| |
| <?php
|
| <!DOCTYPE html>
|
| <html lang="en">
|
| <head>
|
| <meta charset="UTF-8" />
|
| <meta name="viewport" content="width=device-width, initial-scale=1.0" />
|
| <title>Refer a Patient | Skills Therapy Clinic</title>
|
| <link href="https://fonts.googleapis.com/css2?family=Nunito:wght@400;600;700;800;900&family=Lora:ital,wght@0,400;0,600;1,400&display=swap" rel="stylesheet" />
|
| <style>
|
| :root {
|
| --green:
|
| --green-dark:
|
| --green-light:
|
| --orange:
|
| --orange-dark:
|
| --orange-light:
|
| --navy:
|
| --gray:
|
| --light:
|
| --white:
|
| --radius: 18px;
|
| --shadow: 0 6px 28px rgba(26,80,70,0.10);
|
| }
|
| *, *::before, *::after { box-sizing: border-box; margin: 0; padding: 0; }
|
| body { font-family: 'Nunito', sans-serif; color:
|
|
|
|
|
| .stc-hero { padding: 80px 40px 60px; position: relative; overflow: hidden; }
|
| .stc-hero::before { content: ''; position: absolute; top: -80px; right: -80px; width: 400px; height: 400px; background: radial-gradient(circle, rgba(26,158,143,0.13) 0%, transparent 70%); border-radius: 50%; pointer-events: none; }
|
| .stc-hero::after { content: ''; position: absolute; bottom: -60px; left: -60px; width: 280px; height: 280px; background: radial-gradient(circle, rgba(232,116,42,0.09) 0%, transparent 70%); border-radius: 50%; pointer-events: none; }
|
| .stc-hero-inner { max-width: 1100px; margin: 0 auto; display: grid; grid-template-columns: 1fr 1fr; gap: 60px; align-items: center; position: relative; z-index: 1; }
|
| .stc-badge { display: inline-block; background:
|
| .stc-hero h1 { font-size: clamp(2rem, 4vw, 3rem); font-weight: 900; line-height: 1.15; margin-bottom: 20px; color:
|
| .stc-hero h1 span { color:
|
| .stc-hero p { font-size: 1.05rem; color:
|
| .stc-actions { display: flex; gap: 16px; flex-wrap: wrap; align-items: center; }
|
| .stc-btn-primary { background:
|
| .stc-btn-primary:hover { background:
|
| .stc-btn-outline { color:
|
| .stc-btn-outline:hover { background:
|
|
|
|
|
| .stc-hero-card { background:
|
| @keyframes stcFloat { 0%,100%{transform:translateY(0)} 50%{transform:translateY(-10px)} }
|
| .stc-card-tag { font-size: 0.74rem; font-weight: 800; text-transform: uppercase; letter-spacing: 0.1em; color:
|
| .stc-hero-card h3 { font-size: 1.15rem; font-weight: 900; margin-bottom: 18px; color:
|
| .stc-card-list { list-style: none; display: flex; flex-direction: column; gap: 11px; }
|
| .stc-card-list li { display: flex; align-items: center; gap: 10px; font-size: 0.91rem; font-weight: 600; color:
|
| .stc-check { width: 24px; height: 24px; background:
|
| .stc-card-trust { display: flex; align-items: center; gap: 10px; margin-top: 22px; padding-top: 18px; border-top: 1px solid
|
| .stc-avatar { width: 40px; height: 40px; background:
|
| .stc-trust-text { font-size: 0.79rem; color:
|
| .stc-trust-text strong { color:
|
|
|
|
|
| .stc-trust-bar { padding: 20px 40px; display: flex; align-items: center; justify-content: center; gap: 44px; flex-wrap: wrap; }
|
| .stc-trust-item { display: flex; align-items: center; gap: 8px; color: rgba(255,255,255,0.82); font-size: 0.84rem; font-weight: 700; }
|
| .stc-dot { width: 6px; height: 6px; background:
|
|
|
|
|
| .stc-section { padding: 80px 40px; }
|
| .stc-section-inner { max-width: 1100px; margin: 0 auto; }
|
| .stc-label { font-size: 0.76rem; font-weight: 800; text-transform: uppercase; letter-spacing: 0.1em; color:
|
| .stc-label-orange { color:
|
| .stc-title { font-size: clamp(1.6rem, 3vw, 2.3rem); font-weight: 900; line-height: 1.2; color:
|
| .stc-title-white { color:
