{"id":241,"date":"2025-09-10T03:40:41","date_gmt":"2025-09-10T03:40:41","guid":{"rendered":"https:\/\/www.socorrodiaz.com\/web\/?page_id=241"},"modified":"2025-09-16T19:15:00","modified_gmt":"2025-09-16T19:15:00","slug":"general-questionnaire","status":"publish","type":"page","link":"https:\/\/www.socorrodiaz.com\/web\/general-questionnaire\/","title":{"rendered":"General Questionnaire"},"content":{"rendered":"<p>[et_pb_section fb_built=&#8221;1&#8243; admin_label=&#8221;section&#8221; _builder_version=&#8221;4.27.4&#8243; background_color=&#8221;#FCFAF3&#8243; custom_padding=&#8221;||0px||false|false&#8221; global_colors_info=&#8221;{}&#8221; da_is_popup=&#8221;off&#8221; da_exit_intent=&#8221;off&#8221; da_has_close=&#8221;on&#8221; da_alt_close=&#8221;off&#8221; da_dark_close=&#8221;off&#8221; da_not_modal=&#8221;on&#8221; da_is_singular=&#8221;off&#8221; da_with_loader=&#8221;off&#8221; da_has_shadow=&#8221;on&#8221; da_disable_devices=&#8221;off|off|off&#8221;][et_pb_row 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max_width_last_edited=&#8221;off|desktop&#8221; custom_margin=&#8221;||10px||false|false&#8221; header_3_font_size_tablet=&#8221;20px&#8221; header_3_font_size_phone=&#8221;16px&#8221; header_3_font_size_last_edited=&#8221;on|desktop&#8221; locked=&#8221;off&#8221; global_colors_info=&#8221;{}&#8221;]<\/p>\n<h2>Socorro Diaz Intake Form<\/h2>\n<p>[\/et_pb_text][\/et_pb_column][\/et_pb_row][\/et_pb_section][et_pb_section fb_built=&#8221;1&#8243; admin_label=&#8221;Footer&#8221; _builder_version=&#8221;4.27.4&#8243; _module_preset=&#8221;default&#8221; background_color=&#8221;#FCFAF3&#8243; background_enable_image=&#8221;off&#8221; background_size=&#8221;custom&#8221; background_image_width=&#8221;30%&#8221; background_position=&#8221;bottom_right&#8221; animation_style=&#8221;fade&#8221; animation_delay=&#8221;200ms&#8221; animation_starting_opacity=&#8221;20%&#8221; saved_tabs=&#8221;all&#8221; collapsed=&#8221;on&#8221; global_colors_info=&#8221;{}&#8221; da_is_popup=&#8221;off&#8221; da_exit_intent=&#8221;off&#8221; da_has_close=&#8221;on&#8221; da_alt_close=&#8221;off&#8221; da_dark_close=&#8221;off&#8221; da_not_modal=&#8221;on&#8221; da_is_singular=&#8221;off&#8221; da_with_loader=&#8221;off&#8221; da_has_shadow=&#8221;on&#8221; da_disable_devices=&#8221;off|off|off&#8221;][et_pb_row _builder_version=&#8221;4.27.4&#8243; _module_preset=&#8221;default&#8221; max_width=&#8221;660px&#8221; animation_style=&#8221;fade&#8221; global_colors_info=&#8221;{}&#8221;][et_pb_column type=&#8221;4_4&#8243; _builder_version=&#8221;4.21.0&#8243; _module_preset=&#8221;default&#8221; global_colors_info=&#8221;{}&#8221;][et_pb_text _builder_version=&#8221;4.27.4&#8243; _module_preset=&#8221;default&#8221; text_font=&#8221;Poppins|300|||||||&#8221; text_orientation=&#8221;justified&#8221; hover_enabled=&#8221;0&#8243; global_colors_info=&#8221;{}&#8221; text_text_color=&#8221;#040506&#8243; sticky_enabled=&#8221;0&#8243;]<\/p>\n\n<div class=\"wpcf7 no-js\" id=\"wpcf7-f240-o1\" lang=\"es-ES\" dir=\"ltr\" data-wpcf7-id=\"240\">\n<div class=\"screen-reader-response\"><p role=\"status\" aria-live=\"polite\" aria-atomic=\"true\"><\/p> <ul><\/ul><\/div>\n<form action=\"\/web\/wp-json\/wp\/v2\/pages\/241#wpcf7-f240-o1\" method=\"post\" class=\"wpcf7-form init\" aria-label=\"Formulario de contacto\" novalidate=\"novalidate\" data-status=\"init\">\n<fieldset class=\"hidden-fields-container\"><input type=\"hidden\" name=\"_wpcf7\" value=\"240\" \/><input type=\"hidden\" name=\"_wpcf7_version\" value=\"6.1.5\" \/><input type=\"hidden\" name=\"_wpcf7_locale\" value=\"es_ES\" \/><input type=\"hidden\" name=\"_wpcf7_unit_tag\" value=\"wpcf7-f240-o1\" \/><input type=\"hidden\" name=\"_wpcf7_container_post\" value=\"0\" \/><input type=\"hidden\" name=\"_wpcf7_posted_data_hash\" value=\"\" \/><input type=\"hidden\" name=\"_wpcf7_recaptcha_response\" value=\"\" \/>\n<\/fieldset>\n<p><label> First name *<br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"first-name\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required cf7-input\" aria-required=\"true\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"first-name\" \/><\/span><br \/>\n<\/label>\n<\/p>\n<p><label> Last name *<br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"last-name\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required cf7-input\" aria-required=\"true\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"last-name\" \/><\/span><br \/>\n<\/label>\n<\/p>\n<p><label> Email *<br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"your-email\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-email wpcf7-validates-as-required wpcf7-text wpcf7-validates-as-email cf7-input\" aria-required=\"true\" aria-invalid=\"false\" value=\"\" type=\"email\" name=\"your-email\" \/><\/span><br \/>\n<\/label>\n<\/p>\n<p><label> Phone *<br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"phone\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-tel wpcf7-validates-as-required wpcf7-text wpcf7-validates-as-tel cf7-input\" aria-required=\"true\" aria-invalid=\"false\" value=\"\" type=\"tel\" name=\"phone\" \/><\/span><br \/>\n<\/label>\n<\/p>\n<p><label> Birthday *<br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"birthday\"><input class=\"wpcf7-form-control wpcf7-date wpcf7-validates-as-required wpcf7-validates-as-date cf7-input\" aria-required=\"true\" aria-invalid=\"false\" value=\"\" type=\"date\" name=\"birthday\" \/><\/span><br \/>\n<\/label>\n<\/p>\n<p><label> Emergency Contact Information: *<br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"emergency-contact\"><textarea cols=\"40\" rows=\"10\" maxlength=\"2000\" class=\"wpcf7-form-control wpcf7-textarea wpcf7-validates-as-required cf7-input\" aria-required=\"true\" aria-invalid=\"false\" name=\"emergency-contact\"><\/textarea><\/span><br \/>\n<\/label>\n<\/p>\n<p><label> Do you have a specific issue or concern that you are seeking help for?<br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"issue\"><textarea cols=\"40\" rows=\"10\" maxlength=\"2000\" class=\"wpcf7-form-control wpcf7-textarea cf7-input\" aria-invalid=\"false\" name=\"issue\"><\/textarea><\/span><br \/>\n<\/label>\n<\/p>\n<p><label> Are you sensitive to perfumes or fragrances?<br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"sensitive-fragrances\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text cf7-input\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"sensitive-fragrances\" \/><\/span><br \/>\n<\/label>\n<\/p>\n<p><label> Are you sensitive to touch?<br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"sensitive-touch\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text cf7-input\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"sensitive-touch\" \/><\/span><br \/>\n<\/label>\n<\/p>\n<p><label class=\"cf7-checkbox\"><br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"agreement\"><span class=\"wpcf7-form-control wpcf7-checkbox wpcf7-validates-as-required\"><span class=\"wpcf7-list-item first last\"><label><input type=\"checkbox\" name=\"agreement[]\" value=\"I understand that assistance through Socorro Diaz\u2019s programs is not a substitute for medical advice or treatment. This is a soul-level work, and I will only proceed as long as I feel comfortable. It is recommended that I seek the advice of a medical professional for any physical or psychological symptoms I may be having. Socorro\u2019s services merely complement any work done with a qualified medical professional.\" \/><span class=\"wpcf7-list-item-label\">I understand that assistance through Socorro Diaz\u2019s programs is not a substitute for medical advice or treatment. This is a soul-level work, and I will only proceed as long as I feel comfortable. It is recommended that I seek the advice of a medical professional for any physical or psychological symptoms I may be having. Socorro\u2019s services merely complement any work done with a qualified medical professional.