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Number(NIN)” allowed_symbols=”alphanumeric” _builder_version=”3.0.93″][/et_pb_contact_field][et_pb_contact_field field_id=”maritalStatus” field_title=”Marital Status” field_type=”select” select_options=”%91{%22value%22:%22Single%22,%22checked%22:0,%22dragID%22:0},{%22value%22:%22Married%22,%22checked%22:0,%22dragID%22:1}%93″ _builder_version=”3.0.93″][/et_pb_contact_field][et_pb_contact_field field_id=”address” field_title=”Address” field_type=”text” fullwidth_field=”on” _builder_version=”3.0.93″][/et_pb_contact_field][et_pb_contact_field field_id=”postcode” field_title=”Postcode” fullwidth_field=”on” _builder_version=”3.0.93″][/et_pb_contact_field][et_pb_contact_field field_id=”telHome” field_title=”Home Telephone” allowed_symbols=”numbers” required_mark=”off” _builder_version=”3.0.93″][/et_pb_contact_field][et_pb_contact_field field_id=”telMobile” field_title=”Mobile Number” allowed_symbols=”numbers” required_mark=”off” 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conditional_logic=”on” conditional_logic_rules=”%91{%22field%22:%22hasdisability%22,%22condition%22:%22is%22,%22value%22:%22Yes%22}%93″ _builder_version=”3.0.93″][/et_pb_contact_field][et_pb_contact_field field_id=”mentalHealthDiagnosis” field_title=”Please give the name of any diagnosis” field_type=”text” required_mark=”off” fullwidth_field=”on” conditional_logic=”on” conditional_logic_rules=”%91{%22field%22:%22havementalhealthofficerdiagnosis%22,%22condition%22:%22is%22,%22value%22:%22Yes%22}%93″ _builder_version=”3.2.1″][/et_pb_contact_field][et_pb_contact_field field_id=”emergencyTitle” field_title=”Emergency Contact Title” _builder_version=”3.0.93″][/et_pb_contact_field][et_pb_contact_field field_id=”emergencyName” field_title=”Emergency Contact Name” _builder_version=”3.0.93″][/et_pb_contact_field][et_pb_contact_field field_id=”emergencyAddress” field_title=”Emergency Contact Address” field_type=”text” fullwidth_field=”on” _builder_version=”3.0.93″][/et_pb_contact_field][et_pb_contact_field field_id=”emergencyPostcode” field_title=”Emergency Contact Postcode” _builder_version=”3.0.93″][/et_pb_contact_field][et_pb_contact_field field_id=”emergencyRelationship” field_title=”Emergency Contact Relationship” _builder_version=”3.0.93″][/et_pb_contact_field][et_pb_contact_field field_id=”emergencyTelephone” field_title=”Emergency Contact Home/Work Number” _builder_version=”3.0.93″][/et_pb_contact_field][et_pb_contact_field field_id=”emergencyMobileNum” field_title=”Emergency Contact Mobile Number” allowed_symbols=”numbers” _builder_version=”3.0.93″][/et_pb_contact_field][et_pb_contact_field field_id=”discloseEthinicity” field_title=”Disclose Ethnicity (At your discretion for disclosure)” field_type=”select” select_options=”%91{%22value%22:%22Yes%22,%22checked%22:0,%22dragID%22:0},{%22value%22:%22No%22,%22checked%22:0,%22dragID%22:1}%93″ fullwidth_field=”on” _builder_version=”3.0.93″][/et_pb_contact_field][et_pb_contact_field field_id=”ethnicityCountryOfBirth” field_title=”Country of Birth” conditional_logic=”on” conditional_logic_rules=”%91{%22field%22:%22discloseethinicity%22,%22condition%22:%22is%22,%22value%22:%22Yes%22}%93″ _builder_version=”3.0.93″][/et_pb_contact_field][et_pb_contact_field field_id=”ethnicityNationality” field_title=”Nationality” conditional_logic=”on” conditional_logic_rules=”%91{%22field%22:%22discloseethinicity%22,%22condition%22:%22is%22,%22value%22:%22Yes%22}%93″ _builder_version=”3.0.93″][/et_pb_contact_field][et_pb_contact_field field_id=”ethnicityOrigin” field_title=”Please select the category which you feel best describes your ethnic origin:” field_type=”select” select_options=”%91{%22value%22:%22White%22,%22checked%22:0,%22dragID%22:0},{%22value%22:%22Mixed%22,%22checked%22:0,%22dragID%22:1},{%22value%22:%22Asian or Asian British%22,%22checked%22:0,%22dragID%22:2},{%22value%22:%22Black or Black British%22,%22checked%22:0,%22dragID%22:3},{%22value%22:%22Other Ethnic Groups%22,%22checked%22:0,%22dragID%22:4}%93″ required_mark=”off” fullwidth_field=”on” conditional_logic=”on” conditional_logic_rules=”%91{%22field%22:%22discloseethinicity%22,%22condition%22:%22is%22,%22value%22:%22Yes%22}%93″ _builder_version=”3.0.93″][/et_pb_contact_field][et_pb_contact_field