{"id":1609,"date":"2025-05-15T07:06:44","date_gmt":"2025-05-15T07:06:44","guid":{"rendered":"https:\/\/softwavetherapycanada.com\/arc\/?page_id=1609"},"modified":"2025-05-15T07:09:39","modified_gmt":"2025-05-15T07:09:39","slug":"wsib-intake-form","status":"publish","type":"page","link":"https:\/\/softwavetherapycanada.com\/arc\/wsib-intake-form\/","title":{"rendered":"WSIB Intake Form"},"content":{"rendered":"\t\t<div data-elementor-type=\"wp-page\" data-elementor-id=\"1609\" class=\"elementor elementor-1609\" data-elementor-post-type=\"page\">\n\t\t\t\t<div class=\"elementor-element elementor-element-216ba9c e-flex e-con-boxed e-con e-parent\" data-id=\"216ba9c\" data-element_type=\"container\" data-settings=\"{&quot;background_background&quot;:&quot;classic&quot;}\">\n\t\t\t\t\t<div class=\"e-con-inner\">\n\t\t\t\t<div class=\"elementor-element elementor-element-25a8cc4 elementor-widget elementor-widget-heading\" data-id=\"25a8cc4\" data-element_type=\"widget\" data-widget_type=\"heading.default\">\n\t\t\t\t<div class=\"elementor-widget-container\">\n\t\t\t\t\t<h2 class=\"elementor-heading-title elementor-size-default\">WSIB<\/h2>\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t<div class=\"elementor-element elementor-element-984f9ee elementor-widget elementor-widget-heading\" data-id=\"984f9ee\" data-element_type=\"widget\" data-widget_type=\"heading.default\">\n\t\t\t\t<div class=\"elementor-widget-container\">\n\t\t\t\t\t<h2 class=\"elementor-heading-title elementor-size-default\">Intake Form<\/h2>\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t<div class=\"elementor-element elementor-element-1087c0c e-flex e-con-boxed e-con e-parent\" data-id=\"1087c0c\" data-element_type=\"container\">\n\t\t\t\t\t<div class=\"e-con-inner\">\n\t\t<div class=\"elementor-element elementor-element-aae8723 screenform e-flex e-con-boxed e-con e-child\" data-id=\"aae8723\" data-element_type=\"container\" data-settings=\"{&quot;background_background&quot;:&quot;classic&quot;}\">\n\t\t\t\t\t<div class=\"e-con-inner\">\n\t\t\t\t<div class=\"elementor-element elementor-element-37beb41 elementor-widget elementor-widget-heading\" data-id=\"37beb41\" data-element_type=\"widget\" data-widget_type=\"heading.default\">\n\t\t\t\t<div class=\"elementor-widget-container\">\n\t\t\t\t\t<h4 class=\"elementor-heading-title elementor-size-default\">WSIB<\/h4>\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t<div class=\"elementor-element elementor-element-b612de3 elementor-widget elementor-widget-heading\" data-id=\"b612de3\" data-element_type=\"widget\" data-widget_type=\"heading.default\">\n\t\t\t\t<div class=\"elementor-widget-container\">\n\t\t\t\t\t<h2 class=\"elementor-heading-title elementor-size-default\">Intake Form<\/h2>\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t<div class=\"elementor-element elementor-element-b0aaf56 contact-form elementor-widget elementor-widget-shortcode\" data-id=\"b0aaf56\" data-element_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\">\n<div class=\"wpcf7 no-js\" id=\"wpcf7-f1608-o1\" lang=\"en-US\" dir=\"ltr\" data-wpcf7-id=\"1608\">\n<div class=\"screen-reader-response\"><p role=\"status\" aria-live=\"polite\" aria-atomic=\"true\"><\/p> <ul><\/ul><\/div>\n<form action=\"\/arc\/wp-json\/wp\/v2\/pages\/1609#wpcf7-f1608-o1\" method=\"post\" class=\"wpcf7-form init\" aria-label=\"Contact form\" novalidate=\"novalidate\" data-status=\"init\">\n<fieldset class=\"hidden-fields-container\"><input type=\"hidden\" name=\"_wpcf7\" value=\"1608\" \/><input type=\"hidden\" name=\"_wpcf7_version\" value=\"6.1\" \/><input type=\"hidden\" name=\"_wpcf7_locale\" value=\"en_US\" \/><input type=\"hidden\" name=\"_wpcf7_unit_tag\" value=\"wpcf7-f1608-o1\" \/><input type=\"hidden\" name=\"_wpcf7_container_post\" value=\"0\" \/><input type=\"hidden\" name=\"_wpcf7_posted_data_hash\" value=\"\" \/>\n<\/fieldset>\n<div class=\"container mva-mini-form\">\n  <h3>Name (required)<\/h3>\n  <div class=\"row\">\n    <div