<\/span><\/label><\/span><\/span><\/span><br \/>\n<\/label>\n<\/p>\n<p><label> Today's Date: *<br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"todays-date\"><input class=\"wpcf7-form-control wpcf7-date wpcf7-validates-as-required wpcf7-validates-as-date cf7-input\" aria-required=\"true\" aria-invalid=\"false\" value=\"\" type=\"date\" name=\"todays-date\" \/><\/span><br \/>\n<\/label>\n<\/p>\n<p><label> Signature *<br \/>\n<div class=\"dscf7_signature\">\n\t\t\t<div class=\"dscf7_signature_inner\">\n\t\t\t\t<canvas id=\"digital_signature-pad_signature-732\" name=\"signature-732\" class=\"digital_signature-pad\" color=\"#000000\" backcolor=\"#dddddd\" width=\"300\" height=\"200\"><\/canvas>\n\t\t\t\t<input class=\"clearButton\" type=\"button\" value=\"+\">\n\t\t\t<\/div>\n\t\t\t<span class=\"wpcf7-form-control-wrap signature-732\" data-name=\"signature-732\">\n\t\t\t\t<input class=\"wpcf7-form-control wpcf7-signature wpcf7-validates-as-required wpcf7-validates-as-signature cf7-signature dscf7-signature\" value=\"\" type=\"hidden\" name=\"signature-732\"\/>\n\t\t\t\t<input type=\"hidden\" name=\"signature-732-attachment\" class=\"wpcf7_input_signature-732_attachment\"\/>\n\t\t\t\t<input type=\"hidden\" name=\"signature-732-inline\" class=\"wpcf7_input_signature-732_inline\"\/>\n\t\t\t<\/span>\n\t\t<\/div><br \/>\n<\/label>\n<\/p>\n<div class=\"cf7-btn-wrap\">\n\t<p><input class=\"wpcf7-form-control wpcf7-submit has-spinner\" type=\"submit\" value=\"Enviar\" \/>\n\t<\/p>\n<\/div><div class=\"wpcf7-response-output\" aria-hidden=\"true\"><\/div>\n<\/form>\n<\/div>\n\n<p>[\/et_pb_text][\/et_pb_column][\/et_pb_row][\/et_pb_section]<\/p>\n","protected":false},"excerpt":{"rendered":"<p>Socorro Diaz Intake Form\n<div class=\"wpcf7 no-js\" id=\"wpcf7-f240-o2\" lang=\"es-ES\" dir=\"ltr\" data-wpcf7-id=\"240\">\n<div class=\"screen-reader-response\"><p role=\"status\" aria-live=\"polite\" aria-atomic=\"true\"><\/p> <ul><\/ul><\/div>\n<form action=\"\/web\/wp-json\/wp\/v2\/pages\/241#wpcf7-f240-o2\" method=\"post\" class=\"wpcf7-form init\" aria-label=\"Formulario de contacto\" novalidate=\"novalidate\" data-status=\"init\">\n<fieldset class=\"hidden-fields-container\"><input type=\"hidden\" name=\"_wpcf7\" value=\"240\" \/><input type=\"hidden\" name=\"_wpcf7_version\" value=\"6.1.5\" \/><input type=\"hidden\" name=\"_wpcf7_locale\" value=\"es_ES\" \/><input type=\"hidden\" name=\"_wpcf7_unit_tag\" value=\"wpcf7-f240-o2\" \/><input type=\"hidden\" name=\"_wpcf7_container_post\" value=\"0\" \/><input type=\"hidden\" name=\"_wpcf7_posted_data_hash\" value=\"\" \/><input type=\"hidden\" name=\"_wpcf7_recaptcha_response\" value=\"\" \/>\n<\/fieldset>\n<p><label> First name *<br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"first-name\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required 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class=\"wpcf7-form-control wpcf7-tel wpcf7-validates-as-required wpcf7-text wpcf7-validates-as-tel cf7-input\" aria-required=\"true\" aria-invalid=\"false\" value=\"\" type=\"tel\" name=\"phone\" \/><\/span><br \/>\n<\/label>\n<\/p>\n<p><label> Birthday *<br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"birthday\"><input class=\"wpcf7-form-control wpcf7-date wpcf7-validates-as-required wpcf7-validates-as-date cf7-input\" aria-required=\"true\" aria-invalid=\"false\" value=\"\" type=\"date\" name=\"birthday\" \/><\/span><br \/>\n<\/label>\n<\/p>\n<p><label> Emergency Contact Information: *<br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"emergency-contact\"><textarea cols=\"40\" rows=\"10\" maxlength=\"2000\" class=\"wpcf7-form-control wpcf7-textarea wpcf7-validates-as-required cf7-input\" aria-required=\"true\" aria-invalid=\"false\" name=\"emergency-contact\"><\/textarea><\/span><br \/>\n<\/label>\n<\/p>\n<p><label> Do you have a specific issue or concern that you are seeking help for?<br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"issue\"><textarea cols=\"40\" rows=\"10\" maxlength=\"2000\" class=\"wpcf7-form-control wpcf7-textarea cf7-input\" aria-invalid=\"false\" name=\"issue\"><\/textarea><\/span><br \/>\n<\/label>\n<\/p>\n<p><label> Are you sensitive to perfumes or fragrances?<br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"sensitive-fragrances\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text cf7-input\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"sensitive-fragrances\" \/><\/span><br \/>\n<\/label>\n<\/p>\n<p><label> Are you sensitive to touch?