=\"widget\" data-settings=\"{&quot;mf_input_name&quot;:&quot;seguro&quot;}\" data-widget_type=\"mf-text.default\">\n\t\t\t\t<div className=\"elementor-widget-container\">\n\t\t\t\t\t\r\n\t\t<div className=\"mf-input-wrapper\">\r\n\t\t\t\t\t\t\t<label className=\"mf-input-label\" htmlFor=\"mf-input-text-f2601c2\">\r\n\t\t\t\t\t${ parent.decodeEntities(`Child insurance provider`) } \t\t\t\t\t<span className=\"mf-input-required-indicator\"><\/span>\r\n\t\t\t\t<\/label>\r\n\t\t\t\r\n\t\t\t<input\r\n\t\t\t\ttype=\"text\"\r\n\t\t\t\tclassName=\"mf-input mf-conditional-input\"\r\n\t\t\t\tid=\"mf-input-text-f2601c2\"\r\n\t\t\t\tname=\"seguro\"\r\n\t\t\t\tplaceholder=\"${ parent.decodeEntities(`Enter your insurance`) } \"\r\n\t\t\t\t\t\t\t\t\tonInput=${parent.handleChange}\r\n\t\t\t\t\tonBlur=${parent.handleChange}\r\n\t\t\t\t\taria-invalid=${validation.errors['seguro'] ? 'true' : 'false'}\r\n\t\t\t\t\tref=${el =>{\r\n\t\t\t\t\t\t\t\t\t\t\t\tparent.activateValidation({\"message\":\"This field is required.\",\"minLength\":1,\"maxLength\":\"\",\"type\":\"none\",\"required\":false,\"expression\":\"null\"}, el)\r\n\t\t\t\t\t}}\r\n\t\t\t\t\t\t\t\t\/>\r\n\r\n\t\t\t\t\t\t\t<${validation.ErrorMessage}\r\n\t\t\t\t\terrors=${validation.errors}\r\n\t\t\t\t\tname=\"seguro\"\r\n\t\t\t\t\tas=${html`<span className=\"mf-error-message\"><\/span>`}\r\n\t\t\t\t\t\/>\r\n\t\t\t\r\n\t\t\t\t\t<\/div>\r\n\r\n\t\t\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t\t<\/div>\n\t\t<\/div>\n\t\t\t\t\t<\/div>\n\t\t<\/section>\n\t\t\t\t<section className=\"elementor-section elementor-inner-section elementor-element elementor-element-1789ec7 elementor-section-full_width elementor-section-height-default elementor-section-height-default\" data-id=\"1789ec7\" data-element_type=\"section\" data-e-type=\"section\">\n\t\t\t\t\t\t<div className=\"elementor-container elementor-column-gap-default\">\n\t\t\t\t\t<div className=\"elementor-column elementor-col-100 elementor-inner-column elementor-element elementor-element-d047b02\" data-id=\"d047b02\" data-element_type=\"column\" data-e-type=\"column\">\n\t\t\t<div className=\"elementor-widget-wrap elementor-element-populated\">\n\t\t\t\t\t\t<div className=\"elementor-element elementor-element-562db5b elementor-widget elementor-widget-mf-radio\" data-id=\"562db5b\" data-element_type=\"widget\" data-e-type=\"widget\" data-settings=\"{&quot;mf_input_name&quot;:&quot;mf-radio&quot;,&quot;mf_input_list&quot;:[{&quot;mf_input_option_text&quot;:&quot;Yes&quot;,&quot;mf_input_option_value&quot;:&quot;Yes&quot;,&quot;_id&quot;:&quot;105a70f&quot;,&quot;mf_input_option_status&quot;:&quot;&quot;,&quot;mf_input_option_selected&quot;:&quot;&quot;},{&quot;mf_input_option_text&quot;:&quot;No&quot;,&quot;mf_input_option_value&quot;:&quot;No&quot;,&quot;_id&quot;:&quot;9fbdb5b&quot;,&quot;mf_input_option_status&quot;:&quot;&quot;,&quot;mf_input_option_selected&quot;:&quot;&quot;}]}\" data-widget_type=\"mf-radio.default\">\n\t\t\t\t<div className=\"elementor-widget-container\">\n\t\t\t\t\t\t\r\n\r\n\t\t<div className=\"mf-input-wrapper\">\r\n\t\t\t\t\t\t\t<label className=\"mf-input-label\" htmlFor=\"mf-input-radio-562db5b\">\r\n\t\t\t\t\t${ parent.decodeEntities(`Has your child been formally diagnosed with autism by a doctor (MD, PhD, PSYD, etc.)