{"id":11186,"date":"2025-12-02T09:12:38","date_gmt":"2025-12-01T23:12:38","guid":{"rendered":"https:\/\/metronorth.health.qld.gov.au\/caboolture\/?post_type=services&#038;p=11186"},"modified":"2026-02-19T12:12:52","modified_gmt":"2026-02-19T02:12:52","slug":"booking-form","status":"publish","type":"services","link":"https:\/\/metronorth.health.qld.gov.au\/caboolture\/healthcare-services\/audiology\/community-hearing\/booking-form","title":{"rendered":"Community Hearing Screening Program &#8211; Online booking form"},"content":{"rendered":"<div class=\"fusion-fullwidth fullwidth-box fusion-builder-row-1 fusion-flex-container has-pattern-background has-mask-background nonhundred-percent-fullwidth non-hundred-percent-height-scrolling\" style=\"--awb-border-radius-top-left:0px;--awb-border-radius-top-right:0px;--awb-border-radius-bottom-right:0px;--awb-border-radius-bottom-left:0px;--awb-flex-wrap:wrap;\" ><div class=\"fusion-builder-row fusion-row fusion-flex-align-items-flex-start fusion-flex-content-wrap\" style=\"max-width:89.44rem;margin-left: calc(-4% \/ 2 );margin-right: calc(-4% \/ 2 );\"><\/div><\/div>\n","protected":false},"excerpt":{"rendered":"<p>Community Hearing Screening Program Online Booking Form<\/p>\n","protected":false},"featured_media":0,"parent":11175,"menu_order":0,"template":"","categories":[1],"tags":[491,500,499,497,496,495,494,493,492,490,489,488,487,486,428,32],"class_list":["post-11186","services","type-services","status-publish","hentry","category-uncategorized","tag-hearing-assessments","tag-paediatric-services","tag-middle-ear-problems","tag-healthy-hearing-screening-program","tag-speech-discrimination-testing","tag-electrophysiological-testing","tag-behavioural-orientation-audiometry","tag-visual-reinforcement-audiometry","tag-pure-tone-audiometry","tag-hearing-loss","tag-child-hearing-test","tag-infant-hearing-test","tag-hearing-test","tag-hearing","tag-audiology","tag-audiologist"],"acf":{"page_subtitle":"For Parents & Guardians to complete","page_type":"general","page_sections":["general_details","accessing_this_service","general_content"],"general_details":[{"what_we_do":"<p><strong>We offer free hearing screening for eligible children from 9 months to 16 years of age.<\/strong><\/p>\n<p>Hearing screening can establish whether your child has sufficient hearing for speech and language development or learning in the classroom.<\/p>\n<p>Our Community Hearing Screening Program is a free service managed by the Caboolture Hospital Audiology team.\u00a0 We run clinics at community locations with free parking in Caboolture, Redcliffe, Strathpine and Kilcoy.<\/p>\n<p>Hearing screening is performed by specially trained Clinical Assistants working under the supervision of an audiologist.\u00a0<\/p>\n<p>Parents can refer their own children for hearing screening without needing to see a doctor for a referral.\u00a0 Doctors and other professionals working with your child can also make referrals to the Community Hearing Screening Program.<\/p>\n","conditions_treated":"","our_services":"","include_link_to_healthcare_professionals_section":false,"gd_other_content":[{"general_content":[{"heading":"Who can be seen","content":"<p>You can book a hearing screen for your child if:<\/p>\n<ul>\n<li>you are worried about their hearing.<\/li>\n<li>you are worried about their speech and language development.<\/li>\n<li>you are worried about how clearly they are talking.<\/li>\n<li>you are worried about their learning and behaviour and need their hearing checked.<\/li>\n<li>they need a hearing check as part of a developmental or behavioural assessment.<\/li>\n<\/ul>\n<p>Your child can be seen by the Community Hearing Screening Program if:<\/p>\n<ul>\n<li>they are not currently having their hearing tested by another service.<\/li>\n<li>they are not under the care of an Ear, Nose and Throat (ENT) specialist or service.<\/li>\n<li>they have not had their hearing tested anywhere in the last 12 months.<\/li>\n<\/ul>\n<p>To be eligible for the Community Hearing Screening Program, your child must:<\/p>\n<ul>\n<li>have a valid Medicare card.<\/li>\n<li>be over 9 months and under 16 years of age.<\/li>\n<li>have passed their newborn hearing screen if they have not yet reached 3.5 years of age.<\/li>\n<li><a href=\"https:\/\/metronorth.health.qld.gov.au\/caboolture\/wp-content\/uploads\/sites\/4\/2025\/09\/cabh-community-screening-program-catchment.pdf\">live in the catchment area<\/a> for Caboolture Hospital Audiology.<\/li>\n<\/ul>\n"}]}]}],"accessing_this_service":[{"variation":"freetext","free_text":"<p>Parents and carers can make an appointment for their child by:<\/p>\n<ul>\n<li>calling the booking team on <strong>(07) XXXX XXXX<\/strong>, or<\/li>\n<li>by completing the Community Hearing Screening Online Eligibility and Referral Form<\/li>\n<\/ul>\n<p>If you are not sure if your child requires a hearing screen or diagnostic audiology assessment, you can check with your GP, or you can contact the Caboolture Hospital Audiology Department on (07) 5433 8625.<\/p>\n<p>Doctors, clinicians and other professionals working with your child (e.g., teachers) can also refer children to the Community Hearing Screening Program by completing the referral form.<\/p>\n"}],"include_refer_a_patient_panel":false,"refer_a_patient_text":"","refer_a_patient_link":"","specialist_hotline":"1300 364 938","after_your_hospital_appointment":[{"variation":"Preadmission and surgery","free_text":""}],"general_content_0":false,"what_to_bring":[{"category":"child_health","what_to_bring_general":false,"what_to_bring_mental_health":false,"what_to_bring_child_health":[{"display":["every_time","for_appointment"],"every_time":"","_copy":"","for_appointment":"<p>Results from any previous hearing tests including school hearing screening<\/p>\n","_copy2":"","for_procedure":"","_copy3":"","for_overnight":""}]}],"general_content":[{"other_content":[{"heading":"","content":"<p>If you would like your child to have their hearing screened, you can fill out the Eligibility and Referral Form online.<\/p>\n<p>By submitting the online referral form, you agree that our bookings team can call you to discuss the referral and book a hearing screening appointment for your child.<\/p>\n<p>\u00a0We aim to contact you within 5 business days of your enquiry.\u00a0 The call will come from a private number.<\/p>\n<p><strong>If you would prefer to speak directly to our bookings team, please call 5433 8193 during business hours (8:00am to 3:30pm, Monday to Friday).