{"id":1165,"date":"2026-06-14T16:12:16","date_gmt":"2026-06-14T16:12:16","guid":{"rendered":"https:\/\/brainbloomwellness.com\/?page_id=1165"},"modified":"2026-06-15T16:04:36","modified_gmt":"2026-06-15T16:04:36","slug":"clinical_partnership_inquiry","status":"publish","type":"page","link":"https:\/\/brainbloomwellness.com\/es\/clinical_partnership_inquiry\/","title":{"rendered":"Clinical Partnership Inquiry"},"content":{"rendered":"<p>[et_pb_section fb_built=&#8221;1&#8243; theme_builder_area=&#8221;post_content&#8221; _builder_version=&#8221;4.27.6&#8243; _module_preset=&#8221;default&#8221;][et_pb_row _builder_version=&#8221;4.27.6&#8243; _module_preset=&#8221;default&#8221; theme_builder_area=&#8221;post_content&#8221;][et_pb_column _builder_version=&#8221;4.27.6&#8243; _module_preset=&#8221;default&#8221; type=&#8221;4_4&#8243; theme_builder_area=&#8221;post_content&#8221;][et_pb_heading title=&#8221;Clinical Partnership Inquiry&#8221; _builder_version=&#8221;4.27.6&#8243; _module_preset=&#8221;default&#8221; theme_builder_area=&#8221;post_content&#8221; hover_enabled=&#8221;0&#8243; sticky_enabled=&#8221;0&#8243; title_text_align=&#8221;center&#8221; module_alignment=&#8221;center&#8221;][\/et_pb_heading][\/et_pb_column][\/et_pb_row][\/et_pb_section][et_pb_section fb_built=&#8221;1&#8243; admin_label=&#8221;What I Do&#8221; _builder_version=&#8221;4.16&#8243; custom_margin=&#8221;-46px|||||&#8221; custom_padding=&#8221;54px|0px|0|0px|false|false&#8221; global_colors_info=&#8221;{}&#8221; theme_builder_area=&#8221;post_content&#8221;][et_pb_row _builder_version=&#8221;4.27.6&#8243; _module_preset=&#8221;default&#8221; theme_builder_area=&#8221;post_content&#8221; custom_padding=&#8221;5px|||||&#8221; min_height=&#8221;2819.4px&#8221; hover_enabled=&#8221;0&#8243; sticky_enabled=&#8221;0&#8243;][et_pb_column _builder_version=&#8221;4.27.6&#8243; _module_preset=&#8221;default&#8221; type=&#8221;4_4&#8243; theme_builder_area=&#8221;post_content&#8221; hover_enabled=&#8221;0&#8243; sticky_enabled=&#8221;0&#8243; custom_padding=&#8221;|||275px|false|false&#8221;][et_pb_code _builder_version=&#8221;4.27.6&#8243; _module_preset=&#8221;default&#8221; theme_builder_area=&#8221;post_content&#8221; hover_enabled=&#8221;0&#8243; sticky_enabled=&#8221;0&#8243; module_alignment=&#8221;center&#8221;]<style id=\"wpforms-css-vars-1153\">\n\t\t\t\t#wpforms-1153 {\n\t\t\t\t--wpforms-container-padding: 0px;\n--wpforms-container-border-width: 1px;\n--wpforms-container-border-radius: 3px;\n--wpforms-background-color: rgba(0, 0, 0, 0);\n--wpforms-field-size-input-height: 43px;\n--wpforms-field-size-input-spacing: 15px;\n--wpforms-field-size-font-size: 16px;\n--wpforms-field-size-line-height: 19px;\n--wpforms-field-size-padding-h: 14px;\n--wpforms-field-size-checkbox-size: 16px;\n--wpforms-field-size-sublabel-spacing: 5px;\n--wpforms-field-size-icon-size: 1;\n--wpforms-label-size-font-size: 16px;\n--wpforms-label-size-line-height: 19px;\n--wpforms-label-size-sublabel-font-size: 14px;\n--wpforms-label-size-sublabel-line-height: 17px;\n--wpforms-button-size-font-size: 17px;\n--wpforms-button-size-height: 41px;\n--wpforms-button-size-padding-h: 15px;\n--wpforms-button-size-margin-top: 10px;\n--wpforms-container-shadow-size-box-shadow: none;\n\t\t\t}\n\t\t\t<\/style><div class=\"wpforms-container wpforms-container-full wpforms-render-modern\" id=\"wpforms-1153\"><form id=\"wpforms-form-1153\" class=\"wpforms-validate wpforms-form wpforms-ajax-form\" data-formid=\"1153\" method=\"post\" enctype=\"multipart\/form-data\" action=\"\/es\/wp-json\/wp\/v2\/pages\/1165\" data-token=\"041a450bd404f27a85e51c1d1e1f92e0\" data-token-time=\"1781990242\"><noscript class=\"wpforms-error-noscript\">Por favor, activa JavaScript en tu navegador para completar este formulario.<\/noscript><div id=\"wpforms-error-noscript\" style=\"display: none;\">Por favor, activa JavaScript en tu navegador para completar este formulario.<\/div><div class=\"wpforms-field-container\"><div id=\"wpforms-1153-field_1-container\" class=\"wpforms-field wpforms-field-name\" data-field-id=\"1\"><fieldset><legend class=\"wpforms-field-label\">Name <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/legend><div class=\"wpforms-field-row wpforms-field-medium\"><div class=\"wpforms-field-row-block wpforms-first wpforms-one-half\"><input type=\"text\" id=\"wpforms-1153-field_1\" class=\"wpforms-field-name-first wpforms-field-required\" name=\"wpforms[fields][1][first]\" aria-errormessage=\"wpforms-1153-field_1-error\" required><label for=\"wpforms-1153-field_1\" class=\"wpforms-field-sublabel after\">Nombre<\/label><\/div><div class=\"wpforms-field-row-block wpforms-one-half\"><input type=\"text\" id=\"wpforms-1153-field_1-last\" class=\"wpforms-field-name-last wpforms-field-required\" name=\"wpforms[fields][1][last]\" aria-errormessage=\"wpforms-1153-field_1-last-error\" required><label