?`) } \t\t\t\t\t<span className=\"mf-input-required-indicator\">*<\/span>\r\n\t\t\t\t<\/label>\r\n\t\t\t\r\n\t\t\t<div className=\"mf-radio multi-option-input-type\" id=\"mf-input-radio-562db5b\">\r\n\t\t\t\t\t\t\t\t\t<div className=\"mf-radio-option \">\r\n\t\t\t\t\t\t<label>\r\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t<input\r\n\t\t\t\t\t\t\t\ttype=\"radio\"\r\n\t\t\t\t\t\t\t\tclassName=\"mf-input mf-radio-input \"\r\n\t\t\t\t\t\t\t\tname=\"mf-radio\"\r\n\t\t\t\t\t\t\t\tvalue=\"Yes\"\r\n\t\t\t\t\t\t\t\tdata-checked=\"\"\r\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\tonChange=${ parent.handleChange }\r\n\t\t\t\t\t\t\t\t\taria-invalid=${validation.errors['mf-radio'] ? 'true' : 'false'}\r\n\t\t\t\t\t\t\t\t\tref=${el =>{\r\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\tparent.handleRadioDefault(el);\r\n\t\t\t\t\t\t\t\t\t\tparent.activateValidation({\"message\":\"This field is required.\",\"required\":true}, el)\r\n\t\t\t\t\t\t\t\t\t}}\r\n\t\t\t\t\t\t\t\t\tchecked=${'Yes' === parent.getValue('mf-radio')}\r\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\/>\r\n\t\t\t\t\t\t\t<span>\r\n\t\t\t\t\t\t\t\t${ parent.decodeEntities(`Yes`) } \t\t\t\t\t\t\t<\/span>\r\n\t\t\t\t\t\t<\/label>\r\n\t\t\t\t\t<\/div>\r\n\t\t\t\t\t\t\t\t\t\t<div className=\"mf-radio-option \">\r\n\t\t\t\t\t\t<label>\r\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t<input\r\n\t\t\t\t\t\t\t\ttype=\"radio\"\r\n\t\t\t\t\t\t\t\tclassName=\"mf-input mf-radio-input \"\r\n\t\t\t\t\t\t\t\tname=\"mf-radio\"\r\n\t\t\t\t\t\t\t\tvalue=\"No\"\r\n\t\t\t\t\t\t\t\tdata-checked=\"\"\r\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\tonChange=${ parent.handleChange }\r\n\t\t\t\t\t\t\t\t\taria-invalid=${validation.errors['mf-radio'] ? 'true' : 'false'}\r\n\t\t\t\t\t\t\t\t\tref=${el =>{\r\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\tparent.handleRadioDefault(el);\r\n\t\t\t\t\t\t\t\t\t\tparent.activateValidation({\"message\":\"This field is required.\",\"required\":true}, el)\r\n\t\t\t\t\t\t\t\t\t}}\r\n\t\t\t\t\t\t\t\t\tchecked=${'No' === parent.getValue('mf-radio')}\r\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\/>\r\n\t\t\t\t\t\t\t<span>\r\n\t\t\t\t\t\t\t\t${ parent.decodeEntities(`No`) } \t\t\t\t\t\t\t<\/span>\r\n\t\t\t\t\t\t<\/label>\r\n\t\t\t\t\t<\/div>\r\n\t\t\t\t\t\t\t\t<\/div>\r\n\r\n\t\t\t\t\t\t\t<${validation.ErrorMessage}\r\n\t\t\t\t\terrors=${validation.errors}\r\n\t\t\t\t\tname=\"mf-radio\"\r\n\t\t\t\t\tas=${html`<span className=\"mf-error-message\"><\/span>`}\r\n\t\t\t\t\t\/>\r\n\t\t\t\t\t\t\t\t\t<input type=\"hidden\" name=\"mf-radio\" value=\"\" \/>\r\n\t\t<\/div>\r\n\r\n\t\t\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t<div className=\"elementor-element elementor-element-14ec8fa elementor-widget elementor-widget-mf-checkbox\" data-id=\"14ec8fa\" data-element_type=\"widget\" data-e-type=\"widget\" data-settings=\"{&quot;mf_input_name&quot;:&quot;mf-checkbox&quot;,&quot;mf_input_list&quot;:[{&quot;mf_input_option_text&quot;:&quot;ABA