<\/strong><\/p>\n<p><strong>If you need support sooner call\u00a0<\/strong><a href=\"tel:13432584\"><strong>13\u00a0HEALTH\u00a0(13\u00a043\u00a025\u00a084)<\/strong><\/a><strong>\u00a0(open 24 hours) and ask for a child health nurse. <\/strong><\/p>\n<p><strong>Parentline is also available 7 days a week from 8am to 10pm on\u00a0<\/strong><a href=\"tel:1300301300\"><strong>1300 301 300<\/strong><\/a><strong>, to provide free confidential telephone support for parents and carers in Queensland.<\/strong><\/p>\n<script type=\"text\/javascript\">\n\/* <![CDATA[ *\/\nvar gform;gform||(document.addEventListener(\"gform_main_scripts_loaded\",function(){gform.scriptsLoaded=!0}),document.addEventListener(\"gform\/theme\/scripts_loaded\",function(){gform.themeScriptsLoaded=!0}),window.addEventListener(\"DOMContentLoaded\",function(){gform.domLoaded=!0}),gform={domLoaded:!1,scriptsLoaded:!1,themeScriptsLoaded:!1,isFormEditor:()=>\"function\"==typeof InitializeEditor,callIfLoaded:function(o){return!(!gform.domLoaded||!gform.scriptsLoaded||!gform.themeScriptsLoaded&&!gform.isFormEditor()||(gform.isFormEditor()&&console.warn(\"The use of gform.initializeOnLoaded() is deprecated in the form editor context and will be removed in Gravity Forms 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class=\"gform_title\">Community Hearing Screening Program<\/h2>\n                            <p class='gform_description'><\/p>\n                        <\/div><form method='post' enctype='multipart\/form-data'  id='gform_7'  action='\/caboolture\/wp-json\/wp\/v2\/healthcare-services\/11186#gf_7' data-formid='7' novalidate>\n                        <div class='gform-body gform_body'><div id='gform_fields_7' class='gform_fields top_label form_sublabel_above description_above validation_above'><div id=\"field_7_16\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-full gfield_contains_required field_sublabel_above gfield--no-description field_description_above field_validation_above gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_7_16'>What is the suburb\/post code of your home address?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_16' id='input_7_16' type='text' value='' class='large'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_7_19\" class=\"gfield gfield--type-hidden gfield--input-type-hidden gfield--width-full gform_hidden field_sublabel_above gfield--no-description field_description_above field_validation_above gfield_visibility_visible\"  ><div class='ginput_container ginput_container_text'><input name='input_19' id='input_7_19' type='hidden' class='gform_hidden'  aria-invalid=\"false\" value='' \/><\/div><\/div><div id=\"field_7_15\" class=\"gfield gfield--type-html gfield--input-type-html gfield--width-full gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_above gfield--no-description field_description_above field_validation_above gfield_visibility_visible\"  >\n  <div id=\"suggestions\"><\/div>\n  <p id=\"result\"><\/p>\n\n  <\/div><div id=\"field_7_4\" class=\"gfield gfield--type-section gfield--input-type-section gsection field_sublabel_above gfield--no-description field_description_above field_validation_above gfield_visibility_visible\"  ><h3 class=\"gsection_title\">Eligibility<\/h3><\/div><fieldset id=\"field_7_5\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-full gfield_contains_required field_sublabel_above gfield--no-description field_description_above field_validation_above gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >Does your child have a Medicare card?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_7_5'>\n\t\t\t<div class='gchoice gchoice_7_5_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_5' type='radio' value='Yes'  id='choice_7_5_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_7_5_0' id='label_7_5_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_7_5_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_5' type='radio' value='No'  id='choice_7_5_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_7_5_1' id='label_7_5_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_7_8\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-full gfield_contains_required field_sublabel_above gfield--no-description field_description_above field_validation_above gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >What is your child&#039;s age?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_7_8'>\n\t\t\t<div class='gchoice gchoice_7_8_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_8' type='radio' value='0-8 months'  id='choice_7_8_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_7_8_0' id='label_7_8_0' class='gform-field-label gform-field-label--type-inline'>0-8 months<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_7_8_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_8' type='radio' value='9 months to 16 years'  id='choice_7_8_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_7_8_1' id='label_7_8_1' class='gform-field-label gform-field-label--type-inline'>9 months to 16 years<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_7_8_2'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_8' type='radio' value='Over 16 years old'  id='choice_7_8_2' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_7_8_2' id='label_7_8_2' class='gform-field-label gform-field-label--type-inline'>Over 16 years old<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_7_49\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-full gfield_contains_required field_sublabel_above gfield--no-description field_description_above field_validation_above gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >Has your child had their hearing tested or screened in the last 12 months (not including their newborn hearing screen)?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_7_49'>\n\t\t\t<div class='gchoice gchoice_7_49_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_49' type='radio' value='Yes'  id='choice_7_49_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_7_49_0' id='label_7_49_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_7_49_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_49' type='radio' value='No'  id='choice_7_49_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_7_49_1' id='label_7_49_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_7_11\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-full gfield_contains_required field_sublabel_above gfield--has-description field_description_above field_validation_above gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >If your child is younger than 3 years 6 months of age, did they pass their newborn hearing screen at birth?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/legend><div class='gfield_description' id='gfield_description_7_11'><a href=\"https:\/\/www.childrens.health.qld.gov.au\/our-work\/healthy-hearing\/newborn-hearing-screening\">What is this?