class=\"col-md-6 mb-3\">\n      <span class=\"wpcf7-form-control-wrap\" data-name=\"first-name\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required form-control\" aria-required=\"true\" aria-invalid=\"false\" placeholder=\"First Name\" value=\"\" type=\"text\" name=\"first-name\" \/><\/span>\n    <\/div>\n    <div class=\"col-md-6 mb-3\">\n      <span class=\"wpcf7-form-control-wrap\" data-name=\"last-name\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required form-control\" aria-required=\"true\" aria-invalid=\"false\" placeholder=\"Last Name\" value=\"\" type=\"text\" name=\"last-name\" \/><\/span>\n    <\/div>\n  <\/div>\n\n  <h3>Accident Information<\/h3>\n  <div class=\"form-group mb-3\">\n    <span class=\"wpcf7-form-control-wrap\" data-name=\"date-of-loss\"><input class=\"wpcf7-form-control wpcf7-date wpcf7-validates-as-date form-control\" aria-invalid=\"false\" placeholder=\"mm\/dd\/yyyy\" value=\"\" type=\"date\" name=\"date-of-loss\" \/><\/span>\n  <\/div>\n\n  <div class=\"form-group mb-3\">\n    <span class=\"wpcf7-form-control-wrap\" data-name=\"occupation\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text form-control\" aria-invalid=\"false\" placeholder=\"Occupation\" value=\"\" type=\"text\" name=\"occupation\" \/><\/span>\n  <\/div>\n\n  <div class=\"form-group mb-3\">\n    <span class=\"wpcf7-form-control-wrap\" data-name=\"job-duration\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text form-control\" aria-invalid=\"false\" placeholder=\"Length of time at current job\" value=\"\" type=\"text\" name=\"job-duration\" \/><\/span>\n  <\/div>\n\n  <div class=\"form-group mb-3\">\n    <span class=\"wpcf7-form-control-wrap\" data-name=\"sin\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text form-control\" aria-invalid=\"false\" placeholder=\"SIN\" value=\"\" type=\"text\" name=\"sin\" \/><\/span>\n  <\/div>\n\n  <div class=\"form-group mb-3\">\n    <strong>Are you currently receiving treatment from another health care professional?<\/strong><br>\n    <span class=\"wpcf7-form-control-wrap\" data-name=\"receiving-treatment\"><span class=\"wpcf7-form-control wpcf7-radio\"><span class=\"wpcf7-list-item first\"><label><input type=\"radio\" name=\"receiving-treatment\" value=\"Yes\" \/><span class=\"wpcf7-list-item-label\">Yes<\/span><\/label><\/span><span class=\"wpcf7-list-item last\"><label><input type=\"radio\" name=\"receiving-treatment\" value=\"No\" \/><span class=\"wpcf7-list-item-label\">No<\/span><\/label><\/span><\/span><\/span>\n  <\/div>\n\n  <div class=\"form-group mb-3\">\n    <span class=\"wpcf7-form-control-wrap\" data-name=\"treatment-details\"><textarea cols=\"40\" rows=\"10\" maxlength=\"2000\" class=\"wpcf7-form-control wpcf7-textarea form-control\" aria-invalid=\"false\" placeholder=\"If yes, what treatment are you receiving?\" name=\"treatment-details\"><\/textarea><\/span>\n  <\/div>\n\n  <h3>Employer Information<\/h3>\n  <div class=\"form-group mb-3\">\n    <span class=\"wpcf7-form-control-wrap\" data-name=\"employer\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text form-control\" aria-invalid=\"false\" placeholder=\"Employer\" value=\"\" type=\"text\" name=\"employer\" \/><\/span>\n  <\/div>\n\n  <div class=\"form-group mb-3\">\n  <span class=\"wpcf7-form-control-wrap\" data-name=\"address-line-1\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required form-control\" aria-required=\"true\" aria-invalid=\"false\" placeholder=\"Address Line 1\" value=\"\" type=\"text\" name=\"address-line-1\" \/><\/span>\n<\/div>\n\n  <div class=\"form-group mb-3\">\n    <span class=\"wpcf7-form-control-wrap\" data-name=\"address-line-2\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text form-control\" aria-invalid=\"false\" placeholder=\"Address Line 2\" value=\"\" type=\"text\" name=\"address-line-2\" \/><\/span>\n  <\/div>\n\n  <div class=\"row\">\n    <div class=\"col-md-6 mb-3\">\n  <span class=\"wpcf7-form-control-wrap\" data-name=\"city\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required