{"id":26,"date":"2019-10-03T16:36:48","date_gmt":"2019-10-03T20:36:48","guid":{"rendered":"https:\/\/norlina.med.unc.edu\/?page_id=26"},"modified":"2021-07-02T10:12:39","modified_gmt":"2021-07-02T14:12:39","slug":"profile","status":"publish","type":"page","link":"https:\/\/ncschoolpsychology.med.unc.edu\/index.php\/nctbi\/provider-portal\/profile\/","title":{"rendered":"Set up my online TBI Provider Profile"},"content":{"rendered":"\n<h4 class=\"wp-block-heading\">Instructions<\/h4>\n\n\n\n<p>After entering your information, you will receive an email with your private link. Your private link will allow you to continue filling out your profile. You may return to your profile at any time to update your information.<\/p>\n\n\n<!-- template: participants-database\/templates\/pdb-signup-default.php --><div class=\"wrap pdb-signup pdb-instance-2 pdb-scroll-to-error\" >\n\n    <form method=\"post\" enctype=\"multipart\/form-data\"  autocomplete=\"off\" action=\"\/index.php\/wp-json\/wp\/v2\/pages\/26\" ><input name=\"action\" type=\"hidden\" value=\"signup\" \/>\n\n<input name=\"subsource\" type=\"hidden\" value=\"participants-database\" \/>\n\n<input name=\"shortcode_page\" type=\"hidden\" value=\"\/index.php\/wp-json\/wp\/v2\/pages\/26\" \/>\n\n<input name=\"thanks_page\" type=\"hidden\" value=\"\/index.php\/wp-json\/wp\/v2\/pages\/26\" \/>\n\n<input name=\"instance_index\" type=\"hidden\" value=\"2\" \/>\n\n<input name=\"pdb_data_keys\" type=\"hidden\" value=\"1.2.9.27.20.24.28.30.21.31.32\" \/>\n\n<input name=\"session_hash\" type=\"hidden\" value=\"ed9c032e03\" \/>\n\n    <table class=\"form-table pdb-signup\">\n\n      \n      <tbody class=\"field-group field-group-main\">\n        \n                \n        \n        <tr class=\"text-line first_name-input-group\">\n\n          <th for=\"pdb-first_name-2\">First Name<span class=\"reqd\">*<\/span><\/th>\n\n          <td>\n\n            <input name=\"first_name\" id=\"pdb-first_name-2\" class=\"required-field regular-text\" type=\"text\" value=\"\" \/>\n\n                        \n          <\/td>\n\n        <\/tr>\n  \n        \n        <tr class=\"text-line last_name-input-group\">\n\n          <th for=\"pdb-last_name-2\">Last Name<span class=\"reqd\">*<\/span><\/th>\n\n          <td>\n\n            <input name=\"last_name\" id=\"pdb-last_name-2\" class=\"required-field regular-text\" type=\"text\" value=\"\" \/>\n\n                        \n          <\/td>\n\n        <\/tr>\n  \n        \n        <tr class=\"text-line email-input-group\">\n\n          <th for=\"pdb-email-2\">Email<span class=\"reqd\">*<\/span><\/th>\n\n          <td>\n\n            <input name=\"email\" id=\"pdb-email-2\" class=\"required-field regular-text\" type=\"text\" value=\"\" \/>\n\n                        <span class=\"helptext\">This is the email address you would like listed publicly.<\/span>\n                        \n          <\/td>\n\n        <\/tr>\n  \n        \n        <tr class=\"dropdown region-input-group\">\n\n          <th for=\"pdb-region-2\">Region<span class=\"reqd\">*<\/span><\/th>\n\n          <td>\n\n            <select name=\"region\" id=\"pdb-region-2\" class=\"required-field\">\n<option value=\"\" selected=\"selected\">&nbsp;<\/option>\n<option value=\"North Central\">North Central<\/option>\n<option value=\"Northeast\">Northeast<\/option>\n<option value=\"Northwest\">Northwest<\/option>\n<option value=\"Piedmont-Triad\">Piedmont-Triad<\/option>\n<option