|
| .stc-sub { font-size: 1rem; color:
|
| .stc-sub-white { color: rgba(255,255,255,0.72); }
|
| .stc-header { margin-bottom: 44px; }
|
|
|
|
|
| .stc-pop-grid { display: grid; grid-template-columns: repeat(auto-fit, minmax(220px, 1fr)); gap: 18px; }
|
| .stc-pop-card { background:
|
| .stc-pop-card:nth-child(2) { border-top-color:
|
| .stc-pop-card:nth-child(3) { border-top-color:
|
| .stc-pop-card:nth-child(4) { border-top-color:
|
| .stc-pop-card:nth-child(5) { border-top-color:
|
| .stc-pop-card:nth-child(6) { border-top-color:
|
| .stc-pop-card:hover { transform: translateY(-5px); box-shadow: 0 16px 40px rgba(26,80,70,0.14); }
|
| .stc-pop-card h4 { font-size: 0.98rem; font-weight: 800; margin-bottom: 7px; color:
|
| .stc-pop-card p { font-size: 0.84rem; color:
|
|
|
|
|
| .stc-services-grid { display: grid; grid-template-columns: 1fr 1fr; gap: 22px; }
|
| .stc-service-card { background:
|
| .stc-service-card::before { content: ''; position: absolute; top: 0; left: 0; right: 0; height: 5px; background: linear-gradient(90deg,
|
| .stc-service-card.stc-orange::before { background: linear-gradient(90deg,
|
| .stc-service-card:hover { transform: translateY(-5px); }
|
| .stc-num { font-size: 2.4rem; font-weight: 900; color:
|
| .stc-service-card.stc-orange .stc-num { color:
|
| .stc-service-card h3 { font-size: 1.18rem; font-weight: 900; margin-bottom: 11px; color:
|
| .stc-service-card p { font-size: 0.89rem; color:
|
| .stc-tags { display: flex; flex-wrap: wrap; gap: 7px; }
|
| .stc-tag { font-size: 0.76rem; font-weight: 700; padding: 5px 11px; border-radius: 50px; background:
|
| .stc-tag.stc-ot { background:
|
|
|
|
|
| .stc-refer-grid { display: grid; grid-template-columns: repeat(auto-fit, minmax(280px, 1fr)); gap: 18px; }
|
| .stc-refer-card { background:
|
| .stc-refer-card:hover { transform: translateY(-4px); }
|
| .stc-refer-icon { width: 40px; height: 40px; background:
|
| .stc-refer-icon svg { width: 18px; height: 18px; stroke:
|
| .stc-refer-card h4 { font-size: 0.93rem; font-weight: 800; margin-bottom: 5px; color:
|
| .stc-refer-card p { font-size: 0.84rem; color:
|
|
|
|
|
| .stc-steps { display: grid; grid-template-columns: repeat(4,1fr); gap: 18px; position: relative; }
|
| .stc-steps::before { content: ''; position: absolute; top: 35px; left: 12%; right: 12%; height: 2px; background: linear-gradient(90deg,
|
| .stc-step { background:
|
| .stc-step:hover { transform: translateY(-5px); }
|
| .stc-step-num { width: 50px; height: 50px; background:
|
| .stc-step h4 { font-size: 0.93rem; font-weight: 800; margin-bottom: 7px; color:
|
| .stc-step p { font-size: 0.82rem; color:
|
|
|
|
|
| .stc-partner-grid { display: grid; grid-template-columns: repeat(auto-fit, minmax(170px, 1fr)); gap: 13px; margin-top: 44px; }
|
| .stc-partner-chip { background: rgba(255,255,255,0.10); border: 1px solid rgba(255,255,255,0.16); border-radius: 15px; padding: 20px 14px; text-align: center; transition: background 0.2s; }
|
| .stc-partner-chip:hover { background: rgba(255,255,255,0.18); }
|
| .stc-chip-line { width: 28px; height: 3px; background:
|
| .stc-partner-chip span { display: block; font-size: 0.84rem; font-weight: 700; color: rgba(255,255,255,0.88); }
|
|
|
|
|
| .stc-cta { padding: 80px 40px; position: relative; overflow: hidden; }
|
| .stc-cta::before { content: ''; position: absolute; top:-100px; right:-100px; width:400px; height:400px; background:rgba(255,255,255,0.07); border-radius:50%; pointer-events:none; }
|
