{"id":2557,"date":"2026-04-07T21:33:21","date_gmt":"2026-04-07T21:33:21","guid":{"rendered":"https:\/\/www.maryfreebed.com\/kids\/inpatient-admission-inquiry-2\/"},"modified":"2026-04-14T19:30:39","modified_gmt":"2026-04-14T19:30:39","slug":"outpatient-admission-inquiry","status":"publish","type":"page","link":"https:\/\/www.maryfreebed.com\/kids\/outpatient-admission-inquiry\/","title":{"rendered":"Outpatient Admission Inquiry"},"content":{"rendered":"\n<div class=\"wp-block-group alignfull is-style-default has-background has-global-padding is-layout-constrained wp-container-core-group-is-layout-4f6d0aca wp-block-group-is-layout-constrained\" style=\"background:linear-gradient(180deg,rgb(255,156,0) 53%,rgba(255,157,0,0) 53%);margin-top:0;margin-bottom:0;padding-top:var(--wp--preset--spacing--70);padding-right:var(--wp--preset--spacing--50);padding-bottom:var(--wp--preset--spacing--30);padding-left:var(--wp--preset--spacing--50)\">\n<div class=\"wp-block-group alignwide has-base-background-color has-background is-layout-flow wp-container-core-group-is-layout-2a668712 wp-block-group-is-layout-flow\" style=\"border-style:none;border-width:0px;border-top-left-radius:12px;border-top-right-radius:12px;border-bottom-left-radius:32px;border-bottom-right-radius:32px;margin-top:0;margin-bottom:0;padding-top:0;padding-right:0;padding-bottom:0;padding-left:0;box-shadow:var(--wp--preset--shadow--natural)\">\n<div class=\"wp-block-uagb-container uagb-block-4b43a20a alignwide uagb-is-root-container\">\n<div class=\"wp-block-uagb-container uagb-block-3e587c7f\">\n<div class=\"wp-block-group is-vertical is-content-justification-stretch is-nowrap is-layout-flex wp-container-core-group-is-layout-23840d10 wp-block-group-is-layout-flex\" style=\"min-height:100%\">\n<div class=\"wp-block-group is-layout-flow wp-container-core-group-is-layout-19eabfb7 wp-block-group-is-layout-flow\">\n<h1 class=\"wp-block-heading has-text-align-left has-xx-large-font-size\"><strong><strong>Outpatient Admission Inquiry<\/strong><\/strong><\/h1>\n\n\n\n<p style=\"font-size:clamp(0.875rem, 0.875rem + ((1vw - 0.2rem) * 0.196), 1rem);\">Looking for outpatient rehabilitation? We\u2019re here to help. Share your name and contact information below, and our team will reach out to discuss your needs and next steps.<\/p>\n<\/div>\n<\/div>\n<\/div>\n\n\n\n<div class=\"wp-block-uagb-container hero-image-column uagb-block-38e42af9\"><\/div>\n<\/div>\n<\/div>\n<\/div>\n\n\n\n<div class=\"wp-block-group alignfull is-style-section-1 has-base-background-color has-background has-global-padding is-layout-constrained wp-container-core-group-is-layout-d89aad35 wp-block-group-is-layout-constrained is-style-section-1--1\" style=\"margin-top:0;margin-bottom:0;padding-top:var(--wp--preset--spacing--50);padding-right:var(--wp--preset--spacing--50);padding-bottom:var(--wp--preset--spacing--50);padding-left:var(--wp--preset--spacing--50)\">\n<div class=\"wp-block-group alignwide is-style-default has-border-color has-base-background-color has-background is-layout-flow wp-block-group-is-layout-flow\" 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3.1.\"),o(),0))},initializeOnLoaded:function(o){gform.callIfLoaded(o)||(document.addEventListener(\"gform_main_scripts_loaded\",()=>{gform.scriptsLoaded=!0,gform.callIfLoaded(o)}),document.addEventListener(\"gform\/theme\/scripts_loaded\",()=>{gform.themeScriptsLoaded=!0,gform.callIfLoaded(o)}),window.addEventListener(\"DOMContentLoaded\",()=>{gform.domLoaded=!0,gform.callIfLoaded(o)}))},hooks:{action:{},filter:{}},addAction:function(o,r,e,t){gform.addHook(\"action\",o,r,e,t)},addFilter:function(o,r,e,t){gform.addHook(\"filter\",o,r,e,t)},doAction:function(o){gform.doHook(\"action\",o,arguments)},applyFilters:function(o){return gform.doHook(\"filter\",o,arguments)},removeAction:function(o,r){gform.removeHook(\"action\",o,r)},removeFilter:function(o,r,e){gform.removeHook(\"filter\",o,r,e)},addHook:function(o,r,e,t,n){null==gform.hooks[o][r]&&(gform.hooks[o][r]=[]);var 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#112337;--gf-ctrl-choice-size: var(--gf-ctrl-choice-size-md);--gf-ctrl-checkbox-check-size: var(--gf-ctrl-checkbox-check-size-md);--gf-ctrl-radio-check-size: var(--gf-ctrl-radio-check-size-md);--gf-ctrl-btn-font-size: var(--gf-ctrl-btn-font-size-md);--gf-ctrl-btn-padding-x: var(--gf-ctrl-btn-padding-x-md);--gf-ctrl-btn-size: var(--gf-ctrl-btn-size-md);--gf-ctrl-btn-border-color-secondary: #686e77;--gf-ctrl-file-btn-bg-color-hover: #EBEBEB;--gf-field-img-choice-size: var(--gf-field-img-choice-size-md);--gf-field-img-choice-card-space: var(--gf-field-img-choice-card-space-md);--gf-field-img-choice-check-ind-size: var(--gf-field-img-choice-check-ind-size-md);--gf-field-img-choice-check-ind-icon-size: var(--gf-field-img-choice-check-ind-icon-size-md);--gf-field-pg-steps-number-color: rgba(17, 35, 55, 0.8);}<\/style>\n                        <div class='gform_heading'>\n                            <h2 class=\"gform_title\">Kids Outpatient Admission Inquiry<\/h2>\n                            <p class='gform_description'>To make an appointment for outpatient programs or services, call <a href=\"tel:+16168408005\" title=\"Click to Call\">616.840.8005<\/a> or leave your name and contact information below. We&#8217;ll be in touch!<\/p>\n                        <\/div><form method='post' enctype='multipart\/form-data'  id='gform_2'  action='\/kids\/wp-json\/wp\/v2\/pages\/2557' data-formid='2' novalidate>\n                        <div class='gform-body gform_body'><div id='gform_fields_2' class='gform_fields top_label form_sublabel_below description_below validation_below'><fieldset id=\"field_2_1\" class=\"gfield gfield--type-name gfield--input-type-name hipaa_forms_name gfield_contains_required field_sublabel_hidden_label gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Patient 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_2_1'>\n                            \n                            <span id='input_2_1_3_container' class='name_first gform-grid-col gform-grid-col--size-auto' >\n                                                    <input type='text' name='input_1.3' id='input_2_1_3' value=''   aria-required='true'   placeholder='First'  \/>\n                                                    <label for='input_2_1_3' class='gform-field-label gform-field-label--type-sub hidden_sub_label screen-reader-text'>First<\/label>\n                                                <\/span>\n                            \n                            <span id='input_2_1_6_container' class='name_last gform-grid-col gform-grid-col--size-auto' >\n                                                    <input type='text' name='input_1.6' id='input_2_1_6' value=''   aria-required='true'   placeholder='Last'  \/>\n                                                    <label for='input_2_1_6' class='gform-field-label gform-field-label--type-sub hidden_sub_label screen-reader-text'>Last<\/label>\n                                                <\/span>\n                            \n                        <\/div><\/fieldset><div id=\"field_2_4\" class=\"gfield gfield--type-date gfield--input-type-date gfield--input-type-datepicker gfield--datepicker-no-icon gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_2_4'>Patient Date of Birth<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/label><div class='ginput_container ginput_container_date'>\n                            <input name='input_4' id='input_2_4' type='text' value='' class='datepicker gform-datepicker mdy datepicker_no_icon gdatepicker-no-icon'   placeholder='mm\/dd\/yyyy' aria-describedby=\"input_2_4_date_format\" aria-invalid=\"false\" aria-required=\"true\"\/>\n                            <span id='input_2_4_date_format' class='screen-reader-text'>MM slash DD slash YYYY<\/span>\n                        <\/div>\n                        <input type='hidden' id='gforms_calendar_icon_input_2_4' class='gform_hidden' value='https:\/\/www.maryfreebed.com\/kids\/wp-content\/plugins\/gravityforms\/images\/datepicker\/datepicker.svg'\/><\/div><div id=\"field_2_6\" class=\"gfield gfield--type-select gfield--input-type-select gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_2_6'>Patient Status<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/label><div class='ginput_container ginput_container_select'><select name='input_6' id='input_2_6' class='large gfield_select'    aria-required=\"true\" aria-invalid=\"false\" ><option value='Never been a patient at Mary Free Bed' >Never been a patient at Mary Free Bed<\/option><option value='Current patient at Mary Free Bed' >Current patient at Mary Free Bed<\/option><option value='Former patient at Mary Free Bed' >Former patient at Mary Free Bed<\/option><\/select><\/div><\/div><div id=\"field_2_7\" class=\"gfield gfield--type-select gfield--input-type-select gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_2_7'>Appointment