value=\"Sandhills\">Sandhills<\/option>\n<option value=\"Southeast\">Southeast<\/option>\n<option value=\"Southwest\">Southwest<\/option>\n<option value=\"Western\">Western<\/option>\n<\/select>\n\n                        \n          <\/td>\n\n        <\/tr>\n  \n        \n        <tr class=\"text-line phone-input-group\">\n\n          <th for=\"pdb-phone-2\">Phone<span class=\"reqd\">*<\/span><\/th>\n\n          <td>\n\n            <input name=\"phone\" id=\"pdb-phone-2\" class=\"required-field regular-text\" type=\"text\" value=\"\" \/>\n\n                        <span class=\"helptext\">This is the phone number you would like listed publicly.<\/span>\n                        \n          <\/td>\n\n        <\/tr>\n  \n        \n        <tr class=\"dropdown county-input-group\">\n\n          <th for=\"pdb-county-2\">County<span class=\"reqd\">*<\/span><\/th>\n\n          <td>\n\n            <select name=\"county\" id=\"pdb-county-2\" class=\"required-field\">\n<option value=\"\" selected=\"selected\">&nbsp;<\/option>\n<option value=\"Alamance\">Alamance<\/option>\n<option value=\"Alexander\">Alexander<\/option>\n<option value=\"Alleghany\">Alleghany<\/option>\n<option value=\"Anson\">Anson<\/option>\n<option value=\"Ashe\">Ashe<\/option>\n<option value=\"Avery\">Avery<\/option>\n<option value=\"Beaufort\">Beaufort<\/option>\n<option value=\"Bertie\">Bertie<\/option>\n<option value=\"Bladen\">Bladen<\/option>\n<option value=\"Brunswick\">Brunswick<\/option>\n<option value=\"Buncombe\">Buncombe<\/option>\n<option value=\"Burke\">Burke<\/option>\n<option value=\"Cabarrus\">Cabarrus<\/option>\n<option value=\"Caldwell\">Caldwell<\/option>\n<option value=\"Camden\">Camden<\/option>\n<option value=\"Carteret\">Carteret<\/option>\n<option value=\"Caswell\">Caswell<\/option>\n<option value=\"Catawba\">Catawba<\/option>\n<option value=\"Chatham\">Chatham<\/option>\n<option value=\"Cherokee\">Cherokee<\/option>\n<option value=\"Chowan\">Chowan<\/option>\n<option value=\"Clay\">Clay<\/option>\n<option value=\"Cleveland\">Cleveland<\/option>\n<option value=\"Columbus\">Columbus<\/option>\n<option value=\"Craven\">Craven<\/option>\n<option value=\"Cumberland\">Cumberland<\/option>\n<option value=\"Currituck\">Currituck<\/option>\n<option value=\"Dare\">Dare<\/option>\n<option value=\"Davidson\">Davidson<\/option>\n<option value=\"Davie\">Davie<\/option>\n<option value=\"Duplin\">Duplin<\/option>\n<option value=\"Durham\">Durham<\/option>\n<option value=\"Edgecombe\">Edgecombe<\/option>\n<option value=\"Forsyth\">Forsyth<\/option>\n<option value=\"Franklin\">Franklin<\/option>\n<option value=\"Gaston\">Gaston<\/option>\n<option value=\"Gates\">Gates<\/option>\n<option value=\"Graham\">Graham<\/option>\n<option value=\"Granville\">Granville<\/option>\n<option value=\"Greene\">Greene<\/option>\n<option value=\"Guilford\">Guilford<\/option>\n<option value=\"Halifax\">Halifax<\/option>\n<option value=\"Harnett\">Harnett<\/option>\n<option value=\"Haywood\">Haywood<\/option>\n<option value=\"Henderson\">Henderson<\/option>\n<option value=\"Hertford\">Hertford<\/option>\n<option value=\"Hoke\">Hoke<\/option>\n<option value=\"Hyde\">Hyde<\/option>\n<option value=\"Iredell\">Iredell<\/option>\n<option value=\"Jackson\">Jackson<\/option>\n<option value=\"Johnston\">Johnston<\/option>\n<option value=\"Jones\">Jones<\/option>\n<option value=\"Lee\">Lee<\/option>\n<option