for=\"wpforms-1153-field_1-last\" class=\"wpforms-field-sublabel after\">Apellidos<\/label><\/div><\/div><\/fieldset><\/div><div id=\"wpforms-1153-field_2-container\" class=\"wpforms-field wpforms-field-text\" data-field-id=\"2\"><label class=\"wpforms-field-label\" for=\"wpforms-1153-field_2\">Clinic\/Practice Name <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/label><input type=\"text\" id=\"wpforms-1153-field_2\" class=\"wpforms-field-medium wpforms-field-required\" name=\"wpforms[fields][2]\" aria-errormessage=\"wpforms-1153-field_2-error\" required><\/div><div id=\"wpforms-1153-field_3-container\" class=\"wpforms-field wpforms-field-text\" data-field-id=\"3\"><label class=\"wpforms-field-label\" for=\"wpforms-1153-field_3\">Your Title\/Role <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/label><input type=\"text\" id=\"wpforms-1153-field_3\" class=\"wpforms-field-medium wpforms-field-required\" name=\"wpforms[fields][3]\" aria-errormessage=\"wpforms-1153-field_3-error\" required><\/div><div id=\"wpforms-1153-field_5-container\" class=\"wpforms-field wpforms-field-number\" data-field-id=\"5\"><label class=\"wpforms-field-label\" for=\"wpforms-1153-field_5\">Phone Number <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/label><input type=\"number\" id=\"wpforms-1153-field_5\" class=\"wpforms-field-medium wpforms-field-required\" name=\"wpforms[fields][5]\" step=\"any\" aria-errormessage=\"wpforms-1153-field_5-error\" required><\/div><div id=\"wpforms-1153-field_6-container\" class=\"wpforms-field wpforms-field-email\" data-field-id=\"6\"><label class=\"wpforms-field-label\" for=\"wpforms-1153-field_6\">Email <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/label><input type=\"email\" id=\"wpforms-1153-field_6\" class=\"wpforms-field-medium wpforms-field-required\" name=\"wpforms[fields][6]\" spellcheck=\"false\" aria-errormessage=\"wpforms-1153-field_6-error\" required><\/div><div id=\"wpforms-1153-field_8-container\" class=\"wpforms-field wpforms-field-text\" data-field-id=\"8\"><label class=\"wpforms-field-label\" for=\"wpforms-1153-field_8\">Website <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/label><input type=\"text\" id=\"wpforms-1153-field_8\" class=\"wpforms-field-medium wpforms-field-required\" name=\"wpforms[fields][8]\" aria-errormessage=\"wpforms-1153-field_8-error\" required><\/div><div id=\"wpforms-1153-field_9-container\" class=\"wpforms-field wpforms-field-text\" data-field-id=\"9\"><label class=\"wpforms-field-label\" for=\"wpforms-1153-field_9\">City\/State <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/label><input type=\"text\" id=\"wpforms-1153-field_9\" class=\"wpforms-field-medium wpforms-field-required\" name=\"wpforms[fields][9]\" aria-errormessage=\"wpforms-1153-field_9-error\" required><\/div>\t\t<div id=\"wpforms-1153-field_4-container\"\n\t\t\tclass=\"wpforms-field wpforms-field-text\"\n\t\t\tdata-field-type=\"text\"\n\t\t\tdata-field-id=\"4\"\n\t\t\t>\n\t\t\t<label class=\"wpforms-field-label\" for=\"wpforms-1153-field_4\" >your Phone City\/State<\/label>\n\t\t\t<input type=\"text\" id=\"wpforms-1153-field_4\" class=\"wpforms-field-medium\" name=\"wpforms[fields][4]\" >\n\t\t<\/div>\n\t\t<div id=\"wpforms-1153-field_11-container\" class=\"wpforms-field wpforms-field-select wpforms-field-select-style-classic\" data-field-id=\"11\"><label class=\"wpforms-field-label\" for=\"wpforms-1153-field_11\">Type of Clinic <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/label><select id=\"wpforms-1153-field_11\" class=\"wpforms-field-medium wpforms-field-required\" name=\"wpforms[fields][11]\" required=\"required\"><option value=\"\" class=\"placeholder\" disabled  selected='selected'>--- Select Choice ---<\/option><option value=\"Chiropractic\"  class=\"choice-1 depth-1\"  >Chiropractic<\/option><option value=\"Naturopathic\"  class=\"choice-2 depth-1\"  >Naturopathic<\/option><option value=\"Integrative Medicine\"  class=\"choice-3 depth-1\"  >Integrative Medicine<\/option><option value=\"Functional Medicine\"  class=\"choice-4 depth-1\"  >Functional Medicine<\/option><option value=\"Sleep Disorder Clinic\"  class=\"choice-5 depth-1\"  >Sleep Disorder Clinic<\/option><option value=\"ABA Clinic\"  class=\"choice-6 depth-1\"  >ABA Clinic<\/option><option value=\"Rehab Clinics (Addiction)\"  class=\"choice-8 depth-1\"  >Rehab Clinics (Addiction)<\/option><option value=\"Sleep Disorder Center\"  class=\"choice-9 depth-1\"  >Sleep Disorder Center<\/option><option value=\"Trauma Recovery Center\"  class=\"choice-10 depth-1\"  >Trauma Recovery Center<\/option><option value=\"Brain Health Center\"  class=\"choice-11 depth-1\"  >Brain Health Center<\/option><option value=\"Memory Care Facility\"  class=\"choice-12 depth-1\"  >Memory Care Facility<\/option><\/select><\/div><div id=\"wpforms-1153-field_12-container\" class=\"wpforms-field wpforms-field-textarea\" data-field-id=\"12\"><label