<form method="POST" accept-charset="UTF-8" action="/form-process.php" class="questionnaire-form" id="inf_form_1e99347d03f7c9bfbd678ccaeaf80ff4"> <input name="_action" type="hidden" value="https://mx261.infusionsoft.com/app/form/process/1e99347d03f7c9bfbd678ccaeaf80ff4"/> <input name="_redirect" type="hidden" value="https://thegotophysio.com"/> <input name="inf_form_xid" type="hidden" value="https://mx261.infusionsoft.com/app/form/process/1e99347d03f7c9bfbd678ccaeaf80ff4" /> <input name="inf_form_name" type="hidden" value="Test Form (Romeo)" /> <input name="infusionsoft_version" type="hidden" value="1.70.0.613909" /> <ul class="progressbar progressbar--wider"> <li class="active"></li> <li></li> <li></li> <li></li> <li></li> <li></li> <li></li> <li></li> <li></li> <li></li> </ul> <!-- STEP 1 CONTAINER --> <fieldset class="form-group"> <div class="field-wrapper"> <label for="inf_field_FirstName_m" class="name"> <input id="inf_field_FirstName_m" name="inf_field_FirstName" placeholder="First Name *" type="text" required/> </label> <label for="inf_field_LastName_m" class="name"> <input id="inf_field_LastName_m" name="inf_field_LastName" placeholder="Last Name *" type="text" required/> </label> </div> <div class="nav-section"> <button class="previous btn" type="button" value="Previous">Previous</button> <button class="next btn" type="button" value="Next">Next</button> </div> </fieldset> <fieldset class="form-group"> <div class="field-wrapper"> <label class="email" for="inf_field_Email_m"> <input id="inf_field_Email_m" name="inf_field_Email" placeholder="Email *" type="email" required/> </label> <label class="phone" for="inf_field_Phone1_m"> <input id="inf_field_Phone1_m" name="inf_field_Phone1" placeholder="Phone *" type="text" required/> </label> </div> <div class="nav-section"> <button class="previous btn" type="button" value="Previous">Previous</button> <button class="next btn" type="button" value="Next">Next</button> </div> </fieldset> <fieldset class="form-group"> <div class="field-wrapper"> <label class="questions" for="inf_custom_Whatcountryareyoubasedin"> <input id="inf_custom_Whatcountryareyoubasedin" name="inf_custom_Whatcountryareyoubasedin" placeholder="What country are you based in *" type="text" required/> </label> </div> <div class="nav-section"> <button class="previous btn" type="button" value="Previous">Previous</button> <button class="next btn" type="button" value="Next">Next</button> </div> </fieldset> <fieldset class="form-group"> <div class="field-wrapper"> <label for="inf_custom_Whatisyourprofession1" class="questions"> <select required id="inf_custom_Whatisyourprofession1" name="inf_custom_Whatisyourprofession1"><option value="">What Is Your Profession?</option><option value="Physio / Physical Therapist / Sports Therapist">Physio / Physical Therapist / Sports Therapist</option><option value="Osteopath / Chiropractor">Osteopath / Chiropractor</option><option value="Personal Trainer / Strength Coach">Personal Trainer / Strength Coach</option><option value="Other Healthcare Professional Working With People In Pain">Other Healthcare Professional Working With People In Pain</option><option value="Student">Student</option><option value="I Don’t Work With People In Pain">I Don’t Work With People In Pain</option><option value="I Have Pain Myself And Looking For Help">I Have Pain Myself And Looking For Help</option></select> </label> <label class="questions" for="inf_custom_WhatIsYourCurrentWorkingEnvironment1"> <select required id="inf_custom_WhatIsYourCurrentWorkingEnvironment1" name="inf_custom_WhatIsYourCurrentWorkingEnvironment1"><option value="">What Is Your Current Working Environment?</option><option value="Working In Own Private Practice">Working In Own Private Practice</option><option value="Working For Someone Else In Private Practice">Working For Someone Else In Private Practice</option><option value="Working In ProSport">Working In ProSport</option><option value="National Healthcare System">National Healthcare System</option></select> </label> </div> <div class="nav-section"> <button class="previous btn" type="button" value="Previous">Previous</button> <button class="next btn" type="button" value="Next">Next</button> </div> </fieldset> <fieldset class="form-group"> <div class="field-wrapper"> <label class="questions" for="inf_custom_Howmanyyearsareyouqualifiedasatherapist"> <select required id="inf_Howmanyyearsareyouqualifiedasatherapist" name="inf_custom_Howmanyyearsareyouqualifiedasatherapist"><option value="">How many years are you qualified as a therapist?