value=\"Lenoir\">Lenoir<\/option>\n<option value=\"Lincoln\">Lincoln<\/option>\n<option value=\"McDowell\">McDowell<\/option>\n<option value=\"Macon\">Macon<\/option>\n<option value=\"Madison\">Madison<\/option>\n<option value=\"Martin\">Martin<\/option>\n<option value=\"Mecklenburg\">Mecklenburg<\/option>\n<option value=\"Mitchell\">Mitchell<\/option>\n<option value=\"Montgomery\">Montgomery<\/option>\n<option value=\"Moore\">Moore<\/option>\n<option value=\"Nash\">Nash<\/option>\n<option value=\"New Hanover\">New Hanover<\/option>\n<option value=\"Northampton\">Northampton<\/option>\n<option value=\"Onslow\">Onslow<\/option>\n<option value=\"Orange\">Orange<\/option>\n<option value=\"Pamlico\">Pamlico<\/option>\n<option value=\"Pasquotank\">Pasquotank<\/option>\n<option value=\"Pender\">Pender<\/option>\n<option value=\"Perquimans\">Perquimans<\/option>\n<option value=\"Person\">Person<\/option>\n<option value=\"Pitt\">Pitt<\/option>\n<option value=\"Polk\">Polk<\/option>\n<option value=\"Randolph\">Randolph<\/option>\n<option value=\"Richmond\">Richmond<\/option>\n<option value=\"Robeson\">Robeson<\/option>\n<option value=\"Rockingham\">Rockingham<\/option>\n<option value=\"Rowan\">Rowan<\/option>\n<option value=\"Rutherford\">Rutherford<\/option>\n<option value=\"Sampson\">Sampson<\/option>\n<option value=\"Scotland\">Scotland<\/option>\n<option value=\"Stanly\">Stanly<\/option>\n<option value=\"Stokes\">Stokes<\/option>\n<option value=\"Surry\">Surry<\/option>\n<option value=\"Swain\">Swain<\/option>\n<option value=\"Transylvania\">Transylvania<\/option>\n<option value=\"Tyrrell\">Tyrrell<\/option>\n<option value=\"Union\">Union<\/option>\n<option value=\"Vance\">Vance<\/option>\n<option value=\"Wake\">Wake<\/option>\n<option value=\"Warren\">Warren<\/option>\n<option value=\"Washington\">Washington<\/option>\n<option value=\"Watauga\">Watauga<\/option>\n<option value=\"Wayne\">Wayne<\/option>\n<option value=\"Wilkes\">Wilkes<\/option>\n<option value=\"Wilson\">Wilson<\/option>\n<option value=\"Yadkin\">Yadkin<\/option>\n<option value=\"Yancey\">Yancey<\/option>\n<\/select>\n\n                        \n          <\/td>\n\n        <\/tr>\n  \n                \n        <\/tbody>\n\n      \n      <tbody class=\"field-group field-group-personal\">\n        \n                \n        \n        <tr class=\"text-line personal_email-input-group\">\n\n          <th for=\"pdb-personal_email-2\">Personal Email<span class=\"reqd\">*<\/span><\/th>\n\n          <td>\n\n            <input name=\"personal_email\" id=\"pdb-personal_email-2\" class=\"required-field regular-text\" type=\"text\" value=\"\" \/>\n\n                        <span class=\"helptext\">This email will not be listed publicy. It will only be used in the case that the TBI Team is unable to reach you via other methods.  This is also the email that will be used to access\/edit your profile.<\/span>\n                        \n          <\/td>\n\n        <\/tr>\n  \n        \n        <tr class=\"text-line alternate_phone_number-input-group\">\n\n          <th for=\"pdb-alternate_phone_number-2\">Alternate Phone Number<\/th>\n\n          <td>\n\n            <input name=\"alternate_phone_number\" id=\"pdb-alternate_phone_number-2\" class=\" regular-text\" type=\"text\" value=\"\" \/>\n\n                        \n          <\/td>\n\n        <\/tr>\n  \n        \n        <tr class=\"text-line city-input-group\">\n\n          <th