{"id":987965,"date":"2026-02-25T06:11:00","date_gmt":"2026-02-25T11:11:00","guid":{"rendered":"https:\/\/anchoredself.org\/web2\/?page_id=987965"},"modified":"2026-03-06T07:29:14","modified_gmt":"2026-03-06T12:29:14","slug":"registration","status":"publish","type":"page","link":"https:\/\/anchoredself.org\/web\/registration\/","title":{"rendered":"Registration"},"content":{"rendered":"\t\t<div data-elementor-type=\"wp-page\" data-elementor-id=\"987965\" class=\"elementor elementor-987965\" data-elementor-post-type=\"page\">\n\t\t\t\t<div class=\"elementor-element elementor-element-6999fab e-flex e-con-boxed e-con e-parent\" data-id=\"6999fab\" data-element_type=\"container\" data-e-type=\"container\">\n\t\t\t\t\t<div class=\"e-con-inner\">\n\t\t<div class=\"elementor-element elementor-element-fd80592 e-con-full e-flex e-con e-child\" data-id=\"fd80592\" data-element_type=\"container\" data-e-type=\"container\" data-settings=\"{&quot;background_background&quot;:&quot;classic&quot;}\">\n\t\t<div class=\"elementor-element elementor-element-1ffbee4 e-con-full e-flex e-con e-child\" data-id=\"1ffbee4\" data-element_type=\"container\" data-e-type=\"container\">\n\t\t\t\t<div class=\"elementor-element elementor-element-edc54c8 animated-fast elementor-invisible elementor-widget elementor-widget-heading\" data-id=\"edc54c8\" data-element_type=\"widget\" data-e-type=\"widget\" data-settings=\"{&quot;_animation&quot;:&quot;slideInUp&quot;}\" data-widget_type=\"heading.default\">\n\t\t\t\t<div class=\"elementor-widget-container\">\n\t\t\t\t\t<h3 class=\"elementor-heading-title elementor-size-default\">Fill The Registration Form Below<\/h3>\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t<div class=\"elementor-element elementor-element-ba4fb5d e-con-full animated-fast e-flex elementor-invisible e-con e-child\" data-id=\"ba4fb5d\" data-element_type=\"container\" data-e-type=\"container\" data-settings=\"{&quot;animation&quot;:&quot;slideInUp&quot;,&quot;animation_delay&quot;:100}\">\n\t\t\t\t<div class=\"elementor-element elementor-element-b5b9f05 animated-fast elementor-widget-divider--view-line elementor-invisible elementor-widget elementor-widget-divider\" data-id=\"b5b9f05\" data-element_type=\"widget\" data-e-type=\"widget\" data-settings=\"{&quot;_animation&quot;:&quot;zoomIn&quot;}\" data-widget_type=\"divider.default\">\n\t\t\t\t<div class=\"elementor-widget-container\">\n\t\t\t\t\t\t\t<div class=\"elementor-divider\">\n\t\t\t<span class=\"elementor-divider-separator\">\n\t\t\t\t\t\t<\/span>\n\t\t<\/div>\n\t\t\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t<div class=\"elementor-element elementor-element-691fdcf elementor-widget elementor-widget-heading\" data-id=\"691fdcf\" data-element_type=\"widget\" data-e-type=\"widget\" data-widget_type=\"heading.default\">\n\t\t\t\t<div class=\"elementor-widget-container\">\n\t\t\t\t\t<div class=\"elementor-heading-title elementor-size-default\">Sign Up<\/div>\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t<div class=\"elementor-element elementor-element-e880474 animated-fast elementor-widget-divider--view-line elementor-invisible elementor-widget elementor-widget-divider\" data-id=\"e880474\" data-element_type=\"widget\" data-e-type=\"widget\" data-settings=\"{&quot;_animation&quot;:&quot;zoomIn&quot;}\" data-widget_type=\"divider.default\">\n\t\t\t\t<div class=\"elementor-widget-container\">\n\t\t\t\t\t\t\t<div class=\"elementor-divider\">\n\t\t\t<span class=\"elementor-divider-separator\">\n\t\t\t\t\t\t<\/span>\n\t\t<\/div>\n\t\t\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t<div class=\"elementor-element elementor-element-1907c7d