| .stc-cta::after { content: ''; position: absolute; bottom:-80px; left:-80px; width:300px; height:300px; background:rgba(255,255,255,0.05); border-radius:50%; pointer-events:none; }
|
| .stc-cta-inner { position: relative; z-index: 1; max-width: 1100px; margin: 0 auto; display: grid; grid-template-columns: 1fr 1fr; gap: 60px; align-items: start; }
|
| .stc-cta-copy h2 { font-size: clamp(1.7rem, 3.5vw, 2.4rem); font-weight: 900; color:
|
| .stc-cta-copy p { font-size: 1rem; color: rgba(255,255,255,0.82); font-family: 'Lora', serif; line-height: 1.75; margin-bottom: 30px; }
|
| .stc-contact-list { list-style: none; display: flex; flex-direction: column; gap: 15px; }
|
| .stc-contact-list li { display: flex; align-items: center; gap: 13px; }
|
| .stc-contact-icon { width: 42px; height: 42px; background: rgba(255,255,255,0.15); border-radius: 12px; display: flex; align-items: center; justify-content: center; flex-shrink: 0; }
|
| .stc-contact-icon svg { width: 18px; height: 18px; stroke:
|
| .stc-contact-text { font-size: 0.91rem; font-weight: 700; color:
|
| .stc-contact-text a { color: rgba(255,255,255,0.88); text-decoration: none; }
|
| .stc-contact-text a:hover { color:
|
| .stc-contact-text small { display: block; color: rgba(255,255,255,0.52); font-weight: 400; font-size: 0.79rem; }
|
| .stc-form { background:
|
| .stc-form h3 { font-size: 1.12rem; font-weight: 900; color:
|
| .stc-form-row { display: grid; grid-template-columns: 1fr 1fr; gap: 13px; }
|
| .stc-field { display: flex; flex-direction: column; gap: 5px; margin-bottom: 13px; }
|
| .stc-field label { font-size: 0.76rem; font-weight: 800; color:
|
| .stc-field input, .stc-field select, .stc-field textarea { border: 2px solid
|
| .stc-field input:focus, .stc-field select:focus, .stc-field textarea:focus { border-color:
|
| .stc-field textarea { resize: vertical; min-height: 78px; }
|
| .stc-submit { width: 100%; background:
|
| .stc-submit:hover { background:
|
| .stc-form-note { font-size: 0.76rem; color:
|
|
|
|
|
| @media (max-width: 900px) {
|
| .stc-hero-inner { grid-template-columns: 1fr; }
|
| .stc-hero-card { display: none; }
|
| .stc-services-grid { grid-template-columns: 1fr; }
|
| .stc-steps { grid-template-columns: 1fr 1fr; }
|
| .stc-steps::before { display: none; }
|
| .stc-cta-inner { grid-template-columns: 1fr; }
|
| }
|
| @media (max-width: 600px) {
|
| .stc-section { padding: 56px 20px; }
|
| .stc-hero { padding: 48px 20px 38px; }
|
| .stc-trust-bar { gap: 18px; padding: 16px 20px; }
|
| .stc-steps { grid-template-columns: 1fr; }
|
| .stc-form-row { grid-template-columns: 1fr; }
|
| .stc-cta { padding: 56px 20px; }
|
| .stc-form { padding: 26px 18px; }
|
| }
|
|
|
| @keyframes stcFadeUp { from{opacity:0;transform:translateY(20px)} to{opacity:1;transform:translateY(0)} }
|
| .stc-hero-content > * { animation: stcFadeUp 0.55s ease both; }
|
| .stc-hero-content > *:nth-child(1){animation-delay:0.1s}
|
| .stc-hero-content > *:nth-child(2){animation-delay:0.2s}
|
| .stc-hero-content > *:nth-child(3){animation-delay:0.3s}
|
| .stc-hero-content > *:nth-child(4){animation-delay:0.4s}
|
| </style>
|
| </head>
|
| <body>
|
|
|
| <!-- HERO -->
|
| <div class="stc-hero" style="background: linear-gradient(135deg, #e8f7f5 0%, #d5f0eb 45%, #fdf0e6 100%);">
|
| <div class="stc-hero-inner">
|
| <div class="stc-hero-content">
|
| <span class="stc-badge">Referral Partners Welcome</span>
|
| <h1>Your Patients Deserve<br>Specialized Therapy.<br><span>We Are Here to Help.</span></h1>
|
| <p>Skills Therapy Clinic is a bilingual pediatric therapy practice in Clermont, FL. We partner with pediatricians, schools, and healthcare providers so every child gets the evaluation and care they need, close to home.</p>
