{"id":100770,"date":"2022-08-11T08:30:10","date_gmt":"2022-08-11T12:30:10","guid":{"rendered":"https:\/\/rsc.diskdaddy.com\/intake\/"},"modified":"2026-08-24T09:52:34","modified_gmt":"2026-08-24T13:52:34","slug":"intake","status":"publish","type":"page","link":"https:\/\/www.robertssmartcentre.com\/fr\/contact\/intake\/","title":{"rendered":"Intake"},"content":{"rendered":"<p>[et_pb_section fb_built=\u00a0\u00bb1&Prime; _builder_version=\u00a0\u00bb4.27.8&Prime; _module_preset=\u00a0\u00bbdefault\u00a0\u00bb custom_padding=\u00a0\u00bb||125px|||\u00a0\u00bb global_colors_info=\u00a0\u00bb{}\u00a0\u00bb][et_pb_row _builder_version=\u00a0\u00bb4.27.8&Prime; _module_preset=\u00a0\u00bbdefault\u00a0\u00bb global_colors_info=\u00a0\u00bb{}\u00a0\u00bb][et_pb_column type=\u00a0\u00bb4_4&Prime; _builder_version=\u00a0\u00bb4.27.8&Prime; _module_preset=\u00a0\u00bbdefault\u00a0\u00bb global_colors_info=\u00a0\u00bb{}\u00a0\u00bb][et_pb_text _builder_version=\u00a0\u00bb4.27.8&Prime; _module_preset=\u00a0\u00bbdefault\u00a0\u00bb global_colors_info=\u00a0\u00bb{}\u00a0\u00bb]<script>\nvar gform;gform||(document.addEventListener(\"gform_main_scripts_loaded\",function(){gform.scriptsLoaded=!0}),document.addEventListener(\"gform\/theme\/scripts_loaded\",function(){gform.themeScriptsLoaded=!0}),window.addEventListener(\"DOMContentLoaded\",function(){gform.domLoaded=!0}),gform={domLoaded:!1,scriptsLoaded:!1,themeScriptsLoaded:!1,isFormEditor:()=>\"function\"==typeof InitializeEditor,callIfLoaded:function(o){return!(!gform.domLoaded||!gform.scriptsLoaded||!gform.themeScriptsLoaded&&!gform.isFormEditor()||(gform.isFormEditor()&&console.warn(\"The use of gform.initializeOnLoaded() is deprecated in the form editor context and will be removed in Gravity Forms 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d=gform.hooks[o][r];null==n&&(n=r+\"_\"+d.length),gform.hooks[o][r].push({tag:n,callable:e,priority:t=null==t?10:t})},doHook:function(r,o,e){var t;if(e=Array.prototype.slice.call(e,1),null!=gform.hooks[r][o]&&((o=gform.hooks[r][o]).sort(function(o,r){return o.priority-r.priority}),o.forEach(function(o){\"function\"!=typeof(t=o.callable)&&(t=window[t]),\"action\"==r?t.apply(null,e):e[0]=t.apply(null,e)})),\"filter\"==r)return e[0]},removeHook:function(o,r,t,n){var e;null!=gform.hooks[o][r]&&(e=(e=gform.hooks[o][r]).filter(function(o,r,e){return!!(null!=n&&n!=o.tag||null!=t&&t!=o.priority)}),gform.hooks[o][r]=e)}});\n<\/script>\n\n                <div class='gf_browser_gecko gform_wrapper gravity-theme gform-theme--no-framework' data-form-theme='gravity-theme' data-form-index='0' id='gform_wrapper_3' style='display:none'><div id='gf_3' class='gform_anchor' tabindex='-1'><\/div>\n                        <div class='gform_heading'>\n                            <h2 class=\"gform_title\">Intake Form<\/h2>\n                            <p class='gform_description'><\/p>\n                        <\/div><form method='post' enctype='multipart\/form-data'  id='gform_3'  action='\/fr\/wp-json\/wp\/v2\/pages\/100770#gf_3' data-formid='3' novalidate><input id=\"gpnf_session_hash_3\" type=\"hidden\" name=\"gpnf_session_hash\" value=\"291ee0d98d6a\"><input id=\"gw_page_progression\" name=\"gw_page_progression\" value=\"1\" type=\"hidden\" \/><input id=\"gpmpn_pages_visited_3\" name=\"gpmpn_pages_visited_3\" value=\"[1]\" type=\"hidden\" \/><input id=\"gpmpn_page_validity_3\" name=\"gpmpn_page_validity_3\" value=\"{&quot;1&quot;:false,&quot;2&quot;:false,&quot;3&quot;:false,&quot;4&quot;:false,&quot;5&quot;:false,&quot;6&quot;:false,&quot;7&quot;:false,&quot;8&quot;:false,&quot;9&quot;:false,&quot;10&quot;:false,&quot;11&quot;:false,&quot;12&quot;:false,&quot;13&quot;:false,&quot;14&quot;:false,&quot;15&quot;:false,&quot;16&quot;:false,&quot;17&quot;:false,&quot;18&quot;:false,&quot;19&quot;:false,&quot;20&quot;:false,&quot;21&quot;:false,&quot;22&quot;:false,&quot;23&quot;:false,&quot;24&quot;:false,&quot;25&quot;:false}\" type=\"hidden\" \/><div id='gf_page_steps_3' class='gf_page_steps'><div id='gf_step_3_1' class='gf_step gf_step_active gf_step_first'><span class='gf_step_number'>1<\/span><span class='gf_step_label'><\/span><\/div><div id='gf_step_3_2' class='gf_step gf_step_next gf_step_pending'><span class='gf_step_number'>2<\/span><span class='gf_step_label'><\/span><\/div><div id='gf_step_3_3' class='gf_step gf_step_pending'><span class='gf_step_number'>3<\/span><span class='gf_step_label'><\/span><\/div><div id='gf_step_3_4' class='gf_step gf_step_pending'><span class='gf_step_number'>4<\/span><span class='gf_step_label'><\/span><\/div><div id='gf_step_3_5' class='gf_step gf_step_pending'><span class='gf_step_number'>5<\/span><span class='gf_step_label'><\/span><\/div><div id='gf_step_3_6' class='gf_step gf_step_pending'><span class='gf_step_number'>6<\/span><span class='gf_step_label'><\/span><\/div><div id='gf_step_3_7' class='gf_step gf_step_pending'><span class='gf_step_number'>7<\/span><span class='gf_step_label'><\/span><\/div><div id='gf_step_3_8' class='gf_step gf_step_pending'><span class='gf_step_number'>8<\/span><span class='gf_step_label'><\/span><\/div><div id='gf_step_3_9' class='gf_step gf_step_pending'><span class='gf_step_number'>9<\/span><span class='gf_step_label'><\/span><\/div><div id='gf_step_3_10' class='gf_step gf_step_pending'><span class='gf_step_number'>10<\/span><span class='gf_step_label'><\/span><\/div><div id='gf_step_3_11' class='gf_step gf_step_pending'><span class='gf_step_number'>11<\/span><span class='gf_step_label'><\/span><\/div><div id='gf_step_3_12' class='gf_step gf_step_pending'><span class='gf_step_number'>12<\/span><span class='gf_step_label'><\/span><\/div><div id='gf_step_3_13' class='gf_step gf_step_pending'><span class='gf_step_number'>13<\/span><span class='gf_step_label'><\/span><\/div><div id='gf_step_3_14' class='gf_step gf_step_pending'><span class='gf_step_number'>14<\/span><span class='gf_step_label'><\/span><\/div><div id='gf_step_3_15' class='gf_step gf_step_pending'><span class='gf_step_number'>15<\/span><span class='gf_step_label'><\/span><\/div><div id='gf_step_3_16' class='gf_step gf_step_pending'><span class='gf_step_number'>16<\/span><span class='gf_step_label'><\/span><\/div><div id='gf_step_3_17' class='gf_step gf_step_pending'><span class='gf_step_number'>17<\/span><span class='gf_step_label'><\/span><\/div><div id='gf_step_3_18' class='gf_step gf_step_pending'><span class='gf_step_number'>18<\/span><span class='gf_step_label'><\/span><\/div><div id='gf_step_3_19' class='gf_step gf_step_pending'><span class='gf_step_number'>19<\/span><span class='gf_step_label'><\/span><\/div><div id='gf_step_3_20' class='gf_step gf_step_pending'><span class='gf_step_number'>20<\/span><span class='gf_step_label'><\/span><\/div><div id='gf_step_3_21' class='gf_step gf_step_pending'><span class='gf_step_number'>21<\/span><span class='gf_step_label'><\/span><\/div><div id='gf_step_3_22' class='gf_step gf_step_pending'><span class='gf_step_number'>22<\/span><span class='gf_step_label'><\/span><\/div><div id='gf_step_3_23' class='gf_step gf_step_pending'><span class='gf_step_number'>23<\/span><span class='gf_step_label'><\/span><\/div><div id='gf_step_3_24' class='gf_step gf_step_pending'><span class='gf_step_number'>24<\/span><span class='gf_step_label'><\/span><\/div><div id='gf_step_3_25' class='gf_step gf_step_last gf_step_pending'><span class='gf_step_number'>25<\/span><span class='gf_step_label'><\/span><\/div><\/div>\n                        <div class='gform-body gform_body'><div id='gform_page_3_1' class='gform_page ' data-js='page-field-id-0' >\n\t\t\t\t\t<div class='gform_page_fields'><div id='gform_fields_3' class='gform_fields top_label form_sublabel_below description_below validation_below'><div id=\"field_3_1\" class=\"gfield gfield--type-section gfield--input-type-section gsection field_sublabel_below gfield--has-description field_description_below field_validation_below gfield_visibility_visible\"  ><h3 class=\"gsection_title\">Consent to the Collection, Use, and Disclosure of Personal Health Information<\/h3><div class='gsection_description' id='gfield_description_3_1'>Pursuant to the Personal Health Information Protection Act, 2004 (PHIPA)<\/div><\/div><fieldset id=\"field_3_3\" class=\"gfield gfield--type-address gfield--input-type-address gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' ><span class='gform-field-label__text'>Youth&#039;s Address<\/span><span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(N\u00e9cessaire)<\/span><\/span><\/legend>    \n                    <div class='ginput_complex ginput_container has_street has_street2 has_city has_state has_zip ginput_container_address gform-grid-row' id='input_3_3' >\n                         <span class='ginput_full address_line_1 ginput_address_line_1 gform-grid-col' id='input_3_3_1_container' >\n                                        <input type='text' name='input_3.1' id='input_3_3_1' value=''    aria-required='true'   autocomplete=\"address-line1\" \/>\n                                        <label for='input_3_3_1' id='input_3_3_1_label' class='gform-field-label gform-field-label--type-sub '>Adresse postale<\/label>\n                                    <\/span><span class='ginput_full address_line_2 ginput_address_line_2 gform-grid-col' id='input_3_3_2_container' >\n                                        <input type='text' name='input_3.2' id='input_3_3_2' value=''    autocomplete=\"address-line2\" aria-required='false'   \/>\n                                        <label for='input_3_3_2' id='input_3_3_2_label' class='gform-field-label gform-field-label--type-sub '>Adresse ligne 2<\/label>\n                                    <\/span><span class='ginput_left address_city ginput_address_city gform-grid-col' id='input_3_3_3_container' >\n                                    <input type='text' name='input_3.3' id='input_3_3_3' value=''    aria-required='true'   autocomplete=\"address-level2\" \/>\n                                    <label for='input_3_3_3' id='input_3_3_3_label' class='gform-field-label gform-field-label--type-sub '>Ville<\/label>\n                                 <\/span><span class='ginput_right address_state ginput_address_state gform-grid-col' id='input_3_3_4_container' >\n                                        <select name='input_3.4' id='input_3_3_4'     aria-required='true'   autocomplete=\"address-level1\" ><option value='' ><\/option><option value='Alberta' >Alberta<\/option><option value='Colombie-Britannique' >Colombie-Britannique<\/option><option value='Manitoba' >Manitoba<\/option><option value='Nouveau-Brunswick' >Nouveau-Brunswick<\/option><option value='Terre-Neuve-et-Labrador' >Terre-Neuve-et-Labrador<\/option><option value='Territoires du Nord-Ouest' >Territoires du Nord-Ouest<\/option><option value='Nouvelle-\u00c9cosse' >Nouvelle-\u00c9cosse<\/option><option value='Nunavut' >Nunavut<\/option><option value='Ontario' selected='selected'>Ontario<\/option><option value='\u00cele du Prince-\u00c9douard' >\u00cele du Prince-\u00c9douard<\/option><option value='Qu\u00e9bec' >Qu\u00e9bec<\/option><option value='Saskatchewan' >Saskatchewan<\/option><option value='Yukon' >Yukon<\/option><\/select>\n                                        <label for='input_3_3_4' id='input_3_3_4_label' class='gform-field-label gform-field-label--type-sub '>Province<\/label>\n                                      <\/span><span class='ginput_left address_zip ginput_address_zip gform-grid-col' id='input_3_3_5_container' >\n                                    <input type='text' name='input_3.5' id='input_3_3_5' value=''    aria-required='true'   autocomplete=\"postal-code\" \/>\n                                    <label for='input_3_3_5' id='input_3_3_5_label' class='gform-field-label gform-field-label--type-sub '>Code postal<\/label>\n                                <\/span><input type='hidden' class='gform_hidden' name='input_3.6' id='input_3_3_6' value='CA' \/>\n                    <div class='gf_clear gf_clear_complex'><\/div>\n                <\/div><\/fieldset><div id=\"field_3_7\" class=\"gfield gfield--type-section gfield--input-type-section gsection field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><h3 class=\"gsection_title\">Consent \/ Authorization<\/h3><\/div><fieldset id=\"field_3_5\" class=\"gfield gfield--type-name gfield--input-type-name gfield--width-full gfield_contains_required field_sublabel_below gfield--has-description field_description_above field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' ><span class='gform-field-label__text'>Parent\/Guardian Name<\/span><span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(N\u00e9cessaire)<\/span><\/span><\/legend><div class='gfield_description' id='gfield_description_3_5'>(parent\/guardian or youth over 16)<\/div><div class='ginput_complex ginput_container ginput_container--name no_prefix has_first_name no_middle_name has_last_name no_suffix gf_name_has_2 ginput_container_name gform-grid-row' id='input_3_5'>\n                            \n                            <span id='input_3_5_3_container' class='name_first gform-grid-col gform-grid-col--size-auto' >\n                                                    <input type='text' name='input_5.3' id='input_3_5_3' value=''   aria-required='true'     \/>\n                                                    <label for='input_3_5_3' class='gform-field-label gform-field-label--type-sub '>Pr\u00e9nom<\/label>\n                                                <\/span>\n                            \n                            <span id='input_3_5_6_container' class='name_last gform-grid-col gform-grid-col--size-auto' >\n                                                    <input type='text' name='input_5.6' id='input_3_5_6' value=''   aria-required='true'     \/>\n                                                    <label for='input_3_5_6' class='gform-field-label gform-field-label--type-sub '>Nom<\/label>\n                                                <\/span>\n                            \n                        <\/div><\/fieldset><fieldset id=\"field_3_4\" class=\"gfield gfield--type-consent gfield--type-choice gfield--input-type-consent gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible gfield--choice-align-vertical\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' ><span class='gform-field-label__text'>Consent<\/span><span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(N\u00e9cessaire)<\/span><\/span><\/legend><div class='ginput_container ginput_container_consent'><input name='input_4.1' id='input_3_4_1' type='checkbox' value='1'   aria-required=\"true\" aria-invalid=\"false\"   \/> <label class=\"gform-field-label gform-field-label--type-inline gfield_consent_label\" for='input_3_4_1' ><span class='gform-field-label__text'>I authorize Roberts\/Smart Centre, 104-1737 Woodward Drive, Ottawa, ON K2C 0P9 to collect, use, and disclose:<\/span><\/label><input type='hidden' name='input_4.2' value='I authorize Roberts\/Smart Centre, 104-1737 Woodward Drive, Ottawa, ON K2C 0P9 to collect, use, and disclose:' class='gform_hidden' \/><input type='hidden' name='input_4.3' value='1' class='gform_hidden' \/><\/div><\/fieldset><fieldset id=\"field_3_8\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-third gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible gfield--choice-align-vertical\"  ><legend class='gfield_label gform-field-label' ><span class='gform-field-label__text'>Health Information<\/span><span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(N\u00e9cessaire)<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_3_8'>\n\t\t\t<div class='gchoice gchoice_3_8_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_8' type='radio' value='my personal health information'  id='choice_3_8_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_3_8_0' id='label_3_8_0' class='gform-field-label gform-field-label--type-inline'>my personal health information<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_3_8_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_8' type='radio' value='the personal health information of'  id='choice_3_8_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_3_8_1' id='label_3_8_1' class='gform-field-label gform-field-label--type-inline'>the personal health information of<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_3_9\" class=\"gfield gfield--type-name gfield--input-type-name gfield--width-two-thirds gfield_contains_required field_sublabel_below gfield--has-description field_description_above field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' ><span class='gform-field-label__text'>Name<\/span><span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(N\u00e9cessaire)<\/span><\/span><\/legend><div class='gfield_description' id='gfield_description_3_9'>(Name of youth under 16 years of age for whom you are the parent\/guardian)<\/div><div class='ginput_complex ginput_container ginput_container--name no_prefix has_first_name no_middle_name has_last_name no_suffix gf_name_has_2 ginput_container_name gform-grid-row' id='input_3_9'>\n                            \n                            <span id='input_3_9_3_container' class='name_first gform-grid-col gform-grid-col--size-auto' >\n                                                    <input type='text' name='input_9.3' id='input_3_9_3' value=''   aria-required='true'     \/>\n                                                    <label for='input_3_9_3' class='gform-field-label gform-field-label--type-sub '>Pr\u00e9nom<\/label>\n                                                <\/span>\n                            \n                            <span id='input_3_9_6_container' class='name_last gform-grid-col gform-grid-col--size-auto' >\n                                                    <input type='text' name='input_9.6' id='input_3_9_6' value=''   aria-required='true'     \/>\n                                                    <label for='input_3_9_6' class='gform-field-label gform-field-label--type-sub '>Nom<\/label>\n                                                <\/span>\n                            \n                        <\/div><\/fieldset><div id=\"field_3_11\" class=\"gfield gfield--type-form gfield--input-type-form gform-theme__no-reset--children gfield--width-full field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_3_11'><span class='gform-field-label__text'>With the following:<\/span><\/label><div class=\"gpnf-nested-entries-container ginput_container\">\n\n\t<table class=\"gpnf-nested-entries\">\n\n\t\t<thead>\n\t\t<tr>\n\t\t\t\t\t\t\t<th scope=\"col\" class=\"gpnf-field-7\">\n\t\t\t\t\tName\t\t\t\t<\/th>\n\t\t\t\t\t\t\t<th scope=\"col\" class=\"gpnf-field-6\">\n\t\t\t\t\tOrganization & Role\t\t\t\t<\/th>\n\t\t\t\t\t\t\t<th scope=\"col\" class=\"gpnf-field-4\">\n\t\t\t\t\tPhone\t\t\t\t<\/th>\n\t\t\t\t\t\t\t<th scope=\"col\" class=\"gpnf-field-5\">\n\t\t\t\t\tEmail\t\t\t\t<\/th>\n\t\t\t\t\t\t<th scope=\"col\" class=\"gpnf-row-actions\"><span class=\"screen-reader-text\">Actions<\/span><\/th>\n\t\t<\/tr>\n\t\t<\/thead>\n\n\t\t<tbody data-bind=\"visible: entries().length, foreach: entries\">\n\t\t<tr data-bind=\"attr: { 'data-entryid': id }\">\n\t\t\t\t\t\t\t<td class=\"gpnf-field\"\n\t\t\t\t\tdata-bind=\"html: f7.label, attr: { 'data-value': f7.label }\"\n\t\t\t\t\tdata-heading=\"Name\"\n\t\t\t\t>&nbsp;<\/td>\n\t\t\t\t\t\t\t<td class=\"gpnf-field\"\n\t\t\t\t\tdata-bind=\"html: f6.label, attr: { 'data-value': f6.label }\"\n\t\t\t\t\tdata-heading=\"Organization & Role\"\n\t\t\t\t>&nbsp;<\/td>\n\t\t\t\t\t\t\t<td class=\"gpnf-field\"\n\t\t\t\t\tdata-bind=\"html: f4.label, attr: { 'data-value': f4.label }\"\n\t\t\t\t\tdata-heading=\"Phone\"\n\t\t\t\t>&nbsp;<\/td>\n\t\t\t\t\t\t\t<td class=\"gpnf-field\"\n\t\t\t\t\tdata-bind=\"html: f5.label, attr: { 'data-value': f5.label }\"\n\t\t\t\t\tdata-heading=\"Email\"\n\t\t\t\t>&nbsp;<\/td>\n\t\t\t\t\t\t<td class=\"gpnf-row-actions\" style=\"display: none;\" data-bind=\"visible: true\">\n\t\t\t\t<ul>\n\t\t\t\t\t<li class=\"edit\"><button type=\"button\" class=\"edit-button gform-theme-button--secondary\" data-bind=\"click: $parent.editEntry, attr: { 'aria-label': 'Edit Entr\u00e9e {0} where Name is {1}.'.gformFormat( $index() + 1, f7.label ) }\">Modifier<\/button><\/li>\n\t\t\t\t\t\t\t\t\t\t<li class=\"delete\"><button type=\"button\" class=\"delete-button gform-theme-button--simple gform-theme-button--size-md\" data-bind=\"click: $parent.deleteEntry, attr: { 'aria-label': 'Delete Entr\u00e9e {0} where Name is {1}.'.gformFormat( $index() + 1, f7.label ) }\">Supprimer<\/button><\/li>\n\t\t\t\t<\/ul>\n\t\t\t<\/td>\n\t\t<\/tr>\n\t\t<\/tbody>\n\n\t\t<tbody data-bind=\"visible: entries().length <= 0\">\n\t\t<tr class=\"gpnf-no-entries\" data-bind=\"visible: entries().length <= 0\" style=\"display: none;\">\n\t\t\t<td colspan=\"5\">\n\t\t\t\tIl n\u2019y a aucun(e) <span>Entr\u00e9es.<\/span>\t\t\t<\/td>\n\t\t<\/tr>\n\t\t<\/tbody>\n\n\t<\/table>\n\n\t<button type=\"button\" class=\"gpnf-add-entry\"\n\t\t        data-formid=\"3\"\n\t\t        data-nestedformid=\"4\"\n\t\t\t\tdata-bind=\"attr: { disabled: isMaxed }, css: { 'gf-default-disabled': isMaxed }\"\n\t\t\t\t>\n\t\t\t\tAjouter Entr\u00e9e\n\t\t\t<\/button>\t\n\t\t\t<p class=\"gpnf-add-entry-max\" data-bind=\"visible: isMaxed\" style=\"display: none;\">\n\t\t\t\tLe nombre maximal a \u00e9t\u00e9 atteint.\n\t\t\t<\/p>\n<\/div>\n<input type=\"hidden\"\n                name=\"input_11\"\n                id=\"input_3_11\"\n                data-bind=\"value: entryIds\"\n                value=\"\" \/><\/div><div id=\"field_3_12\" class=\"gfield gfield--type-html gfield--input-type-html gfield--width-full gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><p>Information requested and the reason the information is needed:<\/p>\n<p style=\"text-decoration: italics; text-decoration: underline;\">For case management, treatment planning, and service delivery.<\/p>\n<p>I understand the purpose of the collection, use, and disclosure of my or my child\u2019s personal health information between the Roberts\/Smart Centre and the person(s)\/organization(s) listed above. I understand that I can review or withdraw my consent at any time.<\/p><\/div><\/div>\n                    <\/div>\n                    <div class='gform-page-footer gform_page_footer top_label'>\n                         <button type='button' id='gform_next_button_3_10' class='gform_next_button gform-theme-button button' onclick='gform.submission.handleButtonClick(this);' data-submission-type='next' >Next<\/button> <button type='button'  id='gform_save_3_2_link' onclick='gform.submission.handleButtonClick(this);' data-submission-type='save-continue' class='gform_save_link gform-theme-button gform-theme-button--secondary button'  ><svg aria-hidden=\"true\" focusable=\"false\" width=\"16\" height=\"16\" fill=\"none\" xmlns=\"http:\/\/www.w3.org\/2000\/svg\"><path fill-rule=\"evenodd\" clip-rule=\"evenodd\" d=\"M0 8a4 4 0 004 4h3v3a1 1 0 102 0v-3h3a4 4 0 100-8 4 4 0 10-8 0 4 4 0 00-4 4zm9 4H7V7.414L5.707 8.707a1 1 0 01-1.414-1.414l3-3a1 1 0 011.414 0l3 3a1 1 0 01-1.414 1.414L9 7.414V12z\" fill=\"#6B7280\"\/><\/svg> Save and Continue Later<\/button>\n                    <\/div>\n                <\/div>\n                <div id='gform_page_3_2' class='gform_page' data-js='page-field-id-10' style='display:none;'>\n                    <div class='gform_page_fields'>\n                        <div id='gform_fields_3_2' class='gform_fields top_label form_sublabel_below description_below validation_below'><div id=\"field_3_21\" class=\"gfield gfield--type-section gfield--input-type-section gsection field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><h3 class=\"gsection_title\">SECTION A<\/h3><\/div><div id=\"field_3_22\" class=\"gfield gfield--type-form gfield--input-type-form gform-theme__no-reset--children gfield--width-full field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_3_22'><span class='gform-field-label__text'>PROFESSIONALS RESPONSIBLE FOR THE REFERRAL\/APPLICATION<\/span><\/label><div class=\"gpnf-nested-entries-container ginput_container\">\n\n\t<table class=\"gpnf-nested-entries\">\n\n\t\t<thead>\n\t\t<tr>\n\t\t\t\t\t\t\t<th scope=\"col\" class=\"gpnf-field-7\">\n\t\t\t\t\tName\t\t\t\t<\/th>\n\t\t\t\t\t\t\t<th scope=\"col\" class=\"gpnf-field-6\">\n\t\t\t\t\tOrganization & Role\t\t\t\t<\/th>\n\t\t\t\t\t\t\t<th scope=\"col\" class=\"gpnf-field-4\">\n\t\t\t\t\tPhone\t\t\t\t<\/th>\n\t\t\t\t\t\t\t<th scope=\"col\" class=\"gpnf-field-5\">\n\t\t\t\t\tEmail\t\t\t\t<\/th>\n\t\t\t\t\t\t<th scope=\"col\" class=\"gpnf-row-actions\"><span class=\"screen-reader-text\">Actions<\/span><\/th>\n\t\t<\/tr>\n\t\t<\/thead>\n\n\t\t<tbody data-bind=\"visible: entries().length, foreach: entries\">\n\t\t<tr data-bind=\"attr: { 'data-entryid': id }\">\n\t\t\t\t\t\t\t<td class=\"gpnf-field\"\n\t\t\t\t\tdata-bind=\"html: f7.label, attr: { 'data-value': f7.label }\"\n\t\t\t\t\tdata-heading=\"Name\"\n\t\t\t\t>&nbsp;<\/td>\n\t\t\t\t\t\t\t<td class=\"gpnf-field\"\n\t\t\t\t\tdata-bind=\"html: f6.label, attr: { 'data-value': f6.label }\"\n\t\t\t\t\tdata-heading=\"Organization & Role\"\n\t\t\t\t>&nbsp;<\/td>\n\t\t\t\t\t\t\t<td class=\"gpnf-field\"\n\t\t\t\t\tdata-bind=\"html: f4.label, attr: { 'data-value': f4.label }\"\n\t\t\t\t\tdata-heading=\"Phone\"\n\t\t\t\t>&nbsp;<\/td>\n\t\t\t\t\t\t\t<td class=\"gpnf-field\"\n\t\t\t\t\tdata-bind=\"html: f5.label, attr: { 'data-value': f5.label }\"\n\t\t\t\t\tdata-heading=\"Email\"\n\t\t\t\t>&nbsp;<\/td>\n\t\t\t\t\t\t<td class=\"gpnf-row-actions\" style=\"display: none;\" data-bind=\"visible: true\">\n\t\t\t\t<ul>\n\t\t\t\t\t<li class=\"edit\"><button type=\"button\" class=\"edit-button gform-theme-button--secondary\" data-bind=\"click: $parent.editEntry, attr: { 'aria-label': 'Edit Entr\u00e9e {0} where Name is {1}.'.gformFormat( $index() + 1, f7.label ) }\">Modifier<\/button><\/li>\n\t\t\t\t\t\t\t\t\t\t<li class=\"delete\"><button type=\"button\" class=\"delete-button gform-theme-button--simple gform-theme-button--size-md\" data-bind=\"click: $parent.deleteEntry, attr: { 'aria-label': 'Delete Entr\u00e9e {0} where Name is {1}.'.gformFormat( $index() + 1, f7.label ) }\">Supprimer<\/button><\/li>\n\t\t\t\t<\/ul>\n\t\t\t<\/td>\n\t\t<\/tr>\n\t\t<\/tbody>\n\n\t\t<tbody data-bind=\"visible: entries().length <= 0\">\n\t\t<tr class=\"gpnf-no-entries\" data-bind=\"visible: entries().length <= 0\" style=\"display: none;\">\n\t\t\t<td colspan=\"5\">\n\t\t\t\tIl n\u2019y a aucun(e) <span>Entr\u00e9es.<\/span>\t\t\t<\/td>\n\t\t<\/tr>\n\t\t<\/tbody>\n\n\t<\/table>\n\n\t<button type=\"button\" class=\"gpnf-add-entry\"\n\t\t        data-formid=\"3\"\n\t\t        data-nestedformid=\"4\"\n\t\t\t\tdata-bind=\"attr: { disabled: isMaxed }, css: { 'gf-default-disabled': isMaxed }\"\n\t\t\t\t>\n\t\t\t\tAjouter Entr\u00e9e\n\t\t\t<\/button>\t\n\t\t\t<p class=\"gpnf-add-entry-max\" data-bind=\"visible: isMaxed\" style=\"display: none;\">\n\t\t\t\tLe nombre maximal a \u00e9t\u00e9 atteint.\n\t\t\t<\/p>\n<\/div>\n<input type=\"hidden\"\n                name=\"input_22\"\n                id=\"input_3_22\"\n                data-bind=\"value: entryIds\"\n                value=\"\" \/><\/div><fieldset id=\"field_3_23\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield--input-type-checkbox gf_list_2col gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible gfield--choice-align-columns\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' ><span class='gform-field-label__text'>RSC Program Requested<\/span><span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(N\u00e9cessaire)<\/span><\/span><\/legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox ' id='input_3_23'><div class='gchoice gchoice_3_23_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_23.1' type='checkbox'  value='Open Live-In Treatment'  id='choice_3_23_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_3_23_1' id='label_3_23_1' class='gform-field-label gform-field-label--type-inline'>Open Live-In Treatment<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_3_23_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_23.2' type='checkbox'  value='Secure Treatment'  id='choice_3_23_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_3_23_2' id='label_3_23_2' class='gform-field-label gform-field-label--type-inline'>Secure Treatment<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_3_24\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield--input-type-checkbox gf_list_2col gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible gfield--choice-align-columns\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' ><span class='gform-field-label__text'>Is the youth consenting to this treatment application?<\/span><span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(N\u00e9cessaire)<\/span><\/span><\/legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox ' id='input_3_24'><div class='gchoice gchoice_3_24_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_24.1' type='checkbox'  value='Yes'  id='choice_3_24_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_3_24_1' id='label_3_24_1' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_3_24_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_24.2' type='checkbox'  value='No'  id='choice_3_24_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_3_24_2' id='label_3_24_2' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_3_28\" class=\"gfield gfield--type-section gfield--input-type-section gsection field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><h3 class=\"gsection_title\">Youth\u2019s Personal Information<\/h3><\/div><fieldset id=\"field_3_25\" class=\"gfield gfield--type-name gfield--input-type-name gfield--width-full field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' ><span class='gform-field-label__text'>Youth&#039;s Name<\/span><\/legend><div class='ginput_complex ginput_container ginput_container--name no_prefix has_first_name no_middle_name has_last_name no_suffix gf_name_has_2 ginput_container_name gform-grid-row' id='input_3_25'>\n                            \n                            <span id='input_3_25_3_container' class='name_first gform-grid-col gform-grid-col--size-auto' >\n                                                    <input type='text' name='input_25.3' id='input_3_25_3' value=''   aria-required='false'     \/>\n                                                    <label for='input_3_25_3' class='gform-field-label gform-field-label--type-sub '>Pr\u00e9nom<\/label>\n                                                <\/span>\n                            \n                            <span id='input_3_25_6_container' class='name_last gform-grid-col gform-grid-col--size-auto' >\n                                                    <input type='text' name='input_25.6' id='input_3_25_6' value=''   aria-required='false'     \/>\n                                                    <label for='input_3_25_6' class='gform-field-label gform-field-label--type-sub '>Nom<\/label>\n                                                <\/span>\n                            \n                        <\/div><\/fieldset><fieldset id=\"field_3_26\" class=\"gfield gfield--type-address gfield--input-type-address gfield--width-full field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' ><span class='gform-field-label__text'>Current Address<\/span><\/legend>    \n                    <div class='ginput_complex ginput_container has_street has_street2 has_city has_state has_zip ginput_container_address gform-grid-row' id='input_3_26' >\n                         <span class='ginput_full address_line_1 ginput_address_line_1 gform-grid-col' id='input_3_26_1_container' >\n                                        <input type='text' name='input_26.1' id='input_3_26_1' value=''    aria-required='false'    \/>\n                                        <label for='input_3_26_1' id='input_3_26_1_label' class='gform-field-label gform-field-label--type-sub '>Adresse postale<\/label>\n                                    <\/span><span class='ginput_full address_line_2 ginput_address_line_2 gform-grid-col' id='input_3_26_2_container' >\n                                        <input type='text' name='input_26.2' id='input_3_26_2' value=''     aria-required='false'   \/>\n                                        <label for='input_3_26_2' id='input_3_26_2_label' class='gform-field-label gform-field-label--type-sub '>Adresse ligne 2<\/label>\n                                    <\/span><span class='ginput_left address_city ginput_address_city gform-grid-col' id='input_3_26_3_container' >\n                                    <input type='text' name='input_26.3' id='input_3_26_3' value=''    aria-required='false'    \/>\n                                    <label for='input_3_26_3' id='input_3_26_3_label' class='gform-field-label gform-field-label--type-sub '>Ville<\/label>\n                                 <\/span><span class='ginput_right address_state ginput_address_state gform-grid-col' id='input_3_26_4_container' >\n                                        <select name='input_26.4' id='input_3_26_4'     aria-required='false'    ><option value='' selected='selected'><\/option><option value='Alberta' >Alberta<\/option><option value='Colombie-Britannique' >Colombie-Britannique<\/option><option value='Manitoba' >Manitoba<\/option><option value='Nouveau-Brunswick' >Nouveau-Brunswick<\/option><option value='Terre-Neuve-et-Labrador' >Terre-Neuve-et-Labrador<\/option><option value='Territoires du Nord-Ouest' >Territoires du Nord-Ouest<\/option><option value='Nouvelle-\u00c9cosse' >Nouvelle-\u00c9cosse<\/option><option value='Nunavut' >Nunavut<\/option><option value='Ontario' >Ontario<\/option><option value='\u00cele du Prince-\u00c9douard' >\u00cele du Prince-\u00c9douard<\/option><option value='Qu\u00e9bec' >Qu\u00e9bec<\/option><option value='Saskatchewan' >Saskatchewan<\/option><option value='Yukon' >Yukon<\/option><\/select>\n                                        <label for='input_3_26_4' id='input_3_26_4_label' class='gform-field-label gform-field-label--type-sub '>Province<\/label>\n                                      <\/span><span class='ginput_left address_zip ginput_address_zip gform-grid-col' id='input_3_26_5_container' >\n                                    <input type='text' name='input_26.5' id='input_3_26_5' value=''    aria-required='false'    \/>\n                                    <label for='input_3_26_5' id='input_3_26_5_label' class='gform-field-label gform-field-label--type-sub '>Code postal<\/label>\n                                <\/span><input type='hidden' class='gform_hidden' name='input_26.6' id='input_3_26_6' value='CA' \/>\n                    <div class='gf_clear gf_clear_complex'><\/div>\n                <\/div><\/fieldset><div id=\"field_3_27\" class=\"gfield gfield--type-phone gfield--input-type-phone gfield--phone-format-international gfield--width-five-twelfths field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_3_27'><span class='gform-field-label__text'>Home Phone<\/span><\/label><div class='ginput_container ginput_container_phone'><input name='input_27' id='input_3_27' type='tel' value='' class='large'    aria-invalid=\"false\"    \/><\/div><\/div><fieldset id=\"field_3_230\" class=\"gfield gfield--type-date gfield--input-type-date gfield--input-type-datefield gfield--width-seven-twelfths gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' ><span class='gform-field-label__text'>Date of Birth<\/span><span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(N\u00e9cessaire)<\/span><\/span><\/legend><div id='input_3_230' class='ginput_container ginput_complex gform-grid-row'><div class='gfield_date_month ginput_container ginput_container_date gform-grid-col' id='input_3_230_1_container'>\n                                        <input type='number' maxlength='2' name='input_230[]' id='input_3_230_1' value=''   aria-required='true'   placeholder='MM' min='1' max='12' step='1'\/>\n                                        <label for='input_3_230_1' class='gform-field-label gform-field-label--type-sub screen-reader-text'>Mois<\/label>\n                                    <\/div><div class='gfield_date_day ginput_container ginput_container_date gform-grid-col' id='input_3_230_2_container'>\n                                        <input type='number' maxlength='2' name='input_230[]' id='input_3_230_2' value=''   aria-required='true'   placeholder='JJ' min='1' max='31' step='1'\/>\n                                        <label for='input_3_230_2' class='gform-field-label gform-field-label--type-sub screen-reader-text'>Jour<\/label>\n                                    <\/div><div class='gfield_date_year ginput_container ginput_container_date gform-grid-col' id='input_3_230_3_container'>\n                                        <input type='number' maxlength='4' name='input_230[]' id='input_3_230_3' value=''   aria-required='true'   placeholder='AAAA' min='1920' max='2027' step='1'\/>\n                                        <label for='input_3_230_3' class='gform-field-label gform-field-label--type-sub screen-reader-text'>Ann\u00e9e<\/label>\n                                   <\/div>\n                               <\/div><\/fieldset><div id=\"field_3_29\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-half gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_3_29'><span class='gform-field-label__text'>Gender Identity<\/span><span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(N\u00e9cessaire)<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_29' id='input_3_29' type='text' value='' class='large'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_3_30\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-half field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_3_30'><span class='gform-field-label__text'>Preferred Pronoun(s)<\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_30' id='input_3_30' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/div><fieldset id=\"field_3_31\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-half gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible gfield--choice-align-vertical\"  ><legend class='gfield_label gform-field-label' ><span class='gform-field-label__text'>Primary Language<\/span><span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(N\u00e9cessaire)<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_3_31'>\n\t\t\t<div class='gchoice gchoice_3_31_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_31' type='radio' value='English'  id='choice_3_31_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_3_31_0' id='label_3_31_0' class='gform-field-label gform-field-label--type-inline'>English<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_3_31_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_31' type='radio' value='French'  id='choice_3_31_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_3_31_1' id='label_3_31_1' class='gform-field-label gform-field-label--type-inline'>French<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_3_31_2'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_31' type='radio' value='Other'  id='choice_3_31_2' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_3_31_2' id='label_3_31_2' class='gform-field-label gform-field-label--type-inline'>Other<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_3_32\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-half field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_3_32'><span class='gform-field-label__text'>Other Language<\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_32' id='input_3_32' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/div><fieldset id=\"field_3_33\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible gfield--choice-align-vertical\"  ><legend class='gfield_label gform-field-label' ><span class='gform-field-label__text'>Language for Treatment<\/span><span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(N\u00e9cessaire)<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_3_33'>\n\t\t\t<div class='gchoice gchoice_3_33_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_33' type='radio' value='I prefer to receive counselling and treatment documentation in English'  id='choice_3_33_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_3_33_0' id='label_3_33_0' class='gform-field-label gform-field-label--type-inline'>I prefer to receive counselling and treatment documentation in English<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_3_33_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_33' type='radio' value='Je pr\u00e9f\u00e8re recevoir des conseils et des documents sur le traitement en fran\u00e7ais.'  id='choice_3_33_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_3_33_1' id='label_3_33_1' class='gform-field-label gform-field-label--type-inline'>Je pr\u00e9f\u00e8re recevoir des conseils et des documents sur le traitement en fran\u00e7ais.