{"id":1170,"date":"2022-06-16T21:29:39","date_gmt":"2022-06-16T21:29:39","guid":{"rendered":"https:\/\/touchingheadev.wpenginepowered.com\/fortcollins\/?page_id=1170"},"modified":"2025-11-20T14:39:35","modified_gmt":"2025-11-20T14:39:35","slug":"inquire","status":"publish","type":"page","link":"https:\/\/touchinghearts.com\/fortcollins\/inquire\/","title":{"rendered":"Inquire"},"content":{"rendered":"\n<!-- BLOCK CONTENT -->\n<section id=\"block_27a0a83ee0ca7c1e938631de7a12ea0e\" class=\"block form-block\">\n    <div class=\"container\">\n\n        \t\t\t<h2 class=\"h3\">Please use the form below to inquire for personalized care.<\/h2>\n\t\t\n        <div class=\"form-block__form\">\n            <script type=\"text\/javascript\">\n\/* <![CDATA[ *\/\nvar 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ginput_recaptchav3' data-sitekey='6LfZPp4pAAAAABsJyFAAYXmkXxS3XnAjtxApKJom' data-tabindex='0'><input id=\"input_e2b319fd2e41264554e8d155ce5222e0\" class=\"gfield_recaptcha_response\" type=\"hidden\" name=\"input_e2b319fd2e41264554e8d155ce5222e0\" value=\"\"\/><\/div>\n                        <div class='gform-body gform_body'><div id='gform_fields_2' class='gform_fields top_label form_sublabel_below description_below validation_below'><div id=\"field_2_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_2_16'>Comments<\/label><div class='ginput_container'><input name='input_16' id='input_2_16' type='text' value='' autocomplete='new-password'\/><\/div><div class='gfield_description' id='gfield_description_2_16'>This field is for validation purposes and should be left unchanged.<\/div><\/div><fieldset id=\"field_2_3\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield--input-type-checkbox 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' >Inquiring for:<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox ' id='input_2_3'><div class='gchoice gchoice_2_3_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_3.1' type='checkbox'  value='Myself'  id='choice_2_3_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_2_3_1' id='label_2_3_1' class='gform-field-label gform-field-label--type-inline'>Myself<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_2_3_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_3.2' type='checkbox'  value='Spouse'  id='choice_2_3_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_2_3_2' id='label_2_3_2' class='gform-field-label gform-field-label--type-inline'>Spouse<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_2_3_3'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_3.3' type='checkbox'  value='Parent'  id='choice_2_3_3'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_2_3_3' id='label_2_3_3' class='gform-field-label gform-field-label--type-inline'>Parent<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_2_3_4'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_3.4' type='checkbox'  value='Grandparent'  id='choice_2_3_4'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_2_3_4' id='label_2_3_4' class='gform-field-label gform-field-label--type-inline'>Grandparent<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_2_3_5'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_3.5' type='checkbox'  value='Relative or Friend'  id='choice_2_3_5'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_2_3_5' id='label_2_3_5' class='gform-field-label gform-field-label--type-inline'>Relative or Friend<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_2_5\" class=\"gfield gfield--type-name gfield--input-type-name gfield--width-full 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_text\">(Required)<\/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_2_5'>\n                            \n                            <span id='input_2_5_3_container' class='name_first gform-grid-col gform-grid-col--size-auto' >\n                                                    <input type='text' name='input_5.3' id='input_2_5_3' value=''   aria-required='true'     \/>\n                                                    <label for='input_2_5_3' class='gform-field-label gform-field-label--type-sub '>First<\/label>\n                                                <\/span>\n                            \n                            <span id='input_2_5_6_container' class='name_last gform-grid-col gform-grid-col--size-auto' >\n                                                    <input type='text' name='input_5.6' id='input_2_5_6' value=''   aria-required='true'     \/>\n                                                    <label for='input_2_5_6' class='gform-field-label gform-field-label--type-sub '>Last<\/label>\n                                                <\/span>\n                            \n                        <\/div><\/fieldset><div id=\"field_2_6\" class=\"gfield gfield--type-email gfield--input-type-email gfield--width-full 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_2_6'>Email<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/label><div class='ginput_container ginput_container_email'>\n                            <input name='input_6' id='input_2_6' type='email' value='' class='large'    