<\/a><\/div><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_7_11'>\n\t\t\t<div class='gchoice gchoice_7_11_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_11' type='radio' value='Yes'  id='choice_7_11_0' onchange='gformToggleRadioOther( this )' aria-describedby=\"gfield_description_7_11\"   \/>\n\t\t\t\t\t<label for='choice_7_11_0' id='label_7_11_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_7_11_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_11' type='radio' value='No'  id='choice_7_11_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_7_11_1' id='label_7_11_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_7_11_2'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_11' type='radio' value='Not screened'  id='choice_7_11_2' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_7_11_2' id='label_7_11_2' class='gform-field-label gform-field-label--type-inline'>Not screened<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_7_11_3'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_11' type='radio' value='I don&#039;t know'  id='choice_7_11_3' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_7_11_3' id='label_7_11_3' class='gform-field-label gform-field-label--type-inline'>I don't know<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_7_11_4'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_11' type='radio' value='My child is older than 3 years 6 months'  id='choice_7_11_4' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_7_11_4' id='label_7_11_4' class='gform-field-label gform-field-label--type-inline'>My child is older than 3 years 6 months<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_7_6\" class=\"gfield gfield--type-html gfield--input-type-html gfield--width-full gfield_html gfield_html_formatted field_sublabel_above gfield--no-description field_description_above field_validation_above gfield_visibility_visible\"  ><div class=\"alert alert-danger\">\n<h3>Eligibility not met<\/h3>\n<p>Your child does not meet the criteria to be seen by the Community Hearing Screening Program. <\/p>\n<p>Please call the Caboolture Hospital Audiology service on 5433 8193 for further advice for hearing testing options for your child.\n<\/p>\n<\/div><\/div><div id=\"field_7_13\" class=\"gfield gfield--type-html gfield--input-type-html gfield--width-full gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_above gfield--no-description field_description_above field_validation_above gfield_visibility_visible\"  ><div class=\"alert alert-success\">\n<h3>Your child is eligible<\/h3>\n<p>Your child meets the criteria to be seen by the Community Hearing Screening Program. <\/p>\n<p>Please complete the remainder of the form.<\/p>\n<\/div><\/div><div id=\"field_7_20\" class=\"gfield gfield--type-section gfield--input-type-section gsection field_sublabel_above gfield--no-description field_description_above field_validation_above gfield_visibility_visible\"  ><h3 class=\"gsection_title\">Pre-Screening Questions<\/h3><\/div><fieldset id=\"field_7_21\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-full gfield_contains_required field_sublabel_above gfield--no-description field_description_above field_validation_above gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >Are you worried about your child\u2019s hearing or listening?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_7_21'>\n\t\t\t<div class='gchoice gchoice_7_21_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_21' type='radio' value='Yes'  id='choice_7_21_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_7_21_0' id='label_7_21_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_7_21_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_21' type='radio' value='No'  id='choice_7_21_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_7_21_1' id='label_7_21_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_7_22\" class=\"gfield gfield--type-textarea gfield--input-type-textarea gfield--width-full gfield_contains_required field_sublabel_above gfield--no-description field_description_above field_validation_above gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_7_22'>Please tell us what you have noticed.<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_22' id='input_7_22' class='textarea small'     aria-required=\"true\" aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/div><fieldset id=\"field_7_23\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-full gfield_contains_required field_sublabel_above gfield--no-description field_description_above field_validation_above gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >Are you worried about your child\u2019s talking or understanding of speech?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_7_23'>\n\t\t\t<div class='gchoice gchoice_7_23_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_23' type='radio' value='Yes'  id='choice_7_23_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_7_23_0' id='label_7_23_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_7_23_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_23' type='radio' value='No'  id='choice_7_23_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_7_23_1' id='label_7_23_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_7_26\" class=\"gfield gfield--type-textarea gfield--input-type-textarea gfield--width-full gfield_contains_required field_sublabel_above gfield--no-description field_description_above field_validation_above gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_7_26'>Please tell us what you have noticed.<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_26' id='input_7_26' class='textarea small'     aria-required=\"true\" aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/div><fieldset id=\"field_7_24\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-full gfield_contains_required field_sublabel_above gfield--no-description field_description_above field_validation_above gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >Does your child have any learning or behaviour difficulties?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_7_24'>\n\t\t\t<div class='gchoice gchoice_7_24_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_24' type='radio' value='Yes'  id='choice_7_24_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_7_24_0' id='label_7_24_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_7_24_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_24' type='radio' value='No'  id='choice_7_24_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_7_24_1' id='label_7_24_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_7_27\" class=\"gfield gfield--type-textarea gfield--input-type-textarea gfield--width-full gfield_contains_required field_sublabel_above gfield--no-description field_description_above field_validation_above gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_7_27'>Please tell us what you have noticed.