<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><\/div>\n                    <\/div>\n                    <div class='gform-page-footer gform_page_footer top_label'>\n                        <button type='button' id='gform_previous_button_3_34' class='gform_previous_button gform-theme-button gform-theme-button--secondary button' onclick='gform.submission.handleButtonClick(this);' data-submission-type='previous' >Previous<\/button> <button type='button' id='gform_next_button_3_34' class='gform_next_button gform-theme-button button' onclick='gform.submission.handleButtonClick(this);' data-submission-type='next' >Next<\/button> <button type='button'  id='gform_save_3_3_link' onclick='gform.submission.handleButtonClick(this);' data-submission-type='save-continue' class='gform_save_link gform-theme-button gform-theme-button--secondary button'  ><svg aria-hidden=\"true\" focusable=\"false\" width=\"16\" height=\"16\" fill=\"none\" xmlns=\"http:\/\/www.w3.org\/2000\/svg\"><path fill-rule=\"evenodd\" clip-rule=\"evenodd\" d=\"M0 8a4 4 0 004 4h3v3a1 1 0 102 0v-3h3a4 4 0 100-8 4 4 0 10-8 0 4 4 0 00-4 4zm9 4H7V7.414L5.707 8.707a1 1 0 01-1.414-1.414l3-3a1 1 0 011.414 0l3 3a1 1 0 01-1.414 1.414L9 7.414V12z\" fill=\"#6B7280\"\/><\/svg> Save and Continue Later<\/button>\n                    <\/div>\n                <\/div>\n                <div id='gform_page_3_3' class='gform_page' data-js='page-field-id-34' style='display:none;'>\n                    <div class='gform_page_fields'>\n                        <div id='gform_fields_3_3' class='gform_fields top_label form_sublabel_below description_below validation_below'><div id=\"field_3_35\" class=\"gfield gfield--type-section gfield--input-type-section gsection field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><h3 class=\"gsection_title\">School Information<\/h3><\/div><div id=\"field_3_36\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-half field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_3_36'><span class='gform-field-label__text'>School Name<\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_36' id='input_3_36' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_3_37\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-half field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_3_37'><span class='gform-field-label__text'>Grade<\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_37' id='input_3_37' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/div><fieldset id=\"field_3_38\" class=\"gfield gfield--type-address gfield--input-type-address gfield--width-full field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' ><span class='gform-field-label__text'>School Address<\/span><\/legend>    \n                    <div class='ginput_complex ginput_container has_street has_street2 has_city has_state has_zip ginput_container_address gform-grid-row' id='input_3_38' >\n                         <span class='ginput_full address_line_1 ginput_address_line_1 gform-grid-col' id='input_3_38_1_container' >\n                                        <input type='text' name='input_38.1' id='input_3_38_1' value=''    aria-required='false'    \/>\n                                        <label for='input_3_38_1' id='input_3_38_1_label' class='gform-field-label gform-field-label--type-sub '>Adresse postale<\/label>\n                                    <\/span><span class='ginput_full address_line_2 ginput_address_line_2 gform-grid-col' id='input_3_38_2_container' >\n                                        <input type='text' name='input_38.2' id='input_3_38_2' value=''     aria-required='false'   \/>\n                                        <label for='input_3_38_2' id='input_3_38_2_label' class='gform-field-label gform-field-label--type-sub '>Adresse ligne 2<\/label>\n                                    <\/span><span class='ginput_left address_city ginput_address_city gform-grid-col' id='input_3_38_3_container' >\n                                    <input type='text' name='input_38.3' id='input_3_38_3' value=''    aria-required='false'    \/>\n                                    <label for='input_3_38_3' id='input_3_38_3_label' class='gform-field-label gform-field-label--type-sub '>Ville<\/label>\n                                 <\/span><span class='ginput_right address_state ginput_address_state gform-grid-col' id='input_3_38_4_container' >\n                                        <select name='input_38.4' id='input_3_38_4'     aria-required='false'    ><option value='' ><\/option><option value='Alberta' >Alberta<\/option><option value='Colombie-Britannique' >Colombie-Britannique<\/option><option value='Manitoba' >Manitoba<\/option><option value='Nouveau-Brunswick' >Nouveau-Brunswick<\/option><option value='Terre-Neuve-et-Labrador' >Terre-Neuve-et-Labrador<\/option><option value='Territoires du Nord-Ouest' >Territoires du Nord-Ouest<\/option><option value='Nouvelle-\u00c9cosse' >Nouvelle-\u00c9cosse<\/option><option value='Nunavut' >Nunavut<\/option><option value='Ontario' selected='selected'>Ontario<\/option><option value='\u00cele du Prince-\u00c9douard' >\u00cele du Prince-\u00c9douard<\/option><option value='Qu\u00e9bec' >Qu\u00e9bec<\/option><option value='Saskatchewan' >Saskatchewan<\/option><option value='Yukon' >Yukon<\/option><\/select>\n                                        <label for='input_3_38_4' id='input_3_38_4_label' class='gform-field-label gform-field-label--type-sub '>Province<\/label>\n                                      <\/span><span class='ginput_left address_zip ginput_address_zip gform-grid-col' id='input_3_38_5_container' >\n                                    <input type='text' name='input_38.5' id='input_3_38_5' value=''    aria-required='false'    \/>\n                                    <label for='input_3_38_5' id='input_3_38_5_label' class='gform-field-label gform-field-label--type-sub '>Code postal<\/label>\n                                <\/span><input type='hidden' class='gform_hidden' name='input_38.6' id='input_3_38_6' value='CA' \/>\n                    <div class='gf_clear gf_clear_complex'><\/div>\n                <\/div><\/fieldset><div id=\"field_3_39\" class=\"gfield gfield--type-phone gfield--input-type-phone gfield--phone-format-international gfield--width-half field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_3_39'><span class='gform-field-label__text'>Phone<\/span><\/label><div class='ginput_container ginput_container_phone'><input name='input_39' id='input_3_39' type='tel' value='' class='large'    aria-invalid=\"false\"    \/><\/div><\/div><div id=\"field_3_40\" class=\"gfield gfield--type-email gfield--input-type-email gfield--width-half field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_3_40'><span class='gform-field-label__text'>Email<\/span><\/label><div class='ginput_container ginput_container_email'>\n                            <input name='input_40' id='input_3_40' type='email' value='' class='large'     aria-invalid=\"false\"  \/>\n                        <\/div><\/div><fieldset id=\"field_3_41\" class=\"gfield gfield--type-name gfield--input-type-name gfield--width-three-quarter field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' ><span class='gform-field-label__text'>Principal&#039;s Name<\/span><\/legend><div class='ginput_complex ginput_container ginput_container--name no_prefix has_first_name no_middle_name has_last_name no_suffix gf_name_has_2 ginput_container_name gform-grid-row' id='input_3_41'>\n                            \n                            <span id='input_3_41_3_container' class='name_first gform-grid-col gform-grid-col--size-auto' >\n                                                    <input type='text' name='input_41.3' id='input_3_41_3' value=''   aria-required='false'     \/>\n                                                    <label for='input_3_41_3' class='gform-field-label gform-field-label--type-sub '>Pr\u00e9nom<\/label>\n                                                <\/span>\n                            \n                            <span id='input_3_41_6_container' class='name_last gform-grid-col gform-grid-col--size-auto' >\n                                                    <input type='text' name='input_41.6' id='input_3_41_6' value=''   aria-required='false'     \/>\n                                                    <label for='input_3_41_6' class='gform-field-label gform-field-label--type-sub '>Nom<\/label>\n                                                <\/span>\n                            \n                        <\/div><\/fieldset><div id=\"field_3_42\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-quarter field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_3_42'><span class='gform-field-label__text'>Extension<\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_42' id='input_3_42' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/div><fieldset id=\"field_3_43\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gf_list_2col gfield--width-full field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible gfield--choice-align-columns\"  ><legend class='gfield_label gform-field-label' ><span class='gform-field-label__text'>Will the youth continue to attend their current school?<\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_3_43'>\n\t\t\t<div class='gchoice gchoice_3_43_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_43' type='radio' value='Yes'  id='choice_3_43_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_3_43_0' id='label_3_43_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_3_43_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_43' type='radio' value='No'  id='choice_3_43_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_3_43_1' id='label_3_43_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_3_44\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gf_list_2col gfield--width-full field_sublabel_below gfield--has-description field_description_below field_validation_below gfield_visibility_visible gfield--choice-align-columns\"  ><legend class='gfield_label gform-field-label' ><span class='gform-field-label__text'>Will the youth attend RSC\u2019s Private Academy*?<\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_3_44'>\n\t\t\t<div class='gchoice gchoice_3_44_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_44' type='radio' value='Yes'  id='choice_3_44_0' onchange='gformToggleRadioOther( this )' aria-describedby=\"gfield_description_3_44\"   \/>\n\t\t\t\t\t<label for='choice_3_44_0' id='label_3_44_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_3_44_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_44' type='radio' value='No'  id='choice_3_44_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_3_44_1' id='label_3_44_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/div><div class='gfield_description' id='gfield_description_3_44'>*The Debbie Campbell Learning Academy provides temporary or long-term academic opportunities for students who find it\ndifficult to function in the traditional school setting. While concurrently dealing with the challenges of their particular behavioural\nissues, students have the opportunity to achieve provincially recognized credits, with the long-term goal of providing the skills\nnecessary for continued academic success.<\/div><\/fieldset><div id=\"field_3_45\" class=\"gfield gfield--type-textarea gfield--input-type-textarea gfield--width-full field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_3_45'><span class='gform-field-label__text'>If no, what\u2019s the plan for school while in live-in treatment?<\/span><\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_45' id='input_3_45' class='textarea large'      aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/div><\/div>\n                    <\/div>\n                    <div class='gform-page-footer gform_page_footer top_label'>\n                        <button type='button' id='gform_previous_button_3_46' class='gform_previous_button gform-theme-button gform-theme-button--secondary button' onclick='gform.submission.handleButtonClick(this);' data-submission-type='previous' >Previous<\/button> <button type='button' id='gform_next_button_3_46' class='gform_next_button gform-theme-button button' onclick='gform.submission.handleButtonClick(this);' data-submission-type='next' >Next<\/button> <button type='button'  id='gform_save_3_4_link' onclick='gform.submission.handleButtonClick(this);' data-submission-type='save-continue' class='gform_save_link gform-theme-button gform-theme-button--secondary button'  ><svg aria-hidden=\"true\" focusable=\"false\" width=\"16\" height=\"16\" fill=\"none\" xmlns=\"http:\/\/www.w3.org\/2000\/svg\"><path fill-rule=\"evenodd\" clip-rule=\"evenodd\" d=\"M0 8a4 4 0 004 4h3v3a1 1 0 102 0v-3h3a4 4 0 100-8 4 4 0 10-8 0 4 4 0 00-4 4zm9 4H7V7.414L5.707 8.707a1 1 0 01-1.414-1.414l3-3a1 1 0 011.414 0l3 3a1 1 0 01-1.414 1.414L9 7.414V12z\" fill=\"#6B7280\"\/><\/svg> Save and Continue Later<\/button>\n                    <\/div>\n                <\/div>\n                <div id='gform_page_3_4' class='gform_page' data-js='page-field-id-46' style='display:none;'>\n                    <div class='gform_page_fields'>\n                        <div id='gform_fields_3_4' class='gform_fields top_label form_sublabel_below description_below validation_below'><div id=\"field_3_47\" class=\"gfield gfield--type-section gfield--input-type-section gsection field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><h3 class=\"gsection_title\">Family Information<\/h3><\/div><fieldset id=\"field_3_48\" class=\"gfield gfield--type-name gfield--input-type-name gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' ><span class='gform-field-label__text'>Legal Guardian<\/span><span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(N\u00e9cessaire)<\/span><\/span><\/legend><div class='ginput_complex ginput_container ginput_container--name no_prefix has_first_name no_middle_name has_last_name no_suffix gf_name_has_2 ginput_container_name gform-grid-row' id='input_3_48'>\n                            \n                            <span id='input_3_48_3_container' class='name_first gform-grid-col gform-grid-col--size-auto' >\n                                                    <input type='text' name='input_48.3' id='input_3_48_3' value=''   aria-required='true'     \/>\n                                                    <label for='input_3_48_3' class='gform-field-label gform-field-label--type-sub '>Pr\u00e9nom<\/label>\n                                                <\/span>\n                            \n                            <span id='input_3_48_6_container' class='name_last gform-grid-col gform-grid-col--size-auto' >\n                                                    <input type='text' name='input_48.6' id='input_3_48_6' value=''   aria-required='true'     \/>\n                                                    <label for='input_3_48_6' class='gform-field-label gform-field-label--type-sub '>Nom<\/label>\n                                                <\/span>\n                            \n                        <\/div><\/fieldset><fieldset id=\"field_3_49\" class=\"gfield gfield--type-address gfield--input-type-address gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' ><span class='gform-field-label__text'>Address<\/span><span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(N\u00e9cessaire)<\/span><\/span><\/legend>    \n                    <div class='ginput_complex ginput_container has_street has_street2 has_city has_state has_zip ginput_container_address gform-grid-row' id='input_3_49' >\n                         <span class='ginput_full address_line_1 ginput_address_line_1 gform-grid-col' id='input_3_49_1_container' >\n                                        <input type='text' name='input_49.1' id='input_3_49_1' value=''    aria-required='true'    \/>\n                                        <label for='input_3_49_1' id='input_3_49_1_label' class='gform-field-label gform-field-label--type-sub '>Adresse postale<\/label>\n                                    <\/span><span class='ginput_full address_line_2 ginput_address_line_2 gform-grid-col' id='input_3_49_2_container' >\n                                        <input type='text' name='input_49.2' id='input_3_49_2' value=''     aria-required='false'   \/>\n                                        <label for='input_3_49_2' id='input_3_49_2_label' class='gform-field-label gform-field-label--type-sub '>Adresse ligne 2<\/label>\n                                    <\/span><span class='ginput_left address_city ginput_address_city gform-grid-col' id='input_3_49_3_container' >\n                                    <input type='text' name='input_49.3' id='input_3_49_3' value=''    aria-required='true'    \/>\n                                    <label for='input_3_49_3' id='input_3_49_3_label' class='gform-field-label gform-field-label--type-sub '>Ville<\/label>\n                                 <\/span><span class='ginput_right address_state ginput_address_state gform-grid-col' id='input_3_49_4_container' >\n                                        <select name='input_49.4' id='input_3_49_4'     aria-required='true'    ><option value='' ><\/option><option value='Alberta' >Alberta<\/option><option value='Colombie-Britannique' >Colombie-Britannique<\/option><option value='Manitoba' >Manitoba<\/option><option value='Nouveau-Brunswick' >Nouveau-Brunswick<\/option><option value='Terre-Neuve-et-Labrador' >Terre-Neuve-et-Labrador<\/option><option value='Territoires du Nord-Ouest' >Territoires du Nord-Ouest<\/option><option value='Nouvelle-\u00c9cosse' >Nouvelle-\u00c9cosse<\/option><option value='Nunavut' >Nunavut<\/option><option value='Ontario' selected='selected'>Ontario<\/option><option value='\u00cele du Prince-\u00c9douard' >\u00cele du Prince-\u00c9douard<\/option><option value='Qu\u00e9bec' >Qu\u00e9bec<\/option><option value='Saskatchewan' >Saskatchewan<\/option><option value='Yukon' >Yukon<\/option><\/select>\n                                        <label for='input_3_49_4' id='input_3_49_4_label' class='gform-field-label gform-field-label--type-sub '>Province<\/label>\n                                      <\/span><span class='ginput_left address_zip ginput_address_zip gform-grid-col' id='input_3_49_5_container' >\n                                    <input type='text' name='input_49.5' id='input_3_49_5' value=''    aria-required='true'    \/>\n                                    <label for='input_3_49_5' id='input_3_49_5_label' class='gform-field-label gform-field-label--type-sub '>Code postal<\/label>\n                                <\/span><input type='hidden' class='gform_hidden' name='input_49.6' id='input_3_49_6' value='CA' \/>\n                    <div class='gf_clear gf_clear_complex'><\/div>\n                <\/div><\/fieldset><div id=\"field_3_229\" class=\"gfield gfield--type-email gfield--input-type-email gfield--width-third gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_3_229'><span class='gform-field-label__text'>Email<\/span><span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(N\u00e9cessaire)<\/span><\/span><\/label><div class='ginput_container ginput_container_email'>\n                            <input name='input_229' id='input_3_229' type='email' value='' class='large'    aria-required=\"true\" aria-invalid=\"false\"  \/>\n                        <\/div><\/div><div id=\"field_3_227\" class=\"gfield gfield--type-phone gfield--input-type-phone gfield--phone-format-international gfield--width-third gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_3_227'><span class='gform-field-label__text'>Home\/Main<\/span><span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(N\u00e9cessaire)<\/span><\/span><\/label><div class='ginput_container ginput_container_phone'><input name='input_227' id='input_3_227' type='tel' value='' class='large'   aria-required=\"true\" aria-invalid=\"false\"    \/><\/div><\/div><div id=\"field_3_228\" class=\"gfield gfield--type-phone gfield--input-type-phone gfield--phone-format-international gfield--width-third field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_3_228'><span class='gform-field-label__text'>Work\/Other<\/span><\/label><div class='ginput_container ginput_container_phone'><input name='input_228' id='input_3_228' type='tel' value='' class='large'    aria-invalid=\"false\"    \/><\/div><\/div><div id=\"field_3_52\" class=\"gfield gfield--type-section gfield--input-type-section gsection field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><h3 class=\"gsection_title\">Parent 1<\/h3><\/div><fieldset id=\"field_3_51\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield--input-type-checkbox gfield--width-full field_sublabel_below gfield--no-description field_description_below hidden_label field_validation_below gfield_visibility_visible gfield--choice-align-vertical\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' ><span class='gform-field-label__text'>Same as Legal Guardian<\/span><\/legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox ' id='input_3_51'><div class='gchoice gchoice_3_51_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_51.1' type='checkbox'  value='Same as Legal Guardian'  id='choice_3_51_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_3_51_1' id='label_3_51_1' class='gform-field-label gform-field-label--type-inline'>Same as Legal Guardian<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_3_53\" class=\"gfield gfield--type-address gfield--input-type-address gfield--width-full field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' ><span class='gform-field-label__text'>Address<\/span><\/legend>    \n                    <div class='ginput_complex ginput_container has_street has_street2 has_city has_state has_zip ginput_container_address gform-grid-row' id='input_3_53' >\n                         <span class='ginput_full address_line_1 ginput_address_line_1 gform-grid-col' id='input_3_53_1_container' >\n                                        <input type='text' name='input_53.1' id='input_3_53_1' value=''    aria-required='false'    \/>\n                                        <label for='input_3_53_1' id='input_3_53_1_label' class='gform-field-label gform-field-label--type-sub '>Adresse postale<\/label>\n                                    <\/span><span class='ginput_full address_line_2 ginput_address_line_2 gform-grid-col' id='input_3_53_2_container' >\n                                        <input type='text' name='input_53.2' id='input_3_53_2' value=''     aria-required='false'   \/>\n                                        <label for='input_3_53_2' id='input_3_53_2_label' class='gform-field-label gform-field-label--type-sub '>Adresse ligne 2<\/label>\n                                    <\/span><span class='ginput_left address_city ginput_address_city gform-grid-col' id='input_3_53_3_container' >\n                                    <input type='text' name='input_53.3' id='input_3_53_3' value=''    aria-required='false'    \/>\n                                    <label for='input_3_53_3' id='input_3_53_3_label' class='gform-field-label gform-field-label--type-sub '>Ville<\/label>\n                                 <\/span><span class='ginput_right address_state ginput_address_state gform-grid-col' id='input_3_53_4_container' >\n                                        <select name='input_53.4' id='input_3_53_4'     aria-required='false'    ><option value='' ><\/option><option value='Alberta' >Alberta<\/option><option value='Colombie-Britannique' >Colombie-Britannique<\/option><option value='Manitoba' >Manitoba<\/option><option value='Nouveau-Brunswick' >Nouveau-Brunswick<\/option><option value='Terre-Neuve-et-Labrador' >Terre-Neuve-et-Labrador<\/option><option value='Territoires du Nord-Ouest' >Territoires du Nord-Ouest<\/option><option value='Nouvelle-\u00c9cosse' >Nouvelle-\u00c9cosse<\/option><option value='Nunavut' >Nunavut<\/option><option value='Ontario' selected='selected'>Ontario<\/option><option value='\u00cele du Prince-\u00c9douard' >\u00cele du Prince-\u00c9douard<\/option><option value='Qu\u00e9bec' >Qu\u00e9bec<\/option><option value='Saskatchewan' >Saskatchewan<\/option><option value='Yukon' >Yukon<\/option><\/select>\n                                        <label for='input_3_53_4' id='input_3_53_4_label' class='gform-field-label gform-field-label--type-sub '>Province<\/label>\n                                      <\/span><span class='ginput_left address_zip ginput_address_zip gform-grid-col' id='input_3_53_5_container' >\n                                    <input type='text' name='input_53.5' id='input_3_53_5' value=''    aria-required='false'    \/>\n                                    <label for='input_3_53_5' id='input_3_53_5_label' class='gform-field-label gform-field-label--type-sub '>Code postal<\/label>\n                                <\/span><input type='hidden' class='gform_hidden' name='input_53.6' id='input_3_53_6' value='CA' \/>\n                    <div class='gf_clear gf_clear_complex'><\/div>\n                <\/div><\/fieldset><fieldset id=\"field_3_50\" class=\"gfield gfield--type-name gfield--input-type-name gfield--width-full field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' ><span class='gform-field-label__text'>Parent&#039;s Name<\/span><\/legend><div class='ginput_complex ginput_container ginput_container--name no_prefix has_first_name no_middle_name has_last_name no_suffix gf_name_has_2 ginput_container_name gform-grid-row' id='input_3_50'>\n                            \n                            <span id='input_3_50_3_container' class='name_first gform-grid-col gform-grid-col--size-auto' >\n                                                    <input type='text' name='input_50.3' id='input_3_50_3' value=''   aria-required='false'     \/>\n                                                    <label for='input_3_50_3' class='gform-field-label gform-field-label--type-sub '>Pr\u00e9nom<\/label>\n                                                <\/span>\n                            \n                            <span id='input_3_50_6_container' class='name_last gform-grid-col gform-grid-col--size-auto' >\n                                                    <input type='text' name='input_50.6' id='input_3_50_6' value=''   aria-required='false'     \/>\n                                                    <label for='input_3_50_6' class='gform-field-label gform-field-label--type-sub '>Nom<\/label>\n                                                <\/span>\n                            \n                        <\/div><\/fieldset><div id=\"field_3_54\" class=\"gfield gfield--type-phone gfield--input-type-phone gfield--phone-format-international gfield--width-third field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_3_54'><span class='gform-field-label__text'>Home Phone<\/span><\/label><div class='ginput_container ginput_container_phone'><input name='input_54' id='input_3_54' type='tel' value='' class='large'    aria-invalid=\"false\"    \/><\/div><\/div><div id=\"field_3_55\" class=\"gfield gfield--type-phone gfield--input-type-phone gfield--phone-format-international gfield--width-third field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_3_55'><span class='gform-field-label__text'>Work Phone<\/span><\/label><div class='ginput_container ginput_container_phone'><input name='input_55' id='input_3_55' type='tel' value='' class='large'    aria-invalid=\"false\"    \/><\/div><\/div><div id=\"field_3_56\" class=\"gfield gfield--type-phone gfield--input-type-phone gfield--phone-format-international gfield--width-third field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_3_56'><span class='gform-field-label__text'>Cell Phone<\/span><\/label><div class='ginput_container ginput_container_phone'><input name='input_56' id='input_3_56' type='tel' value='' class='large'    aria-invalid=\"false\"    \/><\/div><\/div><div id=\"field_3_57\" class=\"gfield gfield--type-section gfield--input-type-section gsection field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><h3 class=\"gsection_title\">Parent 2<\/h3><\/div><fieldset id=\"field_3_58\" class=\"gfield gfield--type-name gfield--input-type-name gfield--width-full field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' ><span class='gform-field-label__text'>Parent&#039;s Name<\/span><\/legend><div class='ginput_complex ginput_container ginput_container--name no_prefix has_first_name no_middle_name has_last_name no_suffix gf_name_has_2 ginput_container_name gform-grid-row' id='input_3_58'>\n                            \n                            <span id='input_3_58_3_container' class='name_first gform-grid-col gform-grid-col--size-auto' >\n                                                    <input type='text' name='input_58.3' id='input_3_58_3' value=''   aria-required='false'     \/>\n                                                    <label for='input_3_58_3' class='gform-field-label gform-field-label--type-sub '>Pr\u00e9nom<\/label>\n                                                <\/span>\n                            \n                            <span id='input_3_58_6_container' class='name_last gform-grid-col gform-grid-col--size-auto' >\n                                                    <input type='text' name='input_58.6' id='input_3_58_6' value=''   aria-required='false'     \/>\n                                                    <label for='input_3_58_6' class='gform-field-label gform-field-label--type-sub '>Nom<\/label>\n                                                <\/span>\n                            \n                        <\/div><\/fieldset><fieldset id=\"field_3_60\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield--input-type-checkbox gfield--width-full field_sublabel_below gfield--no-description field_description_below hidden_label field_validation_below gfield_visibility_visible gfield--choice-align-vertical\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' ><span class='gform-field-label__text'>Same as Above<\/span><\/legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox ' id='input_3_60'><div class='gchoice gchoice_3_60_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_60.1' type='checkbox'  value='Same as Above'  id='choice_3_60_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_3_60_1' id='label_3_60_1' class='gform-field-label gform-field-label--type-inline'>Same as Above<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_3_61\" class=\"gfield gfield--type-address gfield--input-type-address gfield--width-full field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' ><span class='gform-field-label__text'>Address<\/span><\/legend>    \n                    <div class='ginput_complex ginput_container has_street has_street2 has_city has_state has_zip ginput_container_address gform-grid-row' id='input_3_61' >\n                         <span class='ginput_full address_line_1 ginput_address_line_1 gform-grid-col' id='input_3_61_1_container' >\n                                        <input type='text' name='input_61.1' id='input_3_61_1' value=''    aria-required='false'    \/>\n                                        <label for='input_3_61_1' id='input_3_61_1_label' class='gform-field-label gform-field-label--type-sub '>Adresse postale<\/label>\n                                    <\/span><span class='ginput_full address_line_2 ginput_address_line_2 gform-grid-col' id='input_3_61_2_container' >\n                                        <input type='text' name='input_61.2' id='input_3_61_2' value=''     aria-required='false'   \/>\n                                        <label for='input_3_61_2' id='input_3_61_2_label' class='gform-field-label gform-field-label--type-sub '>Adresse ligne 2<\/label>\n                                    <\/span><span class='ginput_left address_city ginput_address_city gform-grid-col' id='input_3_61_3_container' >\n                                    <input type='text' name='input_61.3' id='input_3_61_3' value=''    aria-required='false'    \/>\n                                    <label for='input_3_61_3' id='input_3_61_3_label' class='gform-field-label gform-field-label--type-sub '>Ville<\/label>\n                                 <\/span><span class='ginput_right address_state ginput_address_state gform-grid-col' id='input_3_61_4_container' >\n                                        <select name='input_61.4' id='input_3_61_4'     aria-required='false'    ><option value='' ><\/option><option value='Alberta' >Alberta<\/option><option value='Colombie-Britannique' >Colombie-Britannique<\/option><option value='Manitoba' >Manitoba<\/option><option value='Nouveau-Brunswick' >Nouveau-Brunswick<\/option><option value='Terre-Neuve-et-Labrador' >Terre-Neuve-et-Labrador<\/option><option value='Territoires du Nord-Ouest' >Territoires du Nord-Ouest<\/option><option value='Nouvelle-\u00c9cosse' >Nouvelle-\u00c9cosse<\/option><option value='Nunavut' >Nunavut<\/option><option value='Ontario' selected='selected'>Ontario<\/option><option value='\u00cele du Prince-\u00c9douard' >\u00cele du Prince-\u00c9douard<\/option><option value='Qu\u00e9bec' >Qu\u00e9bec<\/option><option value='Saskatchewan' >Saskatchewan<\/option><option value='Yukon' >Yukon<\/option><\/select>\n                                        <label for='input_3_61_4' id='input_3_61_4_label' class='gform-field-label gform-field-label--type-sub '>Province<\/label>\n                                      <\/span><span class='ginput_left address_zip ginput_address_zip gform-grid-col' id='input_3_61_5_container' >\n                                    <input type='text' name='input_61.5' id='input_3_61_5' value=''    aria-required='false'    \/>\n                                    <label for='input_3_61_5' id='input_3_61_5_label' class='gform-field-label gform-field-label--type-sub '>Code postal<\/label>\n                                <\/span><input type='hidden' class='gform_hidden' name='input_61.6' id='input_3_61_6' value='CA' \/>\n                    <div class='gf_clear gf_clear_complex'><\/div>\n                <\/div><\/fieldset><div id=\"field_3_62\" class=\"gfield gfield--type-phone gfield--input-type-phone gfield--phone-format-international gfield--width-third field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_3_62'><span class='gform-field-label__text'>Home Phone<\/span><\/label><div class='ginput_container ginput_container_phone'><input name='input_62' id='input_3_62' type='tel' value='' class='large'    aria-invalid=\"false\"    \/><\/div><\/div><div id=\"field_3_63\" class=\"gfield gfield--type-phone gfield--input-type-phone gfield--phone-format-international gfield--width-third field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_3_63'><span class='gform-field-label__text'>Work Phone<\/span><\/label><div class='ginput_container ginput_container_phone'><input name='input_63' id='input_3_63' type='tel' value='' class='large'    aria-invalid=\"false\"    \/><\/div><\/div><div id=\"field_3_64\" class=\"gfield gfield--type-phone gfield--input-type-phone gfield--phone-format-international gfield--width-third field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_3_64'><span class='gform-field-label__text'>Cell Phone<\/span><\/label><div class='ginput_container ginput_container_phone'><input name='input_64' id='input_3_64' type='tel' value='' class='large'    aria-invalid=\"false\"    \/><\/div><\/div><div id=\"field_3_65\" class=\"gfield gfield--type-form gfield--input-type-form gform-theme__no-reset--children gfield--width-full field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_3_65'><span class='gform-field-label__text'>Siblings<\/span><\/label><div class=\"gpnf-nested-entries-container ginput_container\">\n\n\t<table class=\"gpnf-nested-entries\">\n\n\t\t<thead>\n\t\t<tr>\n\t\t\t\t\t\t\t<th scope=\"col\" class=\"gpnf-field-1\">\n\t\t\t\t\tName\t\t\t\t<\/th>\n\t\t\t\t\t\t\t<th scope=\"col\" class=\"gpnf-field-3\">\n\t\t\t\t\tDate\t\t\t\t<\/th>\n\t\t\t\t\t\t\t<th scope=\"col\" class=\"gpnf-field-4\">\n\t\t\t\t\tRelationship\t\t\t\t<\/th>\n\t\t\t\t\t\t<th scope=\"col\" class=\"gpnf-row-actions\"><span class=\"screen-reader-text\">Actions<\/span><\/th>\n\t\t<\/tr>\n\t\t<\/thead>\n\n\t\t<tbody data-bind=\"visible: entries().length, foreach: entries\">\n\t\t<tr data-bind=\"attr: { 'data-entryid': id }\">\n\t\t\t\t\t\t\t<td class=\"gpnf-field\"\n\t\t\t\t\tdata-bind=\"html: f1.label, attr: { 'data-value': f1.label }\"\n\t\t\t\t\tdata-heading=\"Name\"\n\t\t\t\t>&nbsp;<\/td>\n\t\t\t\t\t\t\t<td class=\"gpnf-field\"\n\t\t\t\t\tdata-bind=\"html: f3.label, attr: { 'data-value': f3.label }\"\n\t\t\t\t\tdata-heading=\"Date\"\n\t\t\t\t>&nbsp;<\/td>\n\t\t\t\t\t\t\t<td class=\"gpnf-field\"\n\t\t\t\t\tdata-bind=\"html: f4.label, attr: { 'data-value': f4.label }\"\n\t\t\t\t\tdata-heading=\"Relationship\"\n\t\t\t\t>&nbsp;<\/td>\n\t\t\t\t\t\t<td class=\"gpnf-row-actions\" style=\"display: none;\" data-bind=\"visible: true\">\n\t\t\t\t<ul>\n\t\t\t\t\t<li class=\"edit\"><button type=\"button\" class=\"edit-button gform-theme-button--secondary\" data-bind=\"click: $parent.editEntry, attr: { 'aria-label': 'Edit Sibling {0} where Name is {1}.'.gformFormat( $index() + 1, f1.label ) }\">Modifier<\/button><\/li>\n\t\t\t\t\t\t\t\t\t\t<li class=\"delete\"><button type=\"button\" class=\"delete-button gform-theme-button--simple gform-theme-button--size-md\" data-bind=\"click: $parent.deleteEntry, attr: { 'aria-label': 'Delete Sibling {0} where Name is {1}.'.gformFormat( $index() + 1, f1.label ) }\">Supprimer<\/button><\/li>\n\t\t\t\t<\/ul>\n\t\t\t<\/td>\n\t\t<\/tr>\n\t\t<\/tbody>\n\n\t\t<tbody data-bind=\"visible: entries().length <= 0\">\n\t\t<tr class=\"gpnf-no-entries\" data-bind=\"visible: entries().length <= 0\" style=\"display: none;\">\n\t\t\t<td colspan=\"4\">\n\t\t\t\tIl n\u2019y a aucun(e) <span>Siblings.