form-control\" aria-required=\"true\" aria-invalid=\"false\" placeholder=\"City\" value=\"\" type=\"text\" name=\"city\" \/><\/span>\n<\/div>\n<div class=\"col-md-6 mb-3\">\n  <span class=\"wpcf7-form-control-wrap\" data-name=\"province\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required form-control\" aria-required=\"true\" aria-invalid=\"false\" placeholder=\"Province\" value=\"\" type=\"text\" name=\"province\" \/><\/span>\n<\/div>\n\n<div class=\"form-group mb-3\">\n  <span class=\"wpcf7-form-control-wrap\" data-name=\"postal_code\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required form-control\" aria-required=\"true\" aria-invalid=\"false\" placeholder=\"Postal Code\" value=\"\" type=\"text\" name=\"postal_code\" \/><\/span>\n<\/div>\n\n\n  <div class=\"form-group mb-3\">\n    <span class=\"wpcf7-form-control-wrap\" data-name=\"country\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text form-control\" aria-invalid=\"false\" value=\"Canada\" type=\"text\" name=\"country\" \/><\/span>\n  <\/div>\n\n  <div class=\"row\">\n    <div class=\"col-md-6 mb-3\">\n      <span class=\"wpcf7-form-control-wrap\" data-name=\"supervisor-first\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text form-control\" aria-invalid=\"false\" placeholder=\"Supervisor First Name\" value=\"\" type=\"text\" name=\"supervisor-first\" \/><\/span>\n    <\/div>\n    <div class=\"col-md-6 mb-3\">\n      <span class=\"wpcf7-form-control-wrap\" data-name=\"supervisor-last\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text form-control\" aria-invalid=\"false\" placeholder=\"Supervisor Last Name\" value=\"\" type=\"text\" name=\"supervisor-last\" \/><\/span>\n    <\/div>\n  <\/div>\n\n  <div class=\"form-group mb-3\">\n    <span class=\"wpcf7-form-control-wrap\" data-name=\"supervisor-phone\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-tel wpcf7-text wpcf7-validates-as-tel form-control\" aria-invalid=\"false\" placeholder=\"Supervisor Phone\" value=\"\" type=\"tel\" name=\"supervisor-phone\" \/><\/span>\n  <\/div>\n\n  <div class=\"form-group mb-3\">\n    <span class=\"wpcf7-form-control-wrap\" data-name=\"fax\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text form-control\" aria-invalid=\"false\" placeholder=\"Fax\" value=\"\" type=\"text\" name=\"fax\" \/><\/span>\n  <\/div>\n\n  <h3>Agreement (required)<\/h3>\n <div class=\"form-group mb-3\">\n  <p>I acknowledge that any treatment fees not covered by WSIB will be my responsibility.<\/p>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"radio-615\"><span class=\"wpcf7-form-control wpcf7-radio\"><span class=\"wpcf7-list-item first\"><label><input type=\"radio\" name=\"radio-615\" value=\"Agree\" \/><span class=\"wpcf7-list-item-label\">Agree<\/span><\/label><\/span><span class=\"wpcf7-list-item last\"><label><input type=\"radio\" name=\"radio-615\" value=\"Disagree\" \/><span class=\"wpcf7-list-item-label\">Disagree<\/span><\/label><\/span><\/span><\/span>\n \n<\/div>\n\n\n  <div class=\"text-center mt-4 btn-fomr\">\n    <input class=\"wpcf7-form-control wpcf7-submit has-spinner btn btn-default px-5 py-2 fw-bold\" type=\"submit\" value=\"Submit\" \/>\n  <\/div>\n<\/div><input type='hidden' class='wpcf7-pum' value='{\"closepopup\":false,\"closedelay\":0,\"openpopup\":false,\"openpopup_id\":0}' \/><div class=\"wpcf7-response-output\" aria-hidden=\"true\"><\/div>\n<\/form>\n<\/div>\n<\/div>\n\t\t\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t<div class=\"elementor-element elementor-element-a490b6d e-con-full e-flex e-con e-parent\" data-id=\"a490b6d\" data-element_type=\"container\">\n\t\t\t\t<div class=\"elementor-element elementor-element-0eb2cfc elementor-widget elementor-widget-html\" data-id=\"0eb2cfc\" data-element_type=\"widget\" data-widget_type=\"html.default\">\n\t\t\t\t<div class=\"elementor-widget-container\">\n\t\t\t\t\t<iframe