Actionstep Intake Form

<link type=”text/css” rel=”stylesheet” href=”https://cdn.actionstep.com/assets/DatetimeControl.css” media=”screen”>
<script type=”text/javascript” src=”https://cdn.actionstep.com/assets/Locale.js”></script>
<script type=”text/javascript” src=”https://cdn.actionstep.com/assets/DatetimeControl.js”></script>
<script type=”text/javascript” src=”https://cdn.actionstep.com/assets/phpDateUtilities.js”></script>
<script type=”text/javascript”>
//<!–
if (typeof(ActionStep_Locale) !== ‘undefined’) {
ActionStep_Locale.setDateFormats(‘%m/%d/%Y’, ‘%b %e, %Y’, ‘%A %B %e, %Y’);
ActionStep_Locale.setFirstDayOfTheWeek(‘Sunday’);
}

if (typeof(jQuery) != ‘undefined’) {
jQuery(window).ready(function() {
jQuery(‘.DateControl_CalIcon’).attr(“src”, “https://cdn.actionstep.com/assets/ActionStep_DatetimeControl_Cal.png”);
});
} else {
window.setTimeout(function() {
var calImages = document.getElementsByClassName(“DateControl_CalIcon”);
for (var i=0;i<calImages.length;i++) {
calImages[i].src = “https://cdn.actionstep.com/assets/ActionStep_DatetimeControl_Cal.png”;
}
}, 500);
}
ActionStep_DatetimeControl.CONFIG.dateFormat = ‘MMDDYYYY’;

//–>
</script>
<style>
.AdvancedForm {
margin:0;
padding:0;
font-family:inherit;
line-height:1.4;
font-size:1em;
color:#222;
}
.AdvancedForm .FormField {
margin:0 0 2px 0;
width:100%;
font-size:inherit;
padding:6px;
overflow:hidden;
white-space:nowrap;
vertical-align:top;
}
.AdvancedForm label {
width:18em;
float:left;
font-weight:bold;
margin:0 0 3px 0;
padding-right:10px;
font-size:inherit;
white-space:normal;
text-align:right;
vertical-align:top;
}
.AdvancedForm label.required:after {
content:”*”;
color:red;
display:inline-block;
vertical-align:top;
margin-left:3px;
font-size:0.9em;
}
.AdvancedForm p {
margin:2em 0;
font-size:inherit;
}
.AdvancedForm p.hint {
color:#777;
margin:0;
display:inline-block;
}
.AdvancedForm input,
.AdvancedForm textarea {
border:1px #ccc solid;
padding:0.2em;
margin:0;
display:inline;
font:inherit;
}
.AdvancedForm input[type=text],
.AdvancedForm textarea
{
width:18em;
}
.AdvancedForm input.DateControl_DateInputBox {
width:6em;
}
.AdvancedForm input.TimeControl_TimeInputBox {
width:6em;
}
.AdvancedForm .DateControl_MemoInputBox {
width:10em;
border-color:#ccc;
border-style:dotted;
border-width:0 0 1px 0;
color:#555;
font-style:italic;
}
.AdvancedForm .FormField input:focus,
.AdvancedForm .FormField textarea:focus {
border-color:#aaa;
}
.AdvancedForm .FormField select {
padding:0;
margin:0;
display:inline;
min-width:10em;
max-width:18em;
}
.AdvancedForm .Submit {
background:none;
}
.AdvancedForm button.Submit {
font-weight:bold;
cursor:pointer;
}

</style>
<form id=”ActionStepWebform2″ name=”ActionStepWebform2″ enctype=”application/x-www-form-urlencoded” class=”AdvancedForm Webform3″ method=”post” action=”https://go.actionstep.com/frontend/application/webform/post”>

<input type=”hidden” name=”organization_key” value=”rm7117″ class=”OrganizationKey” id=”organization_key”>

<input type=”hidden” name=”uid” value=”fd89e097d3494d64cfd98b5bbb663b363d76e247″ class=”Uid” id=”uid”>
<div class=”FormField P1FirstName”><label for=”p1__first_name” class=”optional js-label”>Client’s First Name</label>

<input type=”text” name=”p1__first_name” id=”p1__first_name” value=”” class=”P1FirstName”>
<p class=”hint”>First Name</p></div>
<div class=”FormField Dc21CurrentOffer”><label for=”dc21__CurrentOffer” class=”optional js-label”>Client’s Last Name</label>

<input type=”text” name=”dc21__CurrentOffer” id=”dc21__CurrentOffer” value=”” class=”Dc21CurrentOffer” onchange=”;if (this.value != &#39;&#39;) { this.value=ActionStep_Utilities_Math.formatCurrency(this.value); } ” allowEmpty=””>
<p class=”hint”>Last Name</p></div>
<div class=”FormField P1Phone1″><label for=”p1__phone1″ class=”optional js-label”>Phone</label>

<input type=”text” name=”p1__phone1″ id=”p1__phone1″ value=”” class=”P1Phone1″></div>
<div class=”FormField P1EMail”><label for=”p1__e_mail” class=”optional js-label”>Email</label>

<input type=”text” name=”p1__e_mail” id=”p1__e_mail” value=”” class=”P1EMail”></div>
<div class=”FormField Dc20ConflictCheck”><label for=”dc20__ConflictCheck” class=”optional js-label”>How can we help?</label>

<input type=”text” name=”dc20__ConflictCheck” id=”dc20__ConflictCheck” value=”” class=”Dc20ConflictCheck”></div>
<div class=”FormField Submit”>
<input type=”submit” name=”Submit” id=”Submit” value=”Submit” class=”Submit”></div></form>