<\/span>\t\t\t<\/td>\n\t\t<\/tr>\n\t\t<\/tbody>\n\n\t<\/table>\n\n\t<button type=\"button\" class=\"gpnf-add-entry\"\n\t\t        data-formid=\"3\"\n\t\t        data-nestedformid=\"5\"\n\t\t\t\tdata-bind=\"attr: { disabled: isMaxed }, css: { 'gf-default-disabled': isMaxed }\"\n\t\t\t\t>\n\t\t\t\tAjouter Sibling\n\t\t\t<\/button>\t\n\t\t\t<p class=\"gpnf-add-entry-max\" data-bind=\"visible: isMaxed\" style=\"display: none;\">\n\t\t\t\tLe nombre maximal a \u00e9t\u00e9 atteint.\n\t\t\t<\/p>\n<\/div>\n<input type=\"hidden\"\n                name=\"input_65\"\n                id=\"input_3_65\"\n                data-bind=\"value: entryIds\"\n                value=\"\" \/><\/div><div id=\"field_3_66\" class=\"gfield gfield--type-form gfield--input-type-form gform-theme__no-reset--children gfield--width-full field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_3_66'><span class='gform-field-label__text'>Other Significant Support<\/span><\/label><div class=\"gpnf-nested-entries-container ginput_container\">\n\n\t<table class=\"gpnf-nested-entries\">\n\n\t\t<thead>\n\t\t<tr>\n\t\t\t\t\t\t\t<th scope=\"col\" class=\"gpnf-field-1\">\n\t\t\t\t\tName\t\t\t\t<\/th>\n\t\t\t\t\t\t\t<th scope=\"col\" class=\"gpnf-field-4\">\n\t\t\t\t\tRelationship\t\t\t\t<\/th>\n\t\t\t\t\t\t\t<th scope=\"col\" class=\"gpnf-field-7\">\n\t\t\t\t\tPhone\t\t\t\t<\/th>\n\t\t\t\t\t\t\t<th scope=\"col\" class=\"gpnf-field-6\">\n\t\t\t\t\tEmail\t\t\t\t<\/th>\n\t\t\t\t\t\t<th scope=\"col\" class=\"gpnf-row-actions\"><span class=\"screen-reader-text\">Actions<\/span><\/th>\n\t\t<\/tr>\n\t\t<\/thead>\n\n\t\t<tbody data-bind=\"visible: entries().length, foreach: entries\">\n\t\t<tr data-bind=\"attr: { 'data-entryid': id }\">\n\t\t\t\t\t\t\t<td class=\"gpnf-field\"\n\t\t\t\t\tdata-bind=\"html: f1.label, attr: { 'data-value': f1.label }\"\n\t\t\t\t\tdata-heading=\"Name\"\n\t\t\t\t>&nbsp;<\/td>\n\t\t\t\t\t\t\t<td class=\"gpnf-field\"\n\t\t\t\t\tdata-bind=\"html: f4.label, attr: { 'data-value': f4.label }\"\n\t\t\t\t\tdata-heading=\"Relationship\"\n\t\t\t\t>&nbsp;<\/td>\n\t\t\t\t\t\t\t<td class=\"gpnf-field\"\n\t\t\t\t\tdata-bind=\"html: f7.label, attr: { 'data-value': f7.label }\"\n\t\t\t\t\tdata-heading=\"Phone\"\n\t\t\t\t>&nbsp;<\/td>\n\t\t\t\t\t\t\t<td class=\"gpnf-field\"\n\t\t\t\t\tdata-bind=\"html: f6.label, attr: { 'data-value': f6.label }\"\n\t\t\t\t\tdata-heading=\"Email\"\n\t\t\t\t>&nbsp;<\/td>\n\t\t\t\t\t\t<td class=\"gpnf-row-actions\" style=\"display: none;\" data-bind=\"visible: true\">\n\t\t\t\t<ul>\n\t\t\t\t\t<li class=\"edit\"><button type=\"button\" class=\"edit-button gform-theme-button--secondary\" data-bind=\"click: $parent.editEntry, attr: { 'aria-label': 'Edit Support {0} where Name is {1}.'.gformFormat( $index() + 1, f1.label ) }\">Modifier<\/button><\/li>\n\t\t\t\t\t\t\t\t\t\t<li class=\"delete\"><button type=\"button\" class=\"delete-button gform-theme-button--simple gform-theme-button--size-md\" data-bind=\"click: $parent.deleteEntry, attr: { 'aria-label': 'Delete Support {0} where Name is {1}.'.gformFormat( $index() + 1, f1.label ) }\">Supprimer<\/button><\/li>\n\t\t\t\t<\/ul>\n\t\t\t<\/td>\n\t\t<\/tr>\n\t\t<\/tbody>\n\n\t\t<tbody data-bind=\"visible: entries().length <= 0\">\n\t\t<tr class=\"gpnf-no-entries\" data-bind=\"visible: entries().length <= 0\" style=\"display: none;\">\n\t\t\t<td colspan=\"5\">\n\t\t\t\tIl n\u2019y a aucun(e) <span>Supports.<\/span>\t\t\t<\/td>\n\t\t<\/tr>\n\t\t<\/tbody>\n\n\t<\/table>\n\n\t<button type=\"button\" class=\"gpnf-add-entry\"\n\t\t        data-formid=\"3\"\n\t\t        data-nestedformid=\"6\"\n\t\t\t\tdata-bind=\"attr: { disabled: isMaxed }, css: { 'gf-default-disabled': isMaxed }\"\n\t\t\t\t>\n\t\t\t\tAjouter Support\n\t\t\t<\/button>\t\n\t\t\t<p class=\"gpnf-add-entry-max\" data-bind=\"visible: isMaxed\" style=\"display: none;\">\n\t\t\t\tLe nombre maximal a \u00e9t\u00e9 atteint.\n\t\t\t<\/p>\n<\/div>\n<input type=\"hidden\"\n                name=\"input_66\"\n                id=\"input_3_66\"\n                data-bind=\"value: entryIds\"\n                value=\"\" \/><\/div><\/div>\n                    <\/div>\n                    <div class='gform-page-footer gform_page_footer top_label'>\n                        <button type='button' id='gform_previous_button_3_67' class='gform_previous_button gform-theme-button gform-theme-button--secondary button' onclick='gform.submission.handleButtonClick(this);' data-submission-type='previous' >Previous<\/button> <button type='button' id='gform_next_button_3_67' class='gform_next_button gform-theme-button button' onclick='gform.submission.handleButtonClick(this);' data-submission-type='next' >Next<\/button> <button type='button'  id='gform_save_3_5_link' onclick='gform.submission.handleButtonClick(this);' data-submission-type='save-continue' class='gform_save_link gform-theme-button gform-theme-button--secondary button'  ><svg aria-hidden=\"true\" focusable=\"false\" width=\"16\" height=\"16\" fill=\"none\" xmlns=\"http:\/\/www.w3.org\/2000\/svg\"><path fill-rule=\"evenodd\" clip-rule=\"evenodd\" d=\"M0 8a4 4 0 004 4h3v3a1 1 0 102 0v-3h3a4 4 0 100-8 4 4 0 10-8 0 4 4 0 00-4 4zm9 4H7V7.414L5.707 8.707a1 1 0 01-1.414-1.414l3-3a1 1 0 011.414 0l3 3a1 1 0 01-1.414 1.414L9 7.414V12z\" fill=\"#6B7280\"\/><\/svg> Save and Continue Later<\/button>\n                    <\/div>\n                <\/div>\n                <div id='gform_page_3_5' class='gform_page' data-js='page-field-id-67' style='display:none;'>\n                    <div class='gform_page_fields'>\n                        <div id='gform_fields_3_5' class='gform_fields top_label form_sublabel_below description_below validation_below'><div id=\"field_3_68\" class=\"gfield gfield--type-section gfield--input-type-section gsection field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><h3 class=\"gsection_title\">Health &amp; Medical Information<\/h3><\/div><div id=\"field_3_69\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_3_69'><span class='gform-field-label__text'>Health Concerns (e.g. allergies, asthmas, etc.)<\/span><span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(N\u00e9cessaire)<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_69' id='input_3_69' type='text' value='' class='large'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_3_70\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-full field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_3_70'><span class='gform-field-label__text'>Accessibility \/ Physical Disabilities<\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_70' id='input_3_70' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_3_71\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-full field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_3_71'><span class='gform-field-label__text'>Diet \/ Nutrition Recommended by DR or RN<\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_71' id='input_3_71' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_3_72\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-half gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_3_72'><span class='gform-field-label__text'>Health Card N\u00b0<\/span><span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(N\u00e9cessaire)<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_72' id='input_3_72' type='text' value='' class='large'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_3_73\" class=\"gfield gfield--type-date gfield--input-type-date gfield--input-type-datepicker gfield--datepicker-default-icon gfield--width-half gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_3_73'><span class='gform-field-label__text'>Expiry Date<\/span><span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(N\u00e9cessaire)<\/span><\/span><\/label><div class='ginput_container ginput_container_date'>\n\t\t\t\t\t<input\n\t\t\t\t\tplaceholder='mm\/jj\/aaaa'\n\t\t\t\t\tid='input_3_73'\n\t\t\t\t\tclass='datepicker gform-datepicker mdy datepicker_with_icon gdatepicker_with_icon'\n\t\t\t\t\ttype='text'\n\t\t\t\t\tname='input_73'\n\t\t\t\t\tvalue=''\n\t\t\t\t\t \n\t\t\t\t\taria-invalid=\"false\" \n\t\t\t\t\taria-required=\"true\"\n\t\t\t\t\t \n\t\t\t\t\t\n\t\t\t\t\tdata-mask=\"99\/99\/9999\"\n\t\t\t\t\t\/>\n\t\t\t\t<kbd id='keyboardHint_input_3_73' hidden class='down'><\/kbd>\n\t\t\t\t<button type='button' id='datepicker_toggle_input_3_73' class='gform-datepicker-toggle gform-datepicker-toggle--default accCalendar aria-date-picker gform-button gform-theme-button gform-theme-button--simple gform-theme-button--simple-in-ctrl' aria-expanded='false' aria-controls='input_3_73' aria-label='Expiry Date: Choose date on calendar' >\n\t\t\t\t\t\t\t<span class=\"gform-calendar-icon gform-datepicker-toggle-icon gform-datepicker-toggle-icon--default dashicons dashicons-calendar-alt\" aria-hidden=\"true\"><\/span>\n\t\t\t\t\t\t<\/button>\n\t\t\t<\/div><\/div><div id=\"field_3_74\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-half gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_3_74'><span class='gform-field-label__text'>Height<\/span><span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(N\u00e9cessaire)<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_74' id='input_3_74' type='text' value='' class='large'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_3_75\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-half gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_3_75'><span class='gform-field-label__text'>Weight (lbs)<\/span><span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(N\u00e9cessaire)<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_75' id='input_3_75' type='text' value='' class='large'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_3_77\" class=\"gfield gfield--type-section gfield--input-type-section gsection field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><h3 class=\"gsection_title\">Family Physician<\/h3><\/div><fieldset id=\"field_3_78\" class=\"gfield gfield--type-name gfield--input-type-name gfield--width-two-thirds field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' ><span class='gform-field-label__text'>Name<\/span><\/legend><div class='ginput_complex ginput_container ginput_container--name no_prefix has_first_name no_middle_name has_last_name no_suffix gf_name_has_2 ginput_container_name gform-grid-row' id='input_3_78'>\n                            \n                            <span id='input_3_78_3_container' class='name_first gform-grid-col gform-grid-col--size-auto' >\n                                                    <input type='text' name='input_78.3' id='input_3_78_3' value=''   aria-required='false'     \/>\n                                                    <label for='input_3_78_3' class='gform-field-label gform-field-label--type-sub '>Pr\u00e9nom<\/label>\n                                                <\/span>\n                            \n                            <span id='input_3_78_6_container' class='name_last gform-grid-col gform-grid-col--size-auto' >\n                                                    <input type='text' name='input_78.6' id='input_3_78_6' value=''   aria-required='false'     \/>\n                                                    <label for='input_3_78_6' class='gform-field-label gform-field-label--type-sub '>Nom<\/label>\n                                                <\/span>\n                            \n                        <\/div><\/fieldset><div id=\"field_3_79\" class=\"gfield gfield--type-phone gfield--input-type-phone gfield--phone-format-international gfield--width-third field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_3_79'><span class='gform-field-label__text'>Phone<\/span><\/label><div class='ginput_container ginput_container_phone'><input name='input_79' id='input_3_79' type='tel' value='' class='large'    aria-invalid=\"false\"    \/><\/div><\/div><div id=\"field_3_80\" class=\"gfield gfield--type-date gfield--input-type-date gfield--input-type-datepicker gfield--datepicker-default-icon gfield--width-quarter field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_3_80'><span class='gform-field-label__text'>Last Medical<\/span><\/label><div class='ginput_container ginput_container_date'>\n\t\t\t\t\t<input\n\t\t\t\t\tplaceholder='mm\/jj\/aaaa'\n\t\t\t\t\tid='input_3_80'\n\t\t\t\t\tclass='datepicker gform-datepicker mdy datepicker_with_icon gdatepicker_with_icon'\n\t\t\t\t\ttype='text'\n\t\t\t\t\tname='input_80'\n\t\t\t\t\tvalue=''\n\t\t\t\t\t \n\t\t\t\t\taria-invalid=\"false\" \n\t\t\t\t\t\n\t\t\t\t\t \n\t\t\t\t\t\n\t\t\t\t\tdata-mask=\"99\/99\/9999\"\n\t\t\t\t\t\/>\n\t\t\t\t<kbd id='keyboardHint_input_3_80' hidden class='down'><\/kbd>\n\t\t\t\t<button type='button' id='datepicker_toggle_input_3_80' class='gform-datepicker-toggle gform-datepicker-toggle--default accCalendar aria-date-picker gform-button gform-theme-button gform-theme-button--simple gform-theme-button--simple-in-ctrl' aria-expanded='false' aria-controls='input_3_80' aria-label='Last Medical: Choose date on calendar' >\n\t\t\t\t\t\t\t<span class=\"gform-calendar-icon gform-datepicker-toggle-icon gform-datepicker-toggle-icon--default dashicons dashicons-calendar-alt\" aria-hidden=\"true\"><\/span>\n\t\t\t\t\t\t<\/button>\n\t\t\t<\/div><\/div><fieldset id=\"field_3_81\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield--input-type-checkbox gfield--width-three-quarter field_sublabel_below gfield--no-description field_description_below hidden_label field_validation_below gfield_visibility_visible gfield--choice-align-vertical\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' ><span class='gform-field-label__text'>Last Medical - Unknown<\/span><\/legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox ' id='input_3_81'><div class='gchoice gchoice_3_81_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_81.1' type='checkbox'  value='Unknown'  id='choice_3_81_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_3_81_1' id='label_3_81_1' class='gform-field-label gform-field-label--type-inline'>Unknown<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_3_82\" class=\"gfield gfield--type-section gfield--input-type-section gsection field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><h3 class=\"gsection_title\">Dentist<\/h3><\/div><fieldset id=\"field_3_83\" class=\"gfield gfield--type-name gfield--input-type-name gfield--width-two-thirds field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' ><span class='gform-field-label__text'>Name<\/span><\/legend><div class='ginput_complex ginput_container ginput_container--name no_prefix has_first_name no_middle_name has_last_name no_suffix gf_name_has_2 ginput_container_name gform-grid-row' id='input_3_83'>\n                            \n                            <span id='input_3_83_3_container' class='name_first gform-grid-col gform-grid-col--size-auto' >\n                                                    <input type='text' name='input_83.3' id='input_3_83_3' value=''   aria-required='false'     \/>\n                                                    <label for='input_3_83_3' class='gform-field-label gform-field-label--type-sub '>Pr\u00e9nom<\/label>\n                                                <\/span>\n                            \n                            <span id='input_3_83_6_container' class='name_last gform-grid-col gform-grid-col--size-auto' >\n                                                    <input type='text' name='input_83.6' id='input_3_83_6' value=''   aria-required='false'     \/>\n                                                    <label for='input_3_83_6' class='gform-field-label gform-field-label--type-sub '>Nom<\/label>\n                                                <\/span>\n                            \n                        <\/div><\/fieldset><div id=\"field_3_84\" class=\"gfield gfield--type-phone gfield--input-type-phone gfield--phone-format-international gfield--width-third field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_3_84'><span class='gform-field-label__text'>Phone<\/span><\/label><div class='ginput_container ginput_container_phone'><input name='input_84' id='input_3_84' type='tel' value='' class='large'    aria-invalid=\"false\"    \/><\/div><\/div><div id=\"field_3_85\" class=\"gfield gfield--type-date gfield--input-type-date gfield--input-type-datepicker gfield--datepicker-default-icon gfield--width-quarter field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_3_85'><span class='gform-field-label__text'>Last Dental<\/span><\/label><div class='ginput_container ginput_container_date'>\n\t\t\t\t\t<input\n\t\t\t\t\tplaceholder='mm\/jj\/aaaa'\n\t\t\t\t\tid='input_3_85'\n\t\t\t\t\tclass='datepicker gform-datepicker mdy datepicker_with_icon gdatepicker_with_icon'\n\t\t\t\t\ttype='text'\n\t\t\t\t\tname='input_85'\n\t\t\t\t\tvalue=''\n\t\t\t\t\t \n\t\t\t\t\taria-invalid=\"false\" \n\t\t\t\t\t\n\t\t\t\t\t \n\t\t\t\t\t\n\t\t\t\t\tdata-mask=\"99\/99\/9999\"\n\t\t\t\t\t\/>\n\t\t\t\t<kbd id='keyboardHint_input_3_85' hidden class='down'><\/kbd>\n\t\t\t\t<button type='button' id='datepicker_toggle_input_3_85' class='gform-datepicker-toggle gform-datepicker-toggle--default accCalendar aria-date-picker gform-button gform-theme-button gform-theme-button--simple gform-theme-button--simple-in-ctrl' aria-expanded='false' aria-controls='input_3_85' aria-label='Last Dental: Choose date on calendar' >\n\t\t\t\t\t\t\t<span class=\"gform-calendar-icon gform-datepicker-toggle-icon gform-datepicker-toggle-icon--default dashicons dashicons-calendar-alt\" aria-hidden=\"true\"><\/span>\n\t\t\t\t\t\t<\/button>\n\t\t\t<\/div><\/div><fieldset id=\"field_3_86\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield--input-type-checkbox gfield--width-three-quarter field_sublabel_below gfield--no-description field_description_below hidden_label field_validation_below gfield_visibility_visible gfield--choice-align-vertical\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' ><span class='gform-field-label__text'>Last Dental - Unknown<\/span><\/legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox ' id='input_3_86'><div class='gchoice gchoice_3_86_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_86.1' type='checkbox'  value='Unknown'  id='choice_3_86_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_3_86_1' id='label_3_86_1' class='gform-field-label gform-field-label--type-inline'>Unknown<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_3_87\" class=\"gfield gfield--type-section gfield--input-type-section gsection field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><h3 class=\"gsection_title\">Optometrist<\/h3><\/div><fieldset id=\"field_3_88\" class=\"gfield gfield--type-name gfield--input-type-name gfield--width-two-thirds field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' ><span class='gform-field-label__text'>Name<\/span><\/legend><div class='ginput_complex ginput_container ginput_container--name no_prefix has_first_name no_middle_name has_last_name no_suffix gf_name_has_2 ginput_container_name gform-grid-row' id='input_3_88'>\n                            \n                            <span id='input_3_88_3_container' class='name_first gform-grid-col gform-grid-col--size-auto' >\n                                                    <input type='text' name='input_88.3' id='input_3_88_3' value=''   aria-required='false'     \/>\n                                                    <label for='input_3_88_3' class='gform-field-label gform-field-label--type-sub '>Pr\u00e9nom<\/label>\n                                                <\/span>\n                            \n                            <span id='input_3_88_6_container' class='name_last gform-grid-col gform-grid-col--size-auto' >\n                                                    <input type='text' name='input_88.6' id='input_3_88_6' value=''   aria-required='false'     \/>\n                                                    <label for='input_3_88_6' class='gform-field-label gform-field-label--type-sub '>Nom<\/label>\n                                                <\/span>\n                            \n                        <\/div><\/fieldset><div id=\"field_3_89\" class=\"gfield gfield--type-phone gfield--input-type-phone gfield--phone-format-international gfield--width-third field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_3_89'><span class='gform-field-label__text'>Phone<\/span><\/label><div class='ginput_container ginput_container_phone'><input name='input_89' id='input_3_89' type='tel' value='' class='large'    aria-invalid=\"false\"    \/><\/div><\/div><div id=\"field_3_90\" class=\"gfield gfield--type-date gfield--input-type-date gfield--input-type-datepicker gfield--datepicker-default-icon gfield--width-quarter field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_3_90'><span class='gform-field-label__text'>Last Optical<\/span><\/label><div class='ginput_container ginput_container_date'>\n\t\t\t\t\t<input\n\t\t\t\t\tplaceholder='mm\/jj\/aaaa'\n\t\t\t\t\tid='input_3_90'\n\t\t\t\t\tclass='datepicker gform-datepicker mdy datepicker_with_icon gdatepicker_with_icon'\n\t\t\t\t\ttype='text'\n\t\t\t\t\tname='input_90'\n\t\t\t\t\tvalue=''\n\t\t\t\t\t \n\t\t\t\t\taria-invalid=\"false\" \n\t\t\t\t\t\n\t\t\t\t\t \n\t\t\t\t\t\n\t\t\t\t\tdata-mask=\"99\/99\/9999\"\n\t\t\t\t\t\/>\n\t\t\t\t<kbd id='keyboardHint_input_3_90' hidden class='down'><\/kbd>\n\t\t\t\t<button type='button' id='datepicker_toggle_input_3_90' class='gform-datepicker-toggle gform-datepicker-toggle--default accCalendar aria-date-picker gform-button gform-theme-button gform-theme-button--simple gform-theme-button--simple-in-ctrl' aria-expanded='false' aria-controls='input_3_90' aria-label='Last Optical: Choose date on calendar' >\n\t\t\t\t\t\t\t<span class=\"gform-calendar-icon gform-datepicker-toggle-icon gform-datepicker-toggle-icon--default dashicons dashicons-calendar-alt\" aria-hidden=\"true\"><\/span>\n\t\t\t\t\t\t<\/button>\n\t\t\t<\/div><\/div><fieldset id=\"field_3_91\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield--input-type-checkbox gfield--width-three-quarter field_sublabel_below gfield--no-description field_description_below hidden_label field_validation_below gfield_visibility_visible gfield--choice-align-vertical\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' ><span class='gform-field-label__text'>Last Optical - Unknown<\/span><\/legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox ' id='input_3_91'><div class='gchoice gchoice_3_91_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_91.1' type='checkbox'  value='Unknown'  id='choice_3_91_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_3_91_1' id='label_3_91_1' class='gform-field-label gform-field-label--type-inline'>Unknown<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><\/div>\n                    <\/div>\n                    <div class='gform-page-footer gform_page_footer top_label'>\n                        <button type='button' id='gform_previous_button_3_92' class='gform_previous_button gform-theme-button gform-theme-button--secondary button' onclick='gform.submission.handleButtonClick(this);' data-submission-type='previous' >Previous<\/button> <button type='button' id='gform_next_button_3_92' class='gform_next_button gform-theme-button button' onclick='gform.submission.handleButtonClick(this);' data-submission-type='next' >Next<\/button> <button type='button'  id='gform_save_3_6_link' onclick='gform.submission.handleButtonClick(this);' data-submission-type='save-continue' class='gform_save_link gform-theme-button gform-theme-button--secondary button'  ><svg aria-hidden=\"true\" focusable=\"false\" width=\"16\" height=\"16\" fill=\"none\" xmlns=\"http:\/\/www.w3.org\/2000\/svg\"><path fill-rule=\"evenodd\" clip-rule=\"evenodd\" d=\"M0 8a4 4 0 004 4h3v3a1 1 0 102 0v-3h3a4 4 0 100-8 4 4 0 10-8 0 4 4 0 00-4 4zm9 4H7V7.414L5.707 8.707a1 1 0 01-1.414-1.414l3-3a1 1 0 011.414 0l3 3a1 1 0 01-1.414 1.414L9 7.414V12z\" fill=\"#6B7280\"\/><\/svg> Save and Continue Later<\/button>\n                    <\/div>\n                <\/div>\n                <div id='gform_page_3_6' class='gform_page' data-js='page-field-id-92' style='display:none;'>\n                    <div class='gform_page_fields'>\n                        <div id='gform_fields_3_6' class='gform_fields top_label form_sublabel_below description_below validation_below'><div id=\"field_3_93\" class=\"gfield gfield--type-section gfield--input-type-section gsection field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><h3 class=\"gsection_title\">Insurance Provider<\/h3><\/div><div id=\"field_3_95\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-half field_sublabel_below gfield--has-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_3_95'><span class='gform-field-label__text'>Broker<\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_95' id='input_3_95' type='text' value='' class='large'  aria-describedby=\"gfield_description_3_95\"    aria-invalid=\"false\"   \/><\/div><div class='gfield_description' id='gfield_description_3_95'>ie:  Cooperators, Intact ...<\/div><\/div><div id=\"field_3_96\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-half field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_3_96'><span class='gform-field-label__text'>Policy Number<\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_96' id='input_3_96' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_3_97\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-full field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_3_97'><span class='gform-field-label__text'>Status Card Number (if applicable)<\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_97' id='input_3_97' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_3_98\" class=\"gfield gfield--type-form gfield--input-type-form gform-theme__no-reset--children gfield--width-full field_sublabel_below gfield--has-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_3_98'><span class='gform-field-label__text'>Specialist(s)<\/span><\/label><div class='gfield_description' id='gfield_description_3_98'>(e.g. Psychiatrist, Speech Pathologist, Occupational Therapist, etc.)<\/div><div class=\"gpnf-nested-entries-container ginput_container\">\n\n\t<table class=\"gpnf-nested-entries\">\n\n\t\t<thead>\n\t\t<tr>\n\t\t\t\t\t\t\t<th scope=\"col\" class=\"gpnf-field-1\">\n\t\t\t\t\tName\t\t\t\t<\/th>\n\t\t\t\t\t\t\t<th scope=\"col\" class=\"gpnf-field-4\">\n\t\t\t\t\tSpeciality\t\t\t\t<\/th>\n\t\t\t\t\t\t\t<th scope=\"col\" class=\"gpnf-field-5\">\n\t\t\t\t\tPhone\t\t\t\t<\/th>\n\t\t\t\t\t\t<th scope=\"col\" class=\"gpnf-row-actions\"><span class=\"screen-reader-text\">Actions<\/span><\/th>\n\t\t<\/tr>\n\t\t<\/thead>\n\n\t\t<tbody data-bind=\"visible: entries().length, foreach: entries\">\n\t\t<tr data-bind=\"attr: { 'data-entryid': id }\">\n\t\t\t\t\t\t\t<td class=\"gpnf-field\"\n\t\t\t\t\tdata-bind=\"html: f1.label, attr: { 'data-value': f1.label }\"\n\t\t\t\t\tdata-heading=\"Name\"\n\t\t\t\t>&nbsp;<\/td>\n\t\t\t\t\t\t\t<td class=\"gpnf-field\"\n\t\t\t\t\tdata-bind=\"html: f4.label, attr: { 'data-value': f4.label }\"\n\t\t\t\t\tdata-heading=\"Speciality\"\n\t\t\t\t>&nbsp;<\/td>\n\t\t\t\t\t\t\t<td class=\"gpnf-field\"\n\t\t\t\t\tdata-bind=\"html: f5.label, attr: { 'data-value': f5.label }\"\n\t\t\t\t\tdata-heading=\"Phone\"\n\t\t\t\t>&nbsp;<\/td>\n\t\t\t\t\t\t<td class=\"gpnf-row-actions\" style=\"display: none;\" data-bind=\"visible: true\">\n\t\t\t\t<ul>\n\t\t\t\t\t<li class=\"edit\"><button type=\"button\" class=\"edit-button gform-theme-button--secondary\" data-bind=\"click: $parent.editEntry, attr: { 'aria-label': 'Edit Specialist {0} where Name is {1}.'.gformFormat( $index() + 1, f1.label ) }\">Modifier<\/button><\/li>\n\t\t\t\t\t\t\t\t\t\t<li class=\"delete\"><button type=\"button\" class=\"delete-button gform-theme-button--simple gform-theme-button--size-md\" data-bind=\"click: $parent.deleteEntry, attr: { 'aria-label': 'Delete Specialist {0} where Name is {1}.'.gformFormat( $index() + 1, f1.label ) }\">Supprimer<\/button><\/li>\n\t\t\t\t<\/ul>\n\t\t\t<\/td>\n\t\t<\/tr>\n\t\t<\/tbody>\n\n\t\t<tbody data-bind=\"visible: entries().length <= 0\">\n\t\t<tr class=\"gpnf-no-entries\" data-bind=\"visible: entries().length <= 0\" style=\"display: none;\">\n\t\t\t<td colspan=\"4\">\n\t\t\t\tIl n\u2019y a aucun(e) <span>Specialists.<\/span>\t\t\t<\/td>\n\t\t<\/tr>\n\t\t<\/tbody>\n\n\t<\/table>\n\n\t<button type=\"button\" class=\"gpnf-add-entry\"\n\t\t        data-formid=\"3\"\n\t\t        data-nestedformid=\"7\"\n\t\t\t\tdata-bind=\"attr: { disabled: isMaxed }, css: { 'gf-default-disabled': isMaxed }\"\n\t\t\t\t>\n\t\t\t\tAjouter Specialist\n\t\t\t<\/button>\t\n\t\t\t<p class=\"gpnf-add-entry-max\" data-bind=\"visible: isMaxed\" style=\"display: none;\">\n\t\t\t\tLe nombre maximal a \u00e9t\u00e9 atteint.\n\t\t\t<\/p>\n<\/div>\n<input type=\"hidden\"\n                name=\"input_98\"\n                id=\"input_3_98\"\n                data-bind=\"value: entryIds\"\n                value=\"\" \/><\/div><div id=\"field_3_99\" class=\"gfield gfield--type-form gfield--input-type-form gform-theme__no-reset--children gfield--width-full field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_3_99'><span class='gform-field-label__text'>Medication(s)<\/span><\/label><div class=\"gpnf-nested-entries-container ginput_container\">\n\n\t<table class=\"gpnf-nested-entries\">\n\n\t\t<thead>\n\t\t<tr>\n\t\t\t\t\t\t\t<th scope=\"col\" class=\"gpnf-field-4\">\n\t\t\t\t\tMedication\t\t\t\t<\/th>\n\t\t\t\t\t\t\t<th scope=\"col\" class=\"gpnf-field-6\">\n\t\t\t\t\tPrescribed by\t\t\t\t<\/th>\n\t\t\t\t\t\t\t<th scope=\"col\" class=\"gpnf-field-7\">\n\t\t\t\t\tLast Reviewed\t\t\t\t<\/th>\n\t\t\t\t\t\t<th scope=\"col\" class=\"gpnf-row-actions\"><span class=\"screen-reader-text\">Actions<\/span><\/th>\n\t\t<\/tr>\n\t\t<\/thead>\n\n\t\t<tbody data-bind=\"visible: entries().length, foreach: entries\">\n\t\t<tr data-bind=\"attr: { 'data-entryid': id }\">\n\t\t\t\t\t\t\t<td class=\"gpnf-field\"\n\t\t\t\t\tdata-bind=\"html: f4.label, attr: { 'data-value': f4.label }\"\n\t\t\t\t\tdata-heading=\"Medication\"\n\t\t\t\t>&nbsp;<\/td>\n\t\t\t\t\t\t\t<td class=\"gpnf-field\"\n\t\t\t\t\tdata-bind=\"html: f6.label, attr: { 'data-value': f6.label }\"\n\t\t\t\t\tdata-heading=\"Prescribed by\"\n\t\t\t\t>&nbsp;<\/td>\n\t\t\t\t\t\t\t<td class=\"gpnf-field\"\n\t\t\t\t\tdata-bind=\"html: f7.label, attr: { 'data-value': f7.label }\"\n\t\t\t\t\tdata-heading=\"Last Reviewed\"\n\t\t\t\t>&nbsp;<\/td>\n\t\t\t\t\t\t<td class=\"gpnf-row-actions\" style=\"display: none;\" data-bind=\"visible: true\">\n\t\t\t\t<ul>\n\t\t\t\t\t<li class=\"edit\"><button type=\"button\" class=\"edit-button gform-theme-button--secondary\" data-bind=\"click: $parent.editEntry, attr: { 'aria-label': 'Edit Medication {0} where Medication is {1}.'.gformFormat( $index() + 1, f4.label ) }\">Modifier<\/button><\/li>\n\t\t\t\t\t\t\t\t\t\t<li class=\"delete\"><button type=\"button\" class=\"delete-button gform-theme-button--simple gform-theme-button--size-md\" data-bind=\"click: $parent.deleteEntry, attr: { 'aria-label': 'Delete Medication {0} where Medication is {1}.'.gformFormat( $index() + 1, f4.label ) }\">Supprimer<\/button><\/li>\n\t\t\t\t<\/ul>\n\t\t\t<\/td>\n\t\t<\/tr>\n\t\t<\/tbody>\n\n\t\t<tbody data-bind=\"visible: entries().length <= 0\">\n\t\t<tr class=\"gpnf-no-entries\" data-bind=\"visible: entries().length <= 0\" style=\"display: none;\">\n\t\t\t<td colspan=\"4\">\n\t\t\t\tIl n\u2019y a aucun(e) <span>Medications.<\/span>\t\t\t<\/td>\n\t\t<\/tr>\n\t\t<\/tbody>\n\n\t<\/table>\n\n\t<button type=\"button\" class=\"gpnf-add-entry\"\n\t\t        data-formid=\"3\"\n\t\t        data-nestedformid=\"8\"\n\t\t\t\tdata-bind=\"attr: { disabled: isMaxed }, css: { 'gf-default-disabled': isMaxed }\"\n\t\t\t\t>\n\t\t\t\tAjouter Medication\n\t\t\t<\/button>\t\n\t\t\t<p class=\"gpnf-add-entry-max\" data-bind=\"visible: isMaxed\" style=\"display: none;\">\n\t\t\t\tLe nombre maximal a \u00e9t\u00e9 atteint.\n\t\t\t<\/p>\n<\/div>\n<input type=\"hidden\"\n                name=\"input_99\"\n                id=\"input_3_99\"\n                data-bind=\"value: entryIds\"\n                value=\"\" \/><\/div><div id=\"field_3_100\" class=\"gfield gfield--type-section gfield--input-type-section gsection field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><h3 class=\"gsection_title\">Immunizations<\/h3><\/div><div id=\"field_3_102\" class=\"gfield gfield--type-html gfield--input-type-html gfield--width-third gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  >Tripple (Diptheria, Tetanus, Polio)<\/div><div id=\"field_3_103\" class=\"gfield gfield--type-date gfield--input-type-date gfield--input-type-datepicker gfield--datepicker-default-icon gfield--width-third field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_3_103'><span class='gform-field-label__text'>Date (if known)<\/span><\/label><div class='ginput_container ginput_container_date'>\n\t\t\t\t\t<input\n\t\t\t\t\tplaceholder='mm\/jj\/aaaa'\n\t\t\t\t\tid='input_3_103'\n\t\t\t\t\tclass='datepicker gform-datepicker mdy datepicker_with_icon gdatepicker_with_icon'\n\t\t\t\t\ttype='text'\n\t\t\t\t\tname='input_103'\n\t\t\t\t\tvalue=''\n\t\t\t\t\t \n\t\t\t\t\taria-invalid=\"false\" \n\t\t\t\t\t\n\t\t\t\t\t \n\t\t\t\t\t\n\t\t\t\t\tdata-mask=\"99\/99\/9999\"\n\t\t\t\t\t\/>\n\t\t\t\t<kbd id='keyboardHint_input_3_103' hidden class='down'><\/kbd>\n\t\t\t\t<button type='button' id='datepicker_toggle_input_3_103' class='gform-datepicker-toggle gform-datepicker-toggle--default accCalendar aria-date-picker gform-button gform-theme-button gform-theme-button--simple gform-theme-button--simple-in-ctrl' aria-expanded='false' aria-controls='input_3_103' aria-label='Date (if known): Choose date on calendar' >\n\t\t\t\t\t\t\t<span class=\"gform-calendar-icon gform-datepicker-toggle-icon gform-datepicker-toggle-icon--default dashicons dashicons-calendar-alt\" aria-hidden=\"true\"><\/span>\n\t\t\t\t\t\t<\/button>\n\t\t\t<\/div><\/div><fieldset id=\"field_3_104\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gf_list_3col gfield--width-third field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible gfield--choice-align-columns\"  ><legend class='gfield_label gform-field-label' ><span class='gform-field-label__text'>Up to Date<\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_3_104'>\n\t\t\t<div class='gchoice gchoice_3_104_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_104' type='radio' value='Yes'  id='choice_3_104_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_3_104_0' id='label_3_104_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_3_104_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_104' type='radio' value='No'  id='choice_3_104_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_3_104_1' id='label_3_104_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_3_104_2'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_104' type='radio' value='Unknown'  id='choice_3_104_2' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_3_104_2' id='label_3_104_2' class='gform-field-label gform-field-label--type-inline'>Unknown<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_3_105\" class=\"gfield gfield--type-html gfield--input-type-html gfield--width-third gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><b>MMR<\/b> (Measles, Mumps, Rubella)<\/div><div id=\"field_3_106\" class=\"gfield gfield--type-date gfield--input-type-date gfield--input-type-datepicker gfield--datepicker-default-icon gfield--width-third field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_3_106'><span class='gform-field-label__text'>Date (if known)<\/span><\/label><div class='ginput_container ginput_container_date'>\n\t\t\t\t\t<input\n\t\t\t\t\tplaceholder='mm\/jj\/aaaa'\n\t\t\t\t\tid='input_3_106'\n\t\t\t\t\tclass='datepicker gform-datepicker mdy datepicker_with_icon gdatepicker_with_icon'\n\t\t\t\t\ttype='text'\n\t\t\t\t\tname='input_106'\n\t\t\t\t\tvalue=''\n\t\t\t\t\t \n\t\t\t\t\taria-invalid=\"false\" \n\t\t\t\t\t\n\t\t\t\t\t \n\t\t\t\t\t\n\t\t\t\t\tdata-mask=\"99\/99\/9999\"\n\t\t\t\t\t\/>\n\t\t\t\t<kbd id='keyboardHint_input_3_106' hidden class='down'><\/kbd>\n\t\t\t\t<button type='button' id='datepicker_toggle_input_3_106' class='gform-datepicker-toggle gform-datepicker-toggle--default accCalendar aria-date-picker gform-button gform-theme-button gform-theme-button--simple gform-theme-button--simple-in-ctrl' aria-expanded='false' aria-controls='input_3_106' aria-label='Date (if known): Choose date on calendar' >\n\t\t\t\t\t\t\t<span class=\"gform-calendar-icon gform-datepicker-toggle-icon gform-datepicker-toggle-icon--default dashicons dashicons-calendar-alt\" aria-hidden=\"true\"><\/span>\n\t\t\t\t\t\t<\/button>\n\t\t\t<\/div><\/div><fieldset id=\"field_3_107\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gf_list_3col gfield--width-third field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible gfield--choice-align-columns\"  ><legend class='gfield_label gform-field-label' ><span class='gform-field-label__text'>Up to Date<\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_3_107'>\n\t\t\t<div class='gchoice gchoice_3_107_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_107' type='radio' value='Yes'  id='choice_3_107_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_3_107_0' id='label_3_107_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_3_107_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_107' type='radio' value='No'  id='choice_3_107_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_3_107_1' id='label_3_107_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_3_107_2'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_107' type='radio' value='Unknown'  id='choice_3_107_2' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_3_107_2' id='label_3_107_2' class='gform-field-label gform-field-label--type-inline'>Unknown<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_3_108\" class=\"gfield gfield--type-html gfield--input-type-html gfield--width-third gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><b>Tuberculin Test<\/b><\/div><div id=\"field_3_109\" class=\"gfield gfield--type-date gfield--input-type-date gfield--input-type-datepicker gfield--datepicker-default-icon gfield--width-third field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_3_109'><span class='gform-field-label__text'>Date (if known)<\/span><\/label><div class='ginput_container ginput_container_date'>\n\t\t\t\t\t<input\n\t\t\t\t\tplaceholder='mm\/jj\/aaaa'\n\t\t\t\t\tid='input_3_109'\n\t\t\t\t\tclass='datepicker gform-datepicker mdy datepicker_with_icon gdatepicker_with_icon'\n\t\t\t\t\ttype='text'\n\t\t\t\t\tname='input_109'\n\t\t\t\t\tvalue=''\n\t\t\t\t\t \n\t\t\t\t\taria-invalid=\"false\" \n\t\t\t\t\t\n\t\t\t\t\t \n\t\t\t\t\t\n\t\t\t\t\tdata-mask=\"99\/99\/9999\"\n\t\t\t\t\t\/>\n\t\t\t\t<kbd id='keyboardHint_input_3_109' hidden class='down'><\/kbd>\n\t\t\t\t<button type='button' id='datepicker_toggle_input_3_109' class='gform-datepicker-toggle gform-datepicker-toggle--default accCalendar aria-date-picker gform-button gform-theme-button gform-theme-button--simple gform-theme-button--simple-in-ctrl' aria-expanded='false' aria-controls='input_3_109' aria-label='Date (if known): Choose date on calendar' >\n\t\t\t\t\t\t\t<span class=\"gform-calendar-icon gform-datepicker-toggle-icon