{"id":177,"date":"2018-03-01T15:53:03","date_gmt":"2018-03-01T14:53:03","guid":{"rendered":"http:\/\/www.therapiepraxis-balli.de\/contact-form\/"},"modified":"2024-04-29T09:42:35","modified_gmt":"2024-04-29T07:42:35","slug":"contact-form","status":"publish","type":"page","link":"https:\/\/www.therapiepraxis-balli.de\/en\/contact-form\/","title":{"rendered":"Contact form"},"content":{"rendered":"<div class=\"fusion-fullwidth fullwidth-box fusion-builder-row-1 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\"><div class=\"fusion-layout-column fusion_builder_column fusion-builder-column-0 fusion_builder_column_1_6 1_6 fusion-one-sixth fusion-column-first\" style=\"--awb-bg-size:cover;width:16.666666666667%;width:calc(16.666666666667% - ( ( 4% + 4% ) * 0.16666666666667 ) );margin-right: 4%;\"><div class=\"fusion-column-wrapper fusion-flex-column-wrapper-legacy\"><div class=\"fusion-clearfix\"><\/div><\/div><\/div><div class=\"fusion-layout-column fusion_builder_column fusion-builder-column-1 fusion_builder_column_2_3 2_3 fusion-two-third\" style=\"--awb-bg-size:cover;width:66.666666666667%;width:calc(66.666666666667% - ( ( 4% + 4% ) * 0.66666666666667 ) );margin-right: 4%;\"><div class=\"fusion-column-wrapper fusion-flex-column-wrapper-legacy\"><div class=\"fusion-title title fusion-title-1 fusion-sep-none fusion-title-text fusion-title-size-one\" style=\"--awb-margin-bottom:0px;\"><h1 class=\"fusion-title-heading title-heading-left\" style=\"margin:0;\"><p class=\"page-heading\">Contact form<\/p><\/h1><\/div><div class=\"fusion-sep-clear\"><\/div><div class=\"fusion-separator fusion-clearfix\" style=\"float:left;margin-top:26px;margin-bottom:26px;width:100%;max-width:10%;\"><div class=\"fusion-separator-border sep-single\" style=\"--awb-height:20px;--awb-amount:20px;border-color:var(--awb-color5);border-top-width:1px;\"><\/div><\/div><div class=\"fusion-sep-clear\"><\/div><div class=\"fusion-title title fusion-title-2 fusion-sep-none fusion-title-text fusion-title-size-three\" style=\"--awb-margin-bottom:0px;\"><h3 class=\"fusion-title-heading title-heading-left\" style=\"margin:0;\"><p><strong>Due to the high level of demand my waiting list is nearly full. For reasons of organization, I do not accept new inquiries regarding a therapy or waiting list place.<\/strong><\/p>\n<p><strong>With thanks for your anticipated understanding.<\/strong><\/p>\n<p>Use <a href=\"https:\/\/arztsuche-hessen.de\" target=\"_blank\" rel=\"noopener\">https:\/\/arztsuche-hessen.de<\/a> to find different therapists.<\/p><\/h3><\/div><div class=\"fusion-sep-clear\"><\/div><div class=\"fusion-separator fusion-full-width-sep fusion-clearfix\" style=\"float:left;margin-top:26px;margin-bottom:26px;width:100%;max-width:100%;\"><\/div><div class=\"fusion-sep-clear\"><\/div><div class=\"fusion-text fusion-text-1\">\n<div class=\"wpcf7 no-js\" id=\"wpcf7-f403-o1\" lang=\"de-DE\" dir=\"ltr\" data-wpcf7-id=\"403\">\n<div class=\"screen-reader-response\"><p role=\"status\" aria-live=\"polite\" aria-atomic=\"true\"><\/p> <ul><\/ul><\/div>\n<form action=\"\/en\/wp-json\/wp\/v2\/pages\/177#wpcf7-f403-o1\" method=\"post\" class=\"wpcf7-form init\" aria-label=\"Kontaktformular\" novalidate=\"novalidate\" data-status=\"init\">\n<fieldset class=\"hidden-fields-container\"><input