class=\"wpforms-field-label\" for=\"wpforms-1153-field_12\">Other type of Clinics (please list below)<\/label><textarea id=\"wpforms-1153-field_12\" class=\"wpforms-field-medium\" name=\"wpforms[fields][12]\" aria-errormessage=\"wpforms-1153-field_12-error\" ><\/textarea><\/div><div id=\"wpforms-1153-field_13-container\" class=\"wpforms-field wpforms-field-select wpforms-field-select-style-classic\" data-field-id=\"13\"><label class=\"wpforms-field-label\" for=\"wpforms-1153-field_13\">Number of Practitioners<\/label><select id=\"wpforms-1153-field_13\" class=\"wpforms-field-medium\" name=\"wpforms[fields][13]\"><option value=\"Just Me\"  class=\"choice-1 depth-1\"  >Just Me<\/option><option value=\"2-5\"  class=\"choice-2 depth-1\"  >2-5<\/option><option value=\"6-10\"  class=\"choice-3 depth-1\"  >6-10<\/option><option value=\"10+\"  class=\"choice-4 depth-1\"  >10+<\/option><\/select><\/div><div id=\"wpforms-1153-field_14-container\" class=\"wpforms-field wpforms-field-select wpforms-field-select-style-classic\" data-field-id=\"14\"><label class=\"wpforms-field-label\" for=\"wpforms-1153-field_14\">Monthly Client Volume<\/label><select id=\"wpforms-1153-field_14\" class=\"wpforms-field-medium\" name=\"wpforms[fields][14]\"><option value=\"Under 50\"  class=\"choice-1 depth-1\"  >Under 50<\/option><option value=\"50-100\"  class=\"choice-2 depth-1\"  >50-100<\/option><option value=\"100-200\"  class=\"choice-3 depth-1\"  >100-200<\/option><option value=\"200+\"  class=\"choice-4 depth-1\"  >200+<\/option><\/select><\/div><div id=\"wpforms-1153-field_15-container\" class=\"wpforms-field wpforms-field-checkbox\" data-field-id=\"15\"><fieldset><legend class=\"wpforms-field-label\">Services Interest<\/legend><ul id=\"wpforms-1153-field_15\"><li class=\"choice-5 depth-1\"><input type=\"checkbox\" id=\"wpforms-1153-field_15_5\" name=\"wpforms[fields][15][]\" value=\"Anti-Agin &amp; Skin Rejuvenation\" aria-errormessage=\"wpforms-1153-field_15_5-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-1153-field_15_5\">Anti-Agin &amp; Skin Rejuvenation<\/label><\/li><li class=\"choice-11 depth-1\"><input type=\"checkbox\" id=\"wpforms-1153-field_15_11\" name=\"wpforms[fields][15][]\" value=\"Autism &amp; Developmental Support\" aria-errormessage=\"wpforms-1153-field_15_11-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-1153-field_15_11\">Autism &amp; Developmental Support<\/label><\/li><li class=\"choice-1 depth-1\"><input type=\"checkbox\" id=\"wpforms-1153-field_15_1\" name=\"wpforms[fields][15][]\" value=\"Brain &amp; Nervous System Optimization\" aria-errormessage=\"wpforms-1153-field_15_1-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-1153-field_15_1\">Brain &amp; Nervous System Optimization<\/label><\/li><li class=\"choice-10 depth-1\"><input type=\"checkbox\" id=\"wpforms-1153-field_15_10\" name=\"wpforms[fields][15][]\" value=\"Corporate Stress &amp; Burnout Prevention\" aria-errormessage=\"wpforms-1153-field_15_10-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-1153-field_15_10\">Corporate Stress &amp; Burnout Prevention<\/label><\/li><li class=\"choice-4 depth-1\"><input type=\"checkbox\" id=\"wpforms-1153-field_15_4\" name=\"wpforms[fields][15][]\" value=\"Detox &amp; Cellular Restoration\" aria-errormessage=\"wpforms-1153-field_15_4-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-1153-field_15_4\">Detox &amp; Cellular Restoration<\/label><\/li><li class=\"choice-6 depth-1\"><input type=\"checkbox\" id=\"wpforms-1153-field_15_6\" name=\"wpforms[fields][15][]\" value=\"Frequency &amp; Biofeedback Medicine\" aria-errormessage=\"wpforms-1153-field_15_6-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-1153-field_15_6\">Frequency &amp; Biofeedback Medicine<\/label><\/li><li class=\"choice-7 depth-1\"><input type=\"checkbox\" id=\"wpforms-1153-field_15_7\" name=\"wpforms[fields][15][]\" value=\"Holistic &amp; Quantum Nutrition\" aria-errormessage=\"wpforms-1153-field_15_7-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-1153-field_15_7\">Holistic &amp; Quantum Nutrition<\/label><\/li><li class=\"choice-8 depth-1\"><input type=\"checkbox\" id=\"wpforms-1153-field_15_8\" name=\"wpforms[fields][15][]\" value=\"Life &amp; Mindset Coaching\" aria-errormessage=\"wpforms-1153-field_15_8-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-1153-field_15_8\">Life &amp; Mindset Coaching<\/label><\/li><li class=\"choice-2 depth-1\"><input type=\"checkbox\" id=\"wpforms-1153-field_15_2\" name=\"wpforms[fields][15][]\" value=\"Mental Health &amp; Emotional Wellness\" aria-errormessage=\"wpforms-1153-field_15_2-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-1153-field_15_2\">Mental Health &amp; Emotional Wellness<\/label><\/li><li class=\"choice-9 depth-1\"><input type=\"checkbox\" id=\"wpforms-1153-field_15_9\" name=\"wpforms[fields][15][]\" value=\"Ozone Therapy (PMA Members