1"use strict";(self.webpackChunk_N_E=self.webpackChunk_N_E||[]).push([[2393],{2393:function(e,i,r){r.d(i,{Z:function(){return V}});var a=r(5893),n=r(7294),t=r(7536),o=r(5697),l=r.n(o),s=r(1155),d=r(8403),c=r(9521),m=r(5543);let u=c.ZP.div.withConfig({componentId:"sc-73a1b702-0"})([".contact-vob__container{border-radius:8px;box-shadow:",";scroll-margin:145px;}@media screen and (min-width:","){.contact-vob__container{scroll-margin:250px;}}.form__title{color:var(--gray-500,#1a1a1a);font-size:24px;font-weight:bold;margin-bottom:24px;}section{display:block;}section.hidden{display:none;}.section__insurance--submit{background:#fff;padding:24px;}.padded-container__top{padding:0 24px 0 24px;}.padded-container{padding:32px 24px 0 24px;border-radius:8px;}.tertiary-background{background:var(--tertiary-200,#f4f9f9);border-radius:0;border-top:1px solid var(--tertiary-400,#e4eff1);border-bottom:1px solid var(--tertiary-400,#e4eff1);}.section__submit{display:grid;grid-template-columns:1fr;grid-gap:24px;align-items:center;justify-content:center;text-align:center;padding-bottom:24px;background:#fff;}.fields__container{display:grid;grid-template-columns:1fr;grid-gap:24px;align-items:flex-start;margin-bottom:24px;}@media screen and (min-width:","){.fields__container{grid-template-columns:repeat( ",",1fr );}}.fields__container:first-child{margin-bottom:0;}.fields__container--single-column{grid-column:1/-1;}.fields__container.hidden{display:none;}label{font-weight:normal !important;}.section__insurance input{background:#fff;}.fields__container .search-select-input .labels{margin:0 0 4px 0 !important;align-items:flex-end;padding-bottom:4px;}.fields__container .search-select-input .label-container{align-items:flex-end;}.fields__container .search-select-input label{margin-bottom:0;padding-bottom:0;}.required-label{margin-bottom:24px !important;}.option__circle{background:#fff;}.section__contact .option__container{display:block !important;}.section__contact .option__container > .option__label:first-child{margin-bottom:16px;}.section__contact.hidden{display:none;}.validation{padding:24px;text-align:center;display:flex;align-items:center;grid-gap:8px;justify-content:center;}"],e=>(null==e?void 0:e.isFormSubmitted)?"none":"0px 1px 2px 0px rgba(0, 0, 0, 0.3), 0px 1px 3px 1px rgba(0, 0, 0, 0.15)",m.B,m.B,e=>(null==e?void 0:e.singleColumnFields)?"1":"2");var p=r(815),f=r(9435),h=r(6421),x=r(5153),g=r(7900),_=r(5805),b=r(2349),v=r(4633);let j=[{value:"Addiction Treatment for Myself",title:"Getting Treatment for Myself"},{value:"Addiction Treatment for Someone Else",title:"Getting Treatment for a Loved One"},{value:"Alumni",title:"Alumni Support & Inquiries"},{value:"Other Marketing",title:"Other Marketing"},{value:"Press/Media",title:"Press/Media"},{value:"Other",title:"Other (please explain below)"}];var y=r(6725),N=r(5813),S=r(2848),F=r(2746),w=e=>{let{form:i,formState:r,radioForm:n,showReasonAndMessageFields:t}=e,o=!i.formState.isValid||(null==r?void 0:r.isLoading);return(0,a.jsxs)("div",{children:[(0,a.jsx)("div",{className:"padded-container__top",children:(0,a.jsxs)("div",{className:"fields__container",children:[(0,a.jsx)(f.Z,{label:"First Name",fieldName:"firstName",placeholder:"John",required:!0,errorMessage:"First name is required.",...i}),(0,a.jsx)(h.Z,{label:"Last