</option><option value="Still a student ">Still a student </option><option value="0-2 years ">0-2 years</option><option value="2- 5 years">2- 5 years</option><option value="5-9 years">5-9 years</option><option value="10 years +">10 years +</option></select> </label> </div> <div class="nav-section"> <button class="previous btn" type="button" value="Previous">Previous</button> <button class="next btn" type="button" value="Next">Next</button> </div> </fieldset> <fieldset class="form-group"> <div class="field-wrapper"> <label class="questions" for="inf_custom_HowlonghaveyouknownaboutDaveOSullivanthequotGoToPhysi"> <select required id="inf_custom_HowlonghaveyouknownaboutDaveOSullivanthequotGoToPhysi" name="inf_custom_HowlonghaveyouknownaboutDaveOSullivanthequotGoToPhysi"><option value="">How long have you known about Dave O'Sullivan & the "Go-To Physio" brand? </option><option value="Less than a week ">Less than a week</option><option value="1 week to 1 month">1 week to 1 month</option><option value="1 month to 3 months ">1 month to 3 months </option><option value="3+ months">3+ months</option></select> </label> </div> <div class="nav-section"> <button class="previous btn" type="button" value="Previous">Previous</button> <button class="next btn" type="button" value="Next">Next</button> </div> </fieldset> <fieldset class="form-group"> <div class="field-wrapper"> <label class="wider questions" for="inf_custom_Haveyoutriedanyothermentorshipprogramscoursesorresourc"> <textarea id="inf_custom_inf_custom_Haveyoutriedanyothermentorshipprogramscoursesorresourc" name="inf_custom_Haveyoutriedanyothermentorshipprogramscoursesorresourc" placeholder="Have you tried any other mentorship programs, courses or resources for improving as a therapist? What were the results?" required></textarea> </label> </div> <div class="nav-section"> <button class="previous btn" type="button" value="Previous">Previous</button> <button class="next btn" type="button" value="Next">Next</button> </div> </fieldset> <fieldset class="form-group"> <div class="field-wrapper"> <label class="wider questions" for="inf_custom_WhatappealstoyoumostaboutDavesmethodologyandapproach"> <textarea id="inf_custom_WhatappealstoyoumostaboutDavesmethodologyandapproach" name="inf_custom_WhatappealstoyoumostaboutDavesmethodologyandapproach" placeholder="What appeals to you most about Dave's methodology and approach?" required></textarea> </label> </div> <div class="nav-section"> <button class="previous btn" type="button" value="Previous">Previous</button> <button class="next btn" type="button" value="Next">Next</button> </div> </fieldset> <fieldset class="form-group"> <div class="field-wrapper"> <label class="wider questions" for="inf_custom_Specificallywhatgoalsareyoulookingtoachievefromworking"> <textarea id="inf_custom_Specificallywhatgoalsareyoulookingtoachievefromworking" name="inf_custom_Specificallywhatgoalsareyoulookingtoachievefromworking" placeholder="Specifically, what goals are you looking to achieve from working with Dave and the Mentorship program? " required></textarea> </label> </div> <div class="nav-section"> <button class="previous btn" type="button" value="Previous">Previous</button> <button class="next btn" type="button" value="Next">Next</button> </div> </fieldset> <!-- STEP 4 CONTAINER --> <fieldset class="form-group"> <div class="field-wrapper"> <label class="questions" for="inf_custom_Onascaleof110howurgentareyourgoalsforgrowingyourr"> <label for="inf_custom_Onascaleof110howurgentareyourgoalsforgrowingyourr">On a scale of 1-10, how urgent are your goals for growing your reputation and enhancing your skills?</label></br> <select required id="inf_custom_Onascaleof110howurgentareyourgoalsforgrowingyourr" name="inf_custom_Onascaleof110howurgentareyourgoalsforgrowingyourr"><option value="1">1</option><option value="2">2</option><option value="3">3</option><option value="4">4</option><option value="5">5</option><option value="6">6</option><option value="7">7</option><option value="8">8</option><option value="9">9</option><option value="10">10</option></select> </label> <div class="submit-section"> <button class="_submit btn" type="submit">UNLOCK THE TREATMENT PLAN FOR FREE</button> <button class="previous" type="button" value="Previous">Go Back</button> </div> </div> </fieldset> </form>