<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_27' id='input_7_27' class='textarea small'     aria-required=\"true\" aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/div><fieldset id=\"field_7_25\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-full gfield_contains_required field_sublabel_above gfield--no-description field_description_above field_validation_above gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >Does your child require a hearing screen before they can start therapy?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_7_25'>\n\t\t\t<div class='gchoice gchoice_7_25_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_25' type='radio' value='Yes'  id='choice_7_25_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_7_25_0' id='label_7_25_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_7_25_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_25' type='radio' value='No'  id='choice_7_25_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_7_25_1' id='label_7_25_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_7_25_2'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_25' type='radio' value='I am unsure'  id='choice_7_25_2' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_7_25_2' id='label_7_25_2' class='gform-field-label gform-field-label--type-inline'>I am unsure<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_7_28\" class=\"gfield gfield--type-textarea gfield--input-type-textarea gfield--width-full gfield_contains_required field_sublabel_above gfield--no-description field_description_above field_validation_above gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_7_28'>Please specify:<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_28' id='input_7_28' class='textarea small'     aria-required=\"true\" aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/div><fieldset id=\"field_7_29\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-full gfield_contains_required field_sublabel_above gfield--no-description field_description_above field_validation_above gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >The hearing screen will involve looking into and touching your child\u2019s ears, and having a soft probe in their ear for testing.  They may also need to wear headphones.  Do you think your child will be able to tolerate this?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_7_29'>\n\t\t\t<div class='gchoice gchoice_7_29_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_29' type='radio' value='Yes'  id='choice_7_29_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_7_29_0' id='label_7_29_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_7_29_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_29' type='radio' value='No'  id='choice_7_29_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_7_29_1' id='label_7_29_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_7_30\" class=\"gfield gfield--type-textarea gfield--input-type-textarea gfield--width-full gfield_contains_required field_sublabel_above gfield--no-description field_description_above field_validation_above gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_7_30'>Please specify:<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_30' id='input_7_30' class='textarea small'     aria-required=\"true\" aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/div><div id=\"field_7_31\" class=\"gfield gfield--type-section gfield--input-type-section gsection field_sublabel_above gfield--no-description field_description_above field_validation_above gfield_visibility_visible\"  ><h3 class=\"gsection_title\">Child\u2019s Details<\/h3><\/div><fieldset id=\"field_7_32\" class=\"gfield gfield--type-name gfield--input-type-name gfield--width-full gfield_contains_required field_sublabel_above gfield--no-description field_description_above field_validation_above 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_7_32'>\n                            \n                            <span id='input_7_32_3_container' class='name_first gform-grid-col gform-grid-col--size-auto' >\n                                                    <label for='input_7_32_3' class='gform-field-label gform-field-label--type-sub '>First Name<\/label>\n                                                    <input type='text' name='input_32.3' id='input_7_32_3' value=''   aria-required='true'     \/>\n                                                <\/span>\n                            \n                            <span id='input_7_32_6_container' class='name_last gform-grid-col gform-grid-col--size-auto' >\n                                                            <label for='input_7_32_6' class='gform-field-label gform-field-label--type-sub '>Last Name<\/label>\n                                                            <input type='text' name='input_32.6' id='input_7_32_6' value=''   aria-required='true'     \/>\n                                                        <\/span>\n                            \n                        <\/div><\/fieldset><fieldset id=\"field_7_33\" class=\"gfield gfield--type-date gfield--input-type-date gfield--input-type-datefield gfield--width-full gfield_contains_required field_sublabel_above gfield--no-description field_description_above field_validation_above gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Date of Birth<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/legend><div id='input_7_33' class='ginput_container ginput_complex gform-grid-row'>\n                                        <div class='gfield_date_day ginput_container ginput_container_date gform-grid-col' id='input_7_33_2_container'>\n                                            <label for='input_7_33_2' class='gform-field-label gform-field-label--type-sub screen-reader-text'>Day<\/label>\n                                            <input type='number' maxlength='2' name='input_33[]' id='input_7_33_2' value=''   aria-required='true'   placeholder='DD' min='1' max='31' step='1'\/>\n                                        <\/div><div class='gfield_date_month ginput_container ginput_container_date gform-grid-col' id='input_7_33_1_container'>\n                                        <label for='input_7_33_1' class='gform-field-label gform-field-label--type-sub screen-reader-text'>Month<\/label>\n                                        <input type='number' maxlength='2' name='input_33[]' id='input_7_33_1' value=''   aria-required='true'   placeholder='MM' min='1' max='12' step='1'\/>\n                                   <\/div><div