gform-datepicker-toggle-icon--default dashicons dashicons-calendar-alt\" aria-hidden=\"true\"><\/span>\n\t\t\t\t\t\t<\/button>\n\t\t\t<\/div><\/div><fieldset id=\"field_3_110\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gf_list_3col gfield--width-third field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible gfield--choice-align-columns\"  ><legend class='gfield_label gform-field-label' ><span class='gform-field-label__text'>Results<\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_3_110'>\n\t\t\t<div class='gchoice gchoice_3_110_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_110' type='radio' value='Negative'  id='choice_3_110_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_3_110_0' id='label_3_110_0' class='gform-field-label gform-field-label--type-inline'>Negative<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_3_110_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_110' type='radio' value='Positive'  id='choice_3_110_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_3_110_1' id='label_3_110_1' class='gform-field-label gform-field-label--type-inline'>Positive<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_3_110_2'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_110' type='radio' value='Unknown'  id='choice_3_110_2' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_3_110_2' id='label_3_110_2' class='gform-field-label gform-field-label--type-inline'>Unknown<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_3_111\" class=\"gfield gfield--type-html gfield--input-type-html gfield--width-third gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><b>Covid-19 Vaccination<\/b><\/div><div id=\"field_3_112\" class=\"gfield gfield--type-date gfield--input-type-date gfield--input-type-datepicker gfield--datepicker-default-icon gfield--width-third field_sublabel_below gfield--has-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_3_112'><span class='gform-field-label__text'>Date (if known)<\/span><\/label><div class='ginput_container ginput_container_date'>\n\t\t\t\t\t<input\n\t\t\t\t\tplaceholder='mm\/jj\/aaaa'\n\t\t\t\t\tid='input_3_112'\n\t\t\t\t\tclass='datepicker gform-datepicker mdy datepicker_with_icon gdatepicker_with_icon'\n\t\t\t\t\ttype='text'\n\t\t\t\t\tname='input_112'\n\t\t\t\t\tvalue=''\n\t\t\t\t\taria-describedby=\"gfield_description_3_112\" \n\t\t\t\t\taria-invalid=\"false\" \n\t\t\t\t\t\n\t\t\t\t\t \n\t\t\t\t\t\n\t\t\t\t\tdata-mask=\"99\/99\/9999\"\n\t\t\t\t\t\/>\n\t\t\t\t<kbd id='keyboardHint_input_3_112' hidden class='down'><\/kbd>\n\t\t\t\t<button type='button' id='datepicker_toggle_input_3_112' class='gform-datepicker-toggle gform-datepicker-toggle--default accCalendar aria-date-picker gform-button gform-theme-button gform-theme-button--simple gform-theme-button--simple-in-ctrl' aria-expanded='false' aria-controls='input_3_112' aria-label='Date (if known): Choose date on calendar' >\n\t\t\t\t\t\t\t<span class=\"gform-calendar-icon gform-datepicker-toggle-icon gform-datepicker-toggle-icon--default dashicons dashicons-calendar-alt\" aria-hidden=\"true\"><\/span>\n\t\t\t\t\t\t<\/button>\n\t\t\t<\/div><div class='gfield_description' id='gfield_description_3_112'>(last dose)<\/div><\/div><fieldset id=\"field_3_118\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield--input-type-checkbox gf_list_4col gfield--width-third field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible gfield--choice-align-columns\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' ><span class='gform-field-label__text'>Doses<\/span><\/legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox ' id='input_3_118'><div class='gchoice gchoice_3_118_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_118.1' type='checkbox'  value='1'  id='choice_3_118_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_3_118_1' id='label_3_118_1' class='gform-field-label gform-field-label--type-inline'>1<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_3_118_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_118.2' type='checkbox'  value='2'  id='choice_3_118_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_3_118_2' id='label_3_118_2' class='gform-field-label gform-field-label--type-inline'>2<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_3_118_3'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_118.3' type='checkbox'  value='3'  id='choice_3_118_3'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_3_118_3' id='label_3_118_3' class='gform-field-label gform-field-label--type-inline'>3<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_3_118_4'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_118.4' type='checkbox'  value='4'  id='choice_3_118_4'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_3_118_4' id='label_3_118_4' class='gform-field-label gform-field-label--type-inline'>4<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_3_114\" class=\"gfield gfield--type-html gfield--input-type-html gfield--width-third gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><b>Other<\/b> (specify)<\/div><div id=\"field_3_115\" class=\"gfield gfield--type-date gfield--input-type-date gfield--input-type-datepicker gfield--datepicker-default-icon gfield--width-third field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_3_115'><span class='gform-field-label__text'>Date (if known)<\/span><\/label><div class='ginput_container ginput_container_date'>\n\t\t\t\t\t<input\n\t\t\t\t\tplaceholder='mm\/jj\/aaaa'\n\t\t\t\t\tid='input_3_115'\n\t\t\t\t\tclass='datepicker gform-datepicker mdy datepicker_with_icon gdatepicker_with_icon'\n\t\t\t\t\ttype='text'\n\t\t\t\t\tname='input_115'\n\t\t\t\t\tvalue=''\n\t\t\t\t\t \n\t\t\t\t\taria-invalid=\"false\" \n\t\t\t\t\t\n\t\t\t\t\t \n\t\t\t\t\t\n\t\t\t\t\tdata-mask=\"99\/99\/9999\"\n\t\t\t\t\t\/>\n\t\t\t\t<kbd id='keyboardHint_input_3_115' hidden class='down'><\/kbd>\n\t\t\t\t<button type='button' id='datepicker_toggle_input_3_115' class='gform-datepicker-toggle gform-datepicker-toggle--default accCalendar aria-date-picker gform-button gform-theme-button gform-theme-button--simple gform-theme-button--simple-in-ctrl' aria-expanded='false' aria-controls='input_3_115' aria-label='Date (if known): Choose date on calendar' >\n\t\t\t\t\t\t\t<span class=\"gform-calendar-icon gform-datepicker-toggle-icon gform-datepicker-toggle-icon--default dashicons dashicons-calendar-alt\" aria-hidden=\"true\"><\/span>\n\t\t\t\t\t\t<\/button>\n\t\t\t<\/div><\/div><div id=\"field_3_117\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-third field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_3_117'><span class='gform-field-label__text'>Notes<\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_117' id='input_3_117' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/div><\/div>\n                    <\/div>\n                    <div class='gform-page-footer gform_page_footer top_label'>\n                        <button type='button' id='gform_previous_button_3_119' class='gform_previous_button gform-theme-button gform-theme-button--secondary button' onclick='gform.submission.handleButtonClick(this);' data-submission-type='previous' >Previous<\/button> <button type='button' id='gform_next_button_3_119' class='gform_next_button gform-theme-button button' onclick='gform.submission.handleButtonClick(this);' data-submission-type='next' >Next<\/button> <button type='button'  id='gform_save_3_7_link' onclick='gform.submission.handleButtonClick(this);' data-submission-type='save-continue' class='gform_save_link gform-theme-button gform-theme-button--secondary button'  ><svg aria-hidden=\"true\" focusable=\"false\" width=\"16\" height=\"16\" fill=\"none\" xmlns=\"http:\/\/www.w3.org\/2000\/svg\"><path fill-rule=\"evenodd\" clip-rule=\"evenodd\" d=\"M0 8a4 4 0 004 4h3v3a1 1 0 102 0v-3h3a4 4 0 100-8 4 4 0 10-8 0 4 4 0 00-4 4zm9 4H7V7.414L5.707 8.707a1 1 0 01-1.414-1.414l3-3a1 1 0 011.414 0l3 3a1 1 0 01-1.414 1.414L9 7.414V12z\" fill=\"#6B7280\"\/><\/svg> Save and Continue Later<\/button>\n                    <\/div>\n                <\/div>\n                <div id='gform_page_3_7' class='gform_page' data-js='page-field-id-119' style='display:none;'>\n                    <div class='gform_page_fields'>\n                        <div id='gform_fields_3_7' class='gform_fields top_label form_sublabel_below description_below validation_below'><div id=\"field_3_120\" class=\"gfield gfield--type-section gfield--input-type-section gsection field_sublabel_below gfield--has-description field_description_below field_validation_below gfield_visibility_visible\"  ><h3 class=\"gsection_title\">Guardianship Status (Legal Custody)<\/h3><div class='gsection_description' id='gfield_description_3_120'>Please submit legal documentation<\/div><\/div><fieldset id=\"field_3_121\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gf_list_2col gfield--width-half gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible gfield--choice-align-columns\"  ><legend class='gfield_label gform-field-label' ><span class='gform-field-label__text'>Status<\/span><span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(N\u00e9cessaire)<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_3_121'>\n\t\t\t<div class='gchoice gchoice_3_121_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_121' type='radio' value='Parental'  id='choice_3_121_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_3_121_0' id='label_3_121_0' class='gform-field-label gform-field-label--type-inline'>Parental<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_3_121_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_121' type='radio' value='Joint Custody'  id='choice_3_121_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_3_121_1' id='label_3_121_1' class='gform-field-label gform-field-label--type-inline'>Joint Custody<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_3_121_2'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_121' type='radio' value='Single Parent'  id='choice_3_121_2' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_3_121_2' id='label_3_121_2' class='gform-field-label gform-field-label--type-inline'>Single Parent<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_3_121_3'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_121' type='radio' value='Parental &amp; CAS (Temporary Care Agreement)'  id='choice_3_121_3' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_3_121_3' id='label_3_121_3' class='gform-field-label gform-field-label--type-inline'>Parental &amp; CAS (Temporary Care Agreement)<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_3_121_4'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_121' type='radio' value='CAS \/ SAE'  id='choice_3_121_4' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_3_121_4' id='label_3_121_4' class='gform-field-label gform-field-label--type-inline'>CAS \/ SAE<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_3_121_5'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_121' type='radio' value='Independent'  id='choice_3_121_5' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_3_121_5' id='label_3_121_5' class='gform-field-label gform-field-label--type-inline'>Independent<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_3_121_6'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_121' type='radio' value='Other (Specify)'  id='choice_3_121_6' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_3_121_6' id='label_3_121_6' class='gform-field-label gform-field-label--type-inline'>Other (Specify)<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_3_122\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-half field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_3_122'><span class='gform-field-label__text'>Name<\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_122' id='input_3_122' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/div><fieldset id=\"field_3_123\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield--input-type-checkbox gfield--width-half field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible gfield--choice-align-vertical\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' ><span class='gform-field-label__text'>CAS<\/span><\/legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox ' id='input_3_123'><div class='gchoice gchoice_3_123_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_123.1' type='checkbox'  value='Crown Ward'  id='choice_3_123_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_3_123_1' id='label_3_123_1' class='gform-field-label gform-field-label--type-inline'>Crown Ward<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_3_123_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_123.2' type='checkbox'  value='Extended Society Care'  id='choice_3_123_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_3_123_2' id='label_3_123_2' class='gform-field-label gform-field-label--type-inline'>Extended Society Care<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_3_123_3'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_123.3' type='checkbox'  value='Interim Society Care'  id='choice_3_123_3'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_3_123_3' id='label_3_123_3' class='gform-field-label gform-field-label--type-inline'>Interim Society Care<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_3_123_4'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_123.4' type='checkbox'  value='Custody during adjournment'  id='choice_3_123_4'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_3_123_4' id='label_3_123_4' class='gform-field-label gform-field-label--type-inline'>Custody during adjournment<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_3_123_5'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_123.5' type='checkbox'  value='Customary Care Agreement'  id='choice_3_123_5'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_3_123_5' id='label_3_123_5' class='gform-field-label gform-field-label--type-inline'>Customary Care Agreement<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_3_124\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-half field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_3_124'><span class='gform-field-label__text'>Other<\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_124' id='input_3_124' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/div><\/div>\n                    <\/div>\n                    <div class='gform-page-footer gform_page_footer top_label'>\n                        <button type='button' id='gform_previous_button_3_125' class='gform_previous_button gform-theme-button gform-theme-button--secondary button' onclick='gform.submission.handleButtonClick(this);' data-submission-type='previous' >Previous<\/button> <button type='button' id='gform_next_button_3_125' class='gform_next_button gform-theme-button button' onclick='gform.submission.handleButtonClick(this);' data-submission-type='next' >Next<\/button> <button type='button'  id='gform_save_3_8_link' onclick='gform.submission.handleButtonClick(this);' data-submission-type='save-continue' class='gform_save_link gform-theme-button gform-theme-button--secondary button'  ><svg aria-hidden=\"true\" focusable=\"false\" width=\"16\" height=\"16\" fill=\"none\" xmlns=\"http:\/\/www.w3.org\/2000\/svg\"><path fill-rule=\"evenodd\" clip-rule=\"evenodd\" d=\"M0 8a4 4 0 004 4h3v3a1 1 0 102 0v-3h3a4 4 0 100-8 4 4 0 10-8 0 4 4 0 00-4 4zm9 4H7V7.414L5.707 8.707a1 1 0 01-1.414-1.414l3-3a1 1 0 011.414 0l3 3a1 1 0 01-1.414 1.414L9 7.414V12z\" fill=\"#6B7280\"\/><\/svg> Save and Continue Later<\/button>\n                    <\/div>\n                <\/div>\n                <div id='gform_page_3_8' class='gform_page' data-js='page-field-id-125' style='display:none;'>\n                    <div class='gform_page_fields'>\n                        <div id='gform_fields_3_8' class='gform_fields top_label form_sublabel_below description_below validation_below'><div id=\"field_3_126\" class=\"gfield gfield--type-section gfield--input-type-section gsection field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><h3 class=\"gsection_title\">Youth&#039;s Current Living Situation<\/h3><\/div><fieldset id=\"field_3_127\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-quarter field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible gfield--choice-align-vertical\"  ><legend class='gfield_label gform-field-label' ><span class='gform-field-label__text'>Location<\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_3_127'>\n\t\t\t<div class='gchoice gchoice_3_127_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_127' type='radio' value='Family'  id='choice_3_127_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_3_127_0' id='label_3_127_0' class='gform-field-label gform-field-label--type-inline'>Family<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_3_127_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_127' type='radio' value='Children&#039;s Aid Society'  id='choice_3_127_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_3_127_1' id='label_3_127_1' class='gform-field-label gform-field-label--type-inline'>Children's Aid Society<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_3_127_2'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_127' type='radio' value='Friend&#039;s Home'  id='choice_3_127_2' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_3_127_2' id='label_3_127_2' class='gform-field-label gform-field-label--type-inline'>Friend's Home<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_3_127_3'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_127' type='radio' value='Homeless or Hostel'  id='choice_3_127_3' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_3_127_3' id='label_3_127_3' class='gform-field-label gform-field-label--type-inline'>Homeless or Hostel<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_3_127_4'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_127' type='radio' value='Hospital, Treatment Facility - Medical'  id='choice_3_127_4' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_3_127_4' id='label_3_127_4' class='gform-field-label gform-field-label--type-inline'>Hospital, Treatment Facility - Medical<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_3_127_5'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_127' type='radio' value='In Detention'  id='choice_3_127_5' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_3_127_5' id='label_3_127_5' class='gform-field-label gform-field-label--type-inline'>In Detention<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_3_127_6'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_127' type='radio' value='Other (specify)'  id='choice_3_127_6' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_3_127_6' id='label_3_127_6' class='gform-field-label gform-field-label--type-inline'>Other (specify)<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_3_128\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-quarter field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible gfield--choice-align-vertical\"  ><legend class='gfield_label gform-field-label' ><span class='gform-field-label__text'>With<\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_3_128'>\n\t\t\t<div class='gchoice gchoice_3_128_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_128' type='radio' value='Parent(s)'  id='choice_3_128_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_3_128_0' id='label_3_128_0' class='gform-field-label gform-field-label--type-inline'>Parent(s)<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_3_128_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_128' type='radio' value='Kin'  id='choice_3_128_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_3_128_1' id='label_3_128_1' class='gform-field-label gform-field-label--type-inline'>Kin<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_3_129\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield--input-type-checkbox gfield--width-quarter field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible gfield--choice-align-vertical\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' ><span class='gform-field-label__text'>Adopted?<\/span><\/legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox ' id='input_3_129'><div class='gchoice gchoice_3_129_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_129.1' type='checkbox'  value='Yes'  id='choice_3_129_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_3_129_1' id='label_3_129_1' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_3_130\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-quarter field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible gfield--choice-align-vertical\"  ><legend class='gfield_label gform-field-label' ><span class='gform-field-label__text'>Home<\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_3_130'>\n\t\t\t<div class='gchoice gchoice_3_130_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_130' type='radio' value='Foster Home'  id='choice_3_130_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_3_130_0' id='label_3_130_0' class='gform-field-label gform-field-label--type-inline'>Foster Home<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_3_130_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_130' type='radio' value='Group Home'  id='choice_3_130_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_3_130_1' id='label_3_130_1' class='gform-field-label gform-field-label--type-inline'>Group Home<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><\/div>\n                    <\/div>\n                    <div class='gform-page-footer gform_page_footer top_label'>\n                        <button type='button' id='gform_previous_button_3_131' class='gform_previous_button gform-theme-button gform-theme-button--secondary button' onclick='gform.submission.handleButtonClick(this);' data-submission-type='previous' >Previous<\/button> <button type='button' id='gform_next_button_3_131' class='gform_next_button gform-theme-button button' onclick='gform.submission.handleButtonClick(this);' data-submission-type='next' >Next<\/button> <button type='button'  id='gform_save_3_9_link' onclick='gform.submission.handleButtonClick(this);' data-submission-type='save-continue' class='gform_save_link gform-theme-button gform-theme-button--secondary button'  ><svg aria-hidden=\"true\" focusable=\"false\" width=\"16\" height=\"16\" fill=\"none\" xmlns=\"http:\/\/www.w3.org\/2000\/svg\"><path fill-rule=\"evenodd\" clip-rule=\"evenodd\" d=\"M0 8a4 4 0 004 4h3v3a1 1 0 102 0v-3h3a4 4 0 100-8 4 4 0 10-8 0 4 4 0 00-4 4zm9 4H7V7.414L5.707 8.707a1 1 0 01-1.414-1.414l3-3a1 1 0 011.414 0l3 3a1 1 0 01-1.414 1.414L9 7.414V12z\" fill=\"#6B7280\"\/><\/svg> Save and Continue Later<\/button>\n                    <\/div>\n                <\/div>\n                <div id='gform_page_3_9' class='gform_page' data-js='page-field-id-131' style='display:none;'>\n                    <div class='gform_page_fields'>\n                        <div id='gform_fields_3_9' class='gform_fields top_label form_sublabel_below description_below validation_below'><div id=\"field_3_132\" class=\"gfield gfield--type-section gfield--input-type-section gsection field_sublabel_below gfield--has-description field_description_below field_validation_below gfield_visibility_visible\"  ><h3 class=\"gsection_title\">Family Income<\/h3><div class='gsection_description' id='gfield_description_3_132'>*The information provided will help us better serve and meet the needs of various socio-economic groups<\/div><\/div><fieldset id=\"field_3_133\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield--input-type-checkbox gf_list_3col gfield--width-full field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible gfield--choice-align-columns\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' ><span class='gform-field-label__text'>Please indicate what the income level of the youth\u2019s family\/caregiver was last year.<\/span><\/legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox ' id='input_3_133'><div class='gchoice gchoice_3_133_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_133.1' type='checkbox'  value='$0 - $29,999'  id='choice_3_133_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_3_133_1' id='label_3_133_1' class='gform-field-label gform-field-label--type-inline'>$0 - $29,999<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_3_133_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_133.2' type='checkbox'  value='$30,000 - $59,999'  id='choice_3_133_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_3_133_2' id='label_3_133_2' class='gform-field-label gform-field-label--type-inline'>$30,000 - $59,999<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_3_133_3'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_133.3' type='checkbox'  value='$60,000 - $89,999'  id='choice_3_133_3'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_3_133_3' id='label_3_133_3' class='gform-field-label gform-field-label--type-inline'>$60,000 - $89,999<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_3_133_4'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_133.4' type='checkbox'  value='$90,000 - $119,999'  id='choice_3_133_4'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_3_133_4' id='label_3_133_4' class='gform-field-label gform-field-label--type-inline'>$90,000 - $119,999<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_3_133_5'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_133.5' type='checkbox'  value='$120,000 - $149,999'  id='choice_3_133_5'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_3_133_5' id='label_3_133_5' class='gform-field-label gform-field-label--type-inline'>$120,000 - $149,999<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_3_133_6'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_133.6' type='checkbox'  value='$150,000 or more'  id='choice_3_133_6'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_3_133_6' id='label_3_133_6' class='gform-field-label gform-field-label--type-inline'>$150,000 or more<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_3_133_7'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_133.7' type='checkbox'  value='Prefer not to answer'  id='choice_3_133_7'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_3_133_7' id='label_3_133_7' class='gform-field-label gform-field-label--type-inline'>Prefer not to answer<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_3_134\" class=\"gfield gfield--type-section gfield--input-type-section gsection field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><h3 class=\"gsection_title\">History of Family or Caregiver Involvement<\/h3><\/div><div id=\"field_3_135\" class=\"gfield gfield--type-textarea gfield--input-type-textarea gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_3_135'><span class='gform-field-label__text'>Please provide a brief synopsis of the youth\u2019s family relationships and their history, including guardianship history if status has changed over time.<\/span><span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(N\u00e9cessaire)<\/span><\/span><\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_135' id='input_3_135' class='textarea large'     aria-required=\"true\" aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/div><\/div>\n                    <\/div>\n                    <div class='gform-page-footer gform_page_footer top_label'>\n                        <button type='button' id='gform_previous_button_3_136' class='gform_previous_button gform-theme-button gform-theme-button--secondary button' onclick='gform.submission.handleButtonClick(this);' data-submission-type='previous' >Previous<\/button> <button type='button' id='gform_next_button_3_136' class='gform_next_button gform-theme-button button' onclick='gform.submission.handleButtonClick(this);' data-submission-type='next' >Next<\/button> <button type='button'  id='gform_save_3_10_link' onclick='gform.submission.handleButtonClick(this);' data-submission-type='save-continue' class='gform_save_link gform-theme-button gform-theme-button--secondary button'  ><svg aria-hidden=\"true\" focusable=\"false\" width=\"16\" height=\"16\" fill=\"none\" xmlns=\"http:\/\/www.w3.org\/2000\/svg\"><path fill-rule=\"evenodd\" clip-rule=\"evenodd\" d=\"M0 8a4 4 0 004 4h3v3a1 1 0 102 0v-3h3a4 4 0 100-8 4 4 0 10-8 0 4 4 0 00-4 4zm9 4H7V7.414L5.707 8.707a1 1 0 01-1.414-1.414l3-3a1 1 0 011.414 0l3 3a1 1 0 01-1.414 1.414L9 7.414V12z\" fill=\"#6B7280\"\/><\/svg> Save and Continue Later<\/button>\n                    <\/div>\n                <\/div>\n                <div id='gform_page_3_10' class='gform_page' data-js='page-field-id-136' style='display:none;'>\n                    <div class='gform_page_fields'>\n                        <div id='gform_fields_3_10' class='gform_fields top_label form_sublabel_below description_below validation_below'><div id=\"field_3_138\" class=\"gfield gfield--type-section gfield--input-type-section gsection field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><h3 class=\"gsection_title\">Place of Birth &amp; Legal Status<\/h3><\/div><fieldset id=\"field_3_139\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-third field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible gfield--choice-align-vertical\"  ><legend class='gfield_label gform-field-label' ><span class='gform-field-label__text'>Location<\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_3_139'>\n\t\t\t<div class='gchoice gchoice_3_139_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_139' type='radio' value='Canada'  id='choice_3_139_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_3_139_0' id='label_3_139_0' class='gform-field-label gform-field-label--type-inline'>Canada<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_3_139_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_139' type='radio' value='Outside of Canada'  id='choice_3_139_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_3_139_1' id='label_3_139_1' class='gform-field-label gform-field-label--type-inline'>Outside of Canada<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_3_139_2'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_139' type='radio' value='Citizen'  id='choice_3_139_2' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_3_139_2' id='label_3_139_2' class='gform-field-label gform-field-label--type-inline'>Citizen<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_3_139_3'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_139' type='radio' value='Refugee'  id='choice_3_139_3' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_3_139_3' id='label_3_139_3' class='gform-field-label gform-field-label--type-inline'>Refugee<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_3_140\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-third field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_3_140'><span class='gform-field-label__text'>Specify Country<\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_140' id='input_3_140' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_3_141\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-third field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_3_141'><span class='gform-field-label__text'>Legal Status<\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_141' id='input_3_141' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/div><\/div>\n                    <\/div>\n                    <div class='gform-page-footer gform_page_footer top_label'>\n                        <button type='button' id='gform_previous_button_3_142' class='gform_previous_button gform-theme-button gform-theme-button--secondary button' onclick='gform.submission.handleButtonClick(this);' data-submission-type='previous' >Previous<\/button> <button type='button' id='gform_next_button_3_142' class='gform_next_button gform-theme-button button' onclick='gform.submission.handleButtonClick(this);' data-submission-type='next' >Next<\/button> <button type='button'  id='gform_save_3_11_link' onclick='gform.submission.handleButtonClick(this);' data-submission-type='save-continue' class='gform_save_link gform-theme-button gform-theme-button--secondary button'  ><svg aria-hidden=\"true\" focusable=\"false\" width=\"16\" height=\"16\" fill=\"none\" xmlns=\"http:\/\/www.w3.org\/2000\/svg\"><path fill-rule=\"evenodd\" clip-rule=\"evenodd\" d=\"M0 8a4 4 0 004 4h3v3a1 1 0 102 0v-3h3a4 4 0 100-8 4 4 0 10-8 0 4 4 0 00-4 4zm9 4H7V7.414L5.707 8.707a1 1 0 01-1.414-1.414l3-3a1 1 0 011.414 0l3 3a1 1 0 01-1.414 1.414L9 7.414V12z\" fill=\"#6B7280\"\/><\/svg> Save and Continue Later<\/button>\n                    <\/div>\n                <\/div>\n                <div id='gform_page_3_11' class='gform_page' data-js='page-field-id-142' style='display:none;'>\n                    <div class='gform_page_fields'>\n                        <div id='gform_fields_3_11' class='gform_fields top_label form_sublabel_below description_below validation_below'><div id=\"field_3_143\" class=\"gfield gfield--type-section gfield--input-type-section gsection field_sublabel_below gfield--has-description field_description_below field_validation_below gfield_visibility_visible\"  ><h3 class=\"gsection_title\">Youth\u2019s Race<\/h3><div class='gsection_description' id='gfield_description_3_143'>*A set of values that best represents a group of people who possess similar and distinct physical characteristics<\/div><\/div><fieldset id=\"field_3_145\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield--input-type-checkbox gfield--width-half gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible gfield--choice-align-vertical\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' ><span class='gform-field-label__text'>Please choose all that apply<\/span><span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(N\u00e9cessaire)<\/span><\/span><\/legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox ' id='input_3_145'><div class='gchoice gchoice_3_145_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_145.1' type='checkbox'  value='Black (e.g. African, Afro-Caribbean, African-Canadian, etc. descent)'  id='choice_3_145_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_3_145_1' id='label_3_145_1' class='gform-field-label gform-field-label--type-inline'>Black (e.g. African, Afro-Caribbean, African-Canadian, etc. descent)<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_3_145_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_145.2' type='checkbox'  value='East Asian (eg. Chinese, Korean, Japanese, Taiwanese, etc. descent)'  id='choice_3_145_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_3_145_2' id='label_3_145_2' class='gform-field-label gform-field-label--type-inline'>East Asian (eg. Chinese, Korean, Japanese, Taiwanese, etc. descent)<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_3_145_3'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_145.3' type='checkbox'  value='Latino (e.g. Latin American, Hispanic, etc. descent)'  id='choice_3_145_3'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_3_145_3' id='label_3_145_3' class='gform-field-label gform-field-label--type-inline'>Latino (e.g. Latin American, Hispanic, etc. descent)<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_3_145_4'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_145.4' type='checkbox'  value='Middle Eastern (e.g. Arab, Persian, West Asian, Afghan, Egyptian, Iranian, etc. decent)'  id='choice_3_145_4'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_3_145_4' id='label_3_145_4' class='gform-field-label gform-field-label--type-inline'>Middle Eastern (e.g. Arab, Persian, West Asian, Afghan, Egyptian, Iranian, etc. decent)<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_3_145_5'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_145.5' type='checkbox'  value='Indigeneous (First Nations, M\u00e9tis and\/or Inuit decent)'  id='choice_3_145_5'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_3_145_5' id='label_3_145_5' class='gform-field-label gform-field-label--type-inline'>Indigeneous (First Nations, M\u00e9tis and\/or Inuit decent)<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_3_145_6'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_145.6' type='checkbox'  value='South Asian (e.g. East Indian, Pakistani, Sri Lankan, Indo-Caribbean, etc. decent)'  id='choice_3_145_6'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_3_145_6' id='label_3_145_6' class='gform-field-label gform-field-label--type-inline'>South Asian (e.g. East Indian, Pakistani, Sri Lankan, Indo-Caribbean, etc. decent)<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_3_145_7'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_145.7' type='checkbox'  value='Southeast Asian (Filipino, Vietnamese, Cambodian, Thai, other Southeast Asian, etc. descent)'  id='choice_3_145_7'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_3_145_7' id='label_3_145_7' class='gform-field-label gform-field-label--type-inline'>Southeast Asian (Filipino, Vietnamese, Cambodian, Thai, other Southeast Asian, etc. descent)<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_3_145_8'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_145.8' type='checkbox'  value='White (e.g. European, North American, Western, etc. descent)'  id='choice_3_145_8'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_3_145_8' id='label_3_145_8' class='gform-field-label gform-field-label--type-inline'>White (e.g. European, North American, Western, etc. descent)<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_3_145_9'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_145.9' type='checkbox'  value='Prefer not to answer'  id='choice_3_145_9'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_3_145_9' id='label_3_145_9' class='gform-field-label gform-field-label--type-inline'>Prefer not to answer<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_3_145_11'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_145.11' type='checkbox'  value='Another race category'  id='choice_3_145_11'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_3_145_11' id='label_3_145_11' class='gform-field-label gform-field-label--type-inline'>Another race category<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_3_146\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-half field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_3_146'><span class='gform-field-label__text'>Specify<\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_146' id='input_3_146' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_3_147\" class=\"gfield gfield--type-section gfield--input-type-section gsection field_sublabel_below gfield--has-description field_description_below field_validation_below gfield_visibility_visible\"  ><h3 class=\"gsection_title\">Additional Diversity Identification &amp; Needs<\/h3><div class='gsection_description' id='gfield_description_3_147'>Please identify, if applicable, any other diversity identification. Indicate any special needs or accommodations the youth may\nrequire with respect to their religious\/spiritual needs, their gender identification and\/or their ethnic\/cultural identification (food\npreferences for meals and snacks, cultural activities, celebration of religious holidays, or other cultural traditions or practices)<\/div><\/div><div id=\"field_3_148\" class=\"gfield gfield--type-textarea gfield--input-type-textarea gfield--width-full field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_3_148'><span class='gform-field-label__text'>Additional Needs<\/span><\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_148' id='input_3_148' class='textarea large'      aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/div><\/div>\n                    <\/div>\n                    <div class='gform-page-footer gform_page_footer top_label'>\n                        <button type='button' id='gform_previous_button_3_20' class='gform_previous_button gform-theme-button gform-theme-button--secondary button' onclick='gform.submission.handleButtonClick(this);' data-submission-type='previous' >Previous<\/button> <button type='button' id='gform_next_button_3_20' class='gform_next_button gform-theme-button button' onclick='gform.submission.handleButtonClick(this);' data-submission-type='next' >Next<\/button> <button type='button'  id='gform_save_3_12_link' onclick='gform.submission.handleButtonClick(this);' data-submission-type='save-continue' class='gform_save_link gform-theme-button gform-theme-button--secondary button'  ><svg aria-hidden=\"true\" focusable=\"false\" width=\"16\" height=\"16\" fill=\"none\" xmlns=\"http:\/\/www.w3.org\/2000\/svg\"><path fill-rule=\"evenodd\" clip-rule=\"evenodd\" d=\"M0 8a4 4 0 004 4h3v3a1 1 0 102 0v-3h3a4 4 0 100-8 4 4 0 10-8 0 4 4 0 00-4 4zm9 4H7V7.414L5.707 8.707a1 1 0 01-1.414-1.414l3-3a1 1 0 011.414 0l3 3a1 1 0 01-1.414 1.414L9 7.414V12z\" fill=\"#6B7280\"\/><\/svg> Save and Continue Later<\/button>\n                    <\/div>\n                <\/div>\n                <div id='gform_page_3_12' class='gform_page' data-js='page-field-id-20' style='display:none;'>\n                    <div class='gform_page_fields'>\n                        <div id='gform_fields_3_12' class='gform_fields top_label form_sublabel_below description_below validation_below'><div id=\"field_3_150\" class=\"gfield gfield--type-section gfield--input-type-section gsection field_sublabel_below gfield--has-description field_description_below field_validation_below gfield_visibility_visible\"  ><h3 class=\"gsection_title\">Youth\u2019s Ethnic &amp; Cultural Identification<\/h3><div class='gsection_description' id='gfield_description_3_150'>* The information provided will help us better serve and meet the needs of various ethno cultural groups<\/div><\/div><fieldset id=\"field_3_152\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gf_list_2col gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible gfield--choice-align-columns\"  ><legend class='gfield_label gform-field-label' ><span class='gform-field-label__text'>Please select<\/span><span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(N\u00e9cessaire)<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_3_152'>\n\t\t\t<div class='gchoice gchoice_3_152_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_152' type='radio' value='Indigenous'  id='choice_3_152_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_3_152_0' id='label_3_152_0' class='gform-field-label gform-field-label--type-inline'>Indigenous<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_3_152_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_152' type='radio' value='North American'  id='choice_3_152_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_3_152_1' id='label_3_152_1' class='gform-field-label gform-field-label--type-inline'>North American<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_3_152_2'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_152' type='radio' value='British Isles (e.g. Irish, Scottish, English)'  id='choice_3_152_2' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_3_152_2' id='label_3_152_2' class='gform-field-label gform-field-label--type-inline'>British Isles (e.g. Irish, Scottish, English)<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_3_152_3'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_152' type='radio' value='French (e.g. Acadian, French)'  id='choice_3_152_3' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_3_152_3' id='label_3_152_3' class='gform-field-label gform-field-label--type-inline'>French (e.g. Acadian, French)<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_3_152_4'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_152' type='radio' value='Western European (e.g. Austrian, Belgian, Dutch, German, Swiss)'  id='choice_3_152_4' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_3_152_4' id='label_3_152_4' class='gform-field-label gform-field-label--type-inline'>Western European (e.g. Austrian, Belgian, Dutch, German, Swiss)<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_3_152_5'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_152' type='radio' value='Northern European (e.g. Danish, Finnish, Icelandic, Norwegian, Swedish)'  id='choice_3_152_5' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_3_152_5' id='label_3_152_5' class='gform-field-label gform-field-label--type-inline'>Northern European (e.g. Danish, Finnish, Icelandic, Norwegian, Swedish)<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_3_152_6'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_152' type='radio' value='Eastern European (e.g. Czech, Hungarian, Latvian, Polish, etc.)'  id='choice_3_152_6' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_3_152_6' id='label_3_152_6' class='gform-field-label gform-field-label--type-inline'>Eastern European (e.g. Czech, Hungarian, Latvian, Polish, etc.)