elementor-widget elementor-widget-shortcode\" data-id=\"1907c7d\" data-element_type=\"widget\" data-e-type=\"widget\" data-widget_type=\"shortcode.default\">\n\t\t\t\t<div class=\"elementor-widget-container\">\n\t\t\t\t\t\t\t<div class=\"elementor-shortcode\"><div class='fluentform ff-default fluentform_wrapper_12 ffs_default_wrap'><form data-form_id=\"12\" id=\"fluentform_12\" class=\"frm-fluent-form fluent_form_12 ff-el-form-top ff_form_instance_12_1 ff-form-loading ffs_default\" data-form_instance=\"ff_form_instance_12_1\" method=\"POST\" ><fieldset  style=\"border: none!important;margin: 0!important;padding: 0!important;background-color: transparent!important;box-shadow: none!important;outline: none!important; min-inline-size: 100%;\">\n                    <legend class=\"ff_screen_reader_title\" style=\"display: block; margin: 0!important;padding: 0!important;height: 0!important;text-indent: -999999px;width: 0!important;overflow:hidden;\">Chronic Pain Relief Experience - Registration Application<\/legend><input type='hidden' name='__fluent_form_embded_post_id' value='987965' \/><input type=\"hidden\" id=\"_fluentform_12_fluentformnonce\" name=\"_fluentform_12_fluentformnonce\" value=\"dbb7d52f59\" \/><input type=\"hidden\" name=\"_wp_http_referer\" value=\"\/web\/wp-json\/wp\/v2\/pages\/987965\" \/><div class='ff-el-group  ff-custom_html' tabindex='-1' data-name=\"section1_html\" ><h3 style=\"border-bottom: 2px solid #1a7efb;padding-bottom: 10px;margin-top: 30px\">Contact Details<\/h3><\/div><div data-type=\"name-element\" data-name=\"names\" class=\" ff-field_container ff-name-field-wrapper\" ><div class='ff-t-container'><div class='ff-t-cell '><div class='ff-el-group ff-el-form-top'><div class=\"ff-el-input--label ff-el-is-required asterisk-right\"><label for='ff_12_names_first_name_' id='label_ff_12_names_first_name_' >First Name<\/label><\/div><div class='ff-el-input--content'><input type=\"text\" name=\"names[first_name]\" id=\"ff_12_names_first_name_\" class=\"ff-el-form-control\" placeholder=\"First Name\" aria-invalid=\"false\" aria-required=true><\/div><\/div><\/div><div class='ff-t-cell '><div class='ff-el-group ff-el-form-top'><div class=\"ff-el-input--label ff-el-is-required asterisk-right\"><label for='ff_12_names_last_name_' id='label_ff_12_names_last_name_' >Last Name<\/label><\/div><div class='ff-el-input--content'><input type=\"text\" name=\"names[last_name]\" id=\"ff_12_names_last_name_\" class=\"ff-el-form-control\" placeholder=\"Last Name\" aria-invalid=\"false\" aria-required=true><\/div><\/div><\/div><\/div><\/div><div class='ff-el-group'><div class=\"ff-el-input--label ff-el-is-required asterisk-right\"><label for='ff_12_email' id='label_ff_12_email' aria-label=\"Email Address\">Email Address<\/label><div class=\"ff-el-tooltip\" data-content=\"All event correspondence will be sent to this address\"><svg width=\"16\" height=\"16\" viewBox=\"0 0 25 25\"><path d=\"m329 393l0-46c0-2-1-4-2-6-2-2-4-3-7-3l-27 0 0-146c0-3-1-5-3-7-2-1-4-2-7-2l-91 0c-3 0-5 1-7 2-1 2-2 4-2 7l0 46c0 2 1 5 2 6 2 2 4 3 7 3l27 0 0 91-27 0c-3 0-5 1-7 3-1 2-2 4-2 6l0 46c0 3 1 5 2 7 2 1 4 2 7 2l128 0c3 0 5-1 7-2 1-2 2-4 2-7z m-36-256l0-46c0-2-1-4-3-6-2-2-4-3-7-3l-54 0c-3 0-5 1-7 3-2 2-3 4-3 6l0 46c0 3 1 5 3 7 2 1 4 2 7 2l54 0c3 0 5-1 7-2 2-2 3-4 3-7z m182 119c0 40-9 77-29 110-20 34-46 60-80 80-33 20-70 29-110 29-40 0-77-9-110-29-34-20-60-46-80-80-20-33-29-70-29-110 0-40 9-77 29-110 20-34 46-60 80-80 33-20 70-29 110-29 40 0 77 9 110 29 34 20 60 46 80 80 20 33 29 70 29 110z\" transform=\"scale(0.046875 0.046875)\"><\/path><\/svg><\/div><\/div><div class='ff-el-input--content'><input