<br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"sensitive-touch\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text cf7-input\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"sensitive-touch\" \/><\/span><br \/>\n<\/label>\n<\/p>\n<p><label class=\"cf7-checkbox\"><br \/>\n<span 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This is a soul-level work, and I will only proceed as long as I feel comfortable. It is recommended that I seek the advice of a medical professional for any physical or psychological symptoms I may be having. Socorro\u2019s services merely complement any work done with a qualified medical professional.\" \/><span class=\"wpcf7-list-item-label\">I understand that assistance through Socorro Diaz\u2019s programs is not a substitute for medical advice or treatment. This is a soul-level work, and I will only proceed as long as I feel comfortable. It is recommended that I seek the advice of a medical professional for any physical or psychological symptoms I may be having. Socorro\u2019s services merely complement any work done with a qualified medical professional.<\/span><\/label><\/span><\/span><\/span><br \/>\n<\/label>\n<\/p>\n<p><label> Today's Date: *<br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"todays-date\"><input class=\"wpcf7-form-control wpcf7-date wpcf7-validates-as-required wpcf7-validates-as-date cf7-input\" aria-required=\"true\" aria-invalid=\"false\" value=\"\" type=\"date\" name=\"todays-date\" \/><\/span><br \/>\n<\/label>\n<\/p>\n<p><label> Signature *<br \/>\n<div class=\"dscf7_signature\">\n\t\t\t<div class=\"dscf7_signature_inner\">\n\t\t\t\t<canvas id=\"digital_signature-pad_signature-732\" name=\"signature-732\" class=\"digital_signature-pad\" color=\"#000000\" backcolor=\"#dddddd\" width=\"300\" height=\"200\"><\/canvas>\n\t\t\t\t<input class=\"clearButton\" type=\"button\" value=\"+\">\n\t\t\t<\/div>\n\t\t\t<span class=\"wpcf7-form-control-wrap signature-732\" data-name=\"signature-732\">\n\t\t\t\t<input class=\"wpcf7-form-control wpcf7-signature wpcf7-validates-as-required wpcf7-validates-as-signature cf7-signature dscf7-signature\" value=\"\" type=\"hidden\" name=\"signature-732\"\/>\n\t\t\t\t<input type=\"hidden\" name=\"signature-732-attachment\" class=\"wpcf7_input_signature-732_attachment\"\/>\n\t\t\t\t<input type=\"hidden\" name=\"signature-732-inline\" class=\"wpcf7_input_signature-732_inline\"\/>\n\t\t\t<\/span>\n\t\t<\/div><br \/>\n<\/label>\n<\/p>\n<div class=\"cf7-btn-wrap\">\n\t<p><input class=\"wpcf7-form-control wpcf7-submit has-spinner\" type=\"submit\" value=\"Enviar\" \/>\n\t<\/p>\n<\/div><div class=\"wpcf7-response-output\" aria-hidden=\"true\"><\/div>\n<\/form>\n<\/div>\n<\/p>\n","protected":false},"author":1,"featured_media":0,"parent":0,"menu_order":0,"comment_status":"closed","ping_status":"closed","template":"","meta":{"_acf_changed":false,"_et_pb_use_builder":"on","_et_pb_old_content":"<!-- wp:divi\/placeholder \/-->","_et_gb_content_width":"","om_disable_all_campaigns":false,"_joinchat":[],"footnotes":""},"class_list":["post-241","page","type-page","status-publish","hentry"],"acf":[],"jetpack_sharing_enabled":true,"_links":{"self":[{"href":"https:\/\/www.socorrodiaz.com\/web\/wp-json\/wp\/v2\/pages\/241","targetHints":{"allow":["GET"]}}],"collection":[{"href":"https:\/\/www.socorrodiaz.com\/web\/wp-json\/wp\/v2\/pages"}],"about":[{"href":"https:\/\/www.socorrodiaz.com\/web\/wp-json\/wp\/v2\/types\/page"}],"author":[{"embeddable":true,"href":"https:\/\/www.socorrodiaz.com\/web\/wp-json\/wp\/v2\/users\/1"}],"replies":[{"embeddable":true,"href":"https:\/\/www.socorrodiaz.com\/web\/wp-json\/wp\/v2\/comments?post=241"}],"version-history":[{"count":4,"href":"https:\/\/www.socorrodiaz.com\/web\/wp-json\/wp\/v2\/pages\/241\/revisions"}],"predecessor-version":[{"id":437,"href":"https:\/\/www.socorrodiaz.com\/web\/wp-json\/wp\/v2\/pages\/241\/revisions\/437"}],"wp:attachment":[{"href":"https:\/\/www.socorrodiaz.com\/web\/wp-json\/wp\/v2\/media?parent=241"}],"curies":[{"name":"wp","href":"https:\/\/api.w.org\/{rel}","templated":true}]}}