therapy&quot;,&quot;mf_input_option_value&quot;:&quot;ABA therapy&quot;,&quot;_id&quot;:&quot;219e842&quot;,&quot;mf_input_option_status&quot;:&quot;&quot;,&quot;mf_input_option_selected&quot;:&quot;&quot;},{&quot;mf_input_option_text&quot;:&quot;Psychological evaluation&quot;,&quot;mf_input_option_value&quot;:&quot;Psychological evaluation&quot;,&quot;_id&quot;:&quot;892bedd&quot;,&quot;mf_input_option_status&quot;:&quot;&quot;,&quot;mf_input_option_selected&quot;:&quot;&quot;},{&quot;mf_input_option_text&quot;:&quot;Information for new clients&quot;,&quot;mf_input_option_value&quot;:&quot;Information for new clients&quot;,&quot;_id&quot;:&quot;1ab8c16&quot;,&quot;mf_input_option_status&quot;:&quot;&quot;,&quot;mf_input_option_selected&quot;:&quot;&quot;},{&quot;mf_input_option_text&quot;:&quot;Other&quot;,&quot;mf_input_option_value&quot;:&quot;Other&quot;,&quot;_id&quot;:&quot;360c78b&quot;,&quot;mf_input_option_status&quot;:&quot;&quot;,&quot;mf_input_option_selected&quot;:&quot;&quot;}]}\" data-widget_type=\"mf-checkbox.default\">\n\t\t\t\t<div className=\"elementor-widget-container\">\n\t\t\t\t\t\r\n\t\t<div className=\"mf-input-wrapper\">\r\n\t\t\t\t\t\t\t<label className=\"mf-input-label\" htmlFor=\"mf-input-checkbox-14ec8fa\">\r\n\t\t\t\t\t${ parent.decodeEntities(`Interest in services`) } \t\t\t\t\t<span className=\"mf-input-required-indicator\"><\/span>\r\n\t\t\t\t<\/label>\r\n\t\t\t\r\n\t\t\t<div \r\n\t\t\t\t\t\t\t\t\tref=${el => parent.handleCheckbox(el, 'onLoad')}\r\n\t\t\t\t\t\t\t\t\tclassName=\"mf-checkbox multi-option-input-type\"\r\n\t\t\t\t\tid=\"mf-input-checkbox-14ec8fa\">\r\n\t\t\t\t\t\t\t\t\t<div className=\"mf-checkbox-option \">\r\n\t\t\t\t\t\t<label>\r\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t<input type=\"checkbox\"\r\n\t\t\t\t\t\t\t\tclassName=\"mf-input mf-checkbox-input \"\r\n\t\t\t\t\t\t\t\tname=\"mf-checkbox\"\r\n\t\t\t\t\t\t\t\tvalue=\"ABA therapy\"\r\n\t\t\t\t\t\t\t\tdefaultChecked=\"\"\r\n\t\t\t\t\t\t\t\t\r\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\tonInput=${ el =>  parent.handleCheckbox(el.target, 'onClick') }\r\n\t\t\t\t\t\t\t\t\taria-invalid=${validation.errors['mf-checkbox'] ? 'true' : 'false'}\r\n\t\t\t\t\t\t\t\t\tref=${el => {\r\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\tparent.activateValidation({\"message\":\"This field is required.\",\"minLength\":1,\"maxLength\":\"\",\"type\":\"none\",\"required\":false,\"expression\":\"null\"}, el)}\r\n\t\t\t\t\t\t\t\t\t}\r\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\/>\r\n\t\t\t\t\t\t\t<span>\r\n\t\t\t\t\t\t\t\t${ parent.decodeEntities(`ABA therapy`) } \t\t\t\t\t\t\t<\/span>\r\n\t\t\t\t\t\t<\/label>\r\n\t\t\t\t\t<\/div>\r\n\t\t\t\t\t\t\t\t\t\t<div className=\"mf-checkbox-option \">\r\n\t\t\t\t\t\t<label>\r\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t<input type=\"checkbox\"\r\n\t\t\t\t\t\t\t\tclassName=\"mf-input mf-checkbox-input \"\r\n\t\t\t\t\t\t\t\tname=\"mf-checkbox\"\r\n\t\t\t\t\t\t\t\tvalue=\"Psychological evaluation\"\r\n\t\t\t\t\t\t\t\tdefaultChecked=\"\"\r\n\t\t\t\t\t\t\t\t\r\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\tonInput=${ el =>  parent.handleCheckbox(el.target, 'onClick') }\r\n\t\t\t\t\t\t\t\t\taria-invalid=${validation.errors['mf-checkbox'] ? 