Name",fieldName:"lastName",placeholder:"Smith",required:!0,errorMessage:"Last name is required.",...i}),(0,a.jsx)(_.Z,{label:"Email",fieldName:"email",placeholder:"[email protected]",errorMessage:"Email address is not valid.",required:!0,...i}),(0,a.jsx)(b.Z,{label:"Phone",fieldName:"phone",placeholder:"555-555-5555",required:!0,errorMessage:"Phone number is not valid.",...i}),t&&(0,a.jsxs)(a.Fragment,{children:[(0,a.jsx)("div",{className:"fields__container--single-column",children:(0,a.jsx)(x.Z,{required:!0,label:"Inquiring About",fieldName:"Reason_for_Inquiry__c",placeholder:"Select Option:",errorMessage:"Please select reason for inquiry.",options:j,...i})}),(0,a.jsx)("div",{className:"fields__container--single-column",children:(0,a.jsx)(g.Z,{label:"Message",fieldName:"description",errorMessage:"Please enter a message.",required:!0,...i})}),(null==r?void 0:r.showInsuranceRadioOption)&&(0,a.jsx)("div",{className:"fields__container--single-column",children:(0,a.jsx)(v.Z,{fieldName:"
1check_insurance",label:"Can we verify that insurance will cover treatment for you or a loved one?",options:[{value:"yes",label:"Yes"},{value:"no",label:"No"}],...n})})]})]})}),(0,a.jsx)("div",{className:"padded-container",children:!(null==r?void 0:r.isVobForm)&&(0,a.jsxs)("section",{className:"section__submit",children:[(0,a.jsx)(S.TG,{styles:"margin: 0;"}),(0,a.jsx)(y.Z,{theme:"primary",type:"submit",disabled:o,style:{width:"100%"},children:(null==r?void 0:r.isLoading)?(0,a.jsxs)(a.Fragment,{children:[(0,a.jsx)("div",{children:"Submitting... "}),(0,a.jsx)("div",{children:(0,a.jsx)(N.Z,{fill:"var(--gray-400, #6A6A6A)",width:"16",height:"16"})})]}):(0,a.jsx)("div",{children:"Submit"})}),(0,a.jsx)(F.Z,{})]})})]})},q=r(7412),k=r(9358),P=r(6656),C=e=>{let{success:i}=e;return(0,a.jsx)(u,{children:(0,a.jsx)("div",{id:"contact-form__response",children:i?(0,a.jsxs)("div",{className:"validation",children:[(0,a.jsx)(P.Z,{fill:"var(--success, #49a147)"}),(0,a.jsx)("span",{children:"Thank you for your submission."})]}):(0,a.jsxs)("div",{className:"validation error",children:[(0,a.jsx)(k.Z,{fill:"var(--warning, #ffad0d"}),"We are having trouble processing your request at this time please try back again later or give us a call."]})})})},Z=r(5561),T=r(6473),M=r(117),I=r(6506),L=e=>{let{checkboxForm:i,isContactInfoSame:r,isVobContactFieldsRequired:o,updateFormState:l,existingFormValues:s}=e,d=(0,t.Gc)();return(0,n.useEffect)(()=>{r?null==d||d.reset(s):null==d||d.reset({first_name_policy_holder:"",last_name_policy_holder:"",phone:"",email:""})},[r]),(0,a.jsxs)(a.Fragment,{children:[(0,a.jsx)("div",{className:"tertiary-background",children:(0,a.jsxs)("div",{className:"padded-container",children:[(0,a.jsx)("div",{className:"form__title",children:"Insurance Information"}),(0,a.jsx)("p",{children:"Your insurance provider will not be notified or contacted by completing this form."