|
| <div class="stc-actions">
|
| <a href="#stc-refer" class="stc-btn-primary">Submit a Referral</a>
|
| <a href="#stc-services" class="stc-btn-outline">Our Services</a>
|
| </div>
|
| </div>
|
| <div>
|
| <div class="stc-hero-card">
|
| <span class="stc-card-tag">Why Providers Partner With Us</span>
|
| <h3>A clinic you can trust with your families</h3>
|
| <ul class="stc-card-list">
|
| <li><span class="stc-check">✓</span> Bilingual services in English and Spanish</li>
|
| <li><span class="stc-check">✓</span> Speech and Occupational Therapy under one roof</li>
|
| <li><span class="stc-check">✓</span> Accepting new patients now</li>
|
| <li><span class="stc-check">✓</span> In-clinic and telehealth options</li>
|
| <li><span class="stc-check">✓</span> Progress updates shared with referring providers</li>
|
| </ul>
|
| <div class="stc-card-trust">
|
| <div class="stc-avatar">M</div>
|
| <div class="stc-trust-text">
|
| <strong>Mariela Santiago-Rivera, MS CCC-SLP</strong>
|
| Bilingual Speech-Language Pathologist and Clinic Director
|
| </div>
|
| </div>
|
| </div>
|
| </div>
|
| </div>
|
| </div>
|
|
|
| <!-- TRUST BAR -->
|
| <div class="stc-trust-bar" style="background-color: #1e2d3d;">
|
| <div class="stc-trust-item"><span class="stc-dot"></span> Bilingual: English and Spanish</div>
|
| <div class="stc-trust-item"><span class="stc-dot"></span> Pediatric and Adolescent Focus</div>
|
| <div class="stc-trust-item"><span class="stc-dot"></span> Clermont, FL</div>
|
| <div class="stc-trust-item"><span class="stc-dot"></span> In-Clinic and Telehealth</div>
|
| <div class="stc-trust-item"><span class="stc-dot"></span> Accepting New Patients</div>
|
| </div>
|
|
|
| <!-- POPULATIONS -->
|
| <div class="stc-section" id="stc-services" style="background-color: #f7f9f8;">
|
| <div class="stc-section-inner">
|
| <div class="stc-header">
|
| <span class="stc-label">Who We See</span>
|
| <h2 class="stc-title">Diagnoses We Specialize In</h2>
|
| <p class="stc-sub">We work with children and adolescents across a wide range of diagnoses. If you are unsure whether a patient is a good fit, call us before submitting a referral.</p>
|
| </div>
|
| <div class="stc-pop-grid">
|
| <div class="stc-pop-card"><h4>Autism Spectrum Disorder</h4><p>Communication, social language, sensory processing, and AAC for children with ASD at all levels of support need.</p></div>
|
| <div class="stc-pop-card"><h4>Cerebral Palsy</h4><p>Motor skill development, fine motor therapy, adaptive strategies, and functional communication support.</p></div>
|
| <div class="stc-pop-card"><h4>Down Syndrome</h4><p>Language development, speech intelligibility, cognitive skill building, and early literacy foundations.</p></div>
|
| <div class="stc-pop-card"><h4>Intellectual Disabilities</h4><p>Individualized therapy for communication, daily living skills, independence, and school participation.</p></div>
|
| <div class="stc-pop-card"><h4>AAC Users</h4><p>Device-specific implementation, core vocabulary building, and family coaching for augmentative communication.</p></div>
|
| <div class="stc-pop-card"><h4>Developmental Delays</h4><p>Early intervention for children showing delays in speech, language, motor, or self-care milestones.</p></div>
|
| </div>
|
| </div>
|
| </div>
|
|
|
| <!-- SERVICES -->
|
| <div class="stc-section" style="background-color: #ffffff;">
|
| <div class="stc-section-inner">
|
| <div class="stc-header">
|
| <span class="stc-label">What We Offer</span>