field_id=”ethnicityWhite” field_title=”Please select the category which you feel best describes your ethnic origin” field_type=”checkbox” checkbox_options=”%91{%22value%22:%22British%22,%22checked%22:0,%22dragID%22:0},{%22value%22:%22Irish%22,%22checked%22:0,%22dragID%22:1},{%22value%22:%22Any other White Background%22,%22checked%22:0,%22dragID%22:2}%93″ required_mark=”off” fullwidth_field=”on” conditional_logic=”on” conditional_logic_relation=”on” conditional_logic_rules=”%91{%22field%22:%22ethnicityorigin%22,%22condition%22:%22is%22,%22value%22:%22White%22}%93″ _builder_version=”3.0.93″][/et_pb_contact_field][et_pb_contact_field field_id=”ethnicityMixed” field_title=”Please select the category which you feel best describes your ethnic origin” field_type=”checkbox” checkbox_options=”%91{%22value%22:%22White and Black Caribbean%22,%22checked%22:0,%22dragID%22:0},{%22value%22:%22White and Black African%22,%22checked%22:0,%22dragID%22:1},{%22value%22:%22White and Asian%22,%22checked%22:0,%22dragID%22:2},{%22value%22:%22Any other Mixed Background%22,%22checked%22:0,%22dragID%22:3}%93″ required_mark=”off” fullwidth_field=”on” conditional_logic=”on” conditional_logic_relation=”on” conditional_logic_rules=”%91{%22field%22:%22ethnicityorigin%22,%22condition%22:%22is%22,%22value%22:%22Mixed%22}%93″ _builder_version=”3.0.93″][/et_pb_contact_field][et_pb_contact_field field_id=”ethnicityAsian” field_title=”Please select the category which you feel best describes your ethnic origin” field_type=”checkbox” checkbox_options=”%91{%22value%22:%22Indian%22,%22checked%22:0,%22dragID%22:0},{%22value%22:%22Pakistani%22,%22checked%22:0,%22dragID%22:1},{%22value%22:%22Bangladeshi%22,%22checked%22:0,%22dragID%22:2},{%22value%22:%22Any other Asian Background%22,%22checked%22:0,%22dragID%22:3}%93″ required_mark=”off” fullwidth_field=”on” conditional_logic=”on” conditional_logic_relation=”on” conditional_logic_rules=”%91{%22field%22:%22ethnicityorigin%22,%22condition%22:%22is%22,%22value%22:%22Asian or Asian British%22}%93″ _builder_version=”3.0.93″][/et_pb_contact_field][et_pb_contact_field field_id=”ethnicityBlack” field_title=”Please select the category which you feel best describes your ethnic origin” field_type=”checkbox” checkbox_options=”%91{%22value%22:%22Caribbean%22,%22checked%22:0,%22dragID%22:3},{%22value%22:%22African%22,%22checked%22:0,%22dragID%22:1},{%22value%22:%22Any other Black Background%22,%22checked%22:0,%22dragID%22:2}%93″ required_mark=”off” fullwidth_field=”on” conditional_logic=”on” conditional_logic_relation=”on” conditional_logic_rules=”%91{%22field%22:%22ethnicityorigin%22,%22condition%22:%22is%22,%22value%22:%22Black or Black British%22}%93″ _builder_version=”3.0.93″][/et_pb_contact_field][et_pb_contact_field field_id=”ethnicityOther” field_title=”Please select the category which you feel best describes your ethnic origin” field_type=”checkbox” checkbox_options=”%91{%22value%22:%22Chinese%22,%22checked%22:0,%22dragID%22:0},{%22value%22:%22Any other ethnic groups%22,%22checked%22:0,%22dragID%22:1}%93″ required_mark=”off” fullwidth_field=”on” conditional_logic=”on” conditional_logic_relation=”on” conditional_logic_rules=”%91{%22field%22:%22ethnicityorigin%22,%22condition%22:%22is%22,%22value%22:%22Other Ethnic Groups%22}%93″ _builder_version=”3.0.93″][/et_pb_contact_field][et_pb_contact_field field_id=”gpName” field_title=”GP Name” required_mark=”off” fullwidth_field=”on” _builder_version=”3.0.93″][/et_pb_contact_field][et_pb_contact_field field_id=”gpAddress” field_title=”GP Address” field_type=”text” required_mark=”off” fullwidth_field=”on” _builder_version=”3.0.93″][/et_pb_contact_field][et_pb_contact_field field_id=”gpPostcode” field_title=”GP Postcode” required_mark=”off” _builder_version=”3.0.93″][/et_pb_contact_field][et_pb_contact_field field_id=”gpTelephone” field_title=”GP Telephone Number” allowed_symbols=”numbers” required_mark=”off” _builder_version=”3.0.93″][/et_pb_contact_field][et_pb_contact_field field_id=”descriptionOfIssues” field_title=”DESCRIPTION OF ISSUES OR DIFFICULTIES” field_type=”text” fullwidth_field=”on” _builder_version=”3.0.93″][/et_pb_contact_field][/et_pb_contact_form][/et_pb_column][/et_pb_row][/et_pb_section]