<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_3_152_7'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_152' type='radio' value='Southern European (e.g. Bulgarian, Croatian, Greek, Italian, Portuguese, etc.)'  id='choice_3_152_7' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_3_152_7' id='label_3_152_7' class='gform-field-label gform-field-label--type-inline'>Southern European (e.g. Bulgarian, Croatian, Greek, Italian, Portuguese, etc.)<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_3_152_8'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_152' type='radio' value='Other European (Jewish)'  id='choice_3_152_8' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_3_152_8' id='label_3_152_8' class='gform-field-label gform-field-label--type-inline'>Other European (Jewish)<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_3_152_9'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_152' type='radio' value='Caribbean (e.g. Guyanese, Jamaican, Haitian, Puerto Rican, etc.)'  id='choice_3_152_9' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_3_152_9' id='label_3_152_9' class='gform-field-label gform-field-label--type-inline'>Caribbean (e.g. Guyanese, Jamaican, Haitian, Puerto Rican, etc.)<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_3_152_10'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_152' type='radio' value='Latin, Central and South American (e.g. Mexican, Columbian, Peruvian, etc.)'  id='choice_3_152_10' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_3_152_10' id='label_3_152_10' class='gform-field-label gform-field-label--type-inline'>Latin, Central and South American (e.g. Mexican, Columbian, Peruvian, etc.)<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_3_152_11'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_152' type='radio' value='African (e.g. Congolese, Somali, Nigerian, South African, etc.)'  id='choice_3_152_11' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_3_152_11' id='label_3_152_11' class='gform-field-label gform-field-label--type-inline'>African (e.g. Congolese, Somali, Nigerian, South African, etc.)<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_3_152_12'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_152' type='radio' value='West Asian (e.g. Afghan, Armenian, Iranian, etc.)'  id='choice_3_152_12' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_3_152_12' id='label_3_152_12' class='gform-field-label gform-field-label--type-inline'>West Asian (e.g. Afghan, Armenian, Iranian, etc.)<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_3_152_13'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_152' type='radio' value='South Asian (e.g. Bangladeshi, East Indian, Pakistani, Sri Lankan, etc.)'  id='choice_3_152_13' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_3_152_13' id='label_3_152_13' class='gform-field-label gform-field-label--type-inline'>South Asian (e.g. Bangladeshi, East Indian, Pakistani, Sri Lankan, etc.)<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_3_152_14'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_152' type='radio' value='Oceania (e.g. Australian, New Zealander, Pacific Islander)'  id='choice_3_152_14' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_3_152_14' id='label_3_152_14' class='gform-field-label gform-field-label--type-inline'>Oceania (e.g. Australian, New Zealander, Pacific Islander)<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_3_152_15'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_152' type='radio' value='Unknown'  id='choice_3_152_15' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_3_152_15' id='label_3_152_15' class='gform-field-label gform-field-label--type-inline'>Unknown<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_3_152_16'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_152' type='radio' value='Prefer not to answer'  id='choice_3_152_16' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_3_152_16' id='label_3_152_16' class='gform-field-label gform-field-label--type-inline'>Prefer not to answer<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_3_152_17'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_152' type='radio' value='Another race category'  id='choice_3_152_17' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_3_152_17' id='label_3_152_17' class='gform-field-label gform-field-label--type-inline'>Another race category<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_3_153\" class=\"gfield gfield--type-textarea gfield--input-type-textarea gfield--width-full field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_3_153'><span class='gform-field-label__text'>Additional information or details<\/span><\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_153' id='input_3_153' class='textarea small'      aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/div><\/div>\n                    <\/div>\n                    <div class='gform-page-footer gform_page_footer top_label'>\n                        <button type='button' id='gform_previous_button_3_154' class='gform_previous_button gform-theme-button gform-theme-button--secondary button' onclick='gform.submission.handleButtonClick(this);' data-submission-type='previous' >Previous<\/button> <button type='button' id='gform_next_button_3_154' class='gform_next_button gform-theme-button button' onclick='gform.submission.handleButtonClick(this);' data-submission-type='next' >Next<\/button> <button type='button'  id='gform_save_3_13_link' onclick='gform.submission.handleButtonClick(this);' data-submission-type='save-continue' class='gform_save_link gform-theme-button gform-theme-button--secondary button'  ><svg aria-hidden=\"true\" focusable=\"false\" width=\"16\" height=\"16\" fill=\"none\" xmlns=\"http:\/\/www.w3.org\/2000\/svg\"><path fill-rule=\"evenodd\" clip-rule=\"evenodd\" d=\"M0 8a4 4 0 004 4h3v3a1 1 0 102 0v-3h3a4 4 0 100-8 4 4 0 10-8 0 4 4 0 00-4 4zm9 4H7V7.414L5.707 8.707a1 1 0 01-1.414-1.414l3-3a1 1 0 011.414 0l3 3a1 1 0 01-1.414 1.414L9 7.414V12z\" fill=\"#6B7280\"\/><\/svg> Save and Continue Later<\/button>\n                    <\/div>\n                <\/div>\n                <div id='gform_page_3_13' class='gform_page' data-js='page-field-id-154' style='display:none;'>\n                    <div class='gform_page_fields'>\n                        <div id='gform_fields_3_13' class='gform_fields top_label form_sublabel_below description_below validation_below'><div id=\"field_3_155\" class=\"gfield gfield--type-section gfield--input-type-section gsection field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><h3 class=\"gsection_title\">Current &amp; Historical Diagnoses<\/h3><\/div><div id=\"field_3_157\" class=\"gfield gfield--type-form gfield--input-type-form gform-theme__no-reset--children gfield--width-full field_sublabel_below gfield--no-description field_description_below hidden_label field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_3_157'><span class='gform-field-label__text'>Please Enter<\/span><\/label><div class=\"gpnf-nested-entries-container ginput_container\">\n\n\t<table class=\"gpnf-nested-entries\">\n\n\t\t<thead>\n\t\t<tr>\n\t\t\t\t\t\t\t<th scope=\"col\" class=\"gpnf-field-4\">\n\t\t\t\t\tYouth\u2019s Mental Health and Neuro-Developmental Diagnoses\t\t\t\t<\/th>\n\t\t\t\t\t\t\t<th scope=\"col\" class=\"gpnf-field-6\">\n\t\t\t\t\tDiagnosing Professional\t\t\t\t<\/th>\n\t\t\t\t\t\t\t<th scope=\"col\" class=\"gpnf-field-7\">\n\t\t\t\t\tDate\t\t\t\t<\/th>\n\t\t\t\t\t\t<th scope=\"col\" class=\"gpnf-row-actions\"><span class=\"screen-reader-text\">Actions<\/span><\/th>\n\t\t<\/tr>\n\t\t<\/thead>\n\n\t\t<tbody data-bind=\"visible: entries().length, foreach: entries\">\n\t\t<tr data-bind=\"attr: { 'data-entryid': id }\">\n\t\t\t\t\t\t\t<td class=\"gpnf-field\"\n\t\t\t\t\tdata-bind=\"html: f4.label, attr: { 'data-value': f4.label }\"\n\t\t\t\t\tdata-heading=\"Youth\u2019s Mental Health and Neuro-Developmental Diagnoses\"\n\t\t\t\t>&nbsp;<\/td>\n\t\t\t\t\t\t\t<td class=\"gpnf-field\"\n\t\t\t\t\tdata-bind=\"html: f6.label, attr: { 'data-value': f6.label }\"\n\t\t\t\t\tdata-heading=\"Diagnosing Professional\"\n\t\t\t\t>&nbsp;<\/td>\n\t\t\t\t\t\t\t<td class=\"gpnf-field\"\n\t\t\t\t\tdata-bind=\"html: f7.label, attr: { 'data-value': f7.label }\"\n\t\t\t\t\tdata-heading=\"Date\"\n\t\t\t\t>&nbsp;<\/td>\n\t\t\t\t\t\t<td class=\"gpnf-row-actions\" style=\"display: none;\" data-bind=\"visible: true\">\n\t\t\t\t<ul>\n\t\t\t\t\t<li class=\"edit\"><button type=\"button\" class=\"edit-button gform-theme-button--secondary\" data-bind=\"click: $parent.editEntry, attr: { 'aria-label': 'Edit Diagnosis {0} where Youth\u2019s Mental Health and Neuro-Developmental Diagnoses is {1}.'.gformFormat( $index() + 1, f4.label ) }\">Modifier<\/button><\/li>\n\t\t\t\t\t\t\t\t\t\t<li class=\"delete\"><button type=\"button\" class=\"delete-button gform-theme-button--simple gform-theme-button--size-md\" data-bind=\"click: $parent.deleteEntry, attr: { 'aria-label': 'Delete Diagnosis {0} where Youth\u2019s Mental Health and Neuro-Developmental Diagnoses is {1}.'.gformFormat( $index() + 1, f4.label ) }\">Supprimer<\/button><\/li>\n\t\t\t\t<\/ul>\n\t\t\t<\/td>\n\t\t<\/tr>\n\t\t<\/tbody>\n\n\t\t<tbody data-bind=\"visible: entries().length <= 0\">\n\t\t<tr class=\"gpnf-no-entries\" data-bind=\"visible: entries().length <= 0\" style=\"display: none;\">\n\t\t\t<td colspan=\"4\">\n\t\t\t\tIl n\u2019y a aucun(e) <span>Diagnoses.<\/span>\t\t\t<\/td>\n\t\t<\/tr>\n\t\t<\/tbody>\n\n\t<\/table>\n\n\t<button type=\"button\" class=\"gpnf-add-entry\"\n\t\t        data-formid=\"3\"\n\t\t        data-nestedformid=\"9\"\n\t\t\t\tdata-bind=\"attr: { disabled: isMaxed }, css: { 'gf-default-disabled': isMaxed }\"\n\t\t\t\t>\n\t\t\t\tAjouter Diagnosis\n\t\t\t<\/button>\t\n\t\t\t<p class=\"gpnf-add-entry-max\" data-bind=\"visible: isMaxed\" style=\"display: none;\">\n\t\t\t\tLe nombre maximal a \u00e9t\u00e9 atteint.\n\t\t\t<\/p>\n<\/div>\n<input type=\"hidden\"\n                name=\"input_157\"\n                id=\"input_3_157\"\n                data-bind=\"value: entryIds\"\n                value=\"\" \/><\/div><div id=\"field_3_156\" class=\"gfield gfield--type-textarea gfield--input-type-textarea gfield--width-full field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_3_156'><span class='gform-field-label__text'>Please add any additional explanation or comments regarding the information provided above for the youth&#039;s diagnoses, if applicable:<\/span><\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_156' id='input_3_156' class='textarea medium'      aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/div><\/div>\n                    <\/div>\n                    <div class='gform-page-footer gform_page_footer top_label'>\n                        <button type='button' id='gform_previous_button_3_158' class='gform_previous_button gform-theme-button gform-theme-button--secondary button' onclick='gform.submission.handleButtonClick(this);' data-submission-type='previous' >Previous<\/button> <button type='button' id='gform_next_button_3_158' class='gform_next_button gform-theme-button button' onclick='gform.submission.handleButtonClick(this);' data-submission-type='next' >Next<\/button> <button type='button'  id='gform_save_3_14_link' onclick='gform.submission.handleButtonClick(this);' data-submission-type='save-continue' class='gform_save_link gform-theme-button gform-theme-button--secondary button'  ><svg aria-hidden=\"true\" focusable=\"false\" width=\"16\" height=\"16\" fill=\"none\" xmlns=\"http:\/\/www.w3.org\/2000\/svg\"><path fill-rule=\"evenodd\" clip-rule=\"evenodd\" d=\"M0 8a4 4 0 004 4h3v3a1 1 0 102 0v-3h3a4 4 0 100-8 4 4 0 10-8 0 4 4 0 00-4 4zm9 4H7V7.414L5.707 8.707a1 1 0 01-1.414-1.414l3-3a1 1 0 011.414 0l3 3a1 1 0 01-1.414 1.414L9 7.414V12z\" fill=\"#6B7280\"\/><\/svg> Save and Continue Later<\/button>\n                    <\/div>\n                <\/div>\n                <div id='gform_page_3_14' class='gform_page' data-js='page-field-id-158' style='display:none;'>\n                    <div class='gform_page_fields'>\n                        <div id='gform_fields_3_14' class='gform_fields top_label form_sublabel_below description_below validation_below'><div id=\"field_3_159\" class=\"gfield gfield--type-section gfield--input-type-section gsection field_sublabel_below gfield--has-description field_description_below field_validation_below gfield_visibility_visible\"  ><h3 class=\"gsection_title\">Current Primary Presenting Problem Areas<\/h3><div class='gsection_description' id='gfield_description_3_159'>Please check category that apply; choosing as many that apply<\/div><\/div><fieldset id=\"field_3_160\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield--input-type-checkbox gfield--width-third field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible gfield--choice-align-vertical\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' ><span class='gform-field-label__text'>School &amp; Learning<\/span><\/legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox ' id='input_3_160'><div class='gchoice gchoice_3_160_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_160.1' type='checkbox'  value='Truancy'  id='choice_3_160_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_3_160_1' id='label_3_160_1' class='gform-field-label gform-field-label--type-inline'>Truancy<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_3_160_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_160.2' type='checkbox'  value='School Phobia'  id='choice_3_160_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_3_160_2' id='label_3_160_2' class='gform-field-label gform-field-label--type-inline'>School Phobia<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_3_160_3'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_160.3' type='checkbox'  value='Under Achievement'  id='choice_3_160_3'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_3_160_3' id='label_3_160_3' class='gform-field-label gform-field-label--type-inline'>Under Achievement<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_3_160_4'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_160.4' type='checkbox'  value='Learning Problems'  id='choice_3_160_4'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_3_160_4' id='label_3_160_4' class='gform-field-label gform-field-label--type-inline'>Learning Problems<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_3_160_5'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_160.5' type='checkbox'  value='Learning Disability'  id='choice_3_160_5'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_3_160_5' id='label_3_160_5' class='gform-field-label gform-field-label--type-inline'>Learning Disability<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_3_160_6'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_160.6' type='checkbox'  value='Not in School'  id='choice_3_160_6'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_3_160_6' id='label_3_160_6' class='gform-field-label gform-field-label--type-inline'>Not in School<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_3_160_7'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_160.7' type='checkbox'  value='Other'  id='choice_3_160_7'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_3_160_7' id='label_3_160_7' class='gform-field-label gform-field-label--type-inline'>Other<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_3_162\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-third field_sublabel_below gfield--has-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_3_162'><span class='gform-field-label__text'>Other<\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_162' id='input_3_162' type='text' value='' class='large'  aria-describedby=\"gfield_description_3_162\"    aria-invalid=\"false\"   \/><\/div><div class='gfield_description' id='gfield_description_3_162'>Please Specify<\/div><\/div><fieldset id=\"field_3_161\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield--input-type-checkbox gfield--width-third field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible gfield--choice-align-vertical\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' ><span class='gform-field-label__text'>Victimization<\/span><\/legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox ' id='input_3_161'><div class='gchoice gchoice_3_161_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_161.1' type='checkbox'  value='Sexual Abuse (Suspected)'  id='choice_3_161_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_3_161_1' id='label_3_161_1' class='gform-field-label gform-field-label--type-inline'>Sexual Abuse (Suspected)<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_3_161_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_161.2' type='checkbox'  value='Physical Abuse (Suspected)'  id='choice_3_161_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_3_161_2' id='label_3_161_2' class='gform-field-label gform-field-label--type-inline'>Physical Abuse (Suspected)<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_3_161_3'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_161.3' type='checkbox'  value='Emotional Abuse \/ Bullying'  id='choice_3_161_3'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_3_161_3' id='label_3_161_3' class='gform-field-label gform-field-label--type-inline'>Emotional Abuse \/ Bullying<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_3_161_4'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_161.4' type='checkbox'  value='Neglect'  id='choice_3_161_4'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_3_161_4' id='label_3_161_4' class='gform-field-label gform-field-label--type-inline'>Neglect<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_3_161_5'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_161.5' type='checkbox'  value='Sexual Abuse (Verified)'  id='choice_3_161_5'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_3_161_5' id='label_3_161_5' class='gform-field-label gform-field-label--type-inline'>Sexual Abuse (Verified)<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_3_161_6'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_161.6' type='checkbox'  value='Physical Abuse(Verified)'  id='choice_3_161_6'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_3_161_6' id='label_3_161_6' class='gform-field-label gform-field-label--type-inline'>Physical Abuse(Verified)<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_3_163\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-half field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_3_163'><span class='gform-field-label__text'>Age (Sexual Abuse)<\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_163' id='input_3_163' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_3_164\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-half field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_3_164'><span class='gform-field-label__text'>By whom (Sexual Abuse)<\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_164' id='input_3_164' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_3_165\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-half field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_3_165'><span class='gform-field-label__text'>Age (Physical Abuse)<\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_165' id='input_3_165' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_3_166\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-half field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_3_166'><span class='gform-field-label__text'>By whom (Physical Abuse)<\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_166' id='input_3_166' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/div><fieldset id=\"field_3_167\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield--input-type-checkbox gfield--width-half field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible gfield--choice-align-vertical\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' ><span class='gform-field-label__text'>Disruptive Behaviour<\/span><\/legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox ' id='input_3_167'><div class='gchoice gchoice_3_167_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_167.1' type='checkbox'  value='Aggression (Verbal)'  id='choice_3_167_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_3_167_1' id='label_3_167_1' class='gform-field-label gform-field-label--type-inline'>Aggression (Verbal)<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_3_167_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_167.2' type='checkbox'  value='Aggression (Physical)'  id='choice_3_167_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_3_167_2' id='label_3_167_2' class='gform-field-label gform-field-label--type-inline'>Aggression (Physical)<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_3_167_3'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_167.3' type='checkbox'  value='Running'  id='choice_3_167_3'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_3_167_3' id='label_3_167_3' class='gform-field-label gform-field-label--type-inline'>Running<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_3_167_4'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_167.4' type='checkbox'  value='Fire Setting'  id='choice_3_167_4'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_3_167_4' id='label_3_167_4' class='gform-field-label gform-field-label--type-inline'>Fire Setting<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_3_167_5'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_167.5' type='checkbox'  value='Stealing'  id='choice_3_167_5'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_3_167_5' id='label_3_167_5' class='gform-field-label gform-field-label--type-inline'>Stealing<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_3_167_6'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_167.6' type='checkbox'  value='Destruction of Property'  id='choice_3_167_6'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_3_167_6' id='label_3_167_6' class='gform-field-label gform-field-label--type-inline'>Destruction of Property<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_3_167_7'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_167.7' type='checkbox'  value='Sexual Acting Out'  id='choice_3_167_7'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_3_167_7' id='label_3_167_7' class='gform-field-label gform-field-label--type-inline'>Sexual Acting Out<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_3_167_8'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_167.8' type='checkbox'  value='Substance Abuse'  id='choice_3_167_8'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_3_167_8' id='label_3_167_8' class='gform-field-label gform-field-label--type-inline'>Substance Abuse<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_3_167_9'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_167.9' type='checkbox'  value='Defiance'  id='choice_3_167_9'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_3_167_9' id='label_3_167_9' class='gform-field-label gform-field-label--type-inline'>Defiance<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_3_167_11'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_167.11' type='checkbox'  value='Self Control'  id='choice_3_167_11'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_3_167_11' id='label_3_167_11' class='gform-field-label gform-field-label--type-inline'>Self Control<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_3_167_12'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_167.12' type='checkbox'  value='Bullying'  id='choice_3_167_12'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_3_167_12' id='label_3_167_12' class='gform-field-label gform-field-label--type-inline'>Bullying<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_3_168\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield--input-type-checkbox gfield--width-half field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible gfield--choice-align-vertical\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' ><span class='gform-field-label__text'>Thought, Perception and Mood Disturbances<\/span><\/legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox ' id='input_3_168'><div class='gchoice gchoice_3_168_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_168.1' type='checkbox'  value='Disturbances in Thought Process'  id='choice_3_168_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_3_168_1' id='label_3_168_1' class='gform-field-label gform-field-label--type-inline'>Disturbances in Thought Process<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_3_168_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_168.2' type='checkbox'  value='Anxiety or Depression'  id='choice_3_168_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_3_168_2' id='label_3_168_2' class='gform-field-label gform-field-label--type-inline'>Anxiety or Depression<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_3_168_3'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_168.3' type='checkbox'  value='Continued Excited Mood'  id='choice_3_168_3'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_3_168_3' id='label_3_168_3' class='gform-field-label gform-field-label--type-inline'>Continued Excited Mood<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_3_168_4'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_168.4' type='checkbox'  value='Self Harm'  id='choice_3_168_4'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_3_168_4' id='label_3_168_4' class='gform-field-label gform-field-label--type-inline'>Self Harm<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_3_168_5'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_168.5' type='checkbox'  value='Severe Mood Swings or Reactivity'  id='choice_3_168_5'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_3_168_5' id='label_3_168_5' class='gform-field-label gform-field-label--type-inline'>Severe Mood Swings or Reactivity<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_3_168_6'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_168.6' type='checkbox'  value='Suicidal Ideation'  id='choice_3_168_6'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_3_168_6' id='label_3_168_6' class='gform-field-label gform-field-label--type-inline'>Suicidal Ideation<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_3_168_7'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_168.7' type='checkbox'  value='Suicidal Gestures or Attempts'  id='choice_3_168_7'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_3_168_7' id='label_3_168_7' class='gform-field-label gform-field-label--type-inline'>Suicidal Gestures or Attempts<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_3_169\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-full field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_3_169'><span class='gform-field-label__text'>Primary Presenting Problem Areas Additional Comments:<\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_169' id='input_3_169' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/div><fieldset id=\"field_3_170\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield--input-type-checkbox gfield--width-third field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible gfield--choice-align-vertical\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' ><span class='gform-field-label__text'>Family Issues \/ Concerns \/ Dynamics<\/span><\/legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox ' id='input_3_170'><div class='gchoice gchoice_3_170_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_170.1' type='checkbox'  value='Lack of Family Support to Provide Care'  id='choice_3_170_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_3_170_1' id='label_3_170_1' class='gform-field-label gform-field-label--type-inline'>Lack of Family Support to Provide Care<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_3_170_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_170.2' type='checkbox'  value='Family Conflict or Distress'  id='choice_3_170_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_3_170_2' id='label_3_170_2' class='gform-field-label gform-field-label--type-inline'>Family Conflict or Distress<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_3_170_3'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_170.3' type='checkbox'  value='Parent-Child Conflict'  id='choice_3_170_3'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_3_170_3' id='label_3_170_3' class='gform-field-label gform-field-label--type-inline'>Parent-Child Conflict<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_3_170_4'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_170.4' type='checkbox'  value='Substance Abuse'  id='choice_3_170_4'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_3_170_4' id='label_3_170_4' class='gform-field-label gform-field-label--type-inline'>Substance Abuse<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_3_170_5'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_170.5' type='checkbox'  value='Physical or Mental Health Issues'  id='choice_3_170_5'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_3_170_5' id='label_3_170_5' class='gform-field-label gform-field-label--type-inline'>Physical or Mental Health Issues<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_3_170_6'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_170.6' type='checkbox'  value='Other'  id='choice_3_170_6'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_3_170_6' id='label_3_170_6' class='gform-field-label gform-field-label--type-inline'>Other<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_3_171\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-third field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_3_171'><span class='gform-field-label__text'>Other<\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_171' id='input_3_171' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/div><fieldset id=\"field_3_172\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield--input-type-checkbox gfield--width-third field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible gfield--choice-align-vertical\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' ><span class='gform-field-label__text'>Physical \/ Sensory Status<\/span><\/legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox ' id='input_3_172'><div class='gchoice gchoice_3_172_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_172.1' type='checkbox'  value='Neurological or Severe Brain Damage'  id='choice_3_172_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_3_172_1' id='label_3_172_1' class='gform-field-label gform-field-label--type-inline'>Neurological or Severe Brain Damage<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_3_172_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_172.2' type='checkbox'  value='Enuresis'  id='choice_3_172_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_3_172_2' id='label_3_172_2' class='gform-field-label gform-field-label--type-inline'>Enuresis<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_3_172_3'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_172.3' type='checkbox'  value='Encopresis'  id='choice_3_172_3'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_3_172_3' id='label_3_172_3' class='gform-field-label gform-field-label--type-inline'>Encopresis<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_3_172_4'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_172.4' type='checkbox'  value='Sensory Deficits or Disorders'  id='choice_3_172_4'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_3_172_4' id='label_3_172_4' class='gform-field-label gform-field-label--type-inline'>Sensory Deficits or Disorders<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_3_172_5'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_172.5' type='checkbox'  value='Sleep Disturbances'  id='choice_3_172_5'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_3_172_5' id='label_3_172_5' class='gform-field-label gform-field-label--type-inline'>Sleep Disturbances<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_3_172_6'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_172.6' type='checkbox'  value='Psycho-Physiological'  id='choice_3_172_6'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_3_172_6' id='label_3_172_6' class='gform-field-label gform-field-label--type-inline'>Psycho-Physiological<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_3_172_7'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_172.7' type='checkbox'  value='Physical Disability'  id='choice_3_172_7'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_3_172_7' id='label_3_172_7' class='gform-field-label gform-field-label--type-inline'>Physical Disability<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_3_173\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield--input-type-checkbox gfield--width-half field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible gfield--choice-align-vertical\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' ><span class='gform-field-label__text'>Intellectual \/ Adaptive \/ Functional<\/span><\/legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox ' id='input_3_173'><div class='gchoice gchoice_3_173_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_173.1' type='checkbox'  value='Deficits in Intellectual Function'  id='choice_3_173_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_3_173_1' id='label_3_173_1' class='gform-field-label gform-field-label--type-inline'>Deficits in Intellectual Function<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_3_173_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_173.2' type='checkbox'  value='Deficits in Life Skills'  id='choice_3_173_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_3_173_2' id='label_3_173_2' class='gform-field-label gform-field-label--type-inline'>Deficits in Life Skills<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_3_173_3'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_173.3' type='checkbox'  value='Development Delays'  id='choice_3_173_3'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_3_173_3' id='label_3_173_3' class='gform-field-label gform-field-label--type-inline'>Development Delays<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_3_174\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield--input-type-checkbox gfield--width-half field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible gfield--choice-align-vertical\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' ><span class='gform-field-label__text'>Social Withdraw<\/span><\/legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox ' id='input_3_174'><div class='gchoice gchoice_3_174_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_174.1' type='checkbox'  value='Lack of Peer Friendship'  id='choice_3_174_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_3_174_1' id='label_3_174_1' class='gform-field-label gform-field-label--type-inline'>Lack of Peer Friendship<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_3_174_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_174.2' type='checkbox'  value='Lack of Adult Relationships'  id='choice_3_174_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_3_174_2' id='label_3_174_2' class='gform-field-label gform-field-label--type-inline'>Lack of Adult Relationships<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_3_174_3'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_174.3' type='checkbox'  value='Social Isolation'  id='choice_3_174_3'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_3_174_3' id='label_3_174_3' class='gform-field-label gform-field-label--type-inline'>Social Isolation<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><\/div>\n                    <\/div>\n                    <div class='gform-page-footer gform_page_footer top_label'>\n                        <button type='button' id='gform_previous_button_3_176' class='gform_previous_button gform-theme-button gform-theme-button--secondary button' onclick='gform.submission.handleButtonClick(this);' data-submission-type='previous' >Previous<\/button> <button type='button' id='gform_next_button_3_176' class='gform_next_button gform-theme-button button' onclick='gform.submission.handleButtonClick(this);' data-submission-type='next' >Next<\/button> <button type='button'  id='gform_save_3_15_link' onclick='gform.submission.handleButtonClick(this);' data-submission-type='save-continue' class='gform_save_link gform-theme-button gform-theme-button--secondary button'  ><svg aria-hidden=\"true\" focusable=\"false\" width=\"16\" height=\"16\" fill=\"none\" xmlns=\"http:\/\/www.w3.org\/2000\/svg\"><path fill-rule=\"evenodd\" clip-rule=\"evenodd\" d=\"M0 8a4 4 0 004 4h3v3a1 1 0 102 0v-3h3a4 4 0 100-8 4 4 0 10-8 0 4 4 0 00-4 4zm9 4H7V7.414L5.707 8.707a1 1 0 01-1.414-1.414l3-3a1 1 0 011.414 0l3 3a1 1 0 01-1.414 1.414L9 7.414V12z\" fill=\"#6B7280\"\/><\/svg> Save and Continue Later<\/button>\n                    <\/div>\n                <\/div>\n                <div id='gform_page_3_15' class='gform_page' data-js='page-field-id-176' style='display:none;'>\n                    <div class='gform_page_fields'>\n                        <div id='gform_fields_3_15' class='gform_fields top_label form_sublabel_below description_below validation_below'><div id=\"field_3_175\" class=\"gfield gfield--type-section gfield--input-type-section gsection field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><h3 class=\"gsection_title\">Service Involvement<\/h3><\/div><div id=\"field_3_177\" class=\"gfield gfield--type-html gfield--input-type-html gfield--width-three-quarter gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><strong>Please indicate:<\/strong><br\/>\na) if the youth or any family members are currently or have received services from the RSC and<br\/>\nb) if so, when and through which RSC program\/service.