|
| <h2 class="stc-title">Two Specialties. One Coordinated Team.</h2>
|
| <p class="stc-sub">Your patients can receive Speech-Language Therapy and Occupational Therapy at the same location, with providers who communicate and collaborate on care.</p>
|
| </div>
|
| <div class="stc-services-grid">
|
| <div class="stc-service-card">
|
| <div class="stc-num">01</div>
|
| <h3>Speech-Language Therapy</h3>
|
| <p>Comprehensive evaluation and individualized therapy for children with communication needs. Services span articulation, expressive and receptive language, fluency, pragmatic skills, AAC, and early intervention. Bilingual services available in English and Spanish.</p>
|
| <div class="stc-tags">
|
| <span class="stc-tag">Evaluations</span><span class="stc-tag">Early Intervention</span><span class="stc-tag">AAC</span><span class="stc-tag">Parent Coaching</span><span class="stc-tag">Bilingual</span><span class="stc-tag">Telehealth</span>
|
| </div>
|
| </div>
|
| <div class="stc-service-card stc-orange">
|
| <div class="stc-num">02</div>
|
| <h3>Occupational Therapy</h3>
|
| <p>Evidence-based OT services to help children develop fine motor skills, sensory regulation, self-care independence, and school readiness. Our clinic is equipped for sensory-based interventions and hands-on skill building.</p>
|
| <div class="stc-tags">
|
| <span class="stc-tag stc-ot">Evaluations</span><span class="stc-tag stc-ot">Sensory Integration</span><span class="stc-tag stc-ot">Fine Motor</span><span class="stc-tag stc-ot">Self-Care</span><span class="stc-tag stc-ot">School Readiness</span>
|
| </div>
|
| </div>
|
| </div>
|
| </div>
|
| </div>
|
|
|
| <!-- WHEN TO REFER -->
|
| <div class="stc-section" style="background-color: #f7f9f8;">
|
| <div class="stc-section-inner">
|
| <div class="stc-header">
|
| <span class="stc-label">Referral Indicators</span>
|
| <h2 class="stc-title">Signs a Patient May Benefit from Referral</h2>
|
| <p class="stc-sub">Use these as a quick guide. When in doubt, call us and we will consult with you before a formal referral is submitted.</p>
|
| </div>
|
| <div class="stc-refer-grid">
|
| <div class="stc-refer-card">
|
| <div class="stc-refer-icon"><svg viewBox="0 0 24 24"><path d="M21 15a2 2 0 0 1-2 2H7l-4 4V5a2 2 0 0 1 2-2h14a2 2 0 0 1 2 2z"/></svg></div>
|
| <div><h4>Limited or Unclear Speech</h4><p>Child is not meeting speech or language milestones, is difficult to understand, or has stopped progressing.</p></div>
|
| </div>
|
| <div class="stc-refer-card">
|
| <div class="stc-refer-icon"><svg viewBox="0 0 24 24"><circle cx="12" cy="12" r="10"/><path d="M8 14s1.5 2 4 2 4-2 4-2"/><line x1="9" y1="9" x2="9.01" y2="9"/><line x1="15" y1="9" x2="15.01" y2="9"/></svg></div>
|
| <div><h4>Social Communication Challenges</h4><p>Difficulty with back-and-forth interaction, eye contact, social cues, or peer relationships.</p></div>
|
| </div>
|
| <div class="stc-refer-card">
|
| <div class="stc-refer-icon"><svg viewBox="0 0 24 24"><path d="M12 20h9"/><path d="M16.5 3.5a2.121 2.121 0 0 1 3 3L7 19l-4 1 1-4L16.5 3.5z"/></svg></div>
|
| <div><h4>Fine Motor or Writing Difficulties</h4><p>Struggles with pencil grip, handwriting, cutting, or tasks requiring hand-eye coordination.</p></div>
|
| </div>
|
| <div class="stc-refer-card">
|
| <div class="stc-refer-icon"><svg viewBox="0 0 24 24"><path d="M20.84 4.61a5.5 5.5 0 0 0-7.78 0L12 5.67l-1.06-1.06a5.5 5.5 0 0 0-7.78 7.78l1.06 1.06L12 21.23l7.78-7.78 1.06-1.06a5.5 5.5 0 0 0 0-7.78z"/></svg></div>
|