'true' : 'false'}\r\n\t\t\t\t\t\t\t\t\tref=${el => {\r\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\tparent.activateValidation({\"message\":\"This field is required.\",\"minLength\":1,\"maxLength\":\"\",\"type\":\"none\",\"required\":false,\"expression\":\"null\"}, el)}\r\n\t\t\t\t\t\t\t\t\t}\r\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\/>\r\n\t\t\t\t\t\t\t<span>\r\n\t\t\t\t\t\t\t\t${ parent.decodeEntities(`Psychological evaluation`) } \t\t\t\t\t\t\t<\/span>\r\n\t\t\t\t\t\t<\/label>\r\n\t\t\t\t\t<\/div>\r\n\t\t\t\t\t\t\t\t\t\t<div className=\"mf-checkbox-option \">\r\n\t\t\t\t\t\t<label>\r\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t<input type=\"checkbox\"\r\n\t\t\t\t\t\t\t\tclassName=\"mf-input mf-checkbox-input \"\r\n\t\t\t\t\t\t\t\tname=\"mf-checkbox\"\r\n\t\t\t\t\t\t\t\tvalue=\"Information for new clients\"\r\n\t\t\t\t\t\t\t\tdefaultChecked=\"\"\r\n\t\t\t\t\t\t\t\t\r\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\tonInput=${ el =>  parent.handleCheckbox(el.target, 'onClick') }\r\n\t\t\t\t\t\t\t\t\taria-invalid=${validation.errors['mf-checkbox'] ? 'true' : 'false'}\r\n\t\t\t\t\t\t\t\t\tref=${el => {\r\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\tparent.activateValidation({\"message\":\"This field is required.\",\"minLength\":1,\"maxLength\":\"\",\"type\":\"none\",\"required\":false,\"expression\":\"null\"}, el)}\r\n\t\t\t\t\t\t\t\t\t}\r\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\/>\r\n\t\t\t\t\t\t\t<span>\r\n\t\t\t\t\t\t\t\t${ parent.decodeEntities(`Information for new clients`) } \t\t\t\t\t\t\t<\/span>\r\n\t\t\t\t\t\t<\/label>\r\n\t\t\t\t\t<\/div>\r\n\t\t\t\t\t\t\t\t\t\t<div className=\"mf-checkbox-option \">\r\n\t\t\t\t\t\t<label>\r\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t<input type=\"checkbox\"\r\n\t\t\t\t\t\t\t\tclassName=\"mf-input mf-checkbox-input \"\r\n\t\t\t\t\t\t\t\tname=\"mf-checkbox\"\r\n\t\t\t\t\t\t\t\tvalue=\"Other\"\r\n\t\t\t\t\t\t\t\tdefaultChecked=\"\"\r\n\t\t\t\t\t\t\t\t\r\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\tonInput=${ el =>  parent.handleCheckbox(el.target, 'onClick') }\r\n\t\t\t\t\t\t\t\t\taria-invalid=${validation.errors['mf-checkbox'] ? 'true' : 'false'}\r\n\t\t\t\t\t\t\t\t\tref=${el => {\r\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\tparent.activateValidation({\"message\":\"This field is required.\",\"minLength\":1,\"maxLength\":\"\",\"type\":\"none\",\"required\":false,\"expression\":\"null\"}, el)}\r\n\t\t\t\t\t\t\t\t\t}\r\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\/>\r\n\t\t\t\t\t\t\t<span>\r\n\t\t\t\t\t\t\t\t${ parent.decodeEntities(`Other`) } \t\t\t\t\t\t\t<\/span>\r\n\t\t\t\t\t\t<\/label>\r\n\t\t\t\t\t<\/div>\r\n\t\t\t\t\t\t\t\t<\/div>\r\n\t\t\t<input type=\"hidden\" name=\"mf-checkbox\" value=\"\" \/>\r\n\r\n\t\t\t\t\t\t\t<${validation.ErrorMessage}\r\n\t\t\t\t\terrors=${validation.errors}\r\n\t\t\t\t\tname=\"mf-checkbox\"\r\n\t\t\t\t\tas=${html`<span