}),(0,a.jsx)(p.Z,{}),(0,a.jsxs)("div",{className:"fields__container",children:[(0,a.jsx)(M.zt,{}),(0,a.jsx)(M.RC,{}),(0,a.jsx)("div",{className:"fields__container--single-column",children:(0,a.jsx)(M.uL,{})}),(0,a.jsx)("div",{className:"fields__container--single-column",children:(0,a.jsx)(I.Z,{fieldName:"policy_info_same_as_contact",label:"Policy holder and contact information above are the same.",...i})})]}),(0,a.jsxs)("div",{className:"fields__container ".concat(r?"hidden":""),children:[(0,a.jsx)(M.SW,{required:o,label:"Policy Holder's First Name"}),(0,a.jsx)(M.uQ,{required:o,label:"Policy Holder's Last Name"}),(0,a.jsx)(M.LP,{required:o,label:"Policy Holder's Phone Number"}),(0,a.jsx)(M.GT,{required:o,label:"Policy Holder's Email"})]}),(0,a.jsxs)("div",{className:"fields__container",children:[(0,a.jsx)(M.uh,{label:"Policy Holder's Date of Birth"}),(0,a.jsx)(M.V7,{})]})]})}),(0,a.jsxs)("div",{className:"section__submit padded-container",children:[(0,a.jsx)(S.y_,{styles:"margin: 0;"}),(0,a.jsx)(M.Mm,{onClick:()=>{l({isFormSubmitted:!0})}}),(0,a.jsx)(F.Z,{})]})]})};let R={isVobForm:!1,showInsuranceRadioOption:!1,isLoading:!1,isFormSubmitted:!1,isContactFormSubmitSuccess:!1},A=e=>{let{additionalSubmitHandler:i,leadSourcePrefix:r,showReasonAndMessageFields:o=!0,singleColumnFields:l=!1,formTitle:c="Contact Information",handleFinishClickForVobAbandon:m,callTrackingNumber:f,showSignPosting:h,mentalHealthForm:x}=e,g=(0,n.useRef)(null),_=(0,t.cI)({mode:"onTouched"}),b=(0,t.cI)(),v=(0,t.cI)(),[j,y]=(0,n.useState)(R),N=e=>{y(i=>({...i,...e}))},S=(0,t.qo)({control:null==_?void 0:_.control,name:"Reason_for_Inquiry__c"}),F=(0,t.qo)({control:null==v?void 0:v.control,name:"check_insurance"});(0,n.useEffect)(()=>{N({showInsuranceRadioOption:"Addiction Treatment for Myself"===S||"Addiction Treatment for Someone Else"===S})},[S]),(0,n.useEffect)(()=>{N({isVobForm:"yes"===F})},[F]);let k=async e=>{if(N({isLoading:!0}),!(null==j?void 0:j.isVobForm)){let i={leadsource:r?"".concat(r).concat((0,s.bl)()):"WEB-CONTACT-".concat((0,s.bl)()),...e};try{await (0,d.JW)(i),N({isContactFormSubmitSuccess:!0})}catch(e){console.warn(e)}window&&window.dataLayer&&window.dataLayer.push({event:"FormSubmit",formName:"Contact"})}N({isLoading:!1}),N({isFormSubmitted:!0}),g.current.scrollIntoView({behavior:"smooth"}),i&&i()},P=(0,t.qo)({control:null==b?void 0:b.control,name:"policy_info_same_as_contact"}),M=null==_?void 0:_.getValues(),I=P?{first_name_policy_holder:null==M?void 0:M.firstName,last_name_policy_holder:null==M?void 0:M.lastName,phone:null==M?void 0:M.phone,email:null==M?void 0:M.email}:{},A=P?{Source__c:"vtx-contact-form"}:{Referrer_First_Name__c:null==M?void 0:M.firstName,Referrer_Last_Name__c:null==M?void 0:M.lastName,Referrer_Email__c:null==M?void 0:M.email,Referrer_Phone__c:null==M?void 0:M.phone,Source__c:"vtx-contact-form"},V=(null==j?void 0:j.isVobForm)&&!P;return(0,a.jsxs)(u,{...j,singleColumnFields:l,children:[(0,a.jsxs)("div",{className:"contact-vob__container",ref:g,children:[(0,a.jsxs)("section",{className:"section__contact ".concat((null==j?void 0:j.isFormSubmitted)?"hidden":""),children:[(0,a.jsxs)("div",{className:"padded-container",children:[c&&(0,a.jsx)("div",{className:"form__title",children:c}),(0,a.jsx)(p.Z,{})]}),(0,a.jsx)(q.Z,{id:"contact-form",form:_,onSubmit:k,children:(0,a.jsx)(w,{form:_,formState:j,radioForm:v,showReasonAndMessageFields:o})})]}),(0,a.jsx)("section",{className:"section__insurance ".concat((null==j?void 0:j.isVobForm)?"":"hidden"),children:(0,a.jsx)(Z.Z,{callTrackingNumber:f,handleFinishClick:m,children:(0,a.jsx)(T.default,{type:"custom",automationTestingSelector:"contact-form-vob",onSubmit:k,leadSource:r,existingFormValues:I,additionalSalesforceData:A,hideAfterPreviousSubmit:!1,showSignPosting:h,mentalHealthForm:x,children:(0,a.jsx)(L,{existingFormValues:I,checkboxForm:b,isVobContactFieldsRequired:V,isContactInfoSame:P,updateFormState:N})})})})]}),(null==j?void 0:j.isFormSubmitted)&&!(null==j?void 0:j.isVobForm)&&(0,a.jsx)(C,{success:null==j?void 0:j.isContactFormSubmitSuccess})]})};var V=A;A.propTypes={additionalSubmitHandler:l().func,leadSourcePrefix:l().string,
