enlightened-admissions.html

<input type="hidden" name="name_key" value="caller_name">
	<input type="hidden" name="primary_address_key" value="best_callback_number">
	<input type="hidden" name="form_id" value="">

							<div class="form-group ">
								<div class="col-xs-12">
									<input class="form-control" name="caller_name" type="input" required="" placeholder="* Caller Name">
								</div>
							</div>

							<div class="form-group ">
								<div class="col-xs-12">
									<input class="form-control" name="best_callback_number" type="phone" required="" placeholder="* Best Callback Number">
								</div>
							</div>

							<div class="form-group ">
								<div class="col-xs-12">
									<input class="form-control" name="help_seeker" type="input" required="" placeholder="* Seeking Help For.. (self, spouse, etc..)">
								</div>
							</div>

							<div class="form-group ">
								<div class="col-xs-12">
									<hr>
								</div>
							</div>


							<div class="form-group ">
								<div class="col-xs-12">
									<label for="has_insurance" style="color:#999">* Does the person struggling have insurance?</label>
									<select class="form-control" name="has_insurance" required="" placeholder="Does person struggling have insurance?">
										<option value="unselected"></option>
										<option value="yes">Yes</option>
										<option value="no">No</option>
										<option value="cashpay">Cash Pay</option>
										<option value="unsure">Unsure</option>
									</select>
								</div>
							</div>

							<div class="form-group ">
								<div class="col-xs-12">
									<input type="input" class="form-control" name="insurance_provider" placeholder="Insurance Provider">
								</div>
							</div>

							<div class="form-group ">
								<div class="col-xs-12">
									<hr>
								</div>
							</div>

							<div class="form-group ">
								<div class="col-xs-12">
									<textarea class="form-control" name="notes" placeholder="Call Notes"></textarea>
								</div>
							</div>

							<div class="form-group text-center m-t-30">
								<div class="col-xs-12">
									<button class="btn btn-custom btn-bordred btn-block waves-effect waves-light text-uppercase" type="submit">
										Submit
									</button>
								</div>
							</div>