<\/div><fieldset id=\"field_3_178\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield--input-type-checkbox gfield--width-quarter field_sublabel_below gfield--no-description field_description_below hidden_label field_validation_below gfield_visibility_visible gfield--choice-align-vertical\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' ><span class='gform-field-label__text'>N\/A<\/span><\/legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox ' id='input_3_178'><div class='gchoice gchoice_3_178_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_178.1' type='checkbox'  value='N\/A'  id='choice_3_178_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_3_178_1' id='label_3_178_1' class='gform-field-label gform-field-label--type-inline'>N\/A<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_3_179\" class=\"gfield gfield--type-textarea gfield--input-type-textarea gfield--width-full field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_3_179'><span class='gform-field-label__text'>Please Describe<\/span><\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_179' id='input_3_179' class='textarea large'      aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/div><\/div>\n                    <\/div>\n                    <div class='gform-page-footer gform_page_footer top_label'>\n                        <button type='button' id='gform_previous_button_3_180' class='gform_previous_button gform-theme-button gform-theme-button--secondary button' onclick='gform.submission.handleButtonClick(this);' data-submission-type='previous' >Previous<\/button> <button type='button' id='gform_next_button_3_180' class='gform_next_button gform-theme-button button' onclick='gform.submission.handleButtonClick(this);' data-submission-type='next' >Next<\/button> <button type='button'  id='gform_save_3_16_link' onclick='gform.submission.handleButtonClick(this);' data-submission-type='save-continue' class='gform_save_link gform-theme-button gform-theme-button--secondary button'  ><svg aria-hidden=\"true\" focusable=\"false\" width=\"16\" height=\"16\" fill=\"none\" xmlns=\"http:\/\/www.w3.org\/2000\/svg\"><path fill-rule=\"evenodd\" clip-rule=\"evenodd\" d=\"M0 8a4 4 0 004 4h3v3a1 1 0 102 0v-3h3a4 4 0 100-8 4 4 0 10-8 0 4 4 0 00-4 4zm9 4H7V7.414L5.707 8.707a1 1 0 01-1.414-1.414l3-3a1 1 0 011.414 0l3 3a1 1 0 01-1.414 1.414L9 7.414V12z\" fill=\"#6B7280\"\/><\/svg> Save and Continue Later<\/button>\n                    <\/div>\n                <\/div>\n                <div id='gform_page_3_16' class='gform_page' data-js='page-field-id-180' style='display:none;'>\n                    <div class='gform_page_fields'>\n                        <div id='gform_fields_3_16' class='gform_fields top_label form_sublabel_below description_below validation_below'><div id=\"field_3_181\" class=\"gfield gfield--type-section gfield--input-type-section gsection field_sublabel_below gfield--has-description field_description_below field_validation_below gfield_visibility_visible\"  ><h3 class=\"gsection_title\">Placement History (Current and Historical)<\/h3><div class='gsection_description' id='gfield_description_3_181'>Please list current and historical service involvement, other than placements<\/div><\/div><div id=\"field_3_182\" class=\"gfield gfield--type-form gfield--input-type-form gform-theme__no-reset--children gfield--width-full field_sublabel_below gfield--no-description field_description_below hidden_label field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_3_182'><span class='gform-field-label__text'>Untitled<\/span><\/label><div class=\"gpnf-nested-entries-container ginput_container\">\n\n\t<table class=\"gpnf-nested-entries\">\n\n\t\t<thead>\n\t\t<tr>\n\t\t\t\t\t\t\t<th scope=\"col\" class=\"gpnf-field-4\">\n\t\t\t\t\tOrganization \/ Caregiver\t\t\t\t<\/th>\n\t\t\t\t\t\t\t<th scope=\"col\" class=\"gpnf-field-6\">\n\t\t\t\t\tPlacement Type\t\t\t\t<\/th>\n\t\t\t\t\t\t\t<th scope=\"col\" class=\"gpnf-field-7\">\n\t\t\t\t\tStart Date\t\t\t\t<\/th>\n\t\t\t\t\t\t\t<th scope=\"col\" class=\"gpnf-field-8\">\n\t\t\t\t\tEnd Date\t\t\t\t<\/th>\n\t\t\t\t\t\t<th scope=\"col\" class=\"gpnf-row-actions\"><span class=\"screen-reader-text\">Actions<\/span><\/th>\n\t\t<\/tr>\n\t\t<\/thead>\n\n\t\t<tbody data-bind=\"visible: entries().length, foreach: entries\">\n\t\t<tr data-bind=\"attr: { 'data-entryid': id }\">\n\t\t\t\t\t\t\t<td class=\"gpnf-field\"\n\t\t\t\t\tdata-bind=\"html: f4.label, attr: { 'data-value': f4.label }\"\n\t\t\t\t\tdata-heading=\"Organization \/ Caregiver\"\n\t\t\t\t>&nbsp;<\/td>\n\t\t\t\t\t\t\t<td class=\"gpnf-field\"\n\t\t\t\t\tdata-bind=\"html: f6.label, attr: { 'data-value': f6.label }\"\n\t\t\t\t\tdata-heading=\"Placement Type\"\n\t\t\t\t>&nbsp;<\/td>\n\t\t\t\t\t\t\t<td class=\"gpnf-field\"\n\t\t\t\t\tdata-bind=\"html: f7.label, attr: { 'data-value': f7.label }\"\n\t\t\t\t\tdata-heading=\"Start Date\"\n\t\t\t\t>&nbsp;<\/td>\n\t\t\t\t\t\t\t<td class=\"gpnf-field\"\n\t\t\t\t\tdata-bind=\"html: f8.label, attr: { 'data-value': f8.label }\"\n\t\t\t\t\tdata-heading=\"End Date\"\n\t\t\t\t>&nbsp;<\/td>\n\t\t\t\t\t\t<td class=\"gpnf-row-actions\" style=\"display: none;\" data-bind=\"visible: true\">\n\t\t\t\t<ul>\n\t\t\t\t\t<li class=\"edit\"><button type=\"button\" class=\"edit-button gform-theme-button--secondary\" data-bind=\"click: $parent.editEntry, attr: { 'aria-label': 'Edit Entry {0} where Organization \/ Caregiver is {1}.'.gformFormat( $index() + 1, f4.label ) }\">Modifier<\/button><\/li>\n\t\t\t\t\t\t\t\t\t\t<li class=\"delete\"><button type=\"button\" class=\"delete-button gform-theme-button--simple gform-theme-button--size-md\" data-bind=\"click: $parent.deleteEntry, attr: { 'aria-label': 'Delete Entry {0} where Organization \/ Caregiver is {1}.'.gformFormat( $index() + 1, f4.label ) }\">Supprimer<\/button><\/li>\n\t\t\t\t<\/ul>\n\t\t\t<\/td>\n\t\t<\/tr>\n\t\t<\/tbody>\n\n\t\t<tbody data-bind=\"visible: entries().length <= 0\">\n\t\t<tr class=\"gpnf-no-entries\" data-bind=\"visible: entries().length <= 0\" style=\"display: none;\">\n\t\t\t<td colspan=\"5\">\n\t\t\t\tIl n\u2019y a aucun(e) <span>Entries.<\/span>\t\t\t<\/td>\n\t\t<\/tr>\n\t\t<\/tbody>\n\n\t<\/table>\n\n\t<button type=\"button\" class=\"gpnf-add-entry\"\n\t\t        data-formid=\"3\"\n\t\t        data-nestedformid=\"10\"\n\t\t\t\tdata-bind=\"attr: { disabled: isMaxed }, css: { 'gf-default-disabled': isMaxed }\"\n\t\t\t\t>\n\t\t\t\tAjouter Entry\n\t\t\t<\/button>\t\n\t\t\t<p class=\"gpnf-add-entry-max\" data-bind=\"visible: isMaxed\" style=\"display: none;\">\n\t\t\t\tLe nombre maximal a \u00e9t\u00e9 atteint.\n\t\t\t<\/p>\n<\/div>\n<input type=\"hidden\"\n                name=\"input_182\"\n                id=\"input_3_182\"\n                data-bind=\"value: entryIds\"\n                value=\"\" \/><\/div><div id=\"field_3_185\" class=\"gfield gfield--type-section gfield--input-type-section gsection field_sublabel_below gfield--has-description field_description_below field_validation_below gfield_visibility_visible\"  ><h3 class=\"gsection_title\">Youth Criminal Justice Act Involvement (Current &amp; Historical)<\/h3><div class='gsection_description' id='gfield_description_3_185'>Please include any current or outstanding matters, such as bail conditions, probation orders, pending charges, upcoming court dates, etc.<\/div><\/div><fieldset id=\"field_3_187\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield--input-type-checkbox gfield--width-full field_sublabel_below gfield--no-description field_description_below hidden_label field_validation_below gfield_visibility_visible gfield--choice-align-vertical\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' ><span class='gform-field-label__text'>N\/A<\/span><\/legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox ' id='input_3_187'><div class='gchoice gchoice_3_187_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_187.1' type='checkbox'  value='N\/A'  id='choice_3_187_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_3_187_1' id='label_3_187_1' class='gform-field-label gform-field-label--type-inline'>N\/A<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_3_186\" class=\"gfield gfield--type-textarea gfield--input-type-textarea gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_3_186'><span class='gform-field-label__text'>Please Describe<\/span><span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(N\u00e9cessaire)<\/span><\/span><\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_186' id='input_3_186' class='textarea large'     aria-required=\"true\" aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/div><\/div>\n                    <\/div>\n                    <div class='gform-page-footer gform_page_footer top_label'>\n                        <button type='button' id='gform_previous_button_3_232' class='gform_previous_button gform-theme-button gform-theme-button--secondary button' onclick='gform.submission.handleButtonClick(this);' data-submission-type='previous' >Previous<\/button> <button type='button' id='gform_next_button_3_232' class='gform_next_button gform-theme-button button' onclick='gform.submission.handleButtonClick(this);' data-submission-type='next' >Next<\/button> <button type='button'  id='gform_save_3_17_link' onclick='gform.submission.handleButtonClick(this);' data-submission-type='save-continue' class='gform_save_link gform-theme-button gform-theme-button--secondary button'  ><svg aria-hidden=\"true\" focusable=\"false\" width=\"16\" height=\"16\" fill=\"none\" xmlns=\"http:\/\/www.w3.org\/2000\/svg\"><path fill-rule=\"evenodd\" clip-rule=\"evenodd\" d=\"M0 8a4 4 0 004 4h3v3a1 1 0 102 0v-3h3a4 4 0 100-8 4 4 0 10-8 0 4 4 0 00-4 4zm9 4H7V7.414L5.707 8.707a1 1 0 01-1.414-1.414l3-3a1 1 0 011.414 0l3 3a1 1 0 01-1.414 1.414L9 7.414V12z\" fill=\"#6B7280\"\/><\/svg> Save and Continue Later<\/button>\n                    <\/div>\n                <\/div>\n                <div id='gform_page_3_17' class='gform_page' data-js='page-field-id-232' style='display:none;'>\n                    <div class='gform_page_fields'>\n                        <div id='gform_fields_3_17' class='gform_fields top_label form_sublabel_below description_below validation_below'><div id=\"field_3_183\" class=\"gfield gfield--type-section gfield--input-type-section gsection field_sublabel_below gfield--has-description field_description_below field_validation_below gfield_visibility_visible\"  ><h3 class=\"gsection_title\">Service History<\/h3><div class='gsection_description' id='gfield_description_3_183'>Please list current and historical service involvement, other than placements<\/div><\/div><div id=\"field_3_184\" class=\"gfield gfield--type-form gfield--input-type-form gform-theme__no-reset--children gfield--width-full field_sublabel_below gfield--no-description field_description_below hidden_label field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_3_184'><span class='gform-field-label__text'>Untitled<\/span><\/label><div class=\"gpnf-nested-entries-container ginput_container\">\n\n\t<table class=\"gpnf-nested-entries\">\n\n\t\t<thead>\n\t\t<tr>\n\t\t\t\t\t\t\t<th scope=\"col\" class=\"gpnf-field-4\">\n\t\t\t\t\tOrganization \/ Service Provider Name\t\t\t\t<\/th>\n\t\t\t\t\t\t\t<th scope=\"col\" class=\"gpnf-field-6\">\n\t\t\t\t\tService Sector\t\t\t\t<\/th>\n\t\t\t\t\t\t\t<th scope=\"col\" class=\"gpnf-field-7\">\n\t\t\t\t\tStart Date\t\t\t\t<\/th>\n\t\t\t\t\t\t\t<th scope=\"col\" class=\"gpnf-field-8\">\n\t\t\t\t\tEnd Date\t\t\t\t<\/th>\n\t\t\t\t\t\t<th scope=\"col\" class=\"gpnf-row-actions\"><span class=\"screen-reader-text\">Actions<\/span><\/th>\n\t\t<\/tr>\n\t\t<\/thead>\n\n\t\t<tbody data-bind=\"visible: entries().length, foreach: entries\">\n\t\t<tr data-bind=\"attr: { 'data-entryid': id }\">\n\t\t\t\t\t\t\t<td class=\"gpnf-field\"\n\t\t\t\t\tdata-bind=\"html: f4.label, attr: { 'data-value': f4.label }\"\n\t\t\t\t\tdata-heading=\"Organization \/ Service Provider Name\"\n\t\t\t\t>&nbsp;<\/td>\n\t\t\t\t\t\t\t<td class=\"gpnf-field\"\n\t\t\t\t\tdata-bind=\"html: f6.label, attr: { 'data-value': f6.label }\"\n\t\t\t\t\tdata-heading=\"Service Sector\"\n\t\t\t\t>&nbsp;<\/td>\n\t\t\t\t\t\t\t<td class=\"gpnf-field\"\n\t\t\t\t\tdata-bind=\"html: f7.label, attr: { 'data-value': f7.label }\"\n\t\t\t\t\tdata-heading=\"Start Date\"\n\t\t\t\t>&nbsp;<\/td>\n\t\t\t\t\t\t\t<td class=\"gpnf-field\"\n\t\t\t\t\tdata-bind=\"html: f8.label, attr: { 'data-value': f8.label }\"\n\t\t\t\t\tdata-heading=\"End Date\"\n\t\t\t\t>&nbsp;<\/td>\n\t\t\t\t\t\t<td class=\"gpnf-row-actions\" style=\"display: none;\" data-bind=\"visible: true\">\n\t\t\t\t<ul>\n\t\t\t\t\t<li class=\"edit\"><button type=\"button\" class=\"edit-button gform-theme-button--secondary\" data-bind=\"click: $parent.editEntry, attr: { 'aria-label': 'Edit Entr\u00e9e {0} where Organization \/ Service Provider Name is {1}.'.gformFormat( $index() + 1, f4.label ) }\">Modifier<\/button><\/li>\n\t\t\t\t\t\t\t\t\t\t<li class=\"delete\"><button type=\"button\" class=\"delete-button gform-theme-button--simple gform-theme-button--size-md\" data-bind=\"click: $parent.deleteEntry, attr: { 'aria-label': 'Delete Entr\u00e9e {0} where Organization \/ Service Provider Name is {1}.'.gformFormat( $index() + 1, f4.label ) }\">Supprimer<\/button><\/li>\n\t\t\t\t<\/ul>\n\t\t\t<\/td>\n\t\t<\/tr>\n\t\t<\/tbody>\n\n\t\t<tbody data-bind=\"visible: entries().length <= 0\">\n\t\t<tr class=\"gpnf-no-entries\" data-bind=\"visible: entries().length <= 0\" style=\"display: none;\">\n\t\t\t<td colspan=\"5\">\n\t\t\t\tIl n\u2019y a aucun(e) <span>Entr\u00e9es.<\/span>\t\t\t<\/td>\n\t\t<\/tr>\n\t\t<\/tbody>\n\n\t<\/table>\n\n\t<button type=\"button\" class=\"gpnf-add-entry\"\n\t\t        data-formid=\"3\"\n\t\t        data-nestedformid=\"11\"\n\t\t\t\tdata-bind=\"attr: { disabled: isMaxed }, css: { 'gf-default-disabled': isMaxed }\"\n\t\t\t\t>\n\t\t\t\tAjouter Entr\u00e9e\n\t\t\t<\/button>\t\n\t\t\t<p class=\"gpnf-add-entry-max\" data-bind=\"visible: isMaxed\" style=\"display: none;\">\n\t\t\t\tLe nombre maximal a \u00e9t\u00e9 atteint.\n\t\t\t<\/p>\n<\/div>\n<input type=\"hidden\"\n                name=\"input_184\"\n                id=\"input_3_184\"\n                data-bind=\"value: entryIds\"\n                value=\"\" \/><\/div><\/div>\n                    <\/div>\n                    <div class='gform-page-footer gform_page_footer top_label'>\n                        <button type='button' id='gform_previous_button_3_188' class='gform_previous_button gform-theme-button gform-theme-button--secondary button' onclick='gform.submission.handleButtonClick(this);' data-submission-type='previous' >Previous<\/button> <button type='button' id='gform_next_button_3_188' class='gform_next_button gform-theme-button button' onclick='gform.submission.handleButtonClick(this);' data-submission-type='next' >Next<\/button> <button type='button'  id='gform_save_3_18_link' onclick='gform.submission.handleButtonClick(this);' data-submission-type='save-continue' class='gform_save_link gform-theme-button gform-theme-button--secondary button'  ><svg aria-hidden=\"true\" focusable=\"false\" width=\"16\" height=\"16\" fill=\"none\" xmlns=\"http:\/\/www.w3.org\/2000\/svg\"><path fill-rule=\"evenodd\" clip-rule=\"evenodd\" d=\"M0 8a4 4 0 004 4h3v3a1 1 0 102 0v-3h3a4 4 0 100-8 4 4 0 10-8 0 4 4 0 00-4 4zm9 4H7V7.414L5.707 8.707a1 1 0 01-1.414-1.414l3-3a1 1 0 011.414 0l3 3a1 1 0 01-1.414 1.414L9 7.414V12z\" fill=\"#6B7280\"\/><\/svg> Save and Continue Later<\/button>\n                    <\/div>\n                <\/div>\n                <div id='gform_page_3_18' class='gform_page' data-js='page-field-id-188' style='display:none;'>\n                    <div class='gform_page_fields'>\n                        <div id='gform_fields_3_18' class='gform_fields top_label form_sublabel_below description_below validation_below'><div id=\"field_3_189\" class=\"gfield gfield--type-section gfield--input-type-section gsection field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><h3 class=\"gsection_title\">Education (Current &amp; Historical)<\/h3><\/div><div id=\"field_3_190\" class=\"gfield gfield--type-form gfield--input-type-form gform-theme__no-reset--children gfield--width-full field_sublabel_below gfield--no-description field_description_below hidden_label field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_3_190'><span class='gform-field-label__text'>School, School Board, and Program<\/span><\/label><div class=\"gpnf-nested-entries-container ginput_container\">\n\n\t<table class=\"gpnf-nested-entries\">\n\n\t\t<thead>\n\t\t<tr>\n\t\t\t\t\t\t\t<th scope=\"col\" class=\"gpnf-field-4\">\n\t\t\t\t\tSchool, School Board, and Program\t\t\t\t<\/th>\n\t\t\t\t\t\t\t<th scope=\"col\" class=\"gpnf-field-6\">\n\t\t\t\t\tGrade Completed\t\t\t\t<\/th>\n\t\t\t\t\t\t\t<th scope=\"col\" class=\"gpnf-field-7\">\n\t\t\t\t\tStart Date\t\t\t\t<\/th>\n\t\t\t\t\t\t\t<th scope=\"col\" class=\"gpnf-field-8\">\n\t\t\t\t\tStart Date\t\t\t\t<\/th>\n\t\t\t\t\t\t<th scope=\"col\" class=\"gpnf-row-actions\"><span class=\"screen-reader-text\">Actions<\/span><\/th>\n\t\t<\/tr>\n\t\t<\/thead>\n\n\t\t<tbody data-bind=\"visible: entries().length, foreach: entries\">\n\t\t<tr data-bind=\"attr: { 'data-entryid': id }\">\n\t\t\t\t\t\t\t<td class=\"gpnf-field\"\n\t\t\t\t\tdata-bind=\"html: f4.label, attr: { 'data-value': f4.label }\"\n\t\t\t\t\tdata-heading=\"School, School Board, and Program\"\n\t\t\t\t>&nbsp;<\/td>\n\t\t\t\t\t\t\t<td class=\"gpnf-field\"\n\t\t\t\t\tdata-bind=\"html: f6.label, attr: { 'data-value': f6.label }\"\n\t\t\t\t\tdata-heading=\"Grade Completed\"\n\t\t\t\t>&nbsp;<\/td>\n\t\t\t\t\t\t\t<td class=\"gpnf-field\"\n\t\t\t\t\tdata-bind=\"html: f7.label, attr: { 'data-value': f7.label }\"\n\t\t\t\t\tdata-heading=\"Start Date\"\n\t\t\t\t>&nbsp;<\/td>\n\t\t\t\t\t\t\t<td class=\"gpnf-field\"\n\t\t\t\t\tdata-bind=\"html: f8.label, attr: { 'data-value': f8.label }\"\n\t\t\t\t\tdata-heading=\"Start Date\"\n\t\t\t\t>&nbsp;<\/td>\n\t\t\t\t\t\t<td class=\"gpnf-row-actions\" style=\"display: none;\" data-bind=\"visible: true\">\n\t\t\t\t<ul>\n\t\t\t\t\t<li class=\"edit\"><button type=\"button\" class=\"edit-button gform-theme-button--secondary\" data-bind=\"click: $parent.editEntry, attr: { 'aria-label': 'Edit Entry {0} where School, School Board, and Program is {1}.'.gformFormat( $index() + 1, f4.label ) }\">Modifier<\/button><\/li>\n\t\t\t\t\t\t\t\t\t\t<li class=\"delete\"><button type=\"button\" class=\"delete-button gform-theme-button--simple gform-theme-button--size-md\" data-bind=\"click: $parent.deleteEntry, attr: { 'aria-label': 'Delete Entry {0} where School, School Board, and Program is {1}.'.gformFormat( $index() + 1, f4.label ) }\">Supprimer<\/button><\/li>\n\t\t\t\t<\/ul>\n\t\t\t<\/td>\n\t\t<\/tr>\n\t\t<\/tbody>\n\n\t\t<tbody data-bind=\"visible: entries().length <= 0\">\n\t\t<tr class=\"gpnf-no-entries\" data-bind=\"visible: entries().length <= 0\" style=\"display: none;\">\n\t\t\t<td colspan=\"5\">\n\t\t\t\tIl n\u2019y a aucun(e) <span>Entries.<\/span>\t\t\t<\/td>\n\t\t<\/tr>\n\t\t<\/tbody>\n\n\t<\/table>\n\n\t<button type=\"button\" class=\"gpnf-add-entry\"\n\t\t        data-formid=\"3\"\n\t\t        data-nestedformid=\"12\"\n\t\t\t\tdata-bind=\"attr: { disabled: isMaxed }, css: { 'gf-default-disabled': isMaxed }\"\n\t\t\t\t>\n\t\t\t\tAjouter Entry\n\t\t\t<\/button>\t\n\t\t\t<p class=\"gpnf-add-entry-max\" data-bind=\"visible: isMaxed\" style=\"display: none;\">\n\t\t\t\tLe nombre maximal a \u00e9t\u00e9 atteint.\n\t\t\t<\/p>\n<\/div>\n<input type=\"hidden\"\n                name=\"input_190\"\n                id=\"input_3_190\"\n                data-bind=\"value: entryIds\"\n                value=\"\" \/><\/div><div id=\"field_3_191\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-full field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_3_191'><span class='gform-field-label__text'>Location of OSR (Ontario Student Record)<\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_191' id='input_3_191' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_3_192\" class=\"gfield gfield--type-textarea gfield--input-type-textarea gfield--width-full field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_3_192'><span class='gform-field-label__text'>Identify any additional student services or professional support services accessed, including special accommodations made to youth\u2019s attendance requirements.<\/span><\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_192' id='input_3_192' class='textarea large'      aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/div><div id=\"field_3_197\" class=\"gfield gfield--type-section gfield--input-type-section gsection field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><h3 class=\"gsection_title\">Youth &amp; Family Strengths<\/h3><\/div><div id=\"field_3_194\" class=\"gfield gfield--type-html gfield--input-type-html gfield--width-full gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><strong>Please include:<\/strong><br\/>\n<ul><li>Character strengths<\/li>\n<li>Talents, interests, skills, assets<\/li>\n<li>Relationship supports, connections,<\/li>\n<li>Strengths identified in formal assessments, reports, and\/or other professional consultations<\/li><\/ul><\/div><div id=\"field_3_195\" class=\"gfield gfield--type-textarea gfield--input-type-textarea gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_3_195'><span class='gform-field-label__text'>Please Describe<\/span><span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(N\u00e9cessaire)<\/span><\/span><\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_195' id='input_3_195' class='textarea large'     aria-required=\"true\" aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/div><\/div>\n                    <\/div>\n                    <div class='gform-page-footer gform_page_footer top_label'>\n                        <button type='button' id='gform_previous_button_3_196' class='gform_previous_button gform-theme-button gform-theme-button--secondary button' onclick='gform.submission.handleButtonClick(this);' data-submission-type='previous' >Previous<\/button> <button type='button' id='gform_next_button_3_196' class='gform_next_button gform-theme-button button' onclick='gform.submission.handleButtonClick(this);' data-submission-type='next' >Next<\/button> <button type='button'  id='gform_save_3_19_link' onclick='gform.submission.handleButtonClick(this);' data-submission-type='save-continue' class='gform_save_link gform-theme-button gform-theme-button--secondary button'  ><svg aria-hidden=\"true\" focusable=\"false\" width=\"16\" height=\"16\" fill=\"none\" xmlns=\"http:\/\/www.w3.org\/2000\/svg\"><path fill-rule=\"evenodd\" clip-rule=\"evenodd\" d=\"M0 8a4 4 0 004 4h3v3a1 1 0 102 0v-3h3a4 4 0 100-8 4 4 0 10-8 0 4 4 0 00-4 4zm9 4H7V7.414L5.707 8.707a1 1 0 01-1.414-1.414l3-3a1 1 0 011.414 0l3 3a1 1 0 01-1.414 1.414L9 7.414V12z\" fill=\"#6B7280\"\/><\/svg> Save and Continue Later<\/button>\n                    <\/div>\n                <\/div>\n                <div id='gform_page_3_19' class='gform_page' data-js='page-field-id-196' style='display:none;'>\n                    <div class='gform_page_fields'>\n                        <div id='gform_fields_3_19' class='gform_fields top_label form_sublabel_below description_below validation_below'><div id=\"field_3_193\" class=\"gfield gfield--type-section gfield--input-type-section gsection field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><h3 class=\"gsection_title\">Youth &amp; Family Needs<\/h3><\/div><div id=\"field_3_202\" class=\"gfield gfield--type-html gfield--input-type-html gfield--width-full gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><strong>For effective treatment planning, please identify:<\/strong><br\/>\n<ul>\n<li>Immediate goals\/needs to be addressed in the initial phase of treatment<\/li>\n<li>What the youth and\/or family\/caregiver need in order to sustain achievements from previous services received<\/li>\n<li>What they will need from the RSC treatment team within the RSC program<\/li>\n<li>What needs they may have that can only be met outside the RSC and how those needs can be best accommodated for while the youth resides at a RSC Treatment Residence<\/li>\n<\/ul><\/div><div id=\"field_3_199\" class=\"gfield gfield--type-textarea gfield--input-type-textarea gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_3_199'><span class='gform-field-label__text'>Please Describe<\/span><span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(N\u00e9cessaire)<\/span><\/span><\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_199' id='input_3_199' class='textarea large'     aria-required=\"true\" aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/div><div id=\"field_3_231\" class=\"gfield gfield--type-textarea gfield--input-type-textarea gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_3_231'><span class='gform-field-label__text'>Applicant Objectives<\/span><span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(N\u00e9cessaire)<\/span><\/span><\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_231' id='input_3_231' class='textarea large'     aria-required=\"true\" aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/div><\/div>\n                    <\/div>\n                    <div class='gform-page-footer gform_page_footer top_label'>\n                        <button type='button' id='gform_previous_button_3_205' class='gform_previous_button gform-theme-button gform-theme-button--secondary button' onclick='gform.submission.handleButtonClick(this);' data-submission-type='previous' >Previous<\/button> <button type='button' id='gform_next_button_3_205' class='gform_next_button gform-theme-button button' onclick='gform.submission.handleButtonClick(this);' data-submission-type='next' >Next<\/button> <button type='button'  id='gform_save_3_20_link' onclick='gform.submission.handleButtonClick(this);' data-submission-type='save-continue' class='gform_save_link gform-theme-button gform-theme-button--secondary button'  ><svg aria-hidden=\"true\" focusable=\"false\" width=\"16\" height=\"16\" fill=\"none\" xmlns=\"http:\/\/www.w3.org\/2000\/svg\"><path fill-rule=\"evenodd\" clip-rule=\"evenodd\" d=\"M0 8a4 4 0 004 4h3v3a1 1 0 102 0v-3h3a4 4 0 100-8 4 4 0 10-8 0 4 4 0 00-4 4zm9 4H7V7.414L5.707 8.707a1 1 0 01-1.414-1.414l3-3a1 1 0 011.414 0l3 3a1 1 0 01-1.414 1.414L9 7.414V12z\" fill=\"#6B7280\"\/><\/svg> Save and Continue Later<\/button>\n                    <\/div>\n                <\/div>\n                <div id='gform_page_3_20' class='gform_page' data-js='page-field-id-205' style='display:none;'>\n                    <div class='gform_page_fields'>\n                        <div id='gform_fields_3_20' class='gform_fields top_label form_sublabel_below description_below validation_below'><div id=\"field_3_203\" class=\"gfield gfield--type-section gfield--input-type-section gsection field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><h3 class=\"gsection_title\">Anticipated or Recommended Discharge Plan<\/h3><\/div><div id=\"field_3_201\" class=\"gfield gfield--type-html gfield--input-type-html gfield--width-full gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  >Please provide as many details as possible regarding the anticipated&#47;recommended plan for the youth&#39;s discharge from the Roberts&#47;Smart Centre upon completion of their treatment AND the estimated timeline, expected outcomes, and needs for this plan to be successful.<\/div><div id=\"field_3_204\" class=\"gfield gfield--type-textarea gfield--input-type-textarea gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_3_204'><span class='gform-field-label__text'>Please Describe<\/span><span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(N\u00e9cessaire)<\/span><\/span><\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_204' id='input_3_204' class='textarea large'     aria-required=\"true\" aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/div><div id=\"field_3_208\" class=\"gfield gfield--type-section gfield--input-type-section gsection field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><h3 class=\"gsection_title\">Additional Information (if applicable)<\/h3><\/div><div id=\"field_3_207\" class=\"gfield gfield--type-html gfield--input-type-html gfield--width-full gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><strong>Please include:<\/strong><br\/>\n<ul>\n<li>Upcoming appointments that would need to be maintained<\/li><\/li>\n<li>On-going medical treatments the youth requires<\/li>\n<li>Anything relevant for the health and safety of the youth and the members of the treatment team: communicable diseases, significant triggers, safety protocols, imminent risks, etc.<\/li><\/ul><\/div><div id=\"field_3_206\" class=\"gfield gfield--type-textarea gfield--input-type-textarea gfield--width-full field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_3_206'><span class='gform-field-label__text'>Please Describe<\/span><\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_206' id='input_3_206' class='textarea large'      aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/div><\/div>\n                    <\/div>\n                    <div class='gform-page-footer gform_page_footer top_label'>\n                        <button type='button' id='gform_previous_button_3_209' class='gform_previous_button gform-theme-button gform-theme-button--secondary button' onclick='gform.submission.handleButtonClick(this);' data-submission-type='previous' >Previous<\/button> <button type='button' id='gform_next_button_3_209' class='gform_next_button gform-theme-button button' onclick='gform.submission.handleButtonClick(this);' data-submission-type='next' >Next<\/button> <button type='button'  id='gform_save_3_21_link' onclick='gform.submission.handleButtonClick(this);' data-submission-type='save-continue' class='gform_save_link gform-theme-button gform-theme-button--secondary button'  ><svg aria-hidden=\"true\" focusable=\"false\" width=\"16\" height=\"16\" fill=\"none\" xmlns=\"http:\/\/www.w3.org\/2000\/svg\"><path fill-rule=\"evenodd\" clip-rule=\"evenodd\" d=\"M0 8a4 4 0 004 4h3v3a1 1 0 102 0v-3h3a4 4 0 100-8 4 4 0 10-8 0 4 4 0 00-4 4zm9 4H7V7.414L5.707 8.707a1 1 0 01-1.414-1.414l3-3a1 1 0 011.414 0l3 3a1 1 0 01-1.414 1.414L9 7.414V12z\" fill=\"#6B7280\"\/><\/svg> Save and Continue Later<\/button>\n                    <\/div>\n                <\/div>\n                <div id='gform_page_3_21' class='gform_page' data-js='page-field-id-209' style='display:none;'>\n                    <div class='gform_page_fields'>\n                        <div id='gform_fields_3_21' class='gform_fields top_label form_sublabel_below description_below validation_below'><div id=\"field_3_211\" class=\"gfield gfield--type-section gfield--input-type-section gsection field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><h3 class=\"gsection_title\">SECTION B<\/h3><\/div><div id=\"field_3_212\" class=\"gfield gfield--type-html gfield--input-type-html gfield--width-full gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><img decoding=\"async\" src=\"https:\/\/www.robertssmartcentre.com\/wp-content\/uploads\/2026\/05\/INTAKE_SECTIONB.jpg\" style=\"width: 100%; height: auto;\"\/><\/div><\/div>\n                    <\/div>\n                    <div class='gform-page-footer gform_page_footer top_label'>\n                        <button type='button' id='gform_previous_button_3_214' class='gform_previous_button gform-theme-button gform-theme-button--secondary button' onclick='gform.submission.handleButtonClick(this);' data-submission-type='previous' >Previous<\/button> <button type='button' id='gform_next_button_3_214' class='gform_next_button gform-theme-button button' onclick='gform.submission.handleButtonClick(this);' data-submission-type='next' >Next<\/button> <button type='button'  id='gform_save_3_22_link' onclick='gform.submission.handleButtonClick(this);' data-submission-type='save-continue' class='gform_save_link gform-theme-button gform-theme-button--secondary button'  ><svg aria-hidden=\"true\" focusable=\"false\" width=\"16\" height=\"16\" fill=\"none\" xmlns=\"http:\/\/www.w3.org\/2000\/svg\"><path fill-rule=\"evenodd\" clip-rule=\"evenodd\" d=\"M0 8a4 4 0 004 4h3v3a1 1 0 102 0v-3h3a4 4 0 100-8 4 4 0 10-8 0 4 4 0 00-4 4zm9 4H7V7.414L5.707 8.707a1 1 0 01-1.414-1.414l3-3a1 1 0 011.414 0l3 3a1 1 0 01-1.414 1.414L9 7.414V12z\" fill=\"#6B7280\"\/><\/svg> Save and Continue Later<\/button>\n                    <\/div>\n                <\/div>\n                <div id='gform_page_3_22' class='gform_page' data-js='page-field-id-214' style='display:none;'>\n                    <div class='gform_page_fields'>\n                        <div id='gform_fields_3_22' class='gform_fields top_label form_sublabel_below description_below validation_below'><div id=\"field_3_215\" class=\"gfield gfield--type-section gfield--input-type-section gsection field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><h3 class=\"gsection_title\">Secure Treatment Admission Criteria<\/h3><\/div><div id=\"field_3_216\" class=\"gfield gfield--type-html gfield--input-type-html gfield--width-full gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><div style=\"font-family: sans-serif; line-height: 1.5; color: #333;\">\n    <p>The Court may order that a child be committed to a Secure Treatment Program only where the Court is satisfied that:<\/p>\n\n    <ol style=\"list-style-type: lower-alpha; padding-left: 40px;\">\n        <li style=\"margin-bottom: 10px;\">the child has a mental health disorder<\/li>\n        <li style=\"margin-bottom: 10px;\">\n            the child has, as a result of the mental disorder, within forty-five days immediately preceding,\n            <ol style=\"list-style-type: lower-roman; padding-left: 40px; margin: 10px 0;\">\n                <li>the application under subsection 161 (1)<\/li>\n                <li>the child\u2019s detention or custody under the Youth Criminal Justice Act (Canada) or under the Provincial Offences Act, or<\/li>\n                <li>the child\u2019s admission to a psychiatric facility under the Mental Health Act as an involuntary patient,<\/li>\n            <\/ol>\n            caused or attempted to cause serious bodily harm to himself, herself or another person.\n        <\/li>\n        <li style=\"margin-bottom: 10px;\">\n            the child has,\n            <ol style=\"list-style-type: lower-roman; padding-left: 40px; margin: 10px 0;\">\n                <li>within the twelve months immediately preceding the application, but on another occasion than referred to in clause (b), caused, attempted to cause or by words or conduct made a substantial threat to cause serious bodily harm to himself, herself or another person, or<\/li>\n                <li>in committing the act or attempt referred to in clause (b), caused or attempted to cause a person\u2019s death;<\/li>\n            <\/ol>\n        <\/li>\n        <li style=\"margin-bottom: 10px;\">the Secure Treatment Program would be effective to prevent the child from causing or attempting to cause serious bodily harm to himself, herself or another person;<\/li>\n        <li style=\"margin-bottom: 10px;\">treatment appropriate for the child\u2019s mental disorder is available at the place of Secure Treatment to which the application relates; and<\/li>\n        <li style=\"margin-bottom: 10px;\">no less restrictive method of providing treatment appropriate for the child\u2019s mental disorder is appropriate in the circumstances.