className=\"mf-error-message\"><\/span>`}\r\n\t\t\t\t\t\/>\r\n\t\t\t\t\t\t\t\t<\/div>\r\n\r\n\t\t\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t<div className=\"elementor-element elementor-element-8fcd069 elementor-widget elementor-widget-mf-checkbox\" data-id=\"8fcd069\" data-element_type=\"widget\" data-e-type=\"widget\" data-settings=\"{&quot;mf_input_name&quot;:&quot;mf-checkbox&quot;,&quot;mf_input_list&quot;:[{&quot;mf_input_option_text&quot;:&quot;Do you accept my insurance?&quot;,&quot;mf_input_option_value&quot;:&quot;Do you accept my insurance?&quot;,&quot;_id&quot;:&quot;219e842&quot;,&quot;mf_input_option_status&quot;:&quot;&quot;,&quot;mf_input_option_selected&quot;:&quot;&quot;},{&quot;mf_input_option_text&quot;:&quot;Are you in my insurance network?&quot;,&quot;mf_input_option_value&quot;:&quot;Are you in my insurance network?&quot;,&quot;_id&quot;:&quot;892bedd&quot;,&quot;mf_input_option_status&quot;:&quot;&quot;,&quot;mf_input_option_selected&quot;:&quot;&quot;},{&quot;mf_input_option_text&quot;:&quot;What are my costs or co-payments?&quot;,&quot;mf_input_option_value&quot;:&quot;What are my costs or co-payments?&quot;,&quot;_id&quot;:&quot;1ab8c16&quot;,&quot;mf_input_option_status&quot;:&quot;&quot;,&quot;mf_input_option_selected&quot;:&quot;&quot;},{&quot;mf_input_option_text&quot;:&quot;What services are covered?&quot;,&quot;mf_input_option_value&quot;:&quot;What services are covered?&quot;,&quot;_id&quot;:&quot;360c78b&quot;,&quot;mf_input_option_status&quot;:&quot;&quot;,&quot;mf_input_option_selected&quot;:&quot;&quot;},{&quot;_id&quot;:&quot;5abda80&quot;,&quot;mf_input_option_text&quot;:&quot;Is there a waiting list?&quot;,&quot;mf_input_option_value&quot;:&quot;Is there a waiting list?&quot;,&quot;mf_input_option_status&quot;:&quot;&quot;,&quot;mf_input_option_selected&quot;:&quot;&quot;},{&quot;_id&quot;:&quot;a4b5b6f&quot;,&quot;mf_input_option_text&quot;:&quot;Other - Please contact me&quot;,&quot;mf_input_option_value&quot;:&quot;Other - Please contact me&quot;,&quot;mf_input_option_status&quot;:&quot;&quot;,&quot;mf_input_option_selected&quot;:&quot;&quot;}]}\" data-widget_type=\"mf-checkbox.default\">\n\t\t\t\t<div className=\"elementor-widget-container\">\n\t\t\t\t\t\r\n\t\t<div className=\"mf-input-wrapper\">\r\n\t\t\t\t\t\t\t<label className=\"mf-input-label\" htmlFor=\"mf-input-checkbox-8fcd069\">\r\n\t\t\t\t\t${ parent.decodeEntities(`Do you have questions about your coverage?`) } \t\t\t\t\t<span className=\"mf-input-required-indicator\"><\/span>\r\n\t\t\t\t<\/label>\r\n\t\t\t\r\n\t\t\t<div \r\n\t\t\t\t\t\t\t\t\tref=${el => parent.handleCheckbox(el, 'onLoad')}\r\n\t\t\t\t\t\t\t\t\tclassName=\"mf-checkbox multi-option-input-type\"\r\n\t\t\t\t\tid=\"mf-input-checkbox-8fcd069\">\r\n\t\t\t\t\t\t\t\t\t<div className=\"mf-checkbox-option \">\r\n\t\t\t\t\t\t<label>\r\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t<input type=\"checkbox\"\r\n\t\t\t\t\t\t\t\tclassName=\"mf-input mf-checkbox-input \"\r\n\t\t\t\t\t\t\t\tname=\"mf-checkbox\"\r\n\t\t\t\t\t\t\t\tvalue=\"Do you accept my insurance?