type=\"hidden\" name=\"_wpcf7\" value=\"403\" \/><input type=\"hidden\" name=\"_wpcf7_version\" value=\"6.1.5\" \/><input type=\"hidden\" name=\"_wpcf7_locale\" value=\"de_DE\" \/><input type=\"hidden\" name=\"_wpcf7_unit_tag\" value=\"wpcf7-f403-o1\" \/><input type=\"hidden\" name=\"_wpcf7_container_post\" value=\"0\" \/><input type=\"hidden\" name=\"_wpcf7_posted_data_hash\" value=\"\" \/>\n<\/fieldset>\n<div class=\"fusion-layout-column fusion_builder_column fusion_builder_column_1_2  fusion-one-half fusion-column-first fusion-blend-mode 1_2\">\n\t<p><span class=\"wpcf7-form-control-wrap\" data-name=\"geschlecht\"><select class=\"wpcf7-form-control wpcf7-select wpcf7-validates-as-required span2\" aria-required=\"true\" aria-invalid=\"false\" name=\"geschlecht\"><option value=\"Mr\">Mr<\/option><option value=\"Ms\">Ms<\/option><option value=\"Diverse\">Diverse<\/option><\/select><\/span>\n\t<\/p>\n<\/div>\n<div class=\"fusion-layout-column fusion_builder_column fusion_builder_column_1_2  fusion-one-half fusion-column-last fusion-blend-mode 1_2\">\n<\/div>\n<div class=\"fusion-layout-column fusion_builder_column fusion_builder_column_1_2  fusion-one-half fusion-column-first fusion-blend-mode 1_2\">\n\t<p><span class=\"wpcf7-form-control-wrap\" data-name=\"vorname\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required span6\" aria-required=\"true\" aria-invalid=\"false\" placeholder=\"First Name *\" value=\"\" type=\"text\" name=\"vorname\" \/><\/span>\n\t<\/p>\n<\/div>\n<div class=\"fusion-layout-column fusion_builder_column fusion_builder_column_1_2  fusion-one-half fusion-column-last fusion-blend-mode 1_2\">\n\t<p><span class=\"wpcf7-form-control-wrap\" data-name=\"nachname\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required span6\" aria-required=\"true\" aria-invalid=\"false\" placeholder=\"Family name\/Surname *\" value=\"\" type=\"text\" name=\"nachname\" \/><\/span>\n\t<\/p>\n<\/div>\n<div class=\"fusion-layout-column fusion_builder_column fusion_builder_column_1_2  fusion-one-half fusion-column-first fusion-blend-mode 1_2\">\n\t<p><span class=\"wpcf7-form-control-wrap\" data-name=\"strasse\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text span10\" aria-invalid=\"false\" placeholder=\"Street\" value=\"\" type=\"text\" name=\"strasse\" \/><\/span>\n\t<\/p>\n<\/div>\n<div class=\"fusion-layout-column fusion_builder_column fusion_builder_column_1_2  fusion-one-half fusion-column-last fusion-blend-mode 1_2\">\n\t<p><span class=\"wpcf7-form-control-wrap\" data-name=\"hausnummer\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text span2\" aria-invalid=\"false\" placeholder=\"Nr.\" value=\"\" type=\"text\" name=\"hausnummer\" \/><\/span>\n\t<\/p>\n<\/div>\n<div class=\"fusion-layout-column fusion_builder_column fusion_builder_column_1_2  fusion-one-half fusion-column-first fusion-blend-mode 1_2\">\n\t<p><span class=\"wpcf7-form-control-wrap\" data-name=\"plz\"><input size=\"40\" maxlength=\"5\" class=\"wpcf7-form-control wpcf7-text span2\" aria-invalid=\"false\" placeholder=\"Postcode\" value=\"\" type=\"text\" name=\"plz\" \/><\/span>\n\t<\/p>\n<\/div>\n<div class=\"fusion-layout-column fusion_builder_column fusion_builder_column_1_2  fusion-one-half fusion-column-last fusion-blend-mode 1_2\">\n\t<p><span