class='gfield_date_year ginput_container ginput_container_date gform-grid-col' id='input_7_33_3_container'>\n                                            <label for='input_7_33_3' class='gform-field-label gform-field-label--type-sub screen-reader-text'>Year<\/label>\n                                            <input type='number' maxlength='4' name='input_33[]' id='input_7_33_3' value=''   aria-required='true'   placeholder='YYYY' min='1920' max='2027' step='1'\/>\n                                       <\/div>\n                                    <\/div><\/fieldset><fieldset id=\"field_7_34\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-full gfield_contains_required field_sublabel_above gfield--no-description field_description_above field_validation_above gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >Gender<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_7_34'>\n\t\t\t<div class='gchoice gchoice_7_34_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_34' type='radio' value='Male'  id='choice_7_34_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_7_34_0' id='label_7_34_0' class='gform-field-label gform-field-label--type-inline'>Male<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_7_34_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_34' type='radio' value='Female'  id='choice_7_34_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_7_34_1' id='label_7_34_1' class='gform-field-label gform-field-label--type-inline'>Female<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_7_34_2'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_34' type='radio' value='Indeterminate'  id='choice_7_34_2' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_7_34_2' id='label_7_34_2' class='gform-field-label gform-field-label--type-inline'>Indeterminate<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_7_35\" class=\"gfield gfield--type-address gfield--input-type-address gfield--width-full gfield_contains_required field_sublabel_above gfield--no-description field_description_above field_validation_above gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Address<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/legend>    \n                    <div class='ginput_complex ginput_container has_street has_city has_zip ginput_container_address gform-grid-row' id='input_7_35' >\n                         <span class='ginput_full address_line_1 ginput_address_line_1 gform-grid-col' id='input_7_35_1_container' >\n                                        <label for='input_7_35_1' id='input_7_35_1_label' class='gform-field-label gform-field-label--type-sub '>Street Address<\/label>\n                                        <input type='text' name='input_35.1' id='input_7_35_1' value=''    aria-required='true'   autocomplete=\"address-line1\" \/>\n                                   <\/span><span class='ginput_left address_city ginput_address_city gform-grid-col' id='input_7_35_3_container' >\n                                    <label for='input_7_35_3' id='input_7_35_3_label' class='gform-field-label gform-field-label--type-sub '>Suburb<\/label>\n                                    <input type='text' name='input_35.3' id='input_7_35_3' value=''    aria-required='true'   autocomplete=\"address-level2\" \/>\n                                 <\/span><input type='hidden' class='gform_hidden' name='input_35.4' id='input_7_35_4' value=''\/><span class='ginput_right address_zip ginput_address_zip gform-grid-col' id='input_7_35_5_container' >\n                                    <label for='input_7_35_5' id='input_7_35_5_label' class='gform-field-label gform-field-label--type-sub '>Post code<\/label>\n                                    <input type='text' name='input_35.5' id='input_7_35_5' value=''    aria-required='true'   autocomplete=\"postal-code\" \/>\n                                <\/span><input type='hidden' class='gform_hidden' name='input_35.6' id='input_7_35_6' value='Australia' \/>\n                    <div class='gf_clear gf_clear_complex'><\/div>\n                <\/div><\/fieldset><fieldset id=\"field_7_36\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-full field_sublabel_above gfield--no-description field_description_above field_validation_above gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >Was your child born in Queensland?<\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_7_36'>\n\t\t\t<div class='gchoice gchoice_7_36_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_36' type='radio' value='Yes'  id='choice_7_36_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_7_36_0' id='label_7_36_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_7_36_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_36' type='radio' value='No'  id='choice_7_36_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_7_36_1' id='label_7_36_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_7_37\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-full gfield_contains_required field_sublabel_above gfield--no-description field_description_above field_validation_above gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_7_37'>Full name of birth mother at the time of the child\u2019s birth?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_37' id='input_7_37' type='text' value='' class='large'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_7_51\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-third gfield_contains_required field_sublabel_above gfield--has-description field_description_below field_validation_above gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_7_51'>Medicare Card Number<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_51' id='input_7_51' type='text' value='' class='large'  aria-describedby=\"gfield_description_7_51\"   aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><div class='gfield_description' id='gfield_description_7_51'><a href=\"https:\/\/www.servicesaustralia.gov.au\/how-your-medicare-card-and-account-work?context=60092\">What is this<\/a><\/div><\/div><div id=\"field_7_52\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-third gfield_contains_required field_sublabel_above gfield--no-description field_description_above field_validation_above gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_7_52'>Expiry Date<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_52' id='input_7_52' type='text' value='' class='medium'    placeholder='MM\/YYYY' aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_7_53\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-third field_sublabel_above gfield--has-description field_description_below field_validation_above gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_7_53'>Reference