Only)\" aria-errormessage=\"wpforms-1153-field_15_9-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-1153-field_15_9\">Ozone Therapy (PMA Members Only)<\/label><\/li><li class=\"choice-3 depth-1\"><input type=\"checkbox\" id=\"wpforms-1153-field_15_3\" name=\"wpforms[fields][15][]\" value=\"Pain Relief &amp; Physical Recovery\" aria-errormessage=\"wpforms-1153-field_15_3-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-1153-field_15_3\">Pain Relief &amp; Physical Recovery<\/label><\/li><li class=\"choice-12 depth-1\"><input type=\"checkbox\" id=\"wpforms-1153-field_15_12\" name=\"wpforms[fields][15][]\" value=\"Full Service Partnership\" aria-errormessage=\"wpforms-1153-field_15_12-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-1153-field_15_12\">Full Service Partnership<\/label><\/li><\/ul><\/fieldset><\/div><div id=\"wpforms-1153-field_16-container\" class=\"wpforms-field wpforms-field-radio\" data-field-id=\"16\"><fieldset><legend class=\"wpforms-field-label\">Frequency<\/legend><ul id=\"wpforms-1153-field_16\"><li class=\"choice-4 depth-1\"><input type=\"radio\" id=\"wpforms-1153-field_16_4\" name=\"wpforms[fields][16]\" value=\"Flexible\/As Needed\" aria-errormessage=\"wpforms-1153-field_16_4-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-1153-field_16_4\">Flexible\/As Needed<\/label><\/li><li class=\"choice-6 depth-1\"><input type=\"radio\" id=\"wpforms-1153-field_16_6\" name=\"wpforms[fields][16]\" value=\"2-3 times per week\" aria-errormessage=\"wpforms-1153-field_16_6-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-1153-field_16_6\">2-3 times per week<\/label><\/li><li class=\"choice-5 depth-1\"><input type=\"radio\" id=\"wpforms-1153-field_16_5\" name=\"wpforms[fields][16]\" value=\"Daily\" aria-errormessage=\"wpforms-1153-field_16_5-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-1153-field_16_5\">Daily<\/label><\/li><li class=\"choice-1 depth-1\"><input type=\"radio\" id=\"wpforms-1153-field_16_1\" name=\"wpforms[fields][16]\" value=\"Weekly\" aria-errormessage=\"wpforms-1153-field_16_1-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-1153-field_16_1\">Weekly<\/label><\/li><li class=\"choice-2 depth-1\"><input type=\"radio\" id=\"wpforms-1153-field_16_2\" name=\"wpforms[fields][16]\" value=\"Bi-weekly\" aria-errormessage=\"wpforms-1153-field_16_2-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-1153-field_16_2\">Bi-weekly<\/label><\/li><li class=\"choice-3 depth-1\"><input type=\"radio\" id=\"wpforms-1153-field_16_3\" name=\"wpforms[fields][16]\" value=\"Monthly\" aria-errormessage=\"wpforms-1153-field_16_3-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-1153-field_16_3\">Monthly<\/label><\/li><li class=\"choice-7 depth-1\"><input type=\"radio\" id=\"wpforms-1153-field_16_7\" name=\"wpforms[fields][16]\" value=\"Quarterly\" aria-errormessage=\"wpforms-1153-field_16_7-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-1153-field_16_7\">Quarterly<\/label><\/li><\/ul><\/fieldset><\/div><div id=\"wpforms-1153-field_17-container\" class=\"wpforms-field wpforms-field-radio\" data-field-id=\"17\"><fieldset><legend class=\"wpforms-field-label\">Treatment Room<\/legend><ul id=\"wpforms-1153-field_17\"><li class=\"choice-1 depth-1\"><input type=\"radio\" id=\"wpforms-1153-field_17_1\" name=\"wpforms[fields][17]\" value=\"Yes we have a dedicated treatment room\" aria-errormessage=\"wpforms-1153-field_17_1-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-1153-field_17_1\">Yes we have a dedicated treatment room<\/label><\/li><li class=\"choice-2 depth-1\"><input type=\"radio\" id=\"wpforms-1153-field_17_2\" name=\"wpforms[fields][17]\" value=\"We can arrange a space\" aria-errormessage=\"wpforms-1153-field_17_2-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-1153-field_17_2\">We can arrange a space<\/label><\/li><li class=\"choice-3 depth-1\"><input type=\"radio\" id=\"wpforms-1153-field_17_3\" name=\"wpforms[fields][17]\" value=\"No - Sessions would need to be mobile\" aria-errormessage=\"wpforms-1153-field_17_3-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-1153-field_17_3\">No - Sessions would need to be mobile<\/label><\/li><\/ul><\/fieldset><\/div><div id=\"wpforms-1153-field_18-container\" class=\"wpforms-field wpforms-field-checkbox\" data-field-id=\"18\"><fieldset><legend class=\"wpforms-field-label\">Compensation Preference<\/legend><ul id=\"wpforms-1153-field_18\"><li class=\"choice-1 depth-1\"><input type=\"checkbox\" id=\"wpforms-1153-field_18_1\" name=\"wpforms[fields][18][]\" value=\"Room rental arrangement\" aria-errormessage=\"wpforms-1153-field_18_1-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-1153-field_18_1\">Room rental arrangement<\/label><\/li><li class=\"choice-2 depth-1\"><input type=\"checkbox\" id=\"wpforms-1153-field_18_2\" name=\"wpforms[fields][18][]\" value=\"Revenu share percentage\" aria-errormessage=\"wpforms-1153-field_18_2-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-1153-field_18_2\">Revenu