| <div><h4>Sensory Processing Concerns</h4><p>Overreaction or underreaction to touch, sound, or textures that disrupts daily functioning or learning.</p></div>
|
| </div>
|
| <div class="stc-refer-card">
|
| <div class="stc-refer-icon"><svg viewBox="0 0 24 24"><path d="M2 3h6a4 4 0 0 1 4 4v14a3 3 0 0 0-3-3H2z"/><path d="M22 3h-6a4 4 0 0 0-4 4v14a3 3 0 0 1 3-3h7z"/></svg></div>
|
| <div><h4>School Performance or Readiness Gaps</h4><p>Teacher concerns about attention, following directions, or readiness for academic tasks.</p></div>
|
| </div>
|
| <div class="stc-refer-card">
|
| <div class="stc-refer-icon"><svg viewBox="0 0 24 24"><path d="M20 21v-2a4 4 0 0 0-4-4H8a4 4 0 0 0-4 4v2"/><circle cx="12" cy="7" r="4"/></svg></div>
|
| <div><h4>Self-Care Independence</h4><p>Difficulty with dressing, feeding, hygiene, or daily living skills relative to age-appropriate expectations.</p></div>
|
| </div>
|
| </div>
|
| </div>
|
| </div>
|
|
|
| <!-- PROCESS -->
|
| <div class="stc-section" style="background-color: #ffffff;">
|
| <div class="stc-section-inner">
|
| <div class="stc-header">
|
| <span class="stc-label">The Referral Process</span>
|
| <h2 class="stc-title">Simple, Fast, and Coordinated</h2>
|
| <p class="stc-sub">We make it easy to send a referral and keep you informed on your patient's progress every step of the way.</p>
|
| </div>
|
| <div class="stc-steps">
|
| <div class="stc-step"><div class="stc-step-num">1</div><h4>Submit the Referral</h4><p>Use the form on this page or call our office. We only need basic patient and contact information to get started.</p></div>
|
| <div class="stc-step"><div class="stc-step-num">2</div><h4>We Contact the Family</h4><p>Our team reaches out to the family within 2 business days to schedule an evaluation and explain next steps.</p></div>
|
| <div class="stc-step"><div class="stc-step-num">3</div><h4>Evaluation Completed</h4><p>We complete a full evaluation and share a summary with the referring provider when authorized by the family.</p></div>
|
| <div class="stc-step"><div class="stc-step-num">4</div><h4>Ongoing Collaboration</h4><p>We keep you informed on patient progress and welcome open communication throughout the treatment plan.</p></div>
|
| </div>
|
| </div>
|
| </div>
|
|
|
| <!-- PARTNER TYPES -->
|
| <div class="stc-section" style="background-color: #1e2d3d;">
|
| <div class="stc-section-inner">
|
| <div class="stc-header">
|
| <span class="stc-label stc-label-orange">Our Referral Network</span>
|
| <h2 class="stc-title stc-title-white">Who We Partner With</h2>
|
| <p class="stc-sub stc-sub-white">We collaborate with providers across healthcare and education who share our commitment to children's development and whole-child care.</p>
|
| </div>
|
| <div class="stc-partner-grid">
|
| <div class="stc-partner-chip"><div class="stc-chip-line"></div><span>Pediatricians</span></div>
|
| <div class="stc-partner-chip"><div class="stc-chip-line"></div><span>Developmental Pediatricians</span></div>
|
| <div class="stc-partner-chip"><div class="stc-chip-line"></div><span>Schools and Educators</span></div>
|
| <div class="stc-partner-chip"><div class="stc-chip-line"></div><span>Neurologists</span></div>
|
| <div class="stc-partner-chip"><div class="stc-chip-line"></div><span>Psychologists</span></div>
|
| <div class="stc-partner-chip"><div class="stc-chip-line"></div><span>Early Intervention Programs</span></div>
|
| <div class="stc-partner-chip"><div class="stc-chip-line"></div><span>Social Workers</span></div>
|
| <div class="stc-partner-chip"><div class="stc-chip-line"></div><span>Physical Therapists</span></div>
|