type=\"email\" name=\"email\" id=\"ff_12_email\" class=\"ff-el-form-control\" placeholder=\"your.email@example.com\" data-name=\"email\"  aria-invalid=\"false\" aria-required=true><\/div><\/div><div class='ff-el-group'><div class=\"ff-el-input--label ff-el-is-required asterisk-right\"><label for='ff_12_phone_primary' id='label_ff_12_phone_primary' aria-label=\"Primary Phone Number\">Primary Phone Number<\/label><\/div><div class='ff-el-input--content'><input name=\"phone_primary\" class=\"ff-el-form-control ff-el-phone ff_el_with_extended_validation\" type=\"tel\" placeholder=\"(123) 456-7890\" data-name=\"phone_primary\" id=\"ff_12_phone_primary\" inputmode=\"tel\"  aria-invalid='false' aria-required=true><\/div><\/div><div class='ff-el-group'><div class=\"ff-el-input--label ff-el-is-required asterisk-right\"><label for='ff_12_multi_select' id='label_ff_12_multi_select' aria-label=\"Age Range\">Age Range<\/label><\/div><div class='ff-el-input--content'><select name=\"multi_select[]\" id=\"ff_12_multi_select\" class=\"ff-el-form-control  ff_has_multi_select\" multiple=\"1\" data-name=\"multi_select\" data-calc_value=\"0\"  aria-invalid=\"false\" aria-required=\"true\" aria-labelledby=\"label_ff_12_multi_select\"><option value=\"0-17\"  >0-17<\/option><option value=\"18-36\"  >18-36<\/option><option value=\"37-50\"  >37-50<\/option><option value=\"50 and Above\"  >50 and Above<\/option><\/select><\/div><\/div><div class='ff-el-group'><div class=\"ff-el-input--label ff-el-is-required asterisk-right\"><label for='ff_12_gender' id='label_ff_12_gender' aria-label=\"Gender\">Gender<\/label><\/div><div class='ff-el-input--content'><select name=\"gender\" id=\"ff_12_gender\" class=\"ff-el-form-control\" placeholder=\"- Select Gender -\" data-name=\"gender\" data-calc_value=\"0\"  aria-invalid=\"false\" aria-required=\"true\" aria-labelledby=\"label_ff_12_gender\"><option value=\"\">- Select -<\/option><option value=\"female\"  >Female<\/option><option value=\"male\"  >Male<\/option><option value=\"non_binary\"  >Non-binary<\/option><option value=\"prefer_not_say\"  >Prefer not to say<\/option><option value=\"other\"  >Other<\/option><\/select><\/div><\/div><div class='ff-el-group'><div class=\"ff-el-input--label ff-el-is-required asterisk-right\"><label for='ff_12_pain_average' id='label_ff_12_pain_average' aria-label=\"On a scale of 0-10, what is your average pain level on most days?\">On a scale of 0-10, what is your average pain level on most days?<\/label><div class=\"ff-el-tooltip\" data-content=\"0 = No pain | 10 = Worst pain imaginable\"><svg width=\"16\" height=\"16\" viewBox=\"0 0 25 25\"><path d=\"m329 393l0-46c0-2-1-4-2-6-2-2-4-3-7-3l-27 0 0-146c0-3-1-5-3-7-2-1-4-2-7-2l-91 0c-3 0-5 1-7 2-1 2-2 4-2 7l0 46c0 2 1 5 2 6 2 2 4 3 7 3l27 0 0 91-27 0c-3 0-5 1-7 3-1 2-2 4-2 6l0 46c0 3 1 5 2 7 2 1 4 2 7 2l128 0c3 0 5-1 7-2 1-2 2-4 2-7z m-36-256l0-46c0-2-1-4-3-6-2-2-4-3-7-3l-54 0c-3 0-5 1-7 3-2 2-3 4-3 6l0 46c0 3 1 5 3 7 2 1 4 2 7 2l54 0c3 0 5-1 7-2 2-2 3-4 3-7z m182 119c0 40-9 77-29 110-20 34-46 60-80 80-33 20-70 29-110 29-40 0-77-9-110-29-34-20-60-46-80-80-20-33-29-70-29-110 0-40 9-77 29-110 20-34 46-60 80-80 33-20 70-29 110-29 40 0 77 9 110 29 34 20 60 46 80 80 20 33 29 70 29 110z\" transform=\"scale(0.046875 0.046875)\"><\/path><\/svg><\/div><\/div><div class='ff-el-input--content'><input type=\"number\" name=\"pain_average\" id=\"ff_12_pain_average\" class=\"ff-el-form-control\" placeholder=\"0-10\" max=\"10\" step=\"any\" data-name=\"pain_average\" inputmode=\"numeric\"  aria-invalid=\"false\" aria-required=true><\/div><\/div><div class='ff-el-group'><div class=\"ff-el-input--label ff-el-is-required asterisk-right\"><label