share percentage<\/label><\/li><li class=\"choice-3 depth-1\"><input type=\"checkbox\" id=\"wpforms-1153-field_18_3\" name=\"wpforms[fields][18][]\" value=\"Per session fee\" aria-errormessage=\"wpforms-1153-field_18_3-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-1153-field_18_3\">Per session fee<\/label><\/li><li class=\"choice-4 depth-1\"><input type=\"checkbox\" id=\"wpforms-1153-field_18_4\" name=\"wpforms[fields][18][]\" value=\"Retainer agreement\" aria-errormessage=\"wpforms-1153-field_18_4-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-1153-field_18_4\">Retainer agreement<\/label><\/li><li class=\"choice-5 depth-1\"><input type=\"checkbox\" id=\"wpforms-1153-field_18_5\" name=\"wpforms[fields][18][]\" value=\"Open to discussion\" aria-errormessage=\"wpforms-1153-field_18_5-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-1153-field_18_5\">Open to discussion<\/label><\/li><\/ul><\/fieldset><\/div><div id=\"wpforms-1153-field_19-container\" class=\"wpforms-field wpforms-field-textarea\" data-field-id=\"19\"><label class=\"wpforms-field-label\" for=\"wpforms-1153-field_19\">Tell us more about your practice and what you&#039;re looking for. <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/label><textarea id=\"wpforms-1153-field_19\" class=\"wpforms-field-medium wpforms-field-required\" name=\"wpforms[fields][19]\" aria-errormessage=\"wpforms-1153-field_19-error\" required><\/textarea><\/div><script>\n\t\t\t\t( function() {\n\t\t\t\t\tconst style = document.createElement( 'style' );\n\t\t\t\t\tstyle.appendChild( document.createTextNode( '#wpforms-1153-field_4-container { position: absolute !important; overflow: hidden !important; display: inline !important; height: 1px !important; width: 1px !important; z-index: -1000 !important; padding: 0 !important; } #wpforms-1153-field_4-container input { visibility: hidden; } #wpforms-conversational-form-page #wpforms-1153-field_4-container label { counter-increment: none; }' ) );\n\t\t\t\t\tdocument.head.appendChild( style );\n\t\t\t\t\tdocument.currentScript?.remove();\n\t\t\t\t} )();\n\t\t\t<\/script><\/div><!-- .wpforms-field-container --><div class=\"wpforms-submit-container\" ><input type=\"hidden\" name=\"wpforms[id]\" value=\"1153\"><input type=\"hidden\" name=\"page_title\" value=\"\"><input type=\"hidden\" name=\"page_url\" 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17px;\n--wpforms-button-size-height: 41px;\n--wpforms-button-size-padding-h: 15px;\n--wpforms-button-size-margin-top: 10px;\n--wpforms-container-shadow-size-box-shadow: none;\n\t\t\t}\n\t\t\t<\/style><div class=\"wpforms-container wpforms-container-full wpforms-render-modern\" id=\"wpforms-1153\"><form id=\"wpforms-form-1153\" class=\"wpforms-validate wpforms-form wpforms-ajax-form\" data-formid=\"1153\" method=\"post\" enctype=\"multipart\/form-data\" action=\"\/es\/wp-json\/wp\/v2\/pages\/1165\" data-token=\"041a450bd404f27a85e51c1d1e1f92e0\" data-token-time=\"1781990242\"><noscript class=\"wpforms-error-noscript\">Por favor, activa JavaScript en tu navegador para completar este formulario.<\/noscript><div id=\"wpforms-error-noscript\" style=\"display: none;\">Por favor, activa JavaScript en tu navegador para completar este formulario.<\/div><div class=\"wpforms-field-container\"><div id=\"wpforms-1153-field_1-container\" class=\"wpforms-field wpforms-field-name\" data-field-id=\"1\"><fieldset><legend class=\"wpforms-field-label\">Name <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/legend><div class=\"wpforms-field-row wpforms-field-medium\"><div class=\"wpforms-field-row-block wpforms-first wpforms-one-half\"><input type=\"text\" id=\"wpforms-1153-field_1\" class=\"wpforms-field-name-first wpforms-field-required\" name=\"wpforms[fields][1][first]\" aria-errormessage=\"wpforms-1153-field_1-error\" required><label for=\"wpforms-1153-field_1\" class=\"wpforms-field-sublabel after\">Nombre<\/label><\/div><div class=\"wpforms-field-row-block wpforms-one-half\"><input type=\"text\" id=\"wpforms-1153-field_1-last\" class=\"wpforms-field-name-last wpforms-field-required\" name=\"wpforms[fields][1][last]\" aria-errormessage=\"wpforms-1153-field_1-last-error\" required><label for=\"wpforms-1153-field_1-last\" class=\"wpforms-field-sublabel after\">Apellidos<\/label><\/div><\/div><\/fieldset><\/div><div id=\"wpforms-1153-field_2-container\" class=\"wpforms-field wpforms-field-text\" data-field-id=\"2\"><label class=\"wpforms-field-label\" for=\"wpforms-1153-field_2\">Clinic\/Practice Name <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/label><input type=\"text\" id=\"wpforms-1153-field_2\" class=\"wpforms-field-medium wpforms-field-required\" name=\"wpforms[fields][2]\" aria-errormessage=\"wpforms-1153-field_2-error\" required><\/div><div id=\"wpforms-1153-field_3-container\" class=\"wpforms-field wpforms-field-text\" data-field-id=\"3\"><label