| Current File : /home/inlingua/public_html/sensoriumpsychologists.com/backup/screening-registration.php |
<?php
session_start();
include('include/header.php');
include_once('classes/config.php');
if(isset($_SESSION['c_error']) && $_SESSION['c_error']==1)
{
$Caperror='<span style="color:red;">reCAPTCHA is mandatory</span>';
}else{
$Caperror='';
}
?>
<div class="site-breadcrumb">
<div class="container">
<a href="index.php"><i class="fa fa-home"></i> Home</a> <i class="fa fa-angle-right"></i>
<span>Registration</span><i class="fa fa-angle-right"></i>
<span>Screening Registration</span>
</div>
</div>
<section class="event-section">
<div class="container">
<div class="section-title text-center">
<h3>Register for Screening </h3>
<p>When a learning difficulty is suspected in a child, screenings are highly recommended. Screenings can be short and online assessment tool that can indicate the level of risk and also can recommend for further comprehensive testing if required.
If dyslexia, dysgraphia, ADHD or dyscalculia are suspected, comprehensive testing can be performed by a certified psychologist.</p><p>
This is must to understand that two people with a learning difficulty/disability struggle with the same set or severity of symptoms and thus it’s important to understand where strengths and areas of need lie in order to provide the best strategy training and accommodations.
</p>
</div>
</div>
</section>
<section class="contact-page spad pt-0">
<div class="container">
<div class="text-center">
<h3><?php echo $Caperror; ?></h3>
<p></p>
</div>
<div class="sc_contact_form sc_contact_form_contact contact-form" style="border:1px solid #c3c3cc; padding:25px;">
<form method="POST" action="diagnostics/franchise/new-admission.php" class="validate123 comment-form --contact" name="myForm" id="myForm" enctype="multipart/form-data" novalidate="novalidate" >
<?php
$today = date("ymd");
$rand = strtoupper(substr(uniqid(sha1(time())),0,4));
$unique1 = $today . $rand;
$pass=rand(1000,1000000);
?>
<input type="hidden" name="registration_no" value="<?php echo "SU".$unique1;?>" >
<input type="hidden" name="ppasscode" value="<?php echo $pass;?>" >
<input type="hidden" id="emailcheck" value="0" >
<!--<form method="post" name="myform" enctype="multipart/form-data">-->
<div class="row" id="next-1">
<div class="col-lg-4"><h3>PERSONAL DETAILS</h3></div>
<div class="col-lg-8"><div id="Info" style="color:red;display:none;">Your profile is already registered!
<a href="https://www.sensoriumpsychologists.com/diagnostics_login.php"> Click here to login.</a> </div></div>
<div class="col-lg-4">
<label class="required" for="f_name">Student's Name</label>
<input id="child_name" type="text" autocomplete="off" name="child_name" placeholder="Student Name">
</div>
<div class="col-lg-4">
<label class="required" for="f_name">Email</label>
<input type="text" name="email" id="username" autocomplete="off" placeholder="Email" onblur="return check_username();">
</div>
<div class="col-lg-4">
<label class="required" for="f_name">Contact No</label>
<input id="contact_no" type="text" autocomplete="off" name="contact_no" placeholder="Contact No">
</div>
<div class="col-lg-4">
<label class="required" for="f_name">Date Of Birth</label>
<input id="dob" type="text" name="dob" placeholder="Date Of Birth" autocomplete="off">
</div>
<div class="col-lg-4">
<label class="required" for="f_name">Gender</label>
<select name="gender" id="gender">
<option value="">---Gender---</option>
<option value="Male">Male</option>
<option value="Female">Female</option>
</select>
</div>
<div class="col-lg-4">
<label class="required" for="f_name">Education</label>
<select name="education" id="education">
<option value="">---std---</option>
<option value="1">1st</option>
<option value="2">2nd</option>
<option value="3">3rd</option>
<option value="4">4th</option>
<option value="5">5th</option>
</select>
</div>
<div class="col-lg-4">
<label class="required" for="school_name">School Name</label>
<select class="form-control" name="school_name" id="school_name">
<option value="">Select School</option>
<?php $field="and status='active'";
$result=$query->select_where_field('shristi_login','type','franchise',$field);
while($row=$result->fetch_assoc()){
?>
<option value="<?php echo $row['name'].'@@'.$row['table_id'];?>"><?php echo $row['name'];?></option>
<?php }?>
</select>
</div>
<div class="col-lg-4">
<label class="required" for="f_name">Informant</label>
<input id="informant" type="text" name="informant" autocomplete="off" placeholder="informant">