\"\r\n\t\t\t\t\t\t\t\tdefaultChecked=\"\"\r\n\t\t\t\t\t\t\t\t\r\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\tonInput=${ el =>  parent.handleCheckbox(el.target, 'onClick') }\r\n\t\t\t\t\t\t\t\t\taria-invalid=${validation.errors['mf-checkbox'] ? 'true' : 'false'}\r\n\t\t\t\t\t\t\t\t\tref=${el => {\r\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\tparent.activateValidation({\"message\":\"This field is required.\",\"minLength\":1,\"maxLength\":\"\",\"type\":\"none\",\"required\":false,\"expression\":\"null\"}, el)}\r\n\t\t\t\t\t\t\t\t\t}\r\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\/>\r\n\t\t\t\t\t\t\t<span>\r\n\t\t\t\t\t\t\t\t${ parent.decodeEntities(`Do you accept my insurance?`) } \t\t\t\t\t\t\t<\/span>\r\n\t\t\t\t\t\t<\/label>\r\n\t\t\t\t\t<\/div>\r\n\t\t\t\t\t\t\t\t\t\t<div className=\"mf-checkbox-option \">\r\n\t\t\t\t\t\t<label>\r\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t<input type=\"checkbox\"\r\n\t\t\t\t\t\t\t\tclassName=\"mf-input mf-checkbox-input \"\r\n\t\t\t\t\t\t\t\tname=\"mf-checkbox\"\r\n\t\t\t\t\t\t\t\tvalue=\"Are you in my insurance network?\"\r\n\t\t\t\t\t\t\t\tdefaultChecked=\"\"\r\n\t\t\t\t\t\t\t\t\r\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\tonInput=${ el =>  parent.handleCheckbox(el.target, 'onClick') }\r\n\t\t\t\t\t\t\t\t\taria-invalid=${validation.errors['mf-checkbox'] ? 'true' : 'false'}\r\n\t\t\t\t\t\t\t\t\tref=${el => {\r\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\tparent.activateValidation({\"message\":\"This field is required.\",\"minLength\":1,\"maxLength\":\"\",\"type\":\"none\",\"required\":false,\"expression\":\"null\"}, el)}\r\n\t\t\t\t\t\t\t\t\t}\r\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\/>\r\n\t\t\t\t\t\t\t<span>\r\n\t\t\t\t\t\t\t\t${ parent.decodeEntities(`Are you in my insurance network?`) } \t\t\t\t\t\t\t<\/span>\r\n\t\t\t\t\t\t<\/label>\r\n\t\t\t\t\t<\/div>\r\n\t\t\t\t\t\t\t\t\t\t<div className=\"mf-checkbox-option \">\r\n\t\t\t\t\t\t<label>\r\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t<input type=\"checkbox\"\r\n\t\t\t\t\t\t\t\tclassName=\"mf-input mf-checkbox-input \"\r\n\t\t\t\t\t\t\t\tname=\"mf-checkbox\"\r\n\t\t\t\t\t\t\t\tvalue=\"What are my costs or co-payments?\"\r\n\t\t\t\t\t\t\t\tdefaultChecked=\"\"\r\n\t\t\t\t\t\t\t\t\r\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\tonInput=${ el =>  parent.handleCheckbox(el.target, 'onClick') }\r\n\t\t\t\t\t\t\t\t\taria-invalid=${validation.errors['mf-checkbox'] ? 'true' : 'false'}\r\n\t\t\t\t\t\t\t\t\tref=${el => {\r\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\tparent.activateValidation({\"message\":\"This field is required.\",\"minLength\":1,\"maxLength\":\"\",\"type\":\"none\",\"required\":false,\"expression\":\"null\"}, el)}\r\n\t\t\t\t\t\t\t\t\t}\r\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\/>\r\n\t\t\t\t\t\t\t<span>\r\n\t\t\t\t\t\t\t\t${ parent.decodeEntities(`What are my costs or co-payments?