class=\"wpforms-field-label\" for=\"wpforms-1153-field_3\">Your Title\/Role <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/label><input type=\"text\" id=\"wpforms-1153-field_3\" class=\"wpforms-field-medium wpforms-field-required\" name=\"wpforms[fields][3]\" aria-errormessage=\"wpforms-1153-field_3-error\" required><\/div><div id=\"wpforms-1153-field_5-container\" class=\"wpforms-field wpforms-field-number\" data-field-id=\"5\"><label class=\"wpforms-field-label\" for=\"wpforms-1153-field_5\">Phone Number <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/label><input type=\"number\" id=\"wpforms-1153-field_5\" class=\"wpforms-field-medium wpforms-field-required\" name=\"wpforms[fields][5]\" step=\"any\" aria-errormessage=\"wpforms-1153-field_5-error\" required><\/div><div id=\"wpforms-1153-field_6-container\" class=\"wpforms-field wpforms-field-email\" data-field-id=\"6\"><label class=\"wpforms-field-label\" for=\"wpforms-1153-field_6\">Email <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/label><input type=\"email\" id=\"wpforms-1153-field_6\" class=\"wpforms-field-medium wpforms-field-required\" name=\"wpforms[fields][6]\" spellcheck=\"false\" aria-errormessage=\"wpforms-1153-field_6-error\" required><\/div><div id=\"wpforms-1153-field_8-container\" class=\"wpforms-field wpforms-field-text\" data-field-id=\"8\"><label class=\"wpforms-field-label\" for=\"wpforms-1153-field_8\">Website <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/label><input type=\"text\" id=\"wpforms-1153-field_8\" class=\"wpforms-field-medium wpforms-field-required\" name=\"wpforms[fields][8]\" aria-errormessage=\"wpforms-1153-field_8-error\" required><\/div><div id=\"wpforms-1153-field_9-container\" class=\"wpforms-field wpforms-field-text\" data-field-id=\"9\"><label class=\"wpforms-field-label\" for=\"wpforms-1153-field_9\">City\/State <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/label><input type=\"text\" id=\"wpforms-1153-field_9\" class=\"wpforms-field-medium wpforms-field-required\" name=\"wpforms[fields][9]\" aria-errormessage=\"wpforms-1153-field_9-error\" required><\/div>\t\t<div id=\"wpforms-1153-field_4-container\"\n\t\t\tclass=\"wpforms-field wpforms-field-text\"\n\t\t\tdata-field-type=\"text\"\n\t\t\tdata-field-id=\"4\"\n\t\t\t>\n\t\t\t<label class=\"wpforms-field-label\" for=\"wpforms-1153-field_4\" >Number Other Client<\/label>\n\t\t\t<input type=\"text\" id=\"wpforms-1153-field_4\" class=\"wpforms-field-medium\" name=\"wpforms[fields][4]\" >\n\t\t<\/div>\n\t\t<div id=\"wpforms-1153-field_11-container\" class=\"wpforms-field wpforms-field-select wpforms-field-select-style-classic\" data-field-id=\"11\"><label class=\"wpforms-field-label\" for=\"wpforms-1153-field_11\">Type of Clinic <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/label><select id=\"wpforms-1153-field_11\" class=\"wpforms-field-medium wpforms-field-required\" name=\"wpforms[fields][11]\" required=\"required\"><option value=\"\" class=\"placeholder\" disabled  selected='selected'>--- Select Choice ---<\/option><option value=\"Chiropractic\"  class=\"choice-1 depth-1\"  >Chiropractic<\/option><option value=\"Naturopathic\"  class=\"choice-2 depth-1\"  >Naturopathic<\/option><option value=\"Integrative Medicine\"  class=\"choice-3 depth-1\"  >Integrative Medicine<\/option><option value=\"Functional Medicine\"  class=\"choice-4 depth-1\"  >Functional Medicine<\/option><option value=\"Sleep Disorder Clinic\"  class=\"choice-5 depth-1\"  >Sleep Disorder Clinic<\/option><option value=\"ABA Clinic\"  class=\"choice-6 depth-1\"  >ABA Clinic<\/option><option value=\"Rehab Clinics (Addiction)\"  class=\"choice-8 depth-1\"  >Rehab Clinics (Addiction)<\/option><option value=\"Sleep Disorder Center\"  class=\"choice-9 depth-1\"  >Sleep Disorder Center<\/option><option value=\"Trauma Recovery Center\"  class=\"choice-10 depth-1\"  >Trauma Recovery Center<\/option><option value=\"Brain Health Center\"  class=\"choice-11 depth-1\"  >Brain Health Center<\/option><option value=\"Memory Care Facility\"  class=\"choice-12 depth-1\"  >Memory Care Facility<\/option><\/select><\/div><div id=\"wpforms-1153-field_12-container\" class=\"wpforms-field wpforms-field-textarea\" data-field-id=\"12\"><label class=\"wpforms-field-label\" for=\"wpforms-1153-field_12\">Other type of Clinics (please list below)<\/label><textarea id=\"wpforms-1153-field_12\" class=\"wpforms-field-medium\" name=\"wpforms[fields][12]\" aria-errormessage=\"wpforms-1153-field_12-error\" ><\/textarea><\/div><div id=\"wpforms-1153-field_13-container\" class=\"wpforms-field wpforms-field-select wpforms-field-select-style-classic\" data-field-id=\"13\"><label class=\"wpforms-field-label\" for=\"wpforms-1153-field_13\">Number of Practitioners<\/label><select id=\"wpforms-1153-field_13\" class=\"wpforms-field-medium\" name=\"wpforms[fields][13]\"><option value=\"Just Me\"  class=\"choice-1 