</div>
</div>
<div class="row" id="next-2" style="display:none;">
<div class="col-lg-12">
<h3>ADDRESS</h3>
</div>
<div class="col-lg-6">
CORRESPONDANCE ADDRESS <span style="color:#F00;font-weight:bold;font-size:1.4em;">*</span>
<div class="col-lg-12">
<label class="required" for="c_local">Local Address</label>
<textarea placeholder="Local Address" name="c_local" style="margin-bottom: 10px;" id="c_local" rows="3"></textarea>
</div>
<div class="col-lg-12">
<label class="required" for="c_city">City</label>
<input type="text" placeholder="City" name="c_city" id="c_city" />
</div>
<div class="col-lg-12">
<label class="required" for="c_district">District</label>
<input type="text" placeholder=" District" name="c_district" id="c_district" />
</div>
<div class="col-lg-12">
<select class="textboxes" name="c_state" id="c_state">
<option value="">--- Select ---</option>
<?php
$result=$query->select_where('shristi_tblstate','status','1');
while($row=$result->fetch_assoc()){
?>
<option value="<?php echo $row['StateID'];?>"><?php echo $row['StateName'];?></option>
<?php }?>
</select>
</div>
<div class="col-lg-12">
<label class="required" for="c_pincode">Pincode</label>
<input type="text" placeholder=" Pincode" name="c_pincode" id="c_pincode" onkeypress="return isNumberKey(event)" maxlength="6" class="textboxes" />
</div>
</div>
<div class="col-lg-6">
<div class="col-lg-12">PERMANENT ADDRESS <span style="color:#F00;font-weight:bold;font-size:1.4em;">*</span>
<input type="button" value="Copy Correspondance Address" onClick="copy_addr()" ></div>
<div class="col-lg-12">
<label class="required" for="p_local">Permanent Address</label>
<textarea placeholder="Permanent Address" name="p_local" style="margin-bottom: 10px;" id="p_local" rows="3"></textarea>
</div>
<div class="col-lg-12">
<label class="required" for="p_city">City</label>
<input type="text" placeholder="City" name="p_city" id="p_city" />
</div>
<div class="col-lg-12">
<label class="required" for="p_district">District</label>
<input type="text" placeholder=" District" name="p_district" id="p_district" />
</div>
<div class="col-lg-12">
<select class="textboxes" name="p_state" id="p_state">
<option value="">--- Select ---</option>
<?php
$result=$query->select_where('shristi_tblstate','status','1');
while($row=$result->fetch_assoc()){
?>
<option value="<?php echo $row['StateID'];?>"><?php echo $row['StateName'];?></option>
<?php }?>
</select>
</div>
<div class="col-lg-12">
<label class="required" for="p_pincode">Pincode</label>
<input type="text" placeholder=" Pincode" name="p_pincode" id="p_pincode" onkeypress="return isNumberKey(event)" maxlength="6" class="textboxes" />
</div>
</div>
</div>
<div class="row" id="next-3" style="display:none;">
<div class="col-lg-12">
<h3>PROBLEMS & BEHAVIOURS</h3>
</div>
<div class="col-lg-12">
<label class="required" for="problem">PRESENTING PROBLEMS OF THE CHILD</label>
<textarea name="problem" id="problem" rows="2"></textarea>
</div>
<div class="col-lg-12"><h5>POSTNATAL DEVELOPMENT :</h5></div>
<div class="col-lg-6">
<label class="required" for="walking">Walking</label>
<select name="walking" id="walking">
<option value="">---</option>
<option value="10-11 months">10-11 months</option>
<option value="12-13 months">12-13 months</option>
<option value="14-16 months" >14-16 months</option>
<option value="17-20 months">17-20 months</option>
</select>
</div>
<div class="col-lg-6">
<label class="required" for="first_sentence">First Sentence</label>
<select name="first_sentence" id="first_sentence">
<option value="">---</option>
<option value="10-12 months">10-11 months</option>
<option value="12-13 months">12-13 months</option>
<option value="13-15 months">13-15 months</option>
<option value="16-24 months">16-24 months</option>
<option value="not yet">not yet</option>
</select>
</div>
<div class="col-lg-12">
<h5>CHILD'S BEHAVIOUR : </h5>
</div>
<div class="col-lg-4">
<label class="required" for="toilet_behaviour">Toilet Behaviour</label>
<select name="toilet_behaviour" id="toilet_behaviour">
<option value="">---</option>
<option value="Dependent" >Dependent</option>
<option value="Independent">Independent</option>
</select>
</div>
<div class="col-lg-4">
<label class="required" for="self_help">Self help skills (bathing, eating, dressing, communication skills)</label>
<select name="self_help" id="self_help">
<option value="">---</option>
<option value="Dependent" >Dependent</option>
<option value="Independent">Independent</option>
</select>
</div>
<div class="col-lg-4">