`) } \t\t\t\t\t\t\t<\/span>\r\n\t\t\t\t\t\t<\/label>\r\n\t\t\t\t\t<\/div>\r\n\t\t\t\t\t\t\t\t\t\t<div className=\"mf-checkbox-option \">\r\n\t\t\t\t\t\t<label>\r\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t<input type=\"checkbox\"\r\n\t\t\t\t\t\t\t\tclassName=\"mf-input mf-checkbox-input \"\r\n\t\t\t\t\t\t\t\tname=\"mf-checkbox\"\r\n\t\t\t\t\t\t\t\tvalue=\"What services are covered?\"\r\n\t\t\t\t\t\t\t\tdefaultChecked=\"\"\r\n\t\t\t\t\t\t\t\t\r\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\tonInput=${ el =>  parent.handleCheckbox(el.target, 'onClick') }\r\n\t\t\t\t\t\t\t\t\taria-invalid=${validation.errors['mf-checkbox'] ? 'true' : 'false'}\r\n\t\t\t\t\t\t\t\t\tref=${el => {\r\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\tparent.activateValidation({\"message\":\"This field is required.\",\"minLength\":1,\"maxLength\":\"\",\"type\":\"none\",\"required\":false,\"expression\":\"null\"}, el)}\r\n\t\t\t\t\t\t\t\t\t}\r\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\/>\r\n\t\t\t\t\t\t\t<span>\r\n\t\t\t\t\t\t\t\t${ parent.decodeEntities(`What services are covered?`) } \t\t\t\t\t\t\t<\/span>\r\n\t\t\t\t\t\t<\/label>\r\n\t\t\t\t\t<\/div>\r\n\t\t\t\t\t\t\t\t\t\t<div className=\"mf-checkbox-option \">\r\n\t\t\t\t\t\t<label>\r\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t<input type=\"checkbox\"\r\n\t\t\t\t\t\t\t\tclassName=\"mf-input mf-checkbox-input \"\r\n\t\t\t\t\t\t\t\tname=\"mf-checkbox\"\r\n\t\t\t\t\t\t\t\tvalue=\"Is there a waiting list?\"\r\n\t\t\t\t\t\t\t\tdefaultChecked=\"\"\r\n\t\t\t\t\t\t\t\t\r\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\tonInput=${ el =>  parent.handleCheckbox(el.target, 'onClick') }\r\n\t\t\t\t\t\t\t\t\taria-invalid=${validation.errors['mf-checkbox'] ? 'true' : 'false'}\r\n\t\t\t\t\t\t\t\t\tref=${el => {\r\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\tparent.activateValidation({\"message\":\"This field is required.\",\"minLength\":1,\"maxLength\":\"\",\"type\":\"none\",\"required\":false,\"expression\":\"null\"}, el)}\r\n\t\t\t\t\t\t\t\t\t}\r\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\/>\r\n\t\t\t\t\t\t\t<span>\r\n\t\t\t\t\t\t\t\t${ parent.decodeEntities(`Is there a waiting list?`) } \t\t\t\t\t\t\t<\/span>\r\n\t\t\t\t\t\t<\/label>\r\n\t\t\t\t\t<\/div>\r\n\t\t\t\t\t\t\t\t\t\t<div className=\"mf-checkbox-option \">\r\n\t\t\t\t\t\t<label>\r\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t<input type=\"checkbox\"\r\n\t\t\t\t\t\t\t\tclassName=\"mf-input mf-checkbox-input \"\r\n\t\t\t\t\t\t\t\tname=\"mf-checkbox\"\r\n\t\t\t\t\t\t\t\tvalue=\"Other - Please contact me\"\r\n\t\t\t\t\t\t\t\tdefaultChecked=\"\"\r\n\t\t\t\t\t\t\t\t\r\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\tonInput=${ el =>  parent.handleCheckbox(el.target, 'onClick') }\r\n\t\t\t\t\t\t\t\t\taria-invalid=${validation.errors['mf-checkbox'] ? 'true' : 'false'}\r\n\t\t\t\t\t\t\t\t\tref=${el => {\r\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\tparent.activateValidation({\"message\":\"This field is required.