class=\"wpcf7-form-control-wrap\" data-name=\"ort\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text span5\" aria-invalid=\"false\" placeholder=\"Town\" value=\"\" type=\"text\" name=\"ort\" \/><\/span>\n\t<\/p>\n<\/div>\n<div class=\"fusion-layout-column fusion_builder_column fusion_builder_column_1_2  fusion-one-half fusion-column-first fusion-blend-mode 1_2\">\n\t<p><span class=\"wpcf7-form-control-wrap\" data-name=\"email\"><input size=\"40\" maxlength=\"40\" class=\"wpcf7-form-control wpcf7-email wpcf7-validates-as-required wpcf7-text wpcf7-validates-as-email span7\" aria-required=\"true\" aria-invalid=\"false\" placeholder=\"Email Address *\" value=\"\" type=\"email\" name=\"email\" \/><\/span>\n\t<\/p>\n<\/div>\n<div class=\"fusion-layout-column fusion_builder_column fusion_builder_column_1_2  fusion-one-half fusion-column-last fusion-blend-mode 1_2\">\n\t<p><span class=\"wpcf7-form-control-wrap\" data-name=\"telefon\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-tel wpcf7-text wpcf7-validates-as-tel span4\" aria-invalid=\"false\" placeholder=\"Phone number\" value=\"\" type=\"tel\" name=\"telefon\" \/><\/span>\n\t<\/p>\n<\/div>\n<div class=\"fusion-layout-column fusion_builder_column fusion_builder_column_1_1  fusion-one-full fusion-column-first fusion-column-last fusion-blend-mode 1_1\">\n\t<p><span class=\"wpcf7-form-control-wrap\" data-name=\"kommentar\"><textarea cols=\"40\" rows=\"5\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-textarea span12\" aria-invalid=\"false\" placeholder=\"Message\" name=\"kommentar\"><\/textarea><\/span>\n\t<\/p>\n<\/div>\n<h3>Appointment times (Multiple entries possible)\n<\/h3>\n<div class=\"fusion-layout-column fusion_builder_column fusion_builder_column_1_1  fusion-one-full fusion-column-first fusion-column-last fusion-blend-mode 1_1\">\n\t<p><span class=\"span2\">weekdays *<\/span><span class=\"wpcf7-form-control-wrap\" data-name=\"termintage\"><span class=\"wpcf7-form-control wpcf7-checkbox wpcf7-validates-as-required span10\"><span class=\"wpcf7-list-item first\"><input type=\"checkbox\" name=\"termintage[]\" value=\"Monday\" \/><span class=\"wpcf7-list-item-label\">Monday<\/span><\/span><span class=\"wpcf7-list-item last\"><input type=\"checkbox\" name=\"termintage[]\" value=\"Tuesday\" \/><span class=\"wpcf7-list-item-label\">Tuesday<\/span><\/span><\/span><\/span>\n\t<\/p>\n<\/div>\n<div class=\"fusion-layout-column fusion_builder_column fusion_builder_column_1_1  fusion-one-full fusion-column-first fusion-column-last fusion-blend-mode 1_1\">\n\t<p><span class=\"span2\">times *<\/span><span class=\"wpcf7-form-control-wrap\" data-name=\"terminzeiten\"><span class=\"wpcf7-form-control wpcf7-checkbox wpcf7-validates-as-required span10\"><span class=\"wpcf7-list-item first\"><input type=\"checkbox\" name=\"terminzeiten[]\" value=\"Morning (11 am \u2013 2 pm)\" \/><span class=\"wpcf7-list-item-label\">Morning (11 am \u2013 2 pm)<\/span><\/span><span class=\"wpcf7-list-item last\"><input type=\"checkbox\" name=\"terminzeiten[]\" value=\"Afternoon (3pm \u2013 5 pm)\" \/><span class=\"wpcf7-list-item-label\">Afternoon (3pm \u2013 5 pm)<\/span><\/span><\/span><\/span>\n\t<\/p>\n<\/div>\n<p><span class=\"wpcf7-form-control-wrap wpgetcap\"><p class=\"c4wp-display-captcha-form\"><label for=\"Solve