<label class="required" for="sleeping_pattern">Sleeping Pattern</label>
<select name="sleeping_pattern" id="sleeping_pattern">
<option value="">---</option>
<option value="Normal" >Normal</option>
<option value="Disturbed" >Disturbed</option>
</select>
</div>
<div class="col-lg-4">
<label class="required" for="play">Play (during free time)</label>
<select name="play" id="play" >
<option value="">---</option>
<option value="yes" >Yes</option>
<option value="no" >No</option>
</select>
</div>
<div class="col-lg-4">
<label class="required" for="play_group">Play Group</label>
<select name="play_group" id="play_group">
<option value="">---</option>
<option value="yes" >Yes</option>
<option value="no" >No</option>
</select>
</div>
<div class="col-lg-4">
<label class="required" for="type_of_play">Type of play</label>
<select name="type_of_play" id="type_of_play">
<option value="">---</option>
<option value="Indoor games" >Indoor games</option>
<option value="outdoor games" >outdoor games</option>
<option value="indoor as well as outdoor" >indoor as well as outdoor</option>
<option value="All Type" >All Type</option>
</select>
</div>
<div class="col-lg-4">
<label class="required" for="behav_with_family">Behaviour with family</label>
<select name="behav_with_family" id="behav_with_family">
<option value="">---</option>
<option value="normal" >Normal</option>
<option value="good" >Good</option>
<option value="normal but some times aggresive" >normal but some times aggresive</option>
<option value="sads" >Sads</option>
<option value="poor" >Poor</option>
</select>
</div>
<div class="col-lg-4">
<label class="required" for="reln_with_siblings">Relationship with siblings</label>
<select name="reln_with_siblings" id="reln_with_siblings" style="width:50%;">
<option value="">---</option>
<option value="normal and emotionally attached" >Normal and Emotionally attached</option>
<option value="moderate rivalry" >Moderate Rivalry</option>
<option value="severely affected and emotionally detached" >Severely affected and emotionally detached</option>
</select>
</div>
</div>
<div id="submit-1" >
<div class="col-md-12" style="overflow: hidden; margin-top:20px;">
<div class="sc_contact_form_button3">
<div class="site-btn" value="Save & Next >>" onClick="submit_form();">
Save & Next >>
</div>
</div>
</div>
</div>
<!--<input type="submit" name="sumnit" value="Save Now" />--></td>
<div id="submit-2" style="display:none;">
<div class="col-md-12" style="overflow: hidden; margin-top:20px;">
<div class="sc_contact_form_button3">
<div class="site-btn" value="Save & Next >>" onClick="submit_form_next();">
Save & Next >>
</div>
</div>
</div>
</div>
<div id="submit-3" style="display:none;">
<div class="col-md-12" style="overflow: hidden; margin-top:20px;">
<div class="sc_contact_form_button3">
<div class="site-btn" value="Save" onClick="submit_form_save();">
Save
</div>
</div>
</div>
</div>
</form>
</div>
</div>
</div>
</section>
<script src="https://ajax.googleapis.com/ajax/libs/jquery/1.7.1/jquery.min.js" type="text/javascript"></script>
<script type="text/javascript" src="js/jquery.validate.min.js"></script>
<link href="https://code.jquery.com/ui/1.10.4/themes/smoothness/jquery-ui.css" rel="Stylesheet" type="text/css" />
<script type="text/javascript" src="https://code.jquery.com/ui/1.10.4/jquery-ui.js"></script>
<script language="javascript">
$(document).ready(function () {
$("#dob").datepicker({
changeMonth: true,
changeYear: true,
dateFormat: "dd/mm/yy",
yearRange: "-90:+00"
});
});
</script>
<script>
function submit_form()
{
if($("#child_name").val()=="")
{
alert("Error : Please enter child's name...");
$("#child_name").focus();
return false;
}
if($("#username").val()=="")
{
alert("Error : Please enter Email...");
$("#username").focus();
return false;
}
if($("#dob").val()=="")
{
alert("Error : Please select Date Of Birth...");
$("#age").focus();
return false;
}
if($("#gender").val()=="")
{
alert("Error : Please select gender");
$("#gender").focus();
return false;
}
if($("#dob_day").val()=="")
{
alert("Error : Please select Day in D.O.B");
$("#dob_day").focus();
return false;
}
if($("#education").val()=="")
{
alert("Error : Please select Education");
$("#education").focus();
return false;
}
if($("#school_name").val()=="")
{
alert("Error : Please enter school name");
$("#school_name").focus();
return false;
}
if($("#contact_no").val()=="")
{
alert("Error : Please select contact no");
$("#contact_no").focus();
return false;
}
if($("#username").val() !="")
{
var username = $("#username").val();
if(username.length > 2){