Number<\/label><div class='ginput_container ginput_container_text'><input name='input_53' id='input_7_53' type='text' value='' class='small'  aria-describedby=\"gfield_description_7_53\"    aria-invalid=\"false\"   \/><\/div><div class='gfield_description' id='gfield_description_7_53'><a href=\"<a href=\"https:\/\/www.servicesaustralia.gov.au\/how-your-medicare-card-and-account-work?context=60092\">What is this<\/a>\">Where is this<\/a><\/div><\/div><div id=\"field_7_38\" class=\"gfield gfield--type-section gfield--input-type-section gsection field_sublabel_above gfield--no-description field_description_above field_validation_above gfield_visibility_visible\"  ><h3 class=\"gsection_title\">Parent\/Guardian Details<\/h3><\/div><fieldset id=\"field_7_39\" class=\"gfield gfield--type-name gfield--input-type-name gfield--width-full gfield_contains_required field_sublabel_above gfield--no-description field_description_above field_validation_above 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_7_39'>\n                            \n                            <span id='input_7_39_3_container' class='name_first gform-grid-col gform-grid-col--size-auto' >\n                                                    <label for='input_7_39_3' class='gform-field-label gform-field-label--type-sub '>First name<\/label>\n                                                    <input type='text' name='input_39.3' id='input_7_39_3' value=''   aria-required='true'    autocomplete=\"given-name\" \/>\n                                                <\/span>\n                            \n                            <span id='input_7_39_6_container' class='name_last gform-grid-col gform-grid-col--size-auto' >\n                                                            <label for='input_7_39_6' class='gform-field-label gform-field-label--type-sub '>Last name<\/label>\n                                                            <input type='text' name='input_39.6' id='input_7_39_6' value=''   aria-required='true'    autocomplete=\"family-name\" \/>\n                                                        <\/span>\n                            \n                        <\/div><\/fieldset><div id=\"field_7_40\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-full gfield_contains_required field_sublabel_above gfield--no-description field_description_above field_validation_above gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_7_40'>Relationship to child<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_40' id='input_7_40' type='text' value='' class='large'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><fieldset id=\"field_7_41\" class=\"gfield gfield--type-address gfield--input-type-address gfield--width-full field_sublabel_above gfield--no-description field_description_above field_validation_above gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Address (if different to above)<\/legend>    <div id='input_7_41_copy_values_option_container' class='copy_values_option_container' >\n                                        <input type='checkbox' id='input_7_41_copy_values_activated' class='copy_values_activated' value='1' data-source_field_id='35' name='input_41_copy_values_activated'  \/>\n                                        <label for='input_7_41_copy_values_activated' id='input_7_41_copy_values_option_label' class='copy_values_option_label inline gform-field-label gform-field-label--type-inline'>Same as child<\/label>\n                                    <\/div>\n                    <div class='ginput_complex ginput_container has_street has_city has_zip ginput_container_address gform-grid-row' id='input_7_41' >\n                         <span class='ginput_full address_line_1 ginput_address_line_1 gform-grid-col' id='input_7_41_1_container' >\n                                        <label for='input_7_41_1' id='input_7_41_1_label' class='gform-field-label gform-field-label--type-sub '>Street Address<\/label>\n                                        <input type='text' name='input_41.1' id='input_7_41_1' value=''    aria-required='false'   autocomplete=\"address-line1\" \/>\n                                   <\/span><span class='ginput_left address_city ginput_address_city gform-grid-col' id='input_7_41_3_container' >\n                                    <label for='input_7_41_3' id='input_7_41_3_label' class='gform-field-label gform-field-label--type-sub '>Suburb<\/label>\n                                    <input type='text' name='input_41.3' id='input_7_41_3' value=''    aria-required='false'   autocomplete=\"address-level2\" \/>\n                                 <\/span><input type='hidden' class='gform_hidden' name='input_41.4' id='input_7_41_4' value=''\/><span class='ginput_right address_zip ginput_address_zip gform-grid-col' id='input_7_41_5_container' >\n                                    <label for='input_7_41_5' id='input_7_41_5_label' class='gform-field-label gform-field-label--type-sub '>Post Code<\/label>\n                                    <input type='text' name='input_41.5' id='input_7_41_5' value=''    aria-required='false'   autocomplete=\"postal-code\" \/>\n                                <\/span><input type='hidden' class='gform_hidden' name='input_41.6' id='input_7_41_6' value='Australia' \/>\n                    <div class='gf_clear gf_clear_complex'><\/div>\n                <\/div><\/fieldset><div id=\"field_7_42\" class=\"gfield gfield--type-phone gfield--input-type-phone gfield--width-full gfield_contains_required field_sublabel_above gfield--no-description field_description_above field_validation_above gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_7_42'>Phone<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/label><div class='ginput_container ginput_container_phone'><input name='input_42' id='input_7_42' type='tel' value='' class='large'   aria-required=\"true\" aria-invalid=\"false\"  autocomplete=\"tel\" \/><\/div><\/div><div id=\"field_7_43\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-full field_sublabel_above gfield--no-description field_description_above field_validation_above gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_7_43'>What language\/s are spoken at home?<\/label><div class='ginput_container ginput_container_text'><input name='input_43' id='input_7_43' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/div><fieldset id=\"field_7_44\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-full field_sublabel_above gfield--no-description field_description_above field_validation_above gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >Do you need an interpreter?