for='ff_12_time_slot' id='label_ff_12_time_slot' aria-label=\"Select Your Consultation Time\">Select Your Consultation Time<\/label><\/div><div class='ff-el-input--content'><select name=\"time_slot\" id=\"ff_12_time_slot\" class=\"ff-el-form-control\" data-name=\"time_slot\" data-calc_value=\"0\"  aria-invalid=\"false\" aria-required=\"true\" aria-labelledby=\"label_ff_12_time_slot\"><option value=\"\">\u2014 Choose from 41 available slots \u2014<\/option><option value=\"2026-03-28|09:00:00|09:15:00\"  >\ud83d\udcc5 Saturday, March 28, 2026 \u2014 9:00 AM - 9:15 AM EST<\/option><option value=\"2026-03-28|09:20:00|09:35:00\"  >\ud83d\udcc5 Saturday, March 28, 2026 \u2014 9:20 AM - 9:35 AM EST<\/option><option value=\"2026-03-28|09:40:00|09:55:00\"  >\ud83d\udcc5 Saturday, March 28, 2026 \u2014 9:40 AM - 9:55 AM EST<\/option><option value=\"2026-03-28|10:00:00|10:15:00\"  >\ud83d\udcc5 Saturday, March 28, 2026 \u2014 10:00 AM - 10:15 AM EST<\/option><option value=\"2026-03-28|10:20:00|10:35:00\"  >\ud83d\udcc5 Saturday, March 28, 2026 \u2014 10:20 AM - 10:35 AM EST<\/option><option value=\"2026-03-28|10:40:00|10:55:00\"  >\ud83d\udcc5 Saturday, March 28, 2026 \u2014 10:40 AM - 10:55 AM EST<\/option><option value=\"2026-03-28|11:00:00|11:15:00\"  >\ud83d\udcc5 Saturday, March 28, 2026 \u2014 11:00 AM - 11:15 AM EST<\/option><option value=\"2026-03-28|11:20:00|11:35:00\"  >\ud83d\udcc5 Saturday, March 28, 2026 \u2014 11:20 AM - 11:35 AM EST<\/option><option value=\"2026-03-28|11:40:00|11:55:00\"  >\ud83d\udcc5 Saturday, March 28, 2026 \u2014 11:40 AM - 11:55 AM EST<\/option><option value=\"2026-03-28|13:00:00|13:15:00\"  >\ud83d\udcc5 Saturday, March 28, 2026 \u2014 1:00 PM - 1:15 PM EST<\/option><option value=\"2026-03-28|13:20:00|13:35:00\"  >\ud83d\udcc5 Saturday, March 28, 2026 \u2014 1:20 PM - 1:35 PM EST<\/option><option value=\"2026-03-28|13:40:00|13:55:00\"  >\ud83d\udcc5 Saturday, March 28, 2026 \u2014 1:40 PM - 1:55 PM EST<\/option><option value=\"2026-03-28|14:00:00|14:15:00\"  >\ud83d\udcc5 Saturday, March 28, 2026 \u2014 2:00 PM - 2:15 PM EST<\/option><option value=\"2026-03-28|14:20:00|14:35:00\"  >\ud83d\udcc5 Saturday, March 28, 2026 \u2014 2:20 PM - 2:35 PM EST<\/option><option value=\"2026-03-28|14:40:00|14:55:00\"  >\ud83d\udcc5 Saturday, March 28, 2026 \u2014 2:40 PM - 2:55 PM EST<\/option><option value=\"2026-03-28|15:00:00|15:15:00\"  >\ud83d\udcc5 Saturday, March 28, 2026 \u2014 3:00 PM - 3:15 PM EST<\/option><option value=\"2026-03-28|15:20:00|15:35:00\"  >\ud83d\udcc5 Saturday, March 28, 2026 \u2014 3:20 PM - 3:35 PM EST<\/option><option value=\"2026-03-28|15:40:00|15:55:00\"  >\ud83d\udcc5 Saturday, March 28, 2026 \u2014 3:40 PM - 3:55 PM EST<\/option><option value=\"2026-03-28|16:00:00|16:15:00\"  >\ud83d\udcc5 Saturday, March 28, 2026 \u2014 4:00 PM - 4:15 PM EST<\/option><option value=\"2026-03-28|16:20:00|16:35:00\"  >\ud83d\udcc5 Saturday, March 28, 2026 \u2014 4:20 PM - 4:35 PM EST<\/option><option value=\"2026-03-29|09:00:00|09:15:00\"  >\ud83d\udcc5 Sunday, March 29, 2026 \u2014 9:00 AM - 9:15 AM EST<\/option><option value=\"2026-03-29|09:20:00|09:35:00\"  >\ud83d\udcc5 Sunday, March 29, 2026 \u2014 9:20 AM - 9:35 AM EST<\/option><option value=\"2026-03-29|09:40:00|09:55:00\"  >\ud83d\udcc5 Sunday, March 29, 2026 \u2014 9:40 AM - 9:55 AM EST<\/option><option value=\"2026-03-29|10:00:00|10:15:00\"  >\ud83d\udcc5 Sunday, March 29, 2026 \u2014 10:00 AM - 10:15 AM EST<\/option><option value=\"2026-03-29|10:20:00|10:35:00\"  >\ud83d\udcc5 Sunday, March 29, 2026 \u2014 10:20 AM - 10:35 AM EST<\/option><option value=\"2026-03-29|10:40:00|10:55:00\"  >\ud83d\udcc5 Sunday, March 