aria-required=\"true\" aria-invalid=\"false\"  \/>\n                        <\/div><\/div><div id=\"field_2_7\" class=\"gfield gfield--type-phone gfield--input-type-phone gfield--width-full field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_2_7'>Phone<\/label><div class='ginput_container ginput_container_phone'><input name='input_7' id='input_2_7' type='tel' value='' class='large'    aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_2_12\" class=\"gfield gfield--type-select gfield--input-type-select gfield--width-full field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_2_12'>Preferred contact method<\/label><div class='ginput_container ginput_container_select'><select name='input_12' id='input_2_12' class='small gfield_select'     aria-invalid=\"false\" ><option value='' ><\/option><option value='Email' >Email<\/option><option value='Phone' >Phone<\/option><\/select><\/div><\/div><fieldset id=\"field_2_13\" class=\"gfield gfield--type-address gfield--input-type-address gfield--width-half gfield_contains_required field_sublabel_hidden_label gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Location of Care (Zip Code)<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/legend>    \n                    <div class='ginput_complex ginput_container has_zip ginput_container_address gform-grid-row' id='input_2_13' >\n                        <input type='hidden' class='gform_hidden' name='input_13.4' id='input_2_13_4' value=''\/><span class='ginput_right address_zip ginput_address_zip gform-grid-col' id='input_2_13_5_container' >\n                                    <input type='text' name='input_13.5' id='input_2_13_5' value=''    aria-required='true'    \/>\n                                    <label for='input_2_13_5' id='input_2_13_5_label' class='gform-field-label gform-field-label--type-sub hidden_sub_label screen-reader-text'>ZIP \/ Postal Code<\/label>\n                                <\/span><input type='hidden' class='gform_hidden' name='input_13.6' id='input_2_13_6' value='' \/>\n                    <div class='gf_clear gf_clear_complex'><\/div>\n                <\/div><\/fieldset><div id=\"field_2_9\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-half field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_2_9'>Estimated Hours per Week<\/label><div class='ginput_container ginput_container_text'><input name='input_9' id='input_2_9' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_2_11\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-full field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_2_11'>How did you hear about us?<\/label><div class='ginput_container ginput_container_text'><input name='input_11' id='input_2_11' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_2_10\" class=\"gfield gfield--type-textarea gfield--input-type-textarea gfield--width-full field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_2_10'>Question\/Comment<\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_10' id='input_2_10' class='textarea large'      aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/div><fieldset id=\"field_2_14\" class=\"gfield gfield--type-consent gfield--type-choice gfield--input-type-consent 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' >Consent (Optional)<\/legend><div class='ginput_container ginput_container_consent'><input name='input_14.1' id='input_2_14_1' type='checkbox' value='1'    aria-invalid=\"false\"   \/> <label class=\"gform-field-label gform-field-label--type-inline gfield_consent_label\" for='input_2_14_1' >By checking this box, I consent to receive transactional messages related to my account, orders, or services I have requested. These messages may include appointment reminders, order confirmations, and account notifications among others. Message frequency may vary. Message &#038; Data rates may apply.Reply HELP for help or STOP to opt-out.<\/label><input type='hidden' name='input_14.2' value='By checking this box, I consent to receive transactional messages related to my account, orders, or services I have requested. These messages may include appointment reminders, order confirmations, and account notifications among others. Message frequency may vary. Message &amp; Data rates may apply.Reply HELP for help or STOP to opt-out.' class='gform_hidden' \/><input type='hidden' name='input_14.3' value='1' class='gform_hidden' \/><\/div><\/fieldset><fieldset id=\"field_2_15\" class=\"gfield gfield--type-consent gfield--type-choice gfield--input-type-consent gfield--width-full field_sublabel_below gfield--no-description field_description_below hidden_label field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Consent<\/legend><div class='ginput_container ginput_container_consent'><input name='input_15.1' id='input_2_15_1' type='checkbox' value='1'    aria-invalid=\"false\"   \/> <label class=\"gform-field-label gform-field-label--type-inline gfield_consent_label\" for='input_2_15_1' >By checking this box, I consent to receive marketing and promotional messages, including special offers, discounts, new product updates among others. Message frequency may vary. 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