F2F Unsuccessful

[date name="note-date" default=""]
Face-to-Face contact unsuccessful.
Due to: [checkbox  name="dueTo" value="Client|Clinician|Other"][text name="dueToOther" default=" "]
Reason:[checkbox name="reason" value="Canceled|Scheduling Conflict|No Call/No Show|Court|Health Reasons/Sick|Weather|Other"][text name="reasonOther" default=" "]
Further Information: [textarea name="dueToMemo" default=" "]
[comment memo="Verbal or Emotional Violence:"][checkbox name="emotional" value="Learned from caregiver verbal or emotional violence occurred since the last time I saw this client.|Learned from DCF verbal or emotional violence occurred since the last time I saw this client.|Learned from other source verbal or emotional violence occurred since the last time I saw this client.|No verbal or emotional violence occurred since the last time I saw this client"]
[comment memo="Physical Violence"][checkbox name="physical" value="Learned from caregiver physical violence occurred since the last time I saw this client.|Learned from DCF physical violence occurred since the last time I saw this client.|Learned from other source physical violence occurred since the last time I saw this client.|No physical violence occurred since the last time I saw this client."] 
Did Client Reschedule? [checkbox name="reschedule" value="Yes|No"]
Next Appointment is scheduled for [date name="variable_2" default="today"] at [text name="appttime" default="time" size="10"]
[checkbox name="location-next" value="at the client's home| at the office|community location| via telehealth "]

Face-to-Face contact unsuccessful.
Due to:
Reason:
Further Information:
Verbal or Emotional Violence:
Physical Violence
Did Client Reschedule?
Next Appointment is scheduled for at

Result - Copy and paste this output:

Sandbox Metrics: Structured Data Index 0.67, 14 form elements, 17 boilerplate words, 3 text boxes, 1 text areas, 2 dates, 6 checkboxes, 2 comments, 30 total clicks
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