\",\"minLength\":1,\"maxLength\":\"\",\"type\":\"none\",\"required\":false,\"expression\":\"null\"}, el)}\r\n\t\t\t\t\t\t\t\t\t}\r\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\/>\r\n\t\t\t\t\t\t\t<span>\r\n\t\t\t\t\t\t\t\t${ parent.decodeEntities(`Other - Please contact me`) } \t\t\t\t\t\t\t<\/span>\r\n\t\t\t\t\t\t<\/label>\r\n\t\t\t\t\t<\/div>\r\n\t\t\t\t\t\t\t\t<\/div>\r\n\t\t\t<input type=\"hidden\" name=\"mf-checkbox\" value=\"\" \/>\r\n\r\n\t\t\t\t\t\t\t<${validation.ErrorMessage}\r\n\t\t\t\t\terrors=${validation.errors}\r\n\t\t\t\t\tname=\"mf-checkbox\"\r\n\t\t\t\t\tas=${html`<span className=\"mf-error-message\"><\/span>`}\r\n\t\t\t\t\t\/>\r\n\t\t\t\t\t\t\t\t<\/div>\r\n\r\n\t\t\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t<div className=\"elementor-element elementor-element-7025afd elementor-widget elementor-widget-mf-textarea\" data-id=\"7025afd\" data-element_type=\"widget\" data-e-type=\"widget\" data-settings=\"{&quot;mf_input_name&quot;:&quot;mf-comment&quot;}\" data-widget_type=\"mf-textarea.default\">\n\t\t\t\t<div className=\"elementor-widget-container\">\n\t\t\t\t\t\r\n\t\t<div className=\"mf-input-wrapper\">\r\n\t\t\t\t\t\t\t<label className=\"mf-input-label\" htmlFor=\"mf-input-text-area-7025afd\">\r\n\t\t\t\t\t${ parent.decodeEntities(`Comment`) } \t\t\t\t\t<span className=\"mf-input-required-indicator\"><\/span>\r\n\t\t\t\t<\/label>\r\n\t\t\t\r\n\t\t\t<textarea className=\"mf-input mf-textarea mf-conditional-input\" id=\"mf-input-text-area-7025afd\"\r\n\t\t\t\tname=\"mf-comment\" \r\n\t\t\t\tplaceholder=\"${ parent.decodeEntities(``) } \"\r\n\t\t\t\tcols=\"30\" rows=\"10\"\r\n\t\t\t\t\t\t\t\t\tonInput=${ parent.handleChange }\r\n\t\t\t\t\taria-invalid=${validation.errors['mf-comment'] ? 'true' : 'false'}\r\n\t\t\t\t\tref=${ el => parent.activateValidation({\"message\":\"This field is required.\",\"minLength\":1,\"maxLength\":\"\",\"type\":\"none\",\"required\":false,\"expression\":\"null\"}, el)}\r\n\t\t\t\t\t\t\t\t><\/textarea>\r\n\r\n\t\t\t\t\t\t\t<${validation.ErrorMessage}\r\n\t\t\t\t\terrors=${validation.errors}\r\n\t\t\t\t\tname=\"mf-comment\"\r\n\t\t\t\t\tas=${html`<span className=\"mf-error-message\"><\/span>`}\r\n\t\t\t\t\t\/>\r\n\t\t\t\t\t\t\t\t<\/div>\r\n\r\n\t\t\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t<div className=\"elementor-element elementor-element-4c8a396 elementor-widget__width-auto elementor-widget elementor-widget-mf-button\" data-id=\"4c8a396\" data-element_type=\"widget\" data-e-type=\"widget\" data-widget_type=\"mf-button.default\">\n\t\t\t\t<div className=\"elementor-widget-container\">\n\t\t\t\t\t\t\t<div className=\"mf-btn-wraper mf-conditional-input\" data-mf-form-conditional-logic-requirement=\"\">\r\n\t\t\t\t\t\t\t<button type=\"submit\" className=\"metform-btn metform-submit-btn \" id=\"\">\r\n\t\t\t\t\t<span>${ parent.decodeEntities(`Send Message`) } <\/span>\r\n\t\t\t\t<\/button>\r\n\t\t\t        <\/div>\r\n        \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\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\t\t\t\t\t`}\r\n\t\t\t\t\t<\/div>\r\n\r\n\t\t\t\t\t${is_dummy_markup ? message_position === 'bottom' ? props.ResponseDummyMarkup(message_successIcon, message_proClass) : '' : ''}\r\n\t\t\t\t\t${is_dummy_markup ? 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