depth-1\"  >Just Me<\/option><option value=\"2-5\"  class=\"choice-2 depth-1\"  >2-5<\/option><option value=\"6-10\"  class=\"choice-3 depth-1\"  >6-10<\/option><option value=\"10+\"  class=\"choice-4 depth-1\"  >10+<\/option><\/select><\/div><div id=\"wpforms-1153-field_14-container\" class=\"wpforms-field wpforms-field-select wpforms-field-select-style-classic\" data-field-id=\"14\"><label class=\"wpforms-field-label\" for=\"wpforms-1153-field_14\">Monthly Client Volume<\/label><select id=\"wpforms-1153-field_14\" class=\"wpforms-field-medium\" name=\"wpforms[fields][14]\"><option value=\"Under 50\"  class=\"choice-1 depth-1\"  >Under 50<\/option><option value=\"50-100\"  class=\"choice-2 depth-1\"  >50-100<\/option><option value=\"100-200\"  class=\"choice-3 depth-1\"  >100-200<\/option><option value=\"200+\"  class=\"choice-4 depth-1\"  >200+<\/option><\/select><\/div><div id=\"wpforms-1153-field_15-container\" class=\"wpforms-field wpforms-field-checkbox\" data-field-id=\"15\"><fieldset><legend class=\"wpforms-field-label\">Services Interest<\/legend><ul id=\"wpforms-1153-field_15\"><li class=\"choice-5 depth-1\"><input type=\"checkbox\" id=\"wpforms-1153-field_15_5\" name=\"wpforms[fields][15][]\" value=\"Anti-Agin &amp; Skin Rejuvenation\" aria-errormessage=\"wpforms-1153-field_15_5-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-1153-field_15_5\">Anti-Agin &amp; Skin Rejuvenation<\/label><\/li><li class=\"choice-11 depth-1\"><input type=\"checkbox\" id=\"wpforms-1153-field_15_11\" name=\"wpforms[fields][15][]\" value=\"Autism &amp; Developmental Support\" aria-errormessage=\"wpforms-1153-field_15_11-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-1153-field_15_11\">Autism &amp; Developmental Support<\/label><\/li><li class=\"choice-1 depth-1\"><input type=\"checkbox\" id=\"wpforms-1153-field_15_1\" name=\"wpforms[fields][15][]\" value=\"Brain &amp; Nervous System Optimization\" aria-errormessage=\"wpforms-1153-field_15_1-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-1153-field_15_1\">Brain &amp; Nervous System Optimization<\/label><\/li><li class=\"choice-10 depth-1\"><input type=\"checkbox\" id=\"wpforms-1153-field_15_10\" name=\"wpforms[fields][15][]\" value=\"Corporate Stress &amp; Burnout Prevention\" aria-errormessage=\"wpforms-1153-field_15_10-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-1153-field_15_10\">Corporate Stress &amp; Burnout Prevention<\/label><\/li><li class=\"choice-4 depth-1\"><input type=\"checkbox\" id=\"wpforms-1153-field_15_4\" name=\"wpforms[fields][15][]\" value=\"Detox &amp; Cellular Restoration\" aria-errormessage=\"wpforms-1153-field_15_4-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-1153-field_15_4\">Detox &amp; Cellular Restoration<\/label><\/li><li class=\"choice-6 depth-1\"><input type=\"checkbox\" id=\"wpforms-1153-field_15_6\" name=\"wpforms[fields][15][]\" value=\"Frequency &amp; Biofeedback Medicine\" aria-errormessage=\"wpforms-1153-field_15_6-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-1153-field_15_6\">Frequency &amp; Biofeedback Medicine<\/label><\/li><li class=\"choice-7 depth-1\"><input type=\"checkbox\" id=\"wpforms-1153-field_15_7\" name=\"wpforms[fields][15][]\" value=\"Holistic &amp; Quantum Nutrition\" aria-errormessage=\"wpforms-1153-field_15_7-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-1153-field_15_7\">Holistic &amp; Quantum Nutrition<\/label><\/li><li class=\"choice-8 depth-1\"><input type=\"checkbox\" id=\"wpforms-1153-field_15_8\" name=\"wpforms[fields][15][]\" value=\"Life &amp; Mindset Coaching\" aria-errormessage=\"wpforms-1153-field_15_8-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-1153-field_15_8\">Life &amp; Mindset Coaching<\/label><\/li><li class=\"choice-2 depth-1\"><input type=\"checkbox\" id=\"wpforms-1153-field_15_2\" name=\"wpforms[fields][15][]\" value=\"Mental Health &amp; Emotional Wellness\" aria-errormessage=\"wpforms-1153-field_15_2-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-1153-field_15_2\">Mental Health &amp; Emotional Wellness<\/label><\/li><li class=\"choice-9 depth-1\"><input type=\"checkbox\" id=\"wpforms-1153-field_15_9\" name=\"wpforms[fields][15][]\" value=\"Ozone Therapy (PMA Members Only)\" aria-errormessage=\"wpforms-1153-field_15_9-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-1153-field_15_9\">Ozone Therapy (PMA Members Only)<\/label><\/li><li class=\"choice-3 depth-1\"><input type=\"checkbox\" id=\"wpforms-1153-field_15_3\" name=\"wpforms[fields][15][]\" value=\"Pain Relief &amp; Physical Recovery\" aria-errormessage=\"wpforms-1153-field_15_3-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-1153-field_15_3\">Pain Relief &amp; Physical Recovery<\/label><\/li><li class=\"choice-12 depth-1\"><input type=\"checkbox\" id=\"wpforms-1153-field_15_12\" name=\"wpforms[fields][15][]\" value=\"Full Service