29, 2026 \u2014 10:40 AM - 10:55 AM EST<\/option><option value=\"2026-03-29|11:00:00|11:15:00\"  >\ud83d\udcc5 Sunday, March 29, 2026 \u2014 11:00 AM - 11:15 AM EST<\/option><option value=\"2026-03-29|11:20:00|11:35:00\"  >\ud83d\udcc5 Sunday, March 29, 2026 \u2014 11:20 AM - 11:35 AM EST<\/option><option value=\"2026-03-29|11:40:00|11:55:00\"  >\ud83d\udcc5 Sunday, March 29, 2026 \u2014 11:40 AM - 11:55 AM EST<\/option><option value=\"2026-03-29|13:00:00|13:15:00\"  >\ud83d\udcc5 Sunday, March 29, 2026 \u2014 1:00 PM - 1:15 PM EST<\/option><option value=\"2026-03-29|13:20:00|13:35:00\"  >\ud83d\udcc5 Sunday, March 29, 2026 \u2014 1:20 PM - 1:35 PM EST<\/option><option value=\"2026-03-29|13:40:00|13:55:00\"  >\ud83d\udcc5 Sunday, March 29, 2026 \u2014 1:40 PM - 1:55 PM EST<\/option><option value=\"2026-03-29|14:00:00|14:15:00\"  >\ud83d\udcc5 Sunday, March 29, 2026 \u2014 2:00 PM - 2:15 PM EST<\/option><option value=\"2026-03-29|14:20:00|14:35:00\"  >\ud83d\udcc5 Sunday, March 29, 2026 \u2014 2:20 PM - 2:35 PM EST<\/option><option value=\"2026-03-29|14:40:00|14:55:00\"  >\ud83d\udcc5 Sunday, March 29, 2026 \u2014 2:40 PM - 2:55 PM EST<\/option><option value=\"2026-03-29|15:00:00|15:15:00\"  >\ud83d\udcc5 Sunday, March 29, 2026 \u2014 3:00 PM - 3:15 PM EST<\/option><option value=\"2026-03-29|15:20:00|15:35:00\"  >\ud83d\udcc5 Sunday, March 29, 2026 \u2014 3:20 PM - 3:35 PM EST<\/option><option value=\"2026-03-29|15:40:00|15:55:00\"  >\ud83d\udcc5 Sunday, March 29, 2026 \u2014 3:40 PM - 3:55 PM EST<\/option><option value=\"2026-03-29|16:00:00|16:15:00\"  >\ud83d\udcc5 Sunday, March 29, 2026 \u2014 4:00 PM - 4:15 PM EST<\/option><option value=\"2026-03-29|16:20:00|16:35:00\"  >\ud83d\udcc5 Sunday, March 29, 2026 \u2014 4:20 PM - 4:35 PM EST<\/option><option value=\"2026-03-29|16:40:00|16:55:00\"  >\ud83d\udcc5 Sunday, March 29, 2026 \u2014 4:40 PM - 4:55 PM EST<\/option><\/select><\/div><\/div><div class='ff-el-group'><div class=\"ff-el-input--label ff-el-is-required asterisk-right\"><label   aria-label=\"Clinical Assessment Understanding\">Clinical Assessment Understanding<\/label><\/div><div class='ff-el-input--content'><div class='ff-el-form-check'><label class='ff-el-form-check-label' for='consent_clinical_1c51a5a807ffbfe73dcd6e7baa0b874c'><input  type=\"checkbox\" name=\"consent_clinical[]\" data-name=\"consent_clinical\" class=\"ff-el-form-check-input ff-el-form-check-checkbox\" value=\"understand_assessment\"  id='consent_clinical_1c51a5a807ffbfe73dcd6e7baa0b874c' aria-label='I understand this is a clinical assessment and educational experience, not a treatment guarantee' aria-invalid='false' aria-required=true> <span>I understand this is a clinical assessment and educational experience, not a treatment guarantee<\/span><\/label><\/div><div class='ff-el-form-check'><label class='ff-el-form-check-label' for='consent_clinical_ec828c7c99d43fd21e00e72e32bf5a65'><input  type=\"checkbox\" name=\"consent_clinical[]\" data-name=\"consent_clinical\" class=\"ff-el-form-check-input ff-el-form-check-checkbox\" value=\"no_guarantee\"  id='consent_clinical_ec828c7c99d43fd21e00e72e32bf5a65' aria-label='I understand that participation does not guarantee pain relief or any specific outcome' aria-invalid='false' aria-required=true> <span>I understand that participation does not guarantee pain relief or any specific outcome<\/span><\/label><\/div><div class='ff-el-form-check'><label class='ff-el-form-check-label' for='consent_clinical_51832f00363f9af06c6693ef2f46970a'><input  type=\"checkbox\" name=\"consent_clinical[]\" data-name=\"consent_clinical\" class=\"ff-el-form-check-input