1showReasonAndMessageFields:l().bool,singleColumnFields:l().bool,formTitle:l().string,handleFinishClickForVobAbandon:l().func,callTrackingNumber:l().shape({href:l().string,display:l().string}),showSignPosting:l().bool,mentalHealthForm:l().bool}},7900:function(e,i,r){r.d(i,{Z:function(){return m}});var a=r(5893),n=r(7294);let t=r(9521).ZP.div.withConfig({componentId:"sc-f86f614e-0"})(["label{font-weight:bold;margin-bottom:4px;}label.required::after{content:' *';width:12px;height:12px;color:var(--error);}textarea{width:100%;min-height:300px;border-radius:4px;background:var(--gray-100);border:1px solid var(--gray-300);font-family:var(--copy-font,inter);font-size:16px;padding:16px;margin-bottom:8px;}textarea.error,textarea.error:focus,textarea.error:focus-visible{border:2px solid var(--error);}textarea:focus{background:#fff;}.input-error{font-size:12px;color:var(--error);font-weight:bold;display:block;}.label-container{display:grid;grid-template-columns:auto auto;grid-gap:5px;align-items:center;justify-content:space-between;}.required-asterisk{color:var(--error);margin-left:4px;}.label__max-char{font-size:12px;color:var(--gray-400);margin-bottom:4px;padding-bottom:4px;}.helper-text{font-weight:500;font-size:14px;line-height:20px;font-style:italic;color:var(--gray-400,#6a6a6a);display:inline-block;margin-bottom:15px;}",""],e=>e.styles);var o=r(5697),l=r.n(o);let s=/.*\S.*/,d=e=>!!s.test(e)&&e.trim().length>0||"Please include a non-whitespace character.",c=e=>{var i;let{label:r,register:o,formState:{errors:l={}}={},fieldName:c,placeholder:m,required:u,errorMessage:p,styles:f="",maxLength:h="250",pattern:x={value:s,message:"Please include a non-whitespace character."},validate:g,helperText:_}=e,[b,v]=(0,n.useState)(0);return(0,a.jsxs)(t,{styles:f,children:[(0,a.jsxs)("div",{className:"label-container",children:[(0,a.jsx)("div",{children:(0,a.jsx)("label",{htmlFor:c,className:u?"required":"",dangerouslySetInnerHTML:{__html:r}})}),h&&(0,a.jsxs)("span",{className:"label__max-char",children:["(",b,"/",h,")"]})]}),_&&(0,a.jsx)("span",{className:"helper-text",children:_}),(0,a.jsx)("textarea",{type:"text",id:c,maxLength:h,className:"".concat(l[c]?"error":""),...o(c,{required:!!u&&(p||"".concat(r," is required")),pattern:x,validate:g||d}
1),placeholder:m,onChange:e=>{var i;return v(null===(i=e.target.value)||void 0===i?void 0:i.length)}}),l[c]&&(0,a.jsx)("span",{className:"input-error",children:null===(i=l[c])||void 0===i?void 0:i.message})]})};var m=c;c.propTypes={register:l().func.isRequired,fieldName:l().string.isRequired,label:l().string.isRequired,required:l().bool,formState:l().object,placeholder:l().string,errorMessage:l().string,helperText:l().string,maxLength:l().string}}}]);
Line numbers count LF bytes from the start of the resource, as the search results do. Vendor segments are library code the classifier recognised; they are stored but not indexed. Bytes are shown as Latin1 characters, one per byte.