//$('#Loading').show();
$.post("lib/ajaxclass_screening.php", {
username: $('#username').val(),
}, function(response){
if(response=='1'){
$('#Info').show();
$('#emailcheck').val(1);
return false;
}
if(response=='0') {
$('#emailcheck').val(2);
$('#Info').hide();
return true;
}
});
}
}
if($("#emailcheck").val()=="1")
{
$('#Info').show();
$("#username").focus();
return false;
}
if($("#informant").val()=="")
{
alert("Error : Please select informant");
$("#informant").focus();
return false;
}
else
{
$("#next-2").show();
$("#next-1").hide();
$("#submit-1").hide();
$("#submit-2").show();
//return false;
}
}
function check_username(){
var username = $("#username").val();
if(username.length > 2){
//$('#Loading').show();
$.post("lib/ajaxclass_screening.php", {
username: $('#username').val(),
}, function(response){
if(response=='1'){
$('#emailcheck').val(1);
$('#Info').show();
return false;
}
if(response=='0') {
$('#Info').hide();
return true;
}
});
}
}
function submit_form_next()
{
if($("#c_local").val()=="")
{
alert("Error : Please enter local address in 'Correspondance Address'");
$("#c_local").focus();
return false;
}
if($("#c_city").val()=="")
{
alert("Error : Please enter city in 'Correspondance Address'");
$("#c_city").focus();
return false;
}
if($("#c_district").val()=="")
{
alert("Error : Please enter district in 'Correspondance Address'");
$("#c_district").focus();
return false;
}
if($("#c_state").val()=="")
{
alert("Error : Please select state in 'Correspondance Address'");
$("#c_state").focus();
return false;
}
if($("#c_pincode").val()=="")
{
alert("Error : Please enter pincode in 'Correspondance Address'");
$("#c_pincode").focus();
return false;
}
if($("#p_local").val()=="")
{
alert("Error : Please enter local address in 'Permanent Address'");
$("#p_local").focus();
return false;
}
if($("#p_city").val()=="")
{
alert("Error : Please enter city in 'Permanent Address'");
$("#p_city").focus();
return false;
}
var p_city=$("#p_city").val();
if(p_city.length<3)
{
alert("Error : City in 'Permanent Address' must be 3 characters long");
$("#p_city").focus();
return false;
}
if($("#p_district").val()=="")
{
alert("Error : Please enter district in 'Permanent Address'");
$("#p_district").focus();
return false;
}
if($("#p_state").val()=="")
{
alert("Error : Please select state in 'Permanent Address'");
$("#p_state").focus();
return false;
}
if($("#p_pincode").val()=="")
{
alert("Error : Please enter pincode in 'Permanent Address'");
$("#p_pincode").focus();
return false;
}else {
$("#next-3").show();
$("#next-2").hide();
$("#submit-2").hide();
$("#submit-3").show();
}
}
function submit_form_save()
{
if($("#problem").val()=="")
{
alert("Error : Please enter 'PRESENTING PROBLEM OF THE CHILD'");
$("#problem").focus();
return false;
}
if($("#walking").val()=="")
{
alert("Error : Please select walking");
$("#walking").focus();
return false;
}
if($("#first_sentence").val()=="")
{
alert("Error : Please select first sentence");
$("#first_sentence").focus();
return false;
}
if($("#toilet_behaviour").val()=="")
{
alert("Error : Please select 'Toilet Behaviour'");
$("#toilet_behaviour").focus();
return false;
}
if($("#self_help").val()=="")
{
alert("Error : Please select 'Self help skills'");
$("#self_help").focus();
return false;
}
if($("#sleeping_pattern").val()=="")
{
alert("Error : Please select 'Sleeping Pattern'");
$("#sleeping_pattern").focus();
return false;
}
if($("#play").val()=="")
{
alert("Error : Please enter 'Play (during free time)'");
$("#play").focus();
return false;
}
if($("#play_group").val()=="")
{
alert("Error : Please enter 'Play Group'");
$("#play_group").focus();
return false;
}
if($("#type_of_play").val()=="")
{
alert("Error : Please enter 'Type of Play'");
$("#type_of_play").focus();
return false;
}
if($("#behav_with_family").val()=="")
{
alert("Error : Please enter 'Behaviour with Family'");
$("#behav_with_family").focus();
return false;
}
if($("#reln_with_siblings").val()=="")
{
alert("Error : Please enter 'Relationaship with Siblings'");
$("#reln_with_siblings").focus();
return false;
}
var ans=confirm("Are you sure you want to continue?");
if(ans==true)
{
document.myForm.submit();
}
else
{
return false;
}
}
function copy_addr()
{
$("#p_local").val($("#c_local").val());
$("#p_city").val($("#c_city").val());
$("#p_district").val($("#c_district").val());
$("#p_state").val($("#c_state").val());
$("#p_pincode").val($("#c_pincode").val());
}
</script>
<?php include('include/footer.php'); ?>
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