ff-el-form-check-checkbox\" value=\"not_replacement\"  id='consent_clinical_51832f00363f9af06c6693ef2f46970a' aria-label='I understand this experience is not a replacement for ongoing medical care' aria-invalid='false' aria-required=true> <span>I understand this experience is not a replacement for ongoing medical care<\/span><\/label><\/div><\/div><\/div><div class='ff-el-group'><div class=\"ff-el-input--label ff-el-is-required asterisk-right\"><label   aria-label=\"Participation Agreements\">Participation Agreements<\/label><\/div><div class='ff-el-input--content'><div class='ff-el-form-check'><label class='ff-el-form-check-label' for='consent_participation_2c2e62a23c538e6524546c5546cf5ea1'><input  type=\"checkbox\" name=\"consent_participation[]\" data-name=\"consent_participation\" class=\"ff-el-form-check-input ff-el-form-check-checkbox\" value=\"active_participation\"  id='consent_participation_2c2e62a23c538e6524546c5546cf5ea1' aria-label='I agree to actively participate in all program components to the best of my ability' aria-invalid='false' aria-required=true> <span>I agree to actively participate in all program components to the best of my ability<\/span><\/label><\/div><div class='ff-el-form-check'><label class='ff-el-form-check-label' for='consent_participation_ddbbfa900e5da63a9f07655b44923976'><input  type=\"checkbox\" name=\"consent_participation[]\" data-name=\"consent_participation\" class=\"ff-el-form-check-input ff-el-form-check-checkbox\" value=\"confidentiality\"  id='consent_participation_ddbbfa900e5da63a9f07655b44923976' aria-label='I agree to maintain confidentiality regarding other participants&#039; personal information' aria-invalid='false' aria-required=true> <span>I agree to maintain confidentiality regarding other participants' personal information<\/span><\/label><\/div><div class='ff-el-form-check'><label class='ff-el-form-check-label' for='consent_participation_aac73cb1654f4b5757ef572aa2b75a6a'><input  type=\"checkbox\" name=\"consent_participation[]\" data-name=\"consent_participation\" class=\"ff-el-form-check-input ff-el-form-check-checkbox\" value=\"withdraw\"  id='consent_participation_aac73cb1654f4b5757ef572aa2b75a6a' aria-label='I understand I may withdraw from the program at any time' aria-invalid='false' aria-required=true> <span>I understand I may withdraw from the program at any time<\/span><\/label><\/div><\/div><\/div><div class='ff-el-group'><div class=\"ff-el-input--label ff-el-is-required asterisk-right\"><label   aria-label=\"Privacy &amp; Data Use\">Privacy &amp; Data Use<\/label><\/div><div class='ff-el-input--content'><div class='ff-el-form-check'><label class='ff-el-form-check-label' for='consent_privacy_6eed61834380b32f1de7bf26f86ab496'><input  type=\"checkbox\" name=\"consent_privacy[]\" data-name=\"consent_privacy\" class=\"ff-el-form-check-input ff-el-form-check-checkbox\" value=\"data_collection\"  id='consent_privacy_6eed61834380b32f1de7bf26f86ab496' aria-label='I consent to De AnchoredSelf LLC collecting and securely storing my health information for program purposes' aria-invalid='false' aria-required=true> <span>I consent to De AnchoredSelf LLC collecting and securely storing my health information for program purposes<\/span><\/label><\/div><div class='ff-el-form-check'><label class='ff-el-form-check-label' for='consent_privacy_a8dce6ffdedf07846b7491725d4c49a4'><input  type=\"checkbox\" name=\"consent_privacy[]\" data-name=\"consent_privacy\" class=\"ff-el-form-check-input ff-el-form-check-checkbox\" value=\"hipaa\"  id='consent_privacy_a8dce6ffdedf07846b7491725d4c49a4' aria-label='I understand my information will be kept confidential and handled in accordance