<\/li>\n    <\/ol>\n<\/div><\/div><\/div>\n                    <\/div>\n                    <div class='gform-page-footer gform_page_footer top_label'>\n                        <button type='button' id='gform_previous_button_3_217' class='gform_previous_button gform-theme-button gform-theme-button--secondary button' onclick='gform.submission.handleButtonClick(this);' data-submission-type='previous' >Previous<\/button> <button type='button' id='gform_next_button_3_217' class='gform_next_button gform-theme-button button' onclick='gform.submission.handleButtonClick(this);' data-submission-type='next' >Next<\/button> <button type='button'  id='gform_save_3_23_link' onclick='gform.submission.handleButtonClick(this);' data-submission-type='save-continue' class='gform_save_link gform-theme-button gform-theme-button--secondary button'  ><svg aria-hidden=\"true\" focusable=\"false\" width=\"16\" height=\"16\" fill=\"none\" xmlns=\"http:\/\/www.w3.org\/2000\/svg\"><path fill-rule=\"evenodd\" clip-rule=\"evenodd\" d=\"M0 8a4 4 0 004 4h3v3a1 1 0 102 0v-3h3a4 4 0 100-8 4 4 0 10-8 0 4 4 0 00-4 4zm9 4H7V7.414L5.707 8.707a1 1 0 01-1.414-1.414l3-3a1 1 0 011.414 0l3 3a1 1 0 01-1.414 1.414L9 7.414V12z\" fill=\"#6B7280\"\/><\/svg> Save and Continue Later<\/button>\n                    <\/div>\n                <\/div>\n                <div id='gform_page_3_23' class='gform_page' data-js='page-field-id-217' style='display:none;'>\n                    <div class='gform_page_fields'>\n                        <div id='gform_fields_3_23' class='gform_fields top_label form_sublabel_below description_below validation_below'><div id=\"field_3_218\" class=\"gfield gfield--type-section gfield--input-type-section gsection field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><h3 class=\"gsection_title\">Admission Criteria (B)<\/h3><\/div><div id=\"field_3_219\" class=\"gfield gfield--type-html gfield--input-type-html gfield--width-full gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  >Provide details that the child has, as a result of the mental disorder, <strong>within forty-five days <\/strong>immediately preceding, the application under subsection 161(1), <strong>OR<\/strong>\n<ul>\n<li>the child\u2019s detention or custody under the Youth Criminal Justice Act or under the Provincial Offences Act, <strong>OR<\/strong><\/li>\n<li>the child\u2019s admission to a psychiatric facility under the Mental Health Act as an involuntary patient, OR<\/li>\n<li>has caused or attempted to cause <strong>serious bodily harm to himself, herself or another person<\/strong>.<\/li><\/ul><\/div><div id=\"field_3_220\" class=\"gfield gfield--type-form gfield--input-type-form gform-theme__no-reset--children gfield--width-full field_sublabel_below gfield--no-description field_description_below hidden_label field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_3_220'><span class='gform-field-label__text'>Admission Criteria A<\/span><\/label><div class=\"gpnf-nested-entries-container ginput_container\">\n\n\t<table class=\"gpnf-nested-entries\">\n\n\t\t<thead>\n\t\t<tr>\n\t\t\t\t\t\t\t<th scope=\"col\" class=\"gpnf-field-4\">\n\t\t\t\t\tIncident\t\t\t\t<\/th>\n\t\t\t\t\t\t\t<th scope=\"col\" class=\"gpnf-field-7\">\n\t\t\t\t\tDate\t\t\t\t<\/th>\n\t\t\t\t\t\t\t<th scope=\"col\" class=\"gpnf-field-6\">\n\t\t\t\t\tOutcome\t\t\t\t<\/th>\n\t\t\t\t\t\t<th scope=\"col\" class=\"gpnf-row-actions\"><span class=\"screen-reader-text\">Actions<\/span><\/th>\n\t\t<\/tr>\n\t\t<\/thead>\n\n\t\t<tbody data-bind=\"visible: entries().length, foreach: entries\">\n\t\t<tr data-bind=\"attr: { 'data-entryid': id }\">\n\t\t\t\t\t\t\t<td class=\"gpnf-field\"\n\t\t\t\t\tdata-bind=\"html: f4.label, attr: { 'data-value': f4.label }\"\n\t\t\t\t\tdata-heading=\"Incident\"\n\t\t\t\t>&nbsp;<\/td>\n\t\t\t\t\t\t\t<td class=\"gpnf-field\"\n\t\t\t\t\tdata-bind=\"html: f7.label, attr: { 'data-value': f7.label }\"\n\t\t\t\t\tdata-heading=\"Date\"\n\t\t\t\t>&nbsp;<\/td>\n\t\t\t\t\t\t\t<td class=\"gpnf-field\"\n\t\t\t\t\tdata-bind=\"html: f6.label, attr: { 'data-value': f6.label }\"\n\t\t\t\t\tdata-heading=\"Outcome\"\n\t\t\t\t>&nbsp;<\/td>\n\t\t\t\t\t\t<td class=\"gpnf-row-actions\" style=\"display: none;\" data-bind=\"visible: true\">\n\t\t\t\t<ul>\n\t\t\t\t\t<li class=\"edit\"><button type=\"button\" class=\"edit-button gform-theme-button--secondary\" data-bind=\"click: $parent.editEntry, attr: { 'aria-label': 'Edit Entr\u00e9e {0} where Incident is {1}.'.gformFormat( $index() + 1, f4.label ) }\">Modifier<\/button><\/li>\n\t\t\t\t\t\t\t\t\t\t<li class=\"delete\"><button type=\"button\" class=\"delete-button gform-theme-button--simple gform-theme-button--size-md\" data-bind=\"click: $parent.deleteEntry, attr: { 'aria-label': 'Delete Entr\u00e9e {0} where Incident is {1}.'.gformFormat( $index() + 1, f4.label ) }\">Supprimer<\/button><\/li>\n\t\t\t\t<\/ul>\n\t\t\t<\/td>\n\t\t<\/tr>\n\t\t<\/tbody>\n\n\t\t<tbody data-bind=\"visible: entries().length <= 0\">\n\t\t<tr class=\"gpnf-no-entries\" data-bind=\"visible: entries().length <= 0\" style=\"display: none;\">\n\t\t\t<td colspan=\"4\">\n\t\t\t\tIl n\u2019y a aucun(e) <span>Entr\u00e9es.<\/span>\t\t\t<\/td>\n\t\t<\/tr>\n\t\t<\/tbody>\n\n\t<\/table>\n\n\t<button type=\"button\" class=\"gpnf-add-entry\"\n\t\t        data-formid=\"3\"\n\t\t        data-nestedformid=\"13\"\n\t\t\t\tdata-bind=\"attr: { disabled: isMaxed }, css: { 'gf-default-disabled': isMaxed }\"\n\t\t\t\t>\n\t\t\t\tAjouter Entr\u00e9e\n\t\t\t<\/button>\t\n\t\t\t<p class=\"gpnf-add-entry-max\" data-bind=\"visible: isMaxed\" style=\"display: none;\">\n\t\t\t\tLe nombre maximal a \u00e9t\u00e9 atteint.\n\t\t\t<\/p>\n<\/div>\n<input type=\"hidden\"\n                name=\"input_220\"\n                id=\"input_3_220\"\n                data-bind=\"value: entryIds\"\n                value=\"\" \/><\/div><div id=\"field_3_221\" class=\"gfield gfield--type-fileupload gfield--input-type-fileupload gfield--width-full field_sublabel_below gfield--has-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='gform_browse_button_3_221'><span class='gform-field-label__text'>Supporting Documentation<\/span><\/label><div class='ginput_container ginput_container_fileupload'><div id='gform_multifile_upload_3_221' data-settings='{&quot;runtimes&quot;:&quot;html5,flash,html4&quot;,&quot;browse_button&quot;:&quot;gform_browse_button_3_221&quot;,&quot;container&quot;:&quot;gform_multifile_upload_3_221&quot;,&quot;drop_element&quot;:&quot;gform_drag_drop_area_3_221&quot;,&quot;filelist&quot;:&quot;gform_preview_3_221&quot;,&quot;unique_names&quot;:true,&quot;file_data_name&quot;:&quot;file&quot;,&quot;url&quot;:&quot;https:\\\/\\\/www.robertssmartcentre.com\\\/fr\\\/?gf_page=fb962d61be882d5&quot;,&quot;flash_swf_url&quot;:&quot;https:\\\/\\\/www.robertssmartcentre.com\\\/wp-includes\\\/js\\\/plupload\\\/plupload.flash.swf&quot;,&quot;silverlight_xap_url&quot;:&quot;https:\\\/\\\/www.robertssmartcentre.com\\\/wp-includes\\\/js\\\/plupload\\\/plupload.silverlight.xap&quot;,&quot;filters&quot;:{&quot;mime_types&quot;:[{&quot;title&quot;:&quot;Fichiers autoris\\u00e9s&quot;,&quot;extensions&quot;:&quot;pdf,doc,docx&quot;}],&quot;max_file_size&quot;:&quot;134217728b&quot;},&quot;multipart&quot;:true,&quot;urlstream_upload&quot;:false,&quot;multipart_params&quot;:{&quot;form_id&quot;:3,&quot;field_id&quot;:221,&quot;_gform_file_upload_nonce_3_221&quot;:&quot;209b6e7ad2&quot;},&quot;gf_vars&quot;:{&quot;max_files&quot;:0,&quot;message_id&quot;:&quot;gform_multifile_messages_3_221&quot;,&quot;disallowed_extensions&quot;:[&quot;php&quot;,&quot;asp&quot;,&quot;aspx&quot;,&quot;cmd&quot;,&quot;csh&quot;,&quot;bat&quot;,&quot;html&quot;,&quot;htm&quot;,&quot;hta&quot;,&quot;jar&quot;,&quot;exe&quot;,&quot;com&quot;,&quot;js&quot;,&quot;lnk&quot;,&quot;htaccess&quot;,&quot;phar&quot;,&quot;phtml&quot;,&quot;ps1&quot;,&quot;ps2&quot;,&quot;php3&quot;,&quot;php4&quot;,&quot;php5&quot;,&quot;php6&quot;,&quot;py&quot;,&quot;rb&quot;,&quot;tmp&quot;]}}' class='gform_fileupload_multifile'>\n\t\t\t\t\t\t\t\t\t\t<div id='gform_drag_drop_area_3_221' class='gform_drop_area gform-theme-field-control'>\n\t\t\t\t\t\t\t\t\t\t\t<span class='gform_drop_instructions'>D\u00e9posez les fichiers ici ou <\/span>\n\t\t\t\t\t\t\t\t\t\t\t<button type='button' id='gform_browse_button_3_221' class='button gform_button_select_files gform-theme-button gform-theme-button--control' aria-describedby=\"gfield_upload_rules_3_221 gfield_description_3_221\"  >S\u00e9lectionnez des fichiers<\/button>\n\t\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t<\/div><span class='gfield_description gform_fileupload_rules' id='gfield_upload_rules_3_221'>Types de fichiers accept\u00e9s\u00a0: pdf, doc, docx, Taille max. des fichiers\u00a0: 128 MB.<\/span><ul class='validation_message--hidden-on-empty gform-ul-reset' id='gform_multifile_messages_3_221'><\/ul> <div id='gform_preview_3_221' class='ginput_preview_list'><\/div><\/div><div class='gfield_description' id='gfield_description_3_221'>*Please attach supporting documentation i.e. Serious Occurrence Reports (SORs), incident reports, police reports, hospital\ndischarge reports, etc.<\/div><\/div><\/div>\n                    <\/div>\n                    <div class='gform-page-footer gform_page_footer top_label'>\n                        <button type='button' id='gform_previous_button_3_222' class='gform_previous_button gform-theme-button gform-theme-button--secondary button' onclick='gform.submission.handleButtonClick(this);' data-submission-type='previous' >Previous<\/button> <button type='button' id='gform_next_button_3_222' class='gform_next_button gform-theme-button button' onclick='gform.submission.handleButtonClick(this);' data-submission-type='next' >Next<\/button> <button type='button'  id='gform_save_3_24_link' onclick='gform.submission.handleButtonClick(this);' data-submission-type='save-continue' class='gform_save_link gform-theme-button gform-theme-button--secondary button'  ><svg aria-hidden=\"true\" focusable=\"false\" width=\"16\" height=\"16\" fill=\"none\" xmlns=\"http:\/\/www.w3.org\/2000\/svg\"><path fill-rule=\"evenodd\" clip-rule=\"evenodd\" d=\"M0 8a4 4 0 004 4h3v3a1 1 0 102 0v-3h3a4 4 0 100-8 4 4 0 10-8 0 4 4 0 00-4 4zm9 4H7V7.414L5.707 8.707a1 1 0 01-1.414-1.414l3-3a1 1 0 011.414 0l3 3a1 1 0 01-1.414 1.414L9 7.414V12z\" fill=\"#6B7280\"\/><\/svg> Save and Continue Later<\/button>\n                    <\/div>\n                <\/div>\n                <div id='gform_page_3_24' class='gform_page' data-js='page-field-id-222' style='display:none;'>\n                    <div class='gform_page_fields'>\n                        <div id='gform_fields_3_24' class='gform_fields top_label form_sublabel_below description_below validation_below'><div id=\"field_3_223\" class=\"gfield gfield--type-section gfield--input-type-section gsection field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><h3 class=\"gsection_title\">Admission Criteria (C)<\/h3><\/div><div id=\"field_3_224\" class=\"gfield gfield--type-html gfield--input-type-html gfield--width-full gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><strong>Provide details that the child has, as a result of the mental disorder, in the twelve months immediately preceding the application, but on another occasion than referred to in criteria (b)<\/strong>,\n<ul>\n<li>caused, attempted to cause or by words or conduct made a substantial threat to cause serious bodily harm to himself, herself\nor another person, OR<\/li>\n<li>n committing the act or attempt referred to in criteria (b), caused or attempted to cause a person\u2019s death;<\/li>\n<\/ul><\/div><div id=\"field_3_225\" class=\"gfield gfield--type-form gfield--input-type-form gform-theme__no-reset--children gfield--width-full field_sublabel_below gfield--no-description field_description_below hidden_label field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_3_225'><span class='gform-field-label__text'>Admission Criteria (C)<\/span><\/label><div class=\"gpnf-nested-entries-container ginput_container\">\n\n\t<table class=\"gpnf-nested-entries\">\n\n\t\t<thead>\n\t\t<tr>\n\t\t\t\t\t\t\t<th scope=\"col\" class=\"gpnf-field-4\">\n\t\t\t\t\tIncident\t\t\t\t<\/th>\n\t\t\t\t\t\t\t<th scope=\"col\" class=\"gpnf-field-7\">\n\t\t\t\t\tDate\t\t\t\t<\/th>\n\t\t\t\t\t\t\t<th scope=\"col\" class=\"gpnf-field-6\">\n\t\t\t\t\tOutcome\t\t\t\t<\/th>\n\t\t\t\t\t\t<th scope=\"col\" class=\"gpnf-row-actions\"><span class=\"screen-reader-text\">Actions<\/span><\/th>\n\t\t<\/tr>\n\t\t<\/thead>\n\n\t\t<tbody data-bind=\"visible: entries().length, foreach: entries\">\n\t\t<tr data-bind=\"attr: { 'data-entryid': id }\">\n\t\t\t\t\t\t\t<td class=\"gpnf-field\"\n\t\t\t\t\tdata-bind=\"html: f4.label, attr: { 'data-value': f4.label }\"\n\t\t\t\t\tdata-heading=\"Incident\"\n\t\t\t\t>&nbsp;<\/td>\n\t\t\t\t\t\t\t<td class=\"gpnf-field\"\n\t\t\t\t\tdata-bind=\"html: f7.label, attr: { 'data-value': f7.label }\"\n\t\t\t\t\tdata-heading=\"Date\"\n\t\t\t\t>&nbsp;<\/td>\n\t\t\t\t\t\t\t<td class=\"gpnf-field\"\n\t\t\t\t\tdata-bind=\"html: f6.label, attr: { 'data-value': f6.label }\"\n\t\t\t\t\tdata-heading=\"Outcome\"\n\t\t\t\t>&nbsp;<\/td>\n\t\t\t\t\t\t<td class=\"gpnf-row-actions\" style=\"display: none;\" data-bind=\"visible: true\">\n\t\t\t\t<ul>\n\t\t\t\t\t<li class=\"edit\"><button type=\"button\" class=\"edit-button gform-theme-button--secondary\" data-bind=\"click: $parent.editEntry, attr: { 'aria-label': 'Edit Entr\u00e9e {0} where Incident is {1}.'.gformFormat( $index() + 1, f4.label ) }\">Modifier<\/button><\/li>\n\t\t\t\t\t\t\t\t\t\t<li class=\"delete\"><button type=\"button\" class=\"delete-button gform-theme-button--simple gform-theme-button--size-md\" data-bind=\"click: $parent.deleteEntry, attr: { 'aria-label': 'Delete Entr\u00e9e {0} where Incident is {1}.'.gformFormat( $index() + 1, f4.label ) }\">Supprimer<\/button><\/li>\n\t\t\t\t<\/ul>\n\t\t\t<\/td>\n\t\t<\/tr>\n\t\t<\/tbody>\n\n\t\t<tbody data-bind=\"visible: entries().length <= 0\">\n\t\t<tr class=\"gpnf-no-entries\" data-bind=\"visible: entries().length <= 0\" style=\"display: none;\">\n\t\t\t<td colspan=\"4\">\n\t\t\t\tIl n\u2019y a aucun(e) <span>Entr\u00e9es.<\/span>\t\t\t<\/td>\n\t\t<\/tr>\n\t\t<\/tbody>\n\n\t<\/table>\n\n\t<button type=\"button\" class=\"gpnf-add-entry\"\n\t\t        data-formid=\"3\"\n\t\t        data-nestedformid=\"13\"\n\t\t\t\tdata-bind=\"attr: { disabled: isMaxed }, css: { 'gf-default-disabled': isMaxed }\"\n\t\t\t\t>\n\t\t\t\tAjouter Entr\u00e9e\n\t\t\t<\/button>\t\n\t\t\t<p class=\"gpnf-add-entry-max\" data-bind=\"visible: isMaxed\" style=\"display: none;\">\n\t\t\t\tLe nombre maximal a \u00e9t\u00e9 atteint.\n\t\t\t<\/p>\n<\/div>\n<input type=\"hidden\"\n                name=\"input_225\"\n                id=\"input_3_225\"\n                data-bind=\"value: entryIds\"\n                value=\"\" \/><\/div><div id=\"field_3_226\" class=\"gfield gfield--type-fileupload gfield--input-type-fileupload gfield--width-full field_sublabel_below gfield--has-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_3_226'><span class='gform-field-label__text'>Support Documents<\/span><\/label><div class='ginput_container ginput_container_fileupload'><input type='hidden' name='MAX_FILE_SIZE' value='134217728' \/><input name='input_226' id='input_3_226' type='file' class='large' aria-describedby=\"gfield_upload_rules_3_226 gfield_description_3_226\" onchange='javascript:gformValidateFileSize( this, 134217728 );'  \/><span class='gfield_description gform_fileupload_rules' id='gfield_upload_rules_3_226'>Taille max. des fichiers\u00a0: 128 MB.<\/span><div class='gfield_description validation_message gfield_validation_message validation_message--hidden-on-empty' id='live_validation_message_3_226'><\/div> <\/div><div class='gfield_description' id='gfield_description_3_226'>*Please attach supporting documentation i.e. Serious Occurrence Reports (SORs), incident reports, police reports, hospital\ndischarge reports, etc.<\/div><\/div><\/div>\n                    <\/div>\n                    <div class='gform-page-footer gform_page_footer top_label'>\n                        <button type='button' id='gform_previous_button_3_149' class='gform_previous_button gform-theme-button gform-theme-button--secondary button' onclick='gform.submission.handleButtonClick(this);' data-submission-type='previous' >Previous<\/button> <button type='button' id='gform_next_button_3_149' class='gform_next_button gform-theme-button button' onclick='gform.submission.handleButtonClick(this);' data-submission-type='next' >Next<\/button> <button type='button'  id='gform_save_3_25_link' onclick='gform.submission.handleButtonClick(this);' data-submission-type='save-continue' class='gform_save_link gform-theme-button gform-theme-button--secondary button'  ><svg aria-hidden=\"true\" focusable=\"false\" width=\"16\" height=\"16\" fill=\"none\" xmlns=\"http:\/\/www.w3.org\/2000\/svg\"><path fill-rule=\"evenodd\" clip-rule=\"evenodd\" d=\"M0 8a4 4 0 004 4h3v3a1 1 0 102 0v-3h3a4 4 0 100-8 4 4 0 10-8 0 4 4 0 00-4 4zm9 4H7V7.414L5.707 8.707a1 1 0 01-1.414-1.414l3-3a1 1 0 011.414 0l3 3a1 1 0 01-1.414 1.414L9 7.414V12z\" fill=\"#6B7280\"\/><\/svg> Save and Continue Later<\/button>\n                    <\/div>\n                <\/div>\n                <div id='gform_page_3_25' class='gform_page' data-js='page-field-id-149' style='display:none;'>\n                    <div class='gform_page_fields'>\n                        <div id='gform_fields_3_25' class='gform_fields top_label form_sublabel_below description_below validation_below'><div id=\"field_3_13\" class=\"gfield gfield--type-html gfield--input-type-html gfield--width-full gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  >{all_fields}<\/div><div id=\"field_3_15\" class=\"gfield gfield--type-signature gfield--input-type-signature gfield--width-half gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_3_15'><span class='gform-field-label__text'>Signature<\/span><span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(N\u00e9cessaire)<\/span><\/span><\/label><input type='hidden' value='' name='input_15' id='input_3_15_signature_filename'\/><div class='gfield_signature_ui_container gform-theme__no-reset--children' ><div id='input_3_15_Container' class='gfield_signature_container ginput_container' style='height:180px; width:400px; ' ><canvas id='input_3_15' width='400' height='180' style='border-style: Dashed; border-width: 2px; border-color: #DDDDDD; background-color:#FFFFFF; cursor: url(https:\/\/www.robertssmartcentre.com\/wp-content\/plugins\/gravityformssignature\/assets\/img\/pen.cur), pointer;'><\/canvas><\/div><div id='input_3_15_toolbar' style='margin:5px 0;position:relative;height:20px;width:400px;max-width:100%;'><img id = 'input_3_15_resetbutton' src='data:image\/png;base64,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' style='cursor:pointer;float:right;height:24px;width:24px;border:0px solid transparent' alt='Clear Signature' \/ ><\/div><input type='hidden' id='input_3_15_data' name='input_3_15_data' value=''><\/div><\/div><div id=\"field_3_16\" class=\"gfield gfield--type-date gfield--input-type-date gfield--input-type-datepicker gfield--datepicker-default-icon gfield--width-half gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_3_16'><span class='gform-field-label__text'>Date<\/span><span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(N\u00e9cessaire)<\/span><\/span><\/label><div class='ginput_container ginput_container_date'>\n\t\t\t\t\t<input\n\t\t\t\t\tplaceholder='mm\/jj\/aaaa'\n\t\t\t\t\tid='input_3_16'\n\t\t\t\t\tclass='datepicker gform-datepicker mdy datepicker_with_icon gdatepicker_with_icon'\n\t\t\t\t\ttype='text'\n\t\t\t\t\tname='input_16'\n\t\t\t\t\tvalue=''\n\t\t\t\t\t \n\t\t\t\t\taria-invalid=\"false\" \n\t\t\t\t\taria-required=\"true\"\n\t\t\t\t\t \n\t\t\t\t\t\n\t\t\t\t\tdata-mask=\"99\/99\/9999\"\n\t\t\t\t\t\/>\n\t\t\t\t<kbd id='keyboardHint_input_3_16' hidden class='down'><\/kbd>\n\t\t\t\t<button type='button' id='datepicker_toggle_input_3_16' class='gform-datepicker-toggle gform-datepicker-toggle--default accCalendar aria-date-picker gform-button gform-theme-button gform-theme-button--simple gform-theme-button--simple-in-ctrl' aria-expanded='false' aria-controls='input_3_16' aria-label='Date: Choose date on calendar' >\n\t\t\t\t\t\t\t<span class=\"gform-calendar-icon gform-datepicker-toggle-icon gform-datepicker-toggle-icon--default dashicons dashicons-calendar-alt\" aria-hidden=\"true\"><\/span>\n\t\t\t\t\t\t<\/button>\n\t\t\t<\/div><\/div><div id=\"field_3_18\" class=\"gfield gfield--type-signature gfield--input-type-signature gfield--width-half gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_3_18'><span class='gform-field-label__text'>Witness Signature<\/span><span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(N\u00e9cessaire)<\/span><\/span><\/label><input type='hidden' value='' name='input_18' id='input_3_18_signature_filename'\/><div class='gfield_signature_ui_container gform-theme__no-reset--children' ><div id='input_3_18_Container' class='gfield_signature_container ginput_container' style='height:180px; width:400px; ' ><canvas id='input_3_18' width='400' height='180' style='border-style: Dashed; border-width: 2px; border-color: #DDDDDD; background-color:#FFFFFF; cursor: url(https:\/\/www.robertssmartcentre.com\/wp-content\/plugins\/gravityformssignature\/assets\/img\/pen.cur), pointer;'><\/canvas><\/div><div id='input_3_18_toolbar' style='margin:5px 0;position:relative;height:20px;width:400px;max-width:100%;'><img id = 'input_3_18_resetbutton' src='data:image\/png;base64,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' style='cursor:pointer;float:right;height:24px;width:24px;border:0px solid transparent' alt='Clear Signature' \/ ><\/div><input type='hidden' id='input_3_18_data' name='input_3_18_data' value=''><\/div><\/div><div id=\"field_3_19\" class=\"gfield gfield--type-date gfield--input-type-date gfield--input-type-datepicker gfield--datepicker-default-icon gfield--width-half gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_3_19'><span class='gform-field-label__text'>Date<\/span><span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(N\u00e9cessaire)<\/span><\/span><\/label><div class='ginput_container ginput_container_date'>\n\t\t\t\t\t<input\n\t\t\t\t\tplaceholder='mm\/jj\/aaaa'\n\t\t\t\t\tid='input_3_19'\n\t\t\t\t\tclass='datepicker gform-datepicker mdy datepicker_with_icon gdatepicker_with_icon'\n\t\t\t\t\ttype='text'\n\t\t\t\t\tname='input_19'\n\t\t\t\t\tvalue=''\n\t\t\t\t\t \n\t\t\t\t\taria-invalid=\"false\" \n\t\t\t\t\taria-required=\"true\"\n\t\t\t\t\t \n\t\t\t\t\t\n\t\t\t\t\tdata-mask=\"99\/99\/9999\"\n\t\t\t\t\t\/>\n\t\t\t\t<kbd id='keyboardHint_input_3_19' hidden class='down'><\/kbd>\n\t\t\t\t<button type='button' id='datepicker_toggle_input_3_19' class='gform-datepicker-toggle gform-datepicker-toggle--default accCalendar aria-date-picker gform-button gform-theme-button gform-theme-button--simple gform-theme-button--simple-in-ctrl' aria-expanded='false' aria-controls='input_3_19' aria-label='Date: Choose date on calendar' >\n\t\t\t\t\t\t\t<span class=\"gform-calendar-icon gform-datepicker-toggle-icon gform-datepicker-toggle-icon--default dashicons dashicons-calendar-alt\" aria-hidden=\"true\"><\/span>\n\t\t\t\t\t\t<\/button>\n\t\t\t<\/div><\/div><div id=\"field_3_17\" class=\"gfield gfield--type-html gfield--input-type-html gfield--width-full gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  >***This consent is valid until \/ Ce consentement est valide jusqu\u2019\u00e0 : End of treatment \/ Fin du traitement<\/div><\/div><\/div>\n        <div class='gform-page-footer gform_page_footer top_label'><button type='submit' id='gform_previous_button_3' class='gform_previous_button gform-theme-button gform-theme-button--secondary button' onclick='gform.submission.handleButtonClick(this);' data-submission-type='previous' >Previous<\/button> <button type='submit' id='gform_submit_button_3' class='gform_button button' onclick='gform.submission.handleButtonClick(this);' data-submission-type='submit' >Envoyer<\/button> <button type='button'  id='gform_save_3_footer_link' onclick='gform.submission.handleButtonClick(this);' data-submission-type='save-continue' class='gform_save_link gform-theme-button gform-theme-button--secondary button'  ><svg aria-hidden=\"true\" focusable=\"false\" width=\"16\" height=\"16\" fill=\"none\" xmlns=\"http:\/\/www.w3.org\/2000\/svg\"><path fill-rule=\"evenodd\" clip-rule=\"evenodd\" d=\"M0 8a4 4 0 004 4h3v3a1 1 0 102 0v-3h3a4 4 0 100-8 4 4 0 10-8 0 4 4 0 00-4 4zm9 4H7V7.414L5.707 8.707a1 1 0 01-1.414-1.414l3-3a1 1 0 011.414 0l3 3a1 1 0 01-1.414 1.414L9 7.414V12z\" fill=\"#6B7280\"\/><\/svg> Save and Continue Later<\/button>\n            <input type='hidden' class='gform_hidden' name='gform_submission_method' data-js='gform_submission_method_3' value='postback' \/>\n            <input type='hidden' class='gform_hidden' name='gform_theme' data-js='gform_theme_3' id='gform_theme_3' value='gravity-theme' \/>\n            <input type='hidden' class='gform_hidden' name='gform_style_settings' data-js='gform_style_settings_3' id='gform_style_settings_3' value='[]' \/>\n            <input type='hidden' class='gform_hidden' name='is_submit_3' value='1' \/>\n            <input type='hidden' class='gform_hidden' name='gform_submit' value='3' \/>\n            <input type='hidden' class='gform_hidden' name='gform_save' id='gform_save_3' value='' \/>\n                             <input type='hidden' class='gform_hidden' name='gform_resume_token' id='gform_resume_token_3' value='' \/>\n            <input type='hidden' class='gform_hidden' name='gform_currency' data-currency='CAD' value='kAxdFDn0XSrEjk1FPn8O+BP8dvxm+56YGYJSLdNmKV8MpIjGi+wF9YYIT7yI8LPLbKvI8nSCNiQ\/xfwVbCm0crlMp3BH3Dj3CpDKo1P2OI0UMwk=' \/>\n            <input type='hidden' class='gform_hidden' name='gform_unique_id' value='' \/>\n            <input type='hidden' class='gform_hidden' name='state_3' 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\/>\n            <input type='hidden' autocomplete='off' class='gform_hidden' name='gform_target_page_number_3' id='gform_target_page_number_3' value='2' \/>\n            <input type='hidden' autocomplete='off' class='gform_hidden' name='gform_source_page_number_3' id='gform_source_page_number_3' value='1' \/>\n            <input type='hidden' name='gform_field_values' value='' \/>\n            <input type='hidden' name='gform_uploaded_files' id='gform_uploaded_files_3' value='' \/>\n        <\/div>\n             <\/div><\/div>\n                        <\/form>\n                        <\/div>[\/et_pb_text][\/et_pb_column][\/et_pb_row][\/et_pb_section]<\/p>\n","protected":false},"excerpt":{"rendered":"\n                <div class='gf_browser_gecko gform_wrapper gravity-theme gform-theme--no-framework' data-form-theme='gravity-theme' data-form-index='0' id='gform_wrapper_3' style='display:none'><div id='gf_3' class='gform_anchor' tabindex='-1'><\/div>\n                        <div class='gform_heading'>\n                            <h2 class=\"gform_title\">Intake Form<\/h2>\n                            <p class='gform_description'><\/p>\n                        <\/div><form method='post' enctype='multipart\/form-data'  id='gform_3'  action='\/fr\/wp-json\/wp\/v2\/pages\/100770#gf_3' data-formid='3' novalidate><input id=\"gpnf_session_hash_3\" type=\"hidden\" name=\"gpnf_session_hash\" value=\"034b38a04532\"><input id=\"gw_page_progression\" name=\"gw_page_progression\" value=\"1\" type=\"hidden\" \/><input id=\"gpmpn_pages_visited_3\" name=\"gpmpn_pages_visited_3\" value=\"[1]\" type=\"hidden\" \/><input id=\"gpmpn_page_validity_3\" name=\"gpmpn_page_validity_3\" value=\"{&quot;1&quot;:false,&quot;2&quot;:false,&quot;3&quot;:false,&quot;4&quot;:false,&quot;5&quot;:false,&quot;6&quot;:false,&quot;7&quot;:false,&quot;8&quot;:false,&quot;9&quot;:false,&quot;10&quot;:false,&quot;11&quot;:false,&quot;12&quot;:false,&quot;13&quot;:false,&quot;14&quot;:false,&quot;15&quot;:false,&quot;16&quot;:false,&quot;17&quot;:false,&quot;18&quot;:false,&quot;19&quot;:false,&quot;20&quot;:false,&quot;21&quot;:false,&quot;22&quot;:false,&quot;23&quot;:false,&quot;24&quot;:false,&quot;25&quot;:false}\" type=\"hidden\" \/><div id='gf_page_steps_3' class='gf_page_steps'><div id='gf_step_3_1' class='gf_step gf_step_active gf_step_first'><span class='gf_step_number'>1<\/span><span class='gf_step_label'><\/span><\/div><div id='gf_step_3_2' class='gf_step gf_step_next gf_step_pending'><span class='gf_step_number'>2<\/span><span class='gf_step_label'><\/span><\/div><div id='gf_step_3_3' class='gf_step gf_step_pending'><span class='gf_step_number'>3<\/span><span class='gf_step_label'><\/span><\/div><div id='gf_step_3_4' class='gf_step gf_step_pending'><span class='gf_step_number'>4<\/span><span class='gf_step_label'><\/span><\/div><div id='gf_step_3_5' class='gf_step gf_step_pending'><span class='gf_step_number'>5<\/span><span class='gf_step_label'><\/span><\/div><div id='gf_step_3_6' class='gf_step gf_step_pending'><span class='gf_step_number'>6<\/span><span class='gf_step_label'><\/span><\/div><div id='gf_step_3_7' class='gf_step gf_step_pending'><span class='gf_step_number'>7<\/span><span class='gf_step_label'><\/span><\/div><div id='gf_step_3_8' class='gf_step gf_step_pending'><span class='gf_step_number'>8<\/span><span class='gf_step_label'><\/span><\/div><div id='gf_step_3_9' class='gf_step gf_step_pending'><span class='gf_step_number'>9<\/span><span class='gf_step_label'><\/span><\/div><div id='gf_step_3_10' class='gf_step gf_step_pending'><span class='gf_step_number'>10<\/span><span class='gf_step_label'><\/span><\/div><div id='gf_step_3_11' class='gf_step gf_step_pending'><span class='gf_step_number'>11<\/span><span class='gf_step_label'><\/span><\/div><div id='gf_step_3_12' class='gf_step gf_step_pending'><span class='gf_step_number'>12<\/span><span class='gf_step_label'><\/span><\/div><div id='gf_step_3_13' class='gf_step gf_step_pending'><span class='gf_step_number'>13<\/span><span class='gf_step_label'><\/span><\/div><div id='gf_step_3_14' class='gf_step gf_step_pending'><span class='gf_step_number'>14<\/span><span class='gf_step_label'><\/span><\/div><div id='gf_step_3_15' class='gf_step gf_step_pending'><span class='gf_step_number'>15<\/span><span class='gf_step_label'><\/span><\/div><div id='gf_step_3_16' class='gf_step gf_step_pending'><span class='gf_step_number'>16<\/span><span class='gf_step_label'><\/span><\/div><div id='gf_step_3_17' class='gf_step gf_step_pending'><span class='gf_step_number'>17<\/span><span class='gf_step_label'><\/span><\/div><div id='gf_step_3_18' class='gf_step gf_step_pending'><span class='gf_step_number'>18<\/span><span class='gf_step_label'><\/span><\/div><div id='gf_step_3_19' class='gf_step gf_step_pending'><span class='gf_step_number'>19<\/span><span class='gf_step_label'><\/span><\/div><div id='gf_step_3_20' class='gf_step gf_step_pending'><span class='gf_step_number'>20<\/span><span class='gf_step_label'><\/span><\/div><div id='gf_step_3_21' class='gf_step gf_step_pending'><span class='gf_step_number'>21<\/span><span class='gf_step_label'><\/span><\/div><div id='gf_step_3_22' class='gf_step gf_step_pending'><span class='gf_step_number'>22<\/span><span class='gf_step_label'><\/span><\/div><div id='gf_step_3_23' class='gf_step gf_step_pending'><span class='gf_step_number'>23<\/span><span class='gf_step_label'><\/span><\/div><div id='gf_step_3_24' class='gf_step gf_step_pending'><span class='gf_step_number'>24<\/span><span class='gf_step_label'><\/span><\/div><div id='gf_step_3_25' class='gf_step gf_step_last gf_step_pending'><span class='gf_step_number'>25<\/span><span class='gf_step_label'><\/span><\/div><\/div>\n                        <div class='gform-body gform_body'><div id='gform_page_3_1' class='gform_page ' data-js='page-field-id-0' >\n\t\t\t\t\t<div class='gform_page_fields'><div id='gform_fields_3' class='gform_fields top_label form_sublabel_below description_below validation_below'><div id=\"field_3_1\" class=\"gfield gfield--type-section gfield--input-type-section gsection field_sublabel_below gfield--has-description field_description_below field_validation_below gfield_visibility_visible\"  ><h3 class=\"gsection_title\">Consent to the Collection, Use, and Disclosure of Personal Health Information<\/h3><div class='gsection_description' id='gfield_description_3_1'>Pursuant to the Personal Health Information Protection Act, 2004 (PHIPA)<\/div><\/div><fieldset id=\"field_3_3\" class=\"gfield gfield--type-address gfield--input-type-address gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' ><span class='gform-field-label__text'>Youth&#039;s Address<\/span><span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(N\u00e9cessaire)<\/span><\/span><\/legend>    \n                    <div class='ginput_complex ginput_container has_street has_street2 has_city has_state has_zip ginput_container_address gform-grid-row' id='input_3_3' >\n                         <span class='ginput_full address_line_1 ginput_address_line_1 gform-grid-col' id='input_3_3_1_container' >\n                                        <input type='text' name='input_3.1' id='input_3_3_1' value=''    aria-required='true'   autocomplete=\"address-line1\" \/>\n                                        <label for='input_3_3_1' id='input_3_3_1_label' class='gform-field-label gform-field-label--type-sub '>Adresse postale<\/label>\n                                    <\/span><span class='ginput_full address_line_2 ginput_address_line_2 gform-grid-col' id='input_3_3_2_container' >\n                                        <input type='text' name='input_3.2' id='input_3_3_2' value=''    autocomplete=\"address-line2\" aria-required='false'   \/>\n                                        <label for='input_3_3_2' id='input_3_3_2_label' class='gform-field-label gform-field-label--type-sub '>Adresse ligne 2<\/label>\n                                    <\/span><span class='ginput_left address_city ginput_address_city gform-grid-col' id='input_3_3_3_container' >\n                                    <input type='text' name='input_3.3' id='input_3_3_3' value=''    aria-required='true'   autocomplete=\"address-level2\" \/>\n                                    <label for='input_3_3_3' id='input_3_3_3_label' class='gform-field-label gform-field-label--type-sub '>Ville<\/label>\n                                 <\/span><span class='ginput_right address_state ginput_address_state gform-grid-col' id='input_3_3_4_container' >\n                                        <select name='input_3.4' id='input_3_3_4'     aria-required='true'   autocomplete=\"address-level1\" ><option value='' ><\/option><option value='Alberta' >Alberta<\/option><option value='Colombie-Britannique' >Colombie-Britannique<\/option><option value='Manitoba' >Manitoba<\/option><option value='Nouveau-Brunswick' >Nouveau-Brunswick<\/option><option value='Terre-Neuve-et-Labrador' >Terre-Neuve-et-Labrador<\/option><option value='Territoires du Nord-Ouest' >Territoires du Nord-Ouest<\/option><option value='Nouvelle-\u00c9cosse' >Nouvelle-\u00c9cosse<\/option><option value='Nunavut' >Nunavut<\/option><option value='Ontario' selected='selected'>Ontario<\/option><option value='\u00cele du Prince-\u00c9douard' >\u00cele du Prince-\u00c9douard<\/option><option value='Qu\u00e9bec' >Qu\u00e9bec<\/option><option value='Saskatchewan' >Saskatchewan<\/option><option value='Yukon' >Yukon<\/option><\/select>\n                                        <label for='input_3_3_4' id='input_3_3_4_label' class='gform-field-label gform-field-label--type-sub '>Province<\/label>\n                                      <\/span><span class='ginput_left address_zip ginput_address_zip gform-grid-col' id='input_3_3_5_container' >\n                                    <input type='text' name='input_3.5' id='input_3_3_5' value=''    aria-required='true'   autocomplete=\"postal-code\" \/>\n                                    <label for='input_3_3_5' id='input_3_3_5_label' class='gform-field-label gform-field-label--type-sub '>Code postal<\/label>\n                                <\/span><input type='hidden' class='gform_hidden' name='input_3.6' id='input_3_3_6' value='CA' \/>\n                    <div class='gf_clear gf_clear_complex'><\/div>\n                <\/div><\/fieldset><div id=\"field_3_7\" class=\"gfield gfield--type-section gfield--input-type-section gsection field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><h3 class=\"gsection_title\">Consent \/ Authorization<\/h3><\/div><fieldset id=\"field_3_5\" class=\"gfield gfield--type-name gfield--input-type-name gfield--width-full gfield_contains_required field_sublabel_below gfield--has-description field_description_above field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' ><span class='gform-field-label__text'>Parent\/Guardian Name<\/span><span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(N\u00e9cessaire)<\/span><\/span><\/legend><div class='gfield_description' id='gfield_description_3_5'>(parent\/guardian or youth over 16)<\/div><div class='ginput_complex ginput_container ginput_container--name no_prefix has_first_name no_middle_name has_last_name no_suffix gf_name_has_2 ginput_container_name gform-grid-row' id='input_3_5'>\n                            \n                            <span id='input_3_5_3_container' class='name_first gform-grid-col gform-grid-col--size-auto' >\n                                                    <input type='text' name='input_5.3' id='input_3_5_3' value=''   aria-required='true'     \/>\n                                                    <label for='input_3_5_3' class='gform-field-label gform-field-label--type-sub '>Pr\u00e9nom<\/label>\n                                                <\/span>\n                            \n                            <span id='input_3_5_6_container' class='name_last gform-grid-col gform-grid-col--size-auto' >\n                                                    <input type='text' name='input_5.6' id='input_3_5_6' value=''   aria-required='true'     \/>\n                                                    <label for='input_3_5_6' class='gform-field-label gform-field-label--type-sub '>Nom<\/label>\n                                                <\/span>\n                            \n                        <\/div><\/fieldset><fieldset id=\"field_3_4\" class=\"gfield gfield--type-consent gfield--type-choice gfield--input-type-consent gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible gfield--choice-align-vertical\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' ><span class='gform-field-label__text'>Consent<\/span><span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(N\u00e9cessaire)<\/span><\/span><\/legend><div class='ginput_container ginput_container_consent'><input name='input_4.1' id='input_3_4_1' type='checkbox' value='1'   aria-required=\"true\" aria-invalid=\"false\"   \/> <label class=\"gform-field-label gform-field-label--type-inline gfield_consent_label\" for='input_3_4_1' ><span class='gform-field-label__text'>I authorize Roberts\/Smart Centre, 104-1737 Woodward Drive, Ottawa, ON K2C 0P9 to collect, use, and disclose:<\/span><\/label><input type='hidden' name='input_4.2' value='I authorize Roberts\/Smart Centre, 104-1737 Woodward Drive, Ottawa, ON K2C 0P9 to collect, use, and disclose:' class='gform_hidden' \/><input type='hidden' name='input_4.3' value='1' class='gform_hidden' \/><\/div><\/fieldset><fieldset id=\"field_3_8\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-third gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible gfield--choice-align-vertical\"  ><legend class='gfield_label gform-field-label' ><span class='gform-field-label__text'>Health Information<\/span><span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(N\u00e9cessaire)<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_3_8'>\n\t\t\t<div class='gchoice gchoice_3_8_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_8' type='radio' value='my personal health information'  id='choice_3_8_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_3_8_0' id='label_3_8_0' class='gform-field-label gform-field-label--type-inline'>my personal health information<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_3_8_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_8' type='radio' value='the personal health information of'  id='choice_3_8_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_3_8_1' id='label_3_8_1' class='gform-field-label gform-field-label--type-inline'>the personal health information of<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_3_9\" class=\"gfield gfield--type-name gfield--input-type-name gfield--width-two-thirds gfield_contains_required field_sublabel_below gfield--has-description field_description_above field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' ><span class='gform-field-label__text'>Name<\/span><span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(N\u00e9cessaire)<\/span><\/span><\/legend><div class='gfield_description' id='gfield_description_3_9'>(Name of youth under 16 years of age for whom you are the parent\/guardian)<\/div><div class='ginput_complex ginput_container ginput_container--name no_prefix has_first_name no_middle_name has_last_name no_suffix gf_name_has_2 ginput_container_name gform-grid-row' id='input_3_9'>\n                            \n                            <span id='input_3_9_3_container' class='name_first gform-grid-col gform-grid-col--size-auto' >\n                                                    <input type='text' name='input_9.3' id='input_3_9_3' value=''   aria-required='true'     \/>\n                                                    <label for='input_3_9_3' class='gform-field-label gform-field-label--type-sub '>Pr\u00e9nom<\/label>\n                                                <\/span>\n                            \n                            <span id='input_3_9_6_container' class='name_last gform-grid-col gform-grid-col--size-auto' >\n                                                    <input type='text' name='input_9.6' id='input_3_9_6' value=''   aria-required='true'     \/>\n                                                    <label for='input_3_9_6' class='gform-field-label gform-field-label--type-sub '>Nom<\/label>\n                                                <\/span>\n                            \n                        <\/div><\/fieldset><div id=\"field_3_11\" class=\"gfield gfield--type-form gfield--input-type-form gform-theme__no-reset--children gfield--width-full field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_3_11'><span class='gform-field-label__text'>With the following:<\/span><\/label><div class=\"gpnf-nested-entries-container ginput_container\">\n\n\t<table class=\"gpnf-nested-entries\">\n\n\t\t<thead>\n\t\t<tr>\n\t\t\t\t\t\t\t<th scope=\"col\" class=\"gpnf-field-7\">\n\t\t\t\t\tName\t\t\t\t<\/th>\n\t\t\t\t\t\t\t<th scope=\"col\" class=\"gpnf-field-6\">\n\t\t\t\t\tOrganization & Role\t\t\t\t<\/th>\n\t\t\t\t\t\t\t<th scope=\"col\" class=\"gpnf-field-4\">\n\t\t\t\t\tPhone\t\t\t\t<\/th>\n\t\t\t\t\t\t\t<th scope=\"col\" class=\"gpnf-field-5\">\n\t\t\t\t\tEmail\t\t\t\t<\/th>\n\t\t\t\t\t\t<th scope=\"col\" class=\"gpnf-row-actions\"><span class=\"screen-reader-text\">Actions<\/span><\/th>\n\t\t<\/tr>\n\t\t<\/thead>\n\n\t\t<tbody data-bind=\"visible: entries().length, foreach: entries\">\n\t\t<tr data-bind=\"attr: { 'data-entryid': id }\">\n\t\t\t\t\t\t\t<td class=\"gpnf-field\"\n\t\t\t\t\tdata-bind=\"html: f7.label, attr: { 'data-value': f7.label }\"\n\t\t\t\t\tdata-heading=\"Name\"\n\t\t\t\t>&nbsp;<\/td>\n\t\t\t\t\t\t\t<td class=\"gpnf-field\"\n\t\t\t\t\tdata-bind=\"html: f6.label, attr: { 'data-value': f6.label }\"\n\t\t\t\t\tdata-heading=\"Organization & Role\"\n\t\t\t\t>&nbsp;<\/td>\n\t\t\t\t\t\t\t<td class=\"gpnf-field\"\n\t\t\t\t\tdata-bind=\"html: f4.label, attr: { 'data-value': f4.label }\"\n\t\t\t\t\tdata-heading=\"Phone\"\n\t\t\t\t>&nbsp;<\/td>\n\t\t\t\t\t\t\t<td class=\"gpnf-field\"\n\t\t\t\t\tdata-bind=\"html: f5.label, attr: { 'data-value': f5.label }\"\n\t\t\t\t\tdata-heading=\"Email\"\n\t\t\t\t>&nbsp;<\/td>\n\t\t\t\t\t\t<td class=\"gpnf-row-actions\" style=\"display: none;\" data-bind=\"visible: true\">\n\t\t\t\t<ul>\n\t\t\t\t\t<li class=\"edit\"><button type=\"button\" class=\"edit-button gform-theme-button--secondary\" data-bind=\"click: $parent.editEntry, attr: { 'aria-label': 'Edit Entr\u00e9e {0} where Name is {1}.'