| </div>
|
| </div>
|
| </div>
|
|
|
| <!-- CTA / REFERRAL FORM -->
|
| <div class="stc-cta" id="stc-refer" style="background: linear-gradient(135deg, #1a9e8f 0%, #147a6e 100%);">
|
| <div class="stc-cta-inner">
|
| <div class="stc-cta-copy">
|
| <h2>Submit a Referral or Start the Conversation</h2>
|
| <p>Use the form to send us patient information and we will take it from there. You can also call or email our office directly to discuss a case before submitting a formal referral.</p>
|
| <ul class="stc-contact-list">
|
| <li>
|
| <div class="stc-contact-icon"><svg viewBox="0 0 24 24"><path d="M22 16.92v3a2 2 0 0 1-2.18 2 19.79 19.79 0 0 1-8.63-3.07A19.5 19.5 0 0 1 4.69 12 19.79 19.79 0 0 1 1.61 3.5 2 2 0 0 1 3.6 1.32h3a2 2 0 0 1 2 1.72c.127.96.361 1.903.7 2.81a2 2 0 0 1-.45 2.11L7.91 9a16 16 0 0 0 6 6l1.27-.95a2 2 0 0 1 2.11-.45c.907.339 1.85.573 2.81.7A2 2 0 0 1 22 16.92z"/></svg></div>
|
| <div class="stc-contact-text"><a href="tel:4073477589">(407) 347-7589</a><small>Monday through Friday, 8AM to 6PM</small></div>
|
| </li>
|
| <li>
|
| <div class="stc-contact-icon"><svg viewBox="0 0 24 24"><path d="M4 4h16c1.1 0 2 .9 2 2v12c0 1.1-.9 2-2 2H4c-1.1 0-2-.9-2-2V6c0-1.1.9-2 2-2z"/><polyline points="22,6 12,13 2,6"/></svg></div>
|
| <div class="stc-contact-text"><a href="mailto:info@skillstherapyclinic.com">info@skillstherapyclinic.com</a></div>
|
| </li>
|
| <li>
|
| <div class="stc-contact-icon"><svg viewBox="0 0 24 24"><path d="M21 10c0 7-9 13-9 13s-9-6-9-13a9 9 0 0 1 18 0z"/><circle cx="12" cy="10" r="3"/></svg></div>
|
| <div class="stc-contact-text" style="color: rgba(255,255,255,0.78); font-weight: 600;">15701 State Road 50, Suite 202<br>Clermont, FL 34711</div>
|
| </li>
|
| </ul>
|
| </div>
|
| <div class="stc-form">
|
| <h3>Provider Referral Form</h3>
|
| <div class="stc-form-row">
|
| <div class="stc-field"><label>Your First Name</label><input type="text" placeholder="Dr. Maria" /></div>
|
| <div class="stc-field"><label>Your Last Name</label><input type="text" placeholder="Gonzalez" /></div>
|
| </div>
|
| <div class="stc-field"><label>Practice or Organization</label><input type="text" placeholder="Clermont Pediatrics" /></div>
|
| <div class="stc-form-row">
|
| <div class="stc-field"><label>Your Phone</label><input type="tel" placeholder="(407) 000-0000" /></div>
|
| <div class="stc-field"><label>Your Email</label><input type="email" placeholder="you@practice.com" /></div>
|
| </div>
|
| <div class="stc-field">
|
| <label>Service Needed</label>
|
| <select><option value="">Select a service</option><option>Speech-Language Therapy</option><option>Occupational Therapy</option><option>Both Speech and OT</option><option>Not Sure / Needs Evaluation</option></select>
|
| </div>
|
| <div class="stc-field">
|
| <label>Patient Age Range</label>
|
| <select><option value="">Select age range</option><option>0 to 2 years (Early Intervention)</option><option>3 to 5 years (Preschool)</option><option>6 to 12 years (School Age)</option><option>13 to 17 years (Adolescent)</option></select>
|
| </div>
|
| <div class="stc-field"><label>Reason for Referral</label><textarea placeholder="Brief description of concerns, diagnosis if known, and any relevant background information."></textarea></div>
|
| <button class="stc-submit" onclick="alert('Referral received. Our team will follow up within 2 business days.')">Submit Referral</button>
|
| <p class="stc-form-note">We will contact the family directly. Your information is kept confidential.</p>
|
| </div>
|
| </div>
|
| </div>
|
|
|
| </body>
|
| </html>
|
| |
| |