src=\"https:\/\/www.google.com\/maps\/embed?pb=!1m18!1m12!1m3!1d2528.2634840022547!2d-79.27715062381674!3d43.77555807109661!2m3!1f0!2f0!3f0!3m2!1i1024!2i768!4f13.1!3m3!1m2!1s0x89d4d19bebda1ddd%3A0xc1c4cca0249bf38e!2s2240%20Midland%20Ave%2C%20Scarborough%2C%20ON%20M1P%204R9%2C%20Canada!5e1!3m2!1sen!2s!4v1747122853705!5m2!1sen!2s\" width=\"600\" height=\"450\" style=\"border:0;\" allowfullscreen=\"\" loading=\"lazy\" referrerpolicy=\"no-referrer-when-downgrade\"><\/iframe>\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t<div class=\"elementor-element elementor-element-51cb397 e-flex e-con-boxed e-con e-parent\" data-id=\"51cb397\" data-element_type=\"container\" data-settings=\"{&quot;background_background&quot;:&quot;classic&quot;}\">\n\t\t\t\t\t<div class=\"e-con-inner\">\n\t\t<div class=\"elementor-element elementor-element-9afec90 e-con-full e-flex e-con e-child\" data-id=\"9afec90\" data-element_type=\"container\">\n\t\t\t\t<div class=\"elementor-element elementor-element-b5dc4a3 elementor-widget elementor-widget-heading\" data-id=\"b5dc4a3\" data-element_type=\"widget\" data-widget_type=\"heading.default\">\n\t\t\t\t<div class=\"elementor-widget-container\">\n\t\t\t\t\t<h2 class=\"elementor-heading-title elementor-size-default\">Didn\u2019t find the answers you were looking for?<\/h2>\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t<div class=\"elementor-element elementor-element-9698f7b elementor-widget elementor-widget-heading\" data-id=\"9698f7b\" data-element_type=\"widget\" data-widget_type=\"heading.default\">\n\t\t\t\t<div class=\"elementor-widget-container\">\n\t\t\t\t\t<p class=\"elementor-heading-title elementor-size-default\">Just get in touch with us with your preferred method! We will try our best to help you with any and all questions.<\/p>\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t<div class=\"elementor-element elementor-element-1ada86d e-con-full e-flex e-con e-child\" data-id=\"1ada86d\" data-element_type=\"container\">\n\t\t\t\t<div class=\"elementor-element elementor-element-3edc205 elementor-align-center btn-default wow fadeInUp elementor-widget elementor-widget-button\" data-id=\"3edc205\" data-element_type=\"widget\" data-widget_type=\"button.default\">\n\t\t\t\t<div class=\"elementor-widget-container\">\n\t\t\t\t\t\t\t\t\t<div class=\"elementor-button-wrapper\">\n\t\t\t\t\t<a class=\"elementor-button elementor-button-link elementor-size-sm\" href=\"#\">\n\t\t\t\t\t\t<span class=\"elementor-button-content-wrapper\">\n\t\t\t\t\t\t\t\t\t<span class=\"elementor-button-text\">Contact Us<\/span>\n\t\t\t\t\t<\/span>\n\t\t\t\t\t<\/a>\n\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t","protected":false},"excerpt":{"rendered":"<p>WSIB Intake Form WSIB Intake Form Didn\u2019t find the answers you were looking for? Just get in touch with us with your preferred method! We will try our best to help you with any and all questions. Contact Us<\/p>\n","protected":false},"author":2,"featured_media":0,"parent":0,"menu_order":0,"comment_status":"closed","ping_status":"closed","template":"elementor_header_footer","meta":{"_acf_changed":false,"footnotes":""},"class_list":["post-1609","page","type-page","status-publish","hentry"],"acf":[],"_links":{"self":[{"href":"https:\/\/softwavetherapycanada.com\/arc\/wp-json\/wp\/v2\/pages\/1609","targetHints":{"allow":["GET"]}}],"collection":[{"href":"https:\/\/softwavetherapycanada.com\/arc\/wp-json\/wp\/v2\/pages"}],"about":[{"href":"https:\/\/softwavetherapycanada.com\/arc\/wp-json\/wp\/v2\/types\/page"}],"author":[{"embeddable":true,"href":"https:\/\/softwavetherapycanada.com\/arc\/wp-json\/wp\/v2\/users\/2"}],"replies":[{"embeddable":true,"href":"https:\/\/softwavetherapycanada.com\/arc\/wp-json\/wp\/v2\/comments?post=1609"}],"version-history":[{"count":0,"href":"https:\/\/softwavetherapycanada.com\/arc\/wp-json\/wp\/v2\/pages\/1609\/revisions"}],"wp:attachment":[{"href":"https:\/\/softwavetherapycanada.com\/arc\/wp-json\/wp\/v2\/media?parent=1609"}],"curies":[{"name":"wp","href":"https:\/\/api.w.org\/{rel}","templated":true}]}}