<\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_7_44'>\n\t\t\t<div class='gchoice gchoice_7_44_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_44' type='radio' value='Yes'  id='choice_7_44_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_7_44_0' id='label_7_44_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_7_44_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_44' type='radio' value='No'  id='choice_7_44_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_7_44_1' id='label_7_44_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_7_56\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-full gfield_contains_required field_sublabel_above gfield--no-description field_description_above field_validation_above gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_7_56'>Language required:<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_56' id='input_7_56' type='text' value='' class='large'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_7_46\" class=\"gfield gfield--type-section gfield--input-type-section gsection field_sublabel_above gfield--no-description field_description_above field_validation_above gfield_visibility_visible\"  ><h3 class=\"gsection_title\">Screening Locations<\/h3><\/div><div id=\"field_7_57\" class=\"gfield gfield--type-html gfield--input-type-html gfield--width-full gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_above gfield--no-description field_description_above field_validation_above gfield_visibility_visible\"  ><p>Our staff will talk to you about where you can have your child\u2019s hearing screened when they call you to book an appointment.<\/p><\/div><fieldset id=\"field_7_47\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield--input-type-checkbox gfield--width-full field_sublabel_above gfield--has-description field_description_above field_validation_above gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Where would you prefer your child\u2019s hearing screen?<\/legend><div class='gfield_description' id='gfield_description_7_47'>To help us with your booking, please indicate where you would prefer your child to have their hearing screened (tick as many as you like):<\/div><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox gfield_choice--select_all_enabled' id='input_7_47'><div class='gchoice gchoice_7_47_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_47.1' type='checkbox'  value='Caboolture'  id='choice_7_47_1'   aria-describedby=\"gfield_description_7_47\"\/>\n\t\t\t\t\t\t\t\t<label for='choice_7_47_1' id='label_7_47_1' class='gform-field-label gform-field-label--type-inline'>Caboolture<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_7_47_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_47.2' type='checkbox'  value='Redcliffe'  id='choice_7_47_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_7_47_2' id='label_7_47_2' class='gform-field-label gform-field-label--type-inline'>Redcliffe<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_7_47_3'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_47.3' type='checkbox'  value='Strathpine'  id='choice_7_47_3'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_7_47_3' id='label_7_47_3' class='gform-field-label gform-field-label--type-inline'>Strathpine<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_7_47_4'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_47.4' type='checkbox'  value='Kilcoy'  id='choice_7_47_4'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_7_47_4' id='label_7_47_4' class='gform-field-label gform-field-label--type-inline'>Kilcoy<\/label>\n\t\t\t\t\t\t\t<\/div><div class=\"gfield-choice-toggle-all\"><button type=\"button\" id=\"button_47_select_all\" class=\"gfield_choice_all_toggle gform-theme-button--size-sm\" onclick=\"gformToggleCheckboxes( this )\" data-checked=\"0\" data-label-select=\"Select All\" data-label-deselect=\"Deselect All\">Select All<\/button><\/div><\/div><\/div><\/fieldset><div id=\"field_7_48\" class=\"gfield gfield--type-html gfield--input-type-html gfield--width-full gfield_html gfield_html_formatted field_sublabel_above gfield--no-description field_description_above field_validation_above gfield_visibility_visible\"  ><p>By submitting this form, you agree our bookings team can call you to arrange an appointment. We will contact you within 5 business days from a private number.\u201d  Can this please be changed to: By submitting this form, you agree our bookings team can call you on the phone number you have provided to discuss the referral and book an appointment for your child.  We will contact you within 5 business days.  The call will come from a private number.<\/p><\/div><div id=\"field_7_14\" class=\"gfield gfield--type-html gfield--input-type-html gfield--width-full gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_above gfield--no-description field_description_above field_validation_above gfield_visibility_visible\"  >\n\n\n<style>\n  body { font-family: Arial, sans-serif; }\n  #searchInput { width: 300px; padding: 8px; }\n\n  \/* Suggestions dropdown *\/\n  #suggestions {\n    border: 1px solid #ccc;\n    max-height: 150px;\n    overflow-y: auto;\n    position: absolute;\n    background: white;\n    width: 100%;          \/* match input width *\/\n    display: none;\n    z-index: 1000;\n  }\n  #suggestions div {\n    padding: 8px;\n    cursor: pointer;\n  }\n  #suggestions div:hover {\n    background-color: #f0f0f0;\n  }\n\n  \/* Alerts *\/\n  .alert {\n    position: relative;\n    padding: 1rem 1.25rem;\n    margin-bottom: 1rem;\n    border: 1px solid transparent;\n    border-radius: 0.25rem;\n    font-size: 1rem;\n  }\n  .alert-success {\n    color: #0f5132;\n    background-color: #d1e7dd;\n    border-color: #badbcc;\n  }\n  .alert-danger {\n    color: #842029;\n    background-color: #f8d7da;\n    border-color: #f5c2c7;\n  }\n<\/style>\n\n<script>\ndocument.addEventListener(\"DOMContentLoaded\", function() {\n  \/\/ Map of suburbs \u2192 postcodes\n  const suburbPostcodes = {\n    \"bald hills\": \"4036\",\n    \"clear mountain\": \"4500\",\n    \"king scrub\": \"4521\",\n    \"narangba\": \"4504\",\n    \"strathpine\": \"4500\",\n    \"banksia beach\": \"4507\",\n    \"clontarf\": \"4019\",\n    \"kingaham\": \"4515\",\n    \"neurum\": \"4514\",\n    \"taigum\": \"4018\",\n    \"beachmere\": \"4510\",\n    \"commissioners flat\": \"4514\",\n    \"kippa-ring\": \"4021\",\n    \"newport\": \"4020\",\n    \"toorbul\": \"4510\",\n    \"bellara\": \"4507\",\n    \"d\u2019aguilar\": \"4514\",\n    \"kurwongbah\": \"4503\",\n    \"ningi\": \"4511\",\n    \"upper caboolture\": \"4510\",\n    \"bellmere\": \"4510\",\n    \"dakabin\": \"4503\",\n    \"lacey\u2019s creek\": \"4521\",\n    \"north lakes\": \"4509\",\n    \"villeneuve\": \"4514\",\n    \"bellthorpe\": \"4514\",\n    \"dayboro\": \"4521\",\n    \"lawnton\": \"4501\",\n    \"ocean view\": \"4521\",\n    \"wamuran\": \"4512\",\n    \"bongaree\": \"4507\",\n    \"deagon\": \"4017\",\n    \"little goat island\": \"4025\",\n    \"petrie\": \"4502\",\n    \"wamuran basin\": \"4512\",\n    \"bracalba\": \"4512\",\n    \"deception bay\": \"4508\",\n    \"mango hill\": \"4509\",\n    \"redcliffe\": \"4020\",\n    \"warner\": \"4500\",\n    \"bracken ridge\": \"4017\",\n    \"delaney\u2019s creek\": \"4514\",\n    \"margate\": \"4019\",\n    \"rocksberg\": \"4510\",\n    \"welsby\": \"4507\",\n    \"bray park\": \"4500\",\n    \"donnybrook\": \"4510\",\n    \"meldale\": \"4510\",\n    \"rothwell\": \"4022\",\n    \"white patch\": \"4507\",\n    \"brendale\": \"4500\",\n    \"elimbah\": \"4516\",\n    \"monsildale\": \"4515\",\n    \"royston\": \"4515\",\n    \"whiteside\": \"4503\",\n    \"bribie island\": \"4507\",\n    \"fitzgibbon\": \"4018\",\n    \"moodlu\": \"4510\",\n    \"rush creek\": \"4521\",\n    \"winya\": \"4515\",\n    \"brighton\": \"4017\",\n    \"glenfern\": \"4515\",\n    \"moorina\": \"4506\",\n    \"sandgate\": \"4017\",\n    \"woodford\": \"4514\",\n    \"burpengary\": \"4505\",\n    \"godwin beach\": \"4510\",\n    \"morayfield\": \"4506\",\n    \"sandstone point\": \"4511\",\n    \"woody point\": \"4019\",\n    \"burpengary east\": \"4505\",\n    \"griffin\": \"4503\",\n    \"mount archer\": \"4514\",\n    \"sandy creek\": \"4515\",\n    \"woomar\": \"4512\",\n    \"caboolture\": \"4510\",\n    \"hazeldean\": \"4515\",\n    \"mount delaney\": \"4514\",\n    \"scarborough\": \"4020\",\n    \"woorim\": \"4507\",\n    \"caboolture south\": \"4510\",\n    \"jimna\": \"4515\",\n    \"mount kilcoy\": \"4515\",\n    \"sheep station creek\": \"4515\",\n    \"campbells pocket\": \"4521\",\n    \"joyner\": \"4500\",\n    \"mount mee\": \"4521\",\n    \"shorncliffe\": \"4017\",\n    \"cashmere\": \"4500\",\n    \"kallangur\": \"4503\",\n    \"mount pleasant\": \"4520\",\n    \"stanmore\": \"4514\",\n    \"cedarton\": \"4514\",\n    \"kilcoy\": \"4515\",\n    \"murrumba downs\": \"4503\",\n    \"stony creek\": \"4514\"\n  };\n\n\n  function normalize(str) {\n    return str\n      .toLowerCase()\n      .replace(\/[\\u2019\\u2018]\/g, \"'\")\n      .replace(\/[\\u2013\\u2014]\/g, \"-\")\n      .replace(\/[^\\w\\s'-]\/g, \"\")\n      .replace(\/\\s+\/g, \" \")\n      .trim();\n  }\n\n  const inputField = document.querySelector(\"#input_7_16\");\n  const hiddenField = document.querySelector(\"#input_7_19\");\n  const suggestionsDiv = document.querySelector(\"#suggestions\");\n  const resultField = document.querySelector(\"#result\");\n\n  \/\/ Anchor suggestions inside the input\u2019s parent\n  if (inputField && suggestionsDiv) {\n    const parent = inputField.parentNode;\n    parent.style.position = \"relative\";\n    parent.appendChild(suggestionsDiv);\n    suggestionsDiv.style.top = \"100%\";\n    suggestionsDiv.style.left = \"0\";\n    suggestionsDiv.style.width = \"100%\";\n  }\n\n  inputField.addEventListener(\"input\", function() {\n    const raw = inputField.value;\n    const value = normalize(raw);\n    let result = \"\";\n    suggestionsDiv.innerHTML = \"\";\n\n    hiddenField.value = \"\";\n    jQuery(hiddenField).trigger(\"change\");\n\n    if (!value) {\n      resultField.textContent = \"\";\n      suggestionsDiv.style.display = \"none\";\n      return;\n    }\n\n    \/\/ Case 1: Exact suburb match\n    if (suburbPostcodes[value]) {\n      result = `\"${capitalize(value)}\" \"${suburbPostcodes[value]} is a valid suburb, you can use the service\"`;\n      resultField.textContent = result;\n      resultField.className = \"alert alert-success\";\n      hiddenField.value = suburbPostcodes[value];\n      jQuery(hiddenField).trigger(\"change\");\n      suggestionsDiv.style.display = \"none\";\n      return;\n    }\n\n    \/\/ Case 2: Direct postcode input\n    if (\/^\\d{4}$\/.test(value)) {\n      const suburbs = Object.keys(suburbPostcodes).filter(\n        suburb => suburbPostcodes[suburb] === value\n      );\n      if (suburbs.length > 0) {\n        result = `Suburbs with postcode ${value}: ${suburbs.map(capitalize).join(\", \")}`;\n        resultField.textContent = result;\n        resultField.className = \"alert alert-success\";\n        hiddenField.value = value;\n        jQuery(hiddenField).trigger(\"change\");\n\n        suburbs.forEach(suburb => {\n          const div = document.createElement(\"div\");\n          div.textContent = capitalize(suburb);\n          div.onclick = () => {\n            inputField.value = capitalize(suburb);\n            resultField.textContent = `Postcode for \"${capitalize(suburb)}\" is ${value}`;\n            hiddenField.value = value;\n            jQuery(hiddenField).trigger(\"change\");\n            suggestionsDiv.style.display = \"none\";\n          };\n          suggestionsDiv.appendChild(div);\n        });\n        suggestionsDiv.style.display = \"block\";\n        return;\n      }\n    }\n\n    \/\/ Case 3: Partial matches\n    const matches = Object.keys(suburbPostcodes).filter(suburb =>\n      suburb.includes(value)\n    );\n    if (matches.length > 0) {\n      matches.forEach(match => {\n        const div = document.createElement(\"div\");\n        div.textContent = capitalize(match);\n        div.onclick = () => {\n          inputField.value = capitalize(match);\n          resultField.textContent = `${capitalize(match)} \"${suburbPostcodes[match]} is a valid suburb to use the service\"`;\n          resultField.className = \"alert alert-success\";\n          hiddenField.value = suburbPostcodes[match];\n          jQuery(hiddenField).trigger(\"change\");\n          suggestionsDiv.style.display = \"none\";\n        };\n        suggestionsDiv.appendChild(div);\n      });\n      suggestionsDiv.style.display = \"block\";\n    } else {\n      resultField.textContent = \"Not an eligible suburb.\";\n      resultField.className = \"alert alert-danger\";\n      suggestionsDiv.style.display = \"none\";\n    }\n  });\n\n  \/\/ Close suggestions when clicking outside\n  document.addEventListener(\"click\", function(event) {\n    if (!suggestionsDiv.contains(event.target) && event.target !== inputField) {\n      suggestionsDiv.style.display = \"none\";\n    }\n  });\n\n  function capitalize(str) {\n    return str.replace(\/\\b\\w\/g, c => c.toUpperCase());\n  }\n});\n<\/script>\n<\/div><div id=\"field_7_58\" class=\"gfield gfield--type-captcha gfield--input-type-captcha gfield--width-full field_sublabel_above gfield--no-description field_description_above field_validation_above gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_7_58'>CAPTCHA<\/label><div id='input_7_58' 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