with HIPAA regulations' aria-invalid='false' aria-required=true> <span>I understand my information will be kept confidential and handled in accordance with HIPAA regulations<\/span><\/label><\/div><div class='ff-el-form-check'><label class='ff-el-form-check-label' for='consent_privacy_3f700025b3b6e155e7768945d127b083'><input  type=\"checkbox\" name=\"consent_privacy[]\" data-name=\"consent_privacy\" class=\"ff-el-form-check-input ff-el-form-check-checkbox\" value=\"contact_consent\"  id='consent_privacy_3f700025b3b6e155e7768945d127b083' aria-label='I consent to being contacted via email and phone regarding my application and the program' aria-invalid='false' aria-required=true> <span>I consent to being contacted via email and phone regarding my application and the program<\/span><\/label><\/div><\/div><\/div><div class='ff-el-group  ff-custom_html' tabindex='-1' data-name=\"section6b_html\" ><h4 style=\"margin-top:25px\">Attestation &amp; Signature<\/h4><\/div><div class='ff-el-group    ff-el-input--content'><div class='ff-el-form-check ff-el-tc'><label aria-label='I certify that all information provided in this application is true and accurate to the best of my knowledge. I understand that submission of this application does not guarantee acceptance to the Chronic Pain Relief Experience, and that acceptance is subject to clinical review.' class='ff-el-form-check-label ff_tc_label' for=terms_and_conditions_7f954c04c620504b8eeaef06466a2abe><span class='ff_tc_checkbox'><input type=\"checkbox\" name=\"terms_and_conditions\" class=\"ff-el-form-check-input\" data-name=\"terms_and_conditions\" id=\"terms_and_conditions_7f954c04c620504b8eeaef06466a2abe\"  value='on' aria-invalid='false' aria-required=true><\/span> <div class='ff_t_c'>I certify that all information provided in this application is true and accurate to the best of my knowledge. I understand that submission of this application does not guarantee acceptance to the Chronic Pain Relief Experience, and that acceptance is subject to clinical review.<\/div><\/label><\/div><\/div><div class='ff-el-group'><div class=\"ff-el-input--label ff-el-is-required asterisk-right\"><label for='ff_12_signature' id='label_ff_12_signature' aria-label=\"Electronic Signature (Type your full legal name)\">Electronic Signature (Type your full legal name)<\/label><div class=\"ff-el-tooltip\" data-content=\"By typing your name, you are electronically signing this application\"><svg width=\"16\" height=\"16\" viewBox=\"0 0 25 25\"><path d=\"m329 393l0-46c0-2-1-4-2-6-2-2-4-3-7-3l-27 0 0-146c0-3-1-5-3-7-2-1-4-2-7-2l-91 0c-3 0-5 1-7 2-1 2-2 4-2 7l0 46c0 2 1 5 2 6 2 2 4 3 7 3l27 0 0 91-27 0c-3 0-5 1-7 3-1 2-2 4-2 6l0 46c0 3 1 5 2 7 2 1 4 2 7 2l128 0c3 0 5-1 7-2 1-2 2-4 2-7z m-36-256l0-46c0-2-1-4-3-6-2-2-4-3-7-3l-54 0c-3 0-5 1-7 3-2 2-3 4-3 6l0 46c0 3 1 5 3 7 2 1 4 2 7 2l54 0c3 0 5-1 7-2 2-2 3-4 3-7z m182 119c0 40-9 77-29 110-20 34-46 60-80 80-33 20-70 29-110 29-40 0-77-9-110-29-34-20-60-46-80-80-20-33-29-70-29-110 0-40 9-77 29-110 20-34 46-60 80-80 33-20 70-29 110-29 40 0 77 9 110 29 34 20 60 46 80 80 20 33 29 70 29 110z\" transform=\"scale(0.046875 0.046875)\"><\/path><\/svg><\/div><\/div><div class='ff-el-input--content'><input type=\"text\" name=\"signature\" id=\"ff_12_signature\" class=\"ff-el-form-control\" placeholder=\"Type your full legal name\" data-name=\"signature\"  aria-invalid=\"false\" aria-required=true><\/div><\/div><div class='ff-el-group'><div class=\"ff-el-input--label ff-el-is-required asterisk-right\"><label for='ff_12_signature_date' id='label_ff_12_signature_date' aria-label=\"Date\">Date<\/label><\/div><div class='ff-el-input--content'><input  