Modern dark-mode form using Tailwind + JS.
Customize options in REASONS in the JS below.
REASONS
Insurance
Shown only when financial responsibility exists.
Payment capability
Only one can be selected; picking one will uncheck the others.
Status
Treatment Program
Only one program should be selected; choosing one will uncheck the other.
Level of care seeking
You can select multiple levels of care.
Toggle based on whether the contact answered.