Partnership\" aria-errormessage=\"wpforms-1153-field_15_12-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-1153-field_15_12\">Full Service Partnership<\/label><\/li><\/ul><\/fieldset><\/div><div id=\"wpforms-1153-field_16-container\" class=\"wpforms-field wpforms-field-radio\" data-field-id=\"16\"><fieldset><legend class=\"wpforms-field-label\">Frequency<\/legend><ul id=\"wpforms-1153-field_16\"><li class=\"choice-4 depth-1\"><input type=\"radio\" id=\"wpforms-1153-field_16_4\" name=\"wpforms[fields][16]\" value=\"Flexible\/As Needed\" aria-errormessage=\"wpforms-1153-field_16_4-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-1153-field_16_4\">Flexible\/As Needed<\/label><\/li><li class=\"choice-6 depth-1\"><input type=\"radio\" id=\"wpforms-1153-field_16_6\" name=\"wpforms[fields][16]\" value=\"2-3 times per week\" aria-errormessage=\"wpforms-1153-field_16_6-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-1153-field_16_6\">2-3 times per week<\/label><\/li><li class=\"choice-5 depth-1\"><input type=\"radio\" id=\"wpforms-1153-field_16_5\" name=\"wpforms[fields][16]\" value=\"Daily\" aria-errormessage=\"wpforms-1153-field_16_5-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-1153-field_16_5\">Daily<\/label><\/li><li class=\"choice-1 depth-1\"><input type=\"radio\" id=\"wpforms-1153-field_16_1\" name=\"wpforms[fields][16]\" value=\"Weekly\" aria-errormessage=\"wpforms-1153-field_16_1-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-1153-field_16_1\">Weekly<\/label><\/li><li class=\"choice-2 depth-1\"><input type=\"radio\" id=\"wpforms-1153-field_16_2\" name=\"wpforms[fields][16]\" value=\"Bi-weekly\" aria-errormessage=\"wpforms-1153-field_16_2-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-1153-field_16_2\">Bi-weekly<\/label><\/li><li class=\"choice-3 depth-1\"><input type=\"radio\" id=\"wpforms-1153-field_16_3\" name=\"wpforms[fields][16]\" value=\"Monthly\" aria-errormessage=\"wpforms-1153-field_16_3-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-1153-field_16_3\">Monthly<\/label><\/li><li class=\"choice-7 depth-1\"><input type=\"radio\" id=\"wpforms-1153-field_16_7\" name=\"wpforms[fields][16]\" value=\"Quarterly\" aria-errormessage=\"wpforms-1153-field_16_7-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-1153-field_16_7\">Quarterly<\/label><\/li><\/ul><\/fieldset><\/div><div id=\"wpforms-1153-field_17-container\" class=\"wpforms-field wpforms-field-radio\" data-field-id=\"17\"><fieldset><legend class=\"wpforms-field-label\">Treatment Room<\/legend><ul id=\"wpforms-1153-field_17\"><li class=\"choice-1 depth-1\"><input type=\"radio\" id=\"wpforms-1153-field_17_1\" name=\"wpforms[fields][17]\" value=\"Yes we have a dedicated treatment room\" aria-errormessage=\"wpforms-1153-field_17_1-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-1153-field_17_1\">Yes we have a dedicated treatment room<\/label><\/li><li class=\"choice-2 depth-1\"><input type=\"radio\" id=\"wpforms-1153-field_17_2\" name=\"wpforms[fields][17]\" value=\"We can arrange a space\" aria-errormessage=\"wpforms-1153-field_17_2-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-1153-field_17_2\">We can arrange a space<\/label><\/li><li class=\"choice-3 depth-1\"><input type=\"radio\" id=\"wpforms-1153-field_17_3\" name=\"wpforms[fields][17]\" value=\"No - Sessions would need to be mobile\" aria-errormessage=\"wpforms-1153-field_17_3-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-1153-field_17_3\">No - Sessions would need to be mobile<\/label><\/li><\/ul><\/fieldset><\/div><div id=\"wpforms-1153-field_18-container\" class=\"wpforms-field wpforms-field-checkbox\" data-field-id=\"18\"><fieldset><legend class=\"wpforms-field-label\">Compensation Preference<\/legend><ul id=\"wpforms-1153-field_18\"><li class=\"choice-1 depth-1\"><input type=\"checkbox\" id=\"wpforms-1153-field_18_1\" name=\"wpforms[fields][18][]\" value=\"Room rental arrangement\" aria-errormessage=\"wpforms-1153-field_18_1-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-1153-field_18_1\">Room rental arrangement<\/label><\/li><li class=\"choice-2 depth-1\"><input type=\"checkbox\" id=\"wpforms-1153-field_18_2\" name=\"wpforms[fields][18][]\" value=\"Revenu share percentage\" aria-errormessage=\"wpforms-1153-field_18_2-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-1153-field_18_2\">Revenu share percentage<\/label><\/li><li class=\"choice-3 depth-1\"><input type=\"checkbox\" id=\"wpforms-1153-field_18_3\" name=\"wpforms[fields][18][]\" value=\"Per session fee\" aria-errormessage=\"wpforms-1153-field_18_3-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-1153-field_18_3\">Per session fee<\/label><\/li><li class=\"choice-4 depth-1\"><input type=\"checkbox\" id=\"wpforms-1153-field_18_4\" name=\"wpforms[fields][18][]\" value=\"Retainer agreement\" aria-errormessage=\"wpforms-1153-field_18_4-error\"  ><label class=\"wpforms-field-label-inline\" 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