for=\"pdb-city-2\">City<\/th>\n\n          <td>\n\n            <input name=\"city\" id=\"pdb-city-2\" class=\" regular-text\" type=\"text\" value=\"\" \/>\n\n                        \n          <\/td>\n\n        <\/tr>\n  \n        \n        <tr class=\"text-line state-input-group\">\n\n          <th for=\"pdb-state-2\">State<\/th>\n\n          <td>\n\n            <input name=\"state\" id=\"pdb-state-2\" class=\" regular-text\" type=\"text\" value=\"\" \/>\n\n                        \n          <\/td>\n\n        <\/tr>\n  \n        \n        <tr class=\"text-line zip_code-input-group\">\n\n          <th for=\"pdb-zip_code-2\">Zip Code<span class=\"reqd\">*<\/span><\/th>\n\n          <td>\n\n            <input name=\"zip_code\" id=\"pdb-zip_code-2\" class=\"required-field regular-text\" type=\"text\" value=\"\" \/>\n\n                        \n          <\/td>\n\n        <\/tr>\n  \n                \n        <\/tbody>\n\n            \n        <tbody class=\"field-group field-group-submit\">\n      \n        <tr>\n          <td class=\"submit-buttons\">\n            \n           <input name=\"submit_button\" class=\"button-primary pdb-submit\" type=\"submit\" value=\"Sign Up\" \/>\n            \n          <\/td>\n          <td class=\"submit-buttons\">\n            \n           <span class=\"pdb-retrieve-link\"><a href=\"https:\/\/ncschoolpsychology.med.unc.edu\/index.php\/nctbi\/provider-portal\/request-link\/?m=r\">Already on the TBI Registry? Forgot your login information? Click here to have it emailed to you.<\/a><\/span>           \n          <\/td>\n        <\/tr>\n        \n      <\/tbody>\n      \n    <\/table>\n    \n  <\/form>  \n<\/div><!-- end template: participants-database\/templates\/pdb-signup-default.php -->\n\n\n\n<p><\/p>\n","protected":false},"excerpt":{"rendered":"<p>Instructions After entering your information, you will receive an email with your private link. Your private link will allow you to continue filling out your profile. You may return to [&hellip;]<\/p>\n","protected":false},"author":2,"featured_media":0,"parent":68,"menu_order":0,"comment_status":"closed","ping_status":"closed","template":"template-right-sidebar.php","meta":{"footnotes":""},"class_list":["post-26","page","type-page","status-publish","hentry"],"_links":{"self":[{"href":"https:\/\/ncschoolpsychology.med.unc.edu\/index.php\/wp-json\/wp\/v2\/pages\/26","targetHints":{"allow":["GET"]}}],"collection":[{"href":"https:\/\/ncschoolpsychology.med.unc.edu\/index.php\/wp-json\/wp\/v2\/pages"}],"about":[{"href":"https:\/\/ncschoolpsychology.med.unc.edu\/index.php\/wp-json\/wp\/v2\/types\/page"}],"author":[{"embeddable":true,"href":"https:\/\/ncschoolpsychology.med.unc.edu\/index.php\/wp-json\/wp\/v2\/users\/2"}],"replies":[{"embeddable":true,"href":"https:\/\/ncschoolpsychology.med.unc.edu\/index.php\/wp-json\/wp\/v2\/comments?post=26"}],"version-history":[{"count":13,"href":"https:\/\/ncschoolpsychology.med.unc.edu\/index.php\/wp-json\/wp\/v2\/pages\/26\/revisions"}],"predecessor-version":[{"id":3994,"href":"https:\/\/ncschoolpsychology.med.unc.edu\/index.php\/wp-json\/wp\/v2\/pages\/26\/revisions\/3994"}],"up":[{"embeddable":true,"href":"https:\/\/ncschoolpsychology.med.unc.edu\/index.php\/wp-json\/wp\/v2\/pages\/68"}],"wp:attachment":[{"href":"https:\/\/ncschoolpsychology.med.unc.edu\/index.php\/wp-json\/wp\/v2\/media?parent=26"}],"curies":[{"name":"wp","href":"https:\/\/api.w.org\/{rel}","templated":true}]}}