aria-label='Date Use arrow keys to navigate dates. Press enter to select a date.'  aria-haspopup='dialog' data-type-datepicker data-format='m\/d\/Y' type=\"text\" name=\"signature_date\" id=\"ff_12_signature_date\" class=\"ff-el-form-control ff-el-datepicker\" data-name=\"signature_date\"  aria-invalid='false' aria-required=true><\/div><\/div><div class='ff-el-group  ff-custom_html' tabindex='-1' data-name=\"after_submission_html\" ><div style=\"background:#e8f4f8;padding:20px;border-radius:5px;margin-top:25px\"><h4 style=\"margin-top:0\">After Submission - What happens next?<\/h4><ul><li><strong>Confirmation:<\/strong> You will receive an immediate email confirming we received your application<\/li><li><strong>Review:<\/strong> Our clinical team reviews your application within 5-7 business days<\/li><li><strong>Decision:<\/strong> You will be notified of acceptance, waitlist status, or alternative recommendations<\/li><li><strong>Enrollment:<\/strong> Accepted applicants receive payment instructions and must confirm within 72 hours to secure their spot<\/li><li><strong>Preparation:<\/strong> Confirmed participants receive detailed preparation materials 2-3 weeks before the event<\/li><\/ul><p><strong>Questions?<\/strong> Contact us at <a href=\"mailto:contact@anchoredself.org\">contact@anchoredself.org<\/a> or <a href=\"tel:4435317599\">(443) 531-7599<\/a><\/p><p>Thank you for your interest in the Chronic Pain Relief Experience. We look forward to reviewing your application.<\/p><\/div><\/div><div class='ff-el-group ff-text-center ff_submit_btn_wrapper ff_submit_btn_wrapper_custom'><button class=\"ff-btn ff-btn-submit ff-btn-lg ff_btn_style wpf_has_custom_css\" type=\"submit\" name=\"custom_submit_button-12_1\" data-name=\"custom_submit_button-12_1\"  aria-label=\"Submit Application\">Submit Application<\/button><\/div><div class='ff-el-group ff-text-left ff_submit_btn_wrapper ff_submit_btn_wrapper_custom'><button class=\"ff-btn ff-btn-submit ff-btn-md ff_btn_style wpf_has_custom_css\" type=\"submit\" name=\"custom_submit_button-12_2\" data-name=\"custom_submit_button-12_2\"  aria-label=\"Submit\">Submit<\/button><style>form.fluent_form_12 .wpf_has_custom_css.ff-btn-submit { background-color:#1a7efb;border-color:#1a7efb;color:#ffffff;min-width:100%; }form.fluent_form_12 .wpf_has_custom_css.ff-btn-submit:hover { background-color:#ffffff;border-color:#1a7efb;color:#1a7efb;min-width:100%; } 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appointment.<\/p>\n","protected":false},"author":1,"featured_media":0,"parent":0,"menu_order":0,"comment_status":"closed","ping_status":"closed","template":"","meta":{"footnotes":""},"class_list":["post-987965","page","type-page","status-publish","hentry"],"_links":{"self":[{"href":"https:\/\/anchoredself.org\/web\/wp-json\/wp\/v2\/pages\/987965","targetHints":{"allow":["GET"]}}],"collection":[{"href":"https:\/\/anchoredself.org\/web\/wp-json\/wp\/v2\/pages"}],"about":[{"href":"https:\/\/anchoredself.org\/web\/wp-json\/wp\/v2\/types\/page"}],"author":[{"embeddable":true,"href":"https:\/\/anchoredself.org\/web\/wp-json\/wp\/v2\/users\/1"}],"replies":[{"embeddable":true,"href":"https:\/\/anchoredself.org\/web\/wp-json\/wp\/v2\/comments?post=987965"}],"version-history":[{"count":44,"href":"https:\/\/anchoredself.org\/web\/wp-json\/wp\/v2\/pages\/987965\/revisions"}],"predecessor-version":[{"id":988089,"href":"https:\/\/anchoredself.org\/web\/wp-json\/wp\/v2\/pages\/987965\/revisions\/988089"}],"wp:attachment":[{"href":"https:\/\/anchoredself.org\/web\/wp-json\/wp\/v2\/media?parent=987965"}],"curies":[{"name":"wp","href":"https:\/\/api.w.org\/{rel}","templated":true}]}}