Captcha*\">Solve Captcha*<\/label><img decoding=\"async\" src=\"https:\/\/www.therapiepraxis-balli.de\/wp-admin\/admin-ajax.php?action=c4wp_refresh_captcha&c4wp_random_input_captcha=35656\" class=\"c4wp_image\"\/><br\/><a href=\"javascript:void(0);\" class=\"refresh_captcha\" data-imgsrc=\"https:\/\/www.therapiepraxis-balli.de\/wp-admin\/admin-ajax.php?action=c4wp_refresh_captcha&c4wp_random_input_captcha=14475\"><img decoding=\"async\" src=\"https:\/\/www.therapiepraxis-balli.de\/wp-content\/plugins\/wp-captcha\/\/assets\/images\/c4wp-refresh-captcha.png\" class=\"c4wp-refresh-captcha\"\/><\/a><br \/><br \/><strong>Enter Captcha Here : <\/strong><input id=\"c4wp_user_input_captcha\" name=\"c4wp_user_input_captcha\" class=\"c4wp_user_input_captcha\" type=\"text\" autocomplete=\"off\"><\/p><\/span><input type=\"hidden\" name=\"wpgetcap-sn\" \/>\n<\/p>\n<p><br \/>\n<b>Protection of data privacy:<\/b> Your details will be collated into an email and sent directly to Therapiepraxis Verena Balli. Your details will not be passed to any third parties and are only for use within Therapiepraxis Verena Balli. Your information is bound to medical confidentiality and will not be shared with anyone else.\n<\/p>\n<p>* These marked fields are compulsory\n<\/p>\n<div class=\"fusion-layout-column fusion_builder_column fusion_builder_column_1_1  fusion-one-full fusion-column-first fusion-column-last fusion-blend-mode 1_1\">\n\t<p><a href=\"https:\/\/www.therapiepraxis-balli.de\/en\/data-privacy-policy\/\"><span class=\"wpcf7-form-control-wrap\" data-name=\"terms\"><span class=\"wpcf7-form-control wpcf7-checkbox wpcf7-validates-as-required\"><span class=\"wpcf7-list-item first last\"><input type=\"checkbox\" name=\"terms[]\" value=\"I have read the Terms of Use and Privacy Policy, accept them and agree to the storage of my personal information. *\" \/><span class=\"wpcf7-list-item-label\">I have read the Terms of Use and Privacy Policy, accept them and agree to the storage of my personal information. *<\/span><\/span><\/span><\/span><\/a>\n\t<\/p>\n<\/div>\n<div class=\"fusion-layout-column fusion_builder_column fusion_builder_column_1_1  fusion-one-full fusion-column-first fusion-column-last fusion-blend-mode 1_1\">\n\t<p><input class=\"wpcf7-form-control wpcf7-submit has-spinner button\" id=\"submit\" type=\"submit\" value=\"Submit\" \/>\n\t<\/p>\n<\/div><div class=\"fusion-alert alert custom alert-custom fusion-alert-center wpcf7-response-output awb-alert-native-link-color alert-dismissable awb-alert-close-boxed\" style=\"--awb-border-size:1px;--awb-border-top-left-radius:0px;--awb-border-top-right-radius:0px;--awb-border-bottom-left-radius:0px;--awb-border-bottom-right-radius:0px;\" role=\"alert\"><div class=\"fusion-alert-content-wrapper\"><span class=\"fusion-alert-content\"><\/span><\/div><button type=\"button\" class=\"close toggle-alert\" data-dismiss=\"alert\" aria-label=\"Close\">&times;<\/button><\/div>\n<\/form>\n<\/div>\n\n<\/div><div class=\"fusion-clearfix\"><\/div><\/div><\/div><div class=\"fusion-layout-column fusion_builder_column fusion-builder-column-2 fusion_builder_column_1_6 1_6 fusion-one-sixth fusion-column-last\" style=\"--awb-bg-size:cover;width:16.666666666667%;width:calc(16.666666666667% - 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