Type<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/label><div class='ginput_container ginput_container_select'><select name='input_7' id='input_2_7' class='large gfield_select'    aria-required=\"true\" aria-invalid=\"false\" ><option value='Physician consultation' >Physician consultation<\/option><option value='Therapy appointment' >Therapy appointment<\/option><option value='Orthotics &amp; Prosthetics + Bionics appointment (O&amp;P+B)' >Orthotics &amp; Prosthetics + Bionics appointment (O&amp;P+B)<\/option><option value='Other' >Other<\/option><\/select><\/div><\/div><div id=\"field_2_10\" class=\"gfield gfield--type-select gfield--input-type-select gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_2_10'>Preferred Location<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/label><div class='ginput_container ginput_container_select'><select name='input_10' id='input_2_10' class='large gfield_select'    aria-required=\"true\" aria-invalid=\"false\" ><option value='Grand Rapids' selected='selected'>Grand Rapids<\/option><option value='Holland' >Holland<\/option><option value='Kalamazoo' >Kalamazoo<\/option><option value='Lansing (O&amp;P+B only)' >Lansing (O&amp;P+B only)<\/option><option value='Muskegon' >Muskegon<\/option><option value='Saginaw' >Saginaw<\/option><option value='Spartan Nash YMCA' >Spartan Nash YMCA<\/option><option value='St. Joseph (O&amp;P+B only)' >St. Joseph (O&amp;P+B only)<\/option><option value='Traverse City' >Traverse City<\/option><option value='Troy (O&amp;P+B only)' >Troy (O&amp;P+B only)<\/option><\/select><\/div><\/div><div id=\"field_2_11\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_2_11'>Preferred Language<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_11' id='input_2_11' type='text' value='English' class='large'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_2_8\" class=\"gfield gfield--type-textarea gfield--input-type-textarea gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_2_8'>Reason for appointment<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_8' id='input_2_8' class='textarea large'    placeholder='Briefly describe the patient&#039;s illness, injury or condition.' aria-required=\"true\" aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/div><fieldset id=\"field_2_9\" class=\"gfield gfield--type-name gfield--input-type-name gfield--width-full field_sublabel_hidden_label gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Contact Name (if different than patient)<\/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_2_9'>\n                            \n                            <span id='input_2_9_3_container' class='name_first gform-grid-col gform-grid-col--size-auto' >\n                                                    <input type='text' name='input_9.3' id='input_2_9_3' value=''   aria-required='false'   placeholder='First'  \/>\n                                                    <label for='input_2_9_3' class='gform-field-label gform-field-label--type-sub hidden_sub_label screen-reader-text'>First<\/label>\n                                                <\/span>\n                            \n                            <span id='input_2_9_6_container' class='name_last gform-grid-col gform-grid-col--size-auto' >\n                                                    <input type='text' name='input_9.6' id='input_2_9_6' value=''   aria-required='false'   placeholder='Last'  \/>\n                                                    <label for='input_2_9_6' class='gform-field-label gform-field-label--type-sub hidden_sub_label screen-reader-text'>Last<\/label>\n                                                <\/span>\n                            \n                        <\/div><\/fieldset><div id=\"field_2_2\" class=\"gfield gfield--type-phone gfield--input-type-phone hipaa_forms_phone gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_2_2'>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_2' id='input_2_2' type='tel' value='' class='large'  placeholder='Phone Number' aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_2_3\" class=\"gfield gfield--type-email gfield--input-type-email hipaa_forms_email gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_2_3'>Email<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/label><div class='ginput_container ginput_container_email'>\n                            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