.gformFormat( $index() + 1, f7.label ) }\">Modifier<\/button><\/li>\n\t\t\t\t\t\t\t\t\t\t<li class=\"delete\"><button type=\"button\" class=\"delete-button gform-theme-button--simple gform-theme-button--size-md\" data-bind=\"click: $parent.deleteEntry, attr: { 'aria-label': 'Delete Entr\u00e9e {0} where Name is {1}.'.gformFormat( $index() + 1, f7.label ) }\">Supprimer<\/button><\/li>\n\t\t\t\t<\/ul>\n\t\t\t<\/td>\n\t\t<\/tr>\n\t\t<\/tbody>\n\n\t\t<tbody data-bind=\"visible: entries().length <= 0\">\n\t\t<tr class=\"gpnf-no-entries\" data-bind=\"visible: entries().length <= 0\" style=\"display: none;\">\n\t\t\t<td colspan=\"5\">\n\t\t\t\tIl n\u2019y a aucun(e) <span>Entr\u00e9es.<\/span>\t\t\t<\/td>\n\t\t<\/tr>\n\t\t<\/tbody>\n\n\t<\/table>\n\n\t<button type=\"button\" class=\"gpnf-add-entry\"\n\t\t        data-formid=\"3\"\n\t\t        data-nestedformid=\"4\"\n\t\t\t\tdata-bind=\"attr: { disabled: isMaxed }, css: { 'gf-default-disabled': isMaxed }\"\n\t\t\t\t>\n\t\t\t\tAjouter Entr\u00e9e\n\t\t\t<\/button>\t\n\t\t\t<p class=\"gpnf-add-entry-max\" data-bind=\"visible: isMaxed\" style=\"display: none;\">\n\t\t\t\tLe nombre maximal a \u00e9t\u00e9 atteint.\n\t\t\t<\/p>\n<\/div>\n<input type=\"hidden\"\n                name=\"input_11\"\n                id=\"input_3_11\"\n                data-bind=\"value: entryIds\"\n                value=\"\" \/><\/div><div id=\"field_3_12\" class=\"gfield gfield--type-html gfield--input-type-html gfield--width-full gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><p>Information requested and the reason the information is needed:<\/p>\n<p style=\"text-decoration: italics; text-decoration: underline;\">For case management, treatment planning, and service delivery.<\/p>\n<p>I understand the purpose of the collection, use, and disclosure of my or my child\u2019s personal health information between the Roberts\/Smart Centre and the person(s)\/organization(s) listed above. I understand that I can review or withdraw my consent at any time.<\/p><\/div><\/div>\n                    <\/div>\n                    <div class='gform-page-footer gform_page_footer top_label'>\n                         <button type='button' id='gform_next_button_3_10' class='gform_next_button gform-theme-button button' onclick='gform.submission.handleButtonClick(this);' data-submission-type='next' >Next<\/button> <button type='button'  id='gform_save_3_2_link' onclick='gform.submission.handleButtonClick(this);' data-submission-type='save-continue' class='gform_save_link gform-theme-button gform-theme-button--secondary button'  ><svg aria-hidden=\"true\" focusable=\"false\" width=\"16\" height=\"16\" fill=\"none\" xmlns=\"http:\/\/www.w3.org\/2000\/svg\"><path fill-rule=\"evenodd\" clip-rule=\"evenodd\" d=\"M0 8a4 4 0 004 4h3v3a1 1 0 102 0v-3h3a4 4 0 100-8 4 4 0 10-8 0 4 4 0 00-4 4zm9 4H7V7.414L5.707 8.707a1 1 0 01-1.414-1.414l3-3a1 1 0 011.414 0l3 3a1 1 0 01-1.414 1.414L9 7.414V12z\" fill=\"#6B7280\"\/><\/svg> Save and Continue Later<\/button>\n                    <\/div>\n                <\/div>\n                <div id='gform_page_3_2' class='gform_page' data-js='page-field-id-10' style='display:none;'>\n                    <div class='gform_page_fields'>\n                        <div id='gform_fields_3_2' class='gform_fields top_label form_sublabel_below description_below validation_below'><div id=\"field_3_21\" class=\"gfield gfield--type-section gfield--input-type-section gsection field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><h3 class=\"gsection_title\">SECTION A<\/h3><\/div><div id=\"field_3_22\" class=\"gfield gfield--type-form gfield--input-type-form gform-theme__no-reset--children gfield--width-full field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_3_22'><span class='gform-field-label__text'>PROFESSIONALS RESPONSIBLE FOR THE REFERRAL\/APPLICATION<\/span><\/label><div class=\"gpnf-nested-entries-container ginput_container\">\n\n\t<table class=\"gpnf-nested-entries\">\n\n\t\t<thead>\n\t\t<tr>\n\t\t\t\t\t\t\t<th scope=\"col\" class=\"gpnf-field-7\">\n\t\t\t\t\tName\t\t\t\t<\/th>\n\t\t\t\t\t\t\t<th scope=\"col\" class=\"gpnf-field-6\">\n\t\t\t\t\tOrganization & Role\t\t\t\t<\/th>\n\t\t\t\t\t\t\t<th scope=\"col\" class=\"gpnf-field-4\">\n\t\t\t\t\tPhone\t\t\t\t<\/th>\n\t\t\t\t\t\t\t<th scope=\"col\" class=\"gpnf-field-5\">\n\t\t\t\t\tEmail\t\t\t\t<\/th>\n\t\t\t\t\t\t<th scope=\"col\" class=\"gpnf-row-actions\"><span class=\"screen-reader-text\">Actions<\/span><\/th>\n\t\t<\/tr>\n\t\t<\/thead>\n\n\t\t<tbody data-bind=\"visible: entries().length, foreach: entries\">\n\t\t<tr data-bind=\"attr: { 'data-entryid': id }\">\n\t\t\t\t\t\t\t<td class=\"gpnf-field\"\n\t\t\t\t\tdata-bind=\"html: f7.label, attr: { 'data-value': f7.label }\"\n\t\t\t\t\tdata-heading=\"Name\"\n\t\t\t\t>&nbsp;<\/td>\n\t\t\t\t\t\t\t<td class=\"gpnf-field\"\n\t\t\t\t\tdata-bind=\"html: f6.label, attr: { 'data-value': f6.label }\"\n\t\t\t\t\tdata-heading=\"Organization & Role\"\n\t\t\t\t>&nbsp;<\/td>\n\t\t\t\t\t\t\t<td class=\"gpnf-field\"\n\t\t\t\t\tdata-bind=\"html: f4.label, attr: { 'data-value': f4.label }\"\n\t\t\t\t\tdata-heading=\"Phone\"\n\t\t\t\t>&nbsp;<\/td>\n\t\t\t\t\t\t\t<td class=\"gpnf-field\"\n\t\t\t\t\tdata-bind=\"html: f5.label, attr: { 'data-value': f5.label }\"\n\t\t\t\t\tdata-heading=\"Email\"\n\t\t\t\t>&nbsp;<\/td>\n\t\t\t\t\t\t<td class=\"gpnf-row-actions\" style=\"display: none;\" data-bind=\"visible: true\">\n\t\t\t\t<ul>\n\t\t\t\t\t<li class=\"edit\"><button type=\"button\" class=\"edit-button gform-theme-button--secondary\" data-bind=\"click: $parent.editEntry, attr: { 'aria-label': 'Edit Entr\u00e9e {0} where Name is {1}.'.gformFormat( $index() + 1, f7.label ) }\">Modifier<\/button><\/li>\n\t\t\t\t\t\t\t\t\t\t<li class=\"delete\"><button type=\"button\" class=\"delete-button gform-theme-button--simple gform-theme-button--size-md\" data-bind=\"click: $parent.deleteEntry, attr: { 'aria-label': 'Delete Entr\u00e9e {0} where Name is {1}.'.gformFormat( $index() + 1, f7.label ) }\">Supprimer<\/button><\/li>\n\t\t\t\t<\/ul>\n\t\t\t<\/td>\n\t\t<\/tr>\n\t\t<\/tbody>\n\n\t\t<tbody data-bind=\"visible: entries().length <= 0\">\n\t\t<tr class=\"gpnf-no-entries\" data-bind=\"visible: entries().length <= 0\" style=\"display: none;\">\n\t\t\t<td colspan=\"5\">\n\t\t\t\tIl n\u2019y a aucun(e) <span>Entr\u00e9es.<\/span>\t\t\t<\/td>\n\t\t<\/tr>\n\t\t<\/tbody>\n\n\t<\/table>\n\n\t<button type=\"button\" class=\"gpnf-add-entry\"\n\t\t        data-formid=\"3\"\n\t\t        data-nestedformid=\"4\"\n\t\t\t\tdata-bind=\"attr: { disabled: isMaxed }, css: { 'gf-default-disabled': isMaxed }\"\n\t\t\t\t>\n\t\t\t\tAjouter Entr\u00e9e\n\t\t\t<\/button>\t\n\t\t\t<p class=\"gpnf-add-entry-max\" data-bind=\"visible: isMaxed\" style=\"display: none;\">\n\t\t\t\tLe nombre maximal a \u00e9t\u00e9 atteint.\n\t\t\t<\/p>\n<\/div>\n<input type=\"hidden\"\n                name=\"input_22\"\n                id=\"input_3_22\"\n                data-bind=\"value: entryIds\"\n                value=\"\" \/><\/div><fieldset id=\"field_3_23\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield--input-type-checkbox gf_list_2col gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible gfield--choice-align-columns\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' ><span class='gform-field-label__text'>RSC Program Requested<\/span><span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(N\u00e9cessaire)<\/span><\/span><\/legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox ' id='input_3_23'><div class='gchoice gchoice_3_23_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_23.1' type='checkbox'  value='Open Live-In Treatment'  id='choice_3_23_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_3_23_1' id='label_3_23_1' class='gform-field-label gform-field-label--type-inline'>Open Live-In Treatment<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_3_23_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_23.2' type='checkbox'  value='Secure Treatment'  id='choice_3_23_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_3_23_2' id='label_3_23_2' class='gform-field-label gform-field-label--type-inline'>Secure Treatment<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_3_24\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield--input-type-checkbox gf_list_2col gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible gfield--choice-align-columns\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' ><span class='gform-field-label__text'>Is the youth consenting to this treatment application?<\/span><span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(N\u00e9cessaire)<\/span><\/span><\/legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox ' id='input_3_24'><div class='gchoice gchoice_3_24_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_24.1' type='checkbox'  value='Yes'  id='choice_3_24_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_3_24_1' id='label_3_24_1' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_3_24_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_24.2' type='checkbox'  value='No'  id='choice_3_24_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_3_24_2' id='label_3_24_2' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_3_28\" class=\"gfield gfield--type-section gfield--input-type-section gsection field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><h3 class=\"gsection_title\">Youth\u2019s Personal Information<\/h3><\/div><fieldset id=\"field_3_25\" class=\"gfield gfield--type-name gfield--input-type-name gfield--width-full field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' ><span class='gform-field-label__text'>Youth&#039;s Name<\/span><\/legend><div class='ginput_complex ginput_container ginput_container--name no_prefix has_first_name no_middle_name has_last_name no_suffix gf_name_has_2 ginput_container_name gform-grid-row' id='input_3_25'>\n                            \n                            <span id='input_3_25_3_container' class='name_first gform-grid-col gform-grid-col--size-auto' >\n                                                    <input type='text' name='input_25.3' id='input_3_25_3' value=''   aria-required='false'     \/>\n                                                    <label for='input_3_25_3' class='gform-field-label gform-field-label--type-sub '>Pr\u00e9nom<\/label>\n                                                <\/span>\n                            \n                            <span id='input_3_25_6_container' class='name_last gform-grid-col gform-grid-col--size-auto' >\n                                                    <input type='text' name='input_25.6' id='input_3_25_6' value=''   aria-required='false'     \/>\n                                                    <label for='input_3_25_6' class='gform-field-label gform-field-label--type-sub '>Nom<\/label>\n                                                <\/span>\n                            \n                        <\/div><\/fieldset><fieldset id=\"field_3_26\" class=\"gfield gfield--type-address gfield--input-type-address gfield--width-full field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' ><span class='gform-field-label__text'>Current Address<\/span><\/legend>    \n                    <div class='ginput_complex ginput_container has_street has_street2 has_city has_state has_zip ginput_container_address gform-grid-row' id='input_3_26' >\n                         <span class='ginput_full address_line_1 ginput_address_line_1 gform-grid-col' id='input_3_26_1_container' >\n                                        <input type='text' name='input_26.1' id='input_3_26_1' value=''    aria-required='false'    \/>\n                                        <label for='input_3_26_1' id='input_3_26_1_label' class='gform-field-label gform-field-label--type-sub '>Adresse postale<\/label>\n                                    <\/span><span class='ginput_full address_line_2 ginput_address_line_2 gform-grid-col' id='input_3_26_2_container' >\n                                        <input type='text' name='input_26.2' id='input_3_26_2' value=''     aria-required='false'   \/>\n                                        <label for='input_3_26_2' id='input_3_26_2_label' class='gform-field-label gform-field-label--type-sub '>Adresse ligne 2<\/label>\n                                    <\/span><span class='ginput_left address_city ginput_address_city gform-grid-col' id='input_3_26_3_container' >\n                                    <input type='text' name='input_26.3' id='input_3_26_3' value=''    aria-required='false'    \/>\n                                    <label for='input_3_26_3' id='input_3_26_3_label' class='gform-field-label gform-field-label--type-sub '>Ville<\/label>\n                                 <\/span><span class='ginput_right address_state ginput_address_state gform-grid-col' id='input_3_26_4_container' >\n                                        <select name='input_26.4' id='input_3_26_4'     aria-required='false'    ><option value='' selected='selected'><\/option><option value='Alberta' >Alberta<\/option><option value='Colombie-Britannique' >Colombie-Britannique<\/option><option value='Manitoba' >Manitoba<\/option><option value='Nouveau-Brunswick' >Nouveau-Brunswick<\/option><option value='Terre-Neuve-et-Labrador' >Terre-Neuve-et-Labrador<\/option><option value='Territoires du Nord-Ouest' >Territoires du Nord-Ouest<\/option><option value='Nouvelle-\u00c9cosse' >Nouvelle-\u00c9cosse<\/option><option value='Nunavut' >Nunavut<\/option><option value='Ontario' >Ontario<\/option><option value='\u00cele du Prince-\u00c9douard' >\u00cele du Prince-\u00c9douard<\/option><option value='Qu\u00e9bec' >Qu\u00e9bec<\/option><option value='Saskatchewan' >Saskatchewan<\/option><option value='Yukon' >Yukon<\/option><\/select>\n                                        <label for='input_3_26_4' id='input_3_26_4_label' class='gform-field-label gform-field-label--type-sub '>Province<\/label>\n                                      <\/span><span class='ginput_left address_zip ginput_address_zip gform-grid-col' id='input_3_26_5_container' >\n                                    <input type='text' name='input_26.5' id='input_3_26_5' value=''    aria-required='false'    \/>\n                                    <label for='input_3_26_5' id='input_3_26_5_label' class='gform-field-label gform-field-label--type-sub '>Code postal<\/label>\n                                <\/span><input type='hidden' class='gform_hidden' name='input_26.6' id='input_3_26_6' value='CA' \/>\n                    <div class='gf_clear gf_clear_complex'><\/div>\n                <\/div><\/fieldset><div id=\"field_3_27\" class=\"gfield gfield--type-phone gfield--input-type-phone gfield--phone-format-international gfield--width-five-twelfths field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_3_27'><span class='gform-field-label__text'>Home Phone<\/span><\/label><div class='ginput_container ginput_container_phone'><input name='input_27' id='input_3_27' type='tel' value='' class='large'    aria-invalid=\"false\"    \/><\/div><\/div><fieldset id=\"field_3_230\" class=\"gfield gfield--type-date gfield--input-type-date gfield--input-type-datefield gfield--width-seven-twelfths gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' ><span class='gform-field-label__text'>Date of Birth<\/span><span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(N\u00e9cessaire)<\/span><\/span><\/legend><div id='input_3_230' class='ginput_container ginput_complex gform-grid-row'><div class='gfield_date_month ginput_container ginput_container_date gform-grid-col' id='input_3_230_1_container'>\n                                        <input type='number' maxlength='2' name='input_230[]' id='input_3_230_1' value=''   aria-required='true'   placeholder='MM' min='1' max='12' step='1'\/>\n                                        <label for='input_3_230_1' class='gform-field-label gform-field-label--type-sub screen-reader-text'>Mois<\/label>\n                                    <\/div><div class='gfield_date_day ginput_container ginput_container_date gform-grid-col' id='input_3_230_2_container'>\n                                        <input type='number' maxlength='2' name='input_230[]' id='input_3_230_2' value=''   aria-required='true'   placeholder='JJ' min='1' max='31' step='1'\/>\n                                        <label for='input_3_230_2' class='gform-field-label gform-field-label--type-sub screen-reader-text'>Jour<\/label>\n                                    <\/div><div class='gfield_date_year ginput_container ginput_container_date gform-grid-col' id='input_3_230_3_container'>\n                                        <input type='number' maxlength='4' name='input_230[]' id='input_3_230_3' value=''   aria-required='true'   placeholder='AAAA' min='1920' max='2027' step='1'\/>\n                                        <label for='input_3_230_3' class='gform-field-label gform-field-label--type-sub screen-reader-text'>Ann\u00e9e<\/label>\n                                   <\/div>\n                               <\/div><\/fieldset><div id=\"field_3_29\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-half gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_3_29'><span class='gform-field-label__text'>Gender Identity<\/span><span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(N\u00e9cessaire)<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_29' id='input_3_29' type='text' value='' class='large'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_3_30\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-half field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_3_30'><span class='gform-field-label__text'>Preferred Pronoun(s)<\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_30' id='input_3_30' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/div><fieldset id=\"field_3_31\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-half gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible gfield--choice-align-vertical\"  ><legend class='gfield_label gform-field-label' ><span class='gform-field-label__text'>Primary Language<\/span><span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(N\u00e9cessaire)<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_3_31'>\n\t\t\t<div class='gchoice gchoice_3_31_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_31' type='radio' value='English'  id='choice_3_31_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_3_31_0' id='label_3_31_0' class='gform-field-label gform-field-label--type-inline'>English<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_3_31_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_31' type='radio' value='French'  id='choice_3_31_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_3_31_1' id='label_3_31_1' class='gform-field-label gform-field-label--type-inline'>French<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_3_31_2'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_31' type='radio' value='Other'  id='choice_3_31_2' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_3_31_2' id='label_3_31_2' class='gform-field-label gform-field-label--type-inline'>Other<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_3_32\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-half field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_3_32'><span class='gform-field-label__text'>Other Language<\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_32' id='input_3_32' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/div><fieldset id=\"field_3_33\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible gfield--choice-align-vertical\"  ><legend class='gfield_label gform-field-label' ><span class='gform-field-label__text'>Language for Treatment<\/span><span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(N\u00e9cessaire)<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_3_33'>\n\t\t\t<div class='gchoice gchoice_3_33_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_33' type='radio' value='I prefer to receive counselling and treatment documentation in English'  id='choice_3_33_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_3_33_0' id='label_3_33_0' class='gform-field-label gform-field-label--type-inline'>I prefer to receive counselling and treatment documentation in English<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_3_33_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_33' type='radio' value='Je pr\u00e9f\u00e8re recevoir des conseils et des documents sur le traitement en fran\u00e7ais.'  id='choice_3_33_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_3_33_1' id='label_3_33_1' class='gform-field-label gform-field-label--type-inline'>Je pr\u00e9f\u00e8re recevoir des conseils et des documents sur le traitement en fran\u00e7ais.<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><\/div>\n                    <\/div>\n                    <div class='gform-page-footer gform_page_footer top_label'>\n                        <button type='button' id='gform_previous_button_3_34' class='gform_previous_button gform-theme-button gform-theme-button--secondary button' onclick='gform.submission.handleButtonClick(this);' data-submission-type='previous' >Previous<\/button> <button type='button' id='gform_next_button_3_34' class='gform_next_button gform-theme-button button' onclick='gform.submission.handleButtonClick(this);' data-submission-type='next' >Next<\/button> <button type='button'  id='gform_save_3_3_link' onclick='gform.submission.handleButtonClick(this);' data-submission-type='save-continue' class='gform_save_link gform-theme-button gform-theme-button--secondary button'  ><svg aria-hidden=\"true\" focusable=\"false\" width=\"16\" height=\"16\" fill=\"none\" xmlns=\"http:\/\/www.w3.org\/2000\/svg\"><path fill-rule=\"evenodd\" clip-rule=\"evenodd\" d=\"M0 8a4 4 0 004 4h3v3a1 1 0 102 0v-3h3a4 4 0 100-8 4 4 0 10-8 0 4 4 0 00-4 4zm9 4H7V7.414L5.707 8.707a1 1 0 01-1.414-1.414l3-3a1 1 0 011.414 0l3 3a1 1 0 01-1.414 1.414L9 7.414V12z\" fill=\"#6B7280\"\/><\/svg> Save and Continue Later<\/button>\n                    <\/div>\n                <\/div>\n                <div id='gform_page_3_3' class='gform_page' data-js='page-field-id-34' style='display:none;'>\n                    <div class='gform_page_fields'>\n                        <div id='gform_fields_3_3' class='gform_fields top_label form_sublabel_below description_below validation_below'><div id=\"field_3_35\" class=\"gfield gfield--type-section gfield--input-type-section gsection field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><h3 class=\"gsection_title\">School Information<\/h3><\/div><div id=\"field_3_36\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-half field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_3_36'><span class='gform-field-label__text'>School Name<\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_36' id='input_3_36' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_3_37\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-half field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_3_37'><span class='gform-field-label__text'>Grade<\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_37' id='input_3_37' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/div><fieldset id=\"field_3_38\" class=\"gfield gfield--type-address gfield--input-type-address gfield--width-full field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' ><span class='gform-field-label__text'>School Address<\/span><\/legend>    \n                    <div class='ginput_complex ginput_container has_street has_street2 has_city has_state has_zip ginput_container_address gform-grid-row' id='input_3_38' >\n                         <span class='ginput_full address_line_1 ginput_address_line_1 gform-grid-col' id='input_3_38_1_container' >\n                                        <input type='text' name='input_38.1' id='input_3_38_1' value=''    aria-required='false'    \/>\n                                        <label for='input_3_38_1' id='input_3_38_1_label' class='gform-field-label gform-field-label--type-sub '>Adresse postale<\/label>\n                                    <\/span><span class='ginput_full address_line_2 ginput_address_line_2 gform-grid-col' id='input_3_38_2_container' >\n                                        <input type='text' name='input_38.2' id='input_3_38_2' value=''     aria-required='false'   \/>\n                                        <label for='input_3_38_2' id='input_3_38_2_label' class='gform-field-label gform-field-label--type-sub '>Adresse ligne 2<\/label>\n                                    <\/span><span class='ginput_left address_city ginput_address_city gform-grid-col' id='input_3_38_3_container' >\n                                    <input type='text' name='input_38.3' id='input_3_38_3' value=''    aria-required='false'    \/>\n                                    <label for='input_3_38_3' id='input_3_38_3_label' class='gform-field-label gform-field-label--type-sub '>Ville<\/label>\n                                 <\/span><span class='ginput_right address_state ginput_address_state gform-grid-col' id='input_3_38_4_container' >\n                                        <select name='input_38.4' id='input_3_38_4'     aria-required='false'    ><option value='' ><\/option><option value='Alberta' >Alberta<\/option><option value='Colombie-Britannique' >Colombie-Britannique<\/option><option value='Manitoba' >Manitoba<\/option><option value='Nouveau-Brunswick' >Nouveau-Brunswick<\/option><option value='Terre-Neuve-et-Labrador' >Terre-Neuve-et-Labrador<\/option><option value='Territoires du Nord-Ouest' >Territoires du Nord-Ouest<\/option><option value='Nouvelle-\u00c9cosse' >Nouvelle-\u00c9cosse<\/option><option value='Nunavut' >Nunavut<\/option><option value='Ontario' selected='selected'>Ontario<\/option><option value='\u00cele du Prince-\u00c9douard' >\u00cele du Prince-\u00c9douard<\/option><option value='Qu\u00e9bec' >Qu\u00e9bec<\/option><option value='Saskatchewan' >Saskatchewan<\/option><option value='Yukon' >Yukon<\/option><\/select>\n                                        <label for='input_3_38_4' id='input_3_38_4_label' class='gform-field-label gform-field-label--type-sub '>Province<\/label>\n                                      <\/span><span class='ginput_left address_zip ginput_address_zip gform-grid-col' id='input_3_38_5_container' >\n                                    <input type='text' name='input_38.5' id='input_3_38_5' value=''    aria-required='false'    \/>\n                                    <label for='input_3_38_5' id='input_3_38_5_label' class='gform-field-label gform-field-label--type-sub '>Code postal<\/label>\n                                <\/span><input type='hidden' class='gform_hidden' name='input_38.6' id='input_3_38_6' value='CA' \/>\n                    <div class='gf_clear gf_clear_complex'><\/div>\n                <\/div><\/fieldset><div id=\"field_3_39\" class=\"gfield gfield--type-phone gfield--input-type-phone gfield--phone-format-international gfield--width-half field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_3_39'><span class='gform-field-label__text'>Phone<\/span><\/label><div class='ginput_container ginput_container_phone'><input name='input_39' id='input_3_39' type='tel' value='' class='large'    aria-invalid=\"false\"    \/><\/div><\/div><div id=\"field_3_40\" class=\"gfield gfield--type-email gfield--input-type-email gfield--width-half field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_3_40'><span class='gform-field-label__text'>Email<\/span><\/label><div class='ginput_container ginput_container_email'>\n                            <input name='input_40' id='input_3_40' type='email' value='' class='large'     aria-invalid=\"false\"  \/>\n                        <\/div><\/div><fieldset id=\"field_3_41\" class=\"gfield gfield--type-name gfield--input-type-name gfield--width-three-quarter field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' ><span class='gform-field-label__text'>Principal&#039;s Name<\/span><\/legend><div class='ginput_complex ginput_container ginput_container--name no_prefix has_first_name no_middle_name has_last_name no_suffix gf_name_has_2 ginput_container_name gform-grid-row' id='input_3_41'>\n                            \n                            <span id='input_3_41_3_container' class='name_first gform-grid-col gform-grid-col--size-auto' >\n                                                    <input type='text' name='input_41.3' id='input_3_41_3' value=''   aria-required='false'     \/>\n                                                    <label for='input_3_41_3' class='gform-field-label gform-field-label--type-sub '>Pr\u00e9nom<\/label>\n                                                <\/span>\n                            \n                            <span id='input_3_41_6_container' class='name_last gform-grid-col gform-grid-col--size-auto' >\n                                                    <input type='text' name='input_41.6' id='input_3_41_6' value=''   aria-required='false'     \/>\n                                                    <label for='input_3_41_6' class='gform-field-label gform-field-label--type-sub '>Nom<\/label>\n                                                <\/span>\n                            \n                        <\/div><\/fieldset><div id=\"field_3_42\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-quarter field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_3_42'><span class='gform-field-label__text'>Extension<\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_42' id='input_3_42' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/div><fieldset id=\"field_3_43\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gf_list_2col gfield--width-full field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible gfield--choice-align-columns\"  ><legend class='gfield_label gform-field-label' ><span class='gform-field-label__text'>Will the youth continue to attend their current school?<\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_3_43'>\n\t\t\t<div class='gchoice gchoice_3_43_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_43' type='radio' value='Yes'  id='choice_3_43_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_3_43_0' id='label_3_43_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_3_43_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_43' type='radio' value='No'  id='choice_3_43_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_3_43_1' id='label_3_43_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_3_44\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gf_list_2col gfield--width-full field_sublabel_below gfield--has-description field_description_below field_validation_below gfield_visibility_visible gfield--choice-align-columns\"  ><legend class='gfield_label gform-field-label' ><span class='gform-field-label__text'>Will the youth attend RSC\u2019s Private Academy*?<\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_3_44'>\n\t\t\t<div class='gchoice gchoice_3_44_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_44' type='radio' value='Yes'  id='choice_3_44_0' onchange='gformToggleRadioOther( this )' aria-describedby=\"gfield_description_3_44\"   \/>\n\t\t\t\t\t<label for='choice_3_44_0' id='label_3_44_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_3_44_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_44' type='radio' value='No'  id='choice_3_44_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_3_44_1' id='label_3_44_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/div><div class='gfield_description' id='gfield_description_3_44'>*The Debbie Campbell Learning Academy provides temporary or long-term academic opportunities for students who find it\ndifficult to function in the traditional school setting. While concurrently dealing with the challenges of their particular behavioural\nissues, students have the opportunity to achieve provincially recognized credits, with the long-term goal of providing the skills\nnecessary for continued academic success.<\/div><\/fieldset><div id=\"field_3_45\" class=\"gfield gfield--type-textarea gfield--input-type-textarea gfield--width-full field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_3_45'><span class='gform-field-label__text'>If no, what\u2019s the plan for school while in live-in treatment?<\/span><\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_45' id='input_3_45' class='textarea large'      aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/div><\/div>\n                    <\/div>\n                    <div class='gform-page-footer gform_page_footer top_label'>\n                        <button type='button' id='gform_previous_button_3_46' class='gform_previous_button gform-theme-button gform-theme-button--secondary button' onclick='gform.submission.handleButtonClick(this);' data-submission-type='previous' >Previous<\/button> <button type='button' id='gform_next_button_3_46' class='gform_next_button gform-theme-button button' onclick='gform.submission.handleButtonClick(this);' data-submission-type='next' >Next<\/button> <button type='button'  id='gform_save_3_4_link' onclick='gform.submission.handleButtonClick(this);' data-submission-type='save-continue' class='gform_save_link gform-theme-button gform-theme-button--secondary button'  ><svg aria-hidden=\"true\" focusable=\"false\" width=\"16\" height=\"16\" fill=\"none\" xmlns=\"http:\/\/www.w3.org\/2000\/svg\"><path fill-rule=\"evenodd\" clip-rule=\"evenodd\" d=\"M0 8a4 4 0 004 4h3v3a1 1 0 102 0v-3h3a4 4 0 100-8 4 4 0 10-8 0 4 4 0 00-4 4zm9 4H7V7.414L5.707 8.707a1 1 0 01-1.414-1.414l3-3a1 1 0 011.414 0l3 3a1 1 0 01-1.414 1.414L9 7.414V12z\" fill=\"#6B7280\"\/><\/svg> Save and Continue Later<\/button>\n                    <\/div>\n                <\/div>\n                <div id='gform_page_3_4' class='gform_page' data-js='page-field-id-46' style='display:none;'>\n                    <div class='gform_page_fields'>\n                        <div id='gform_fields_3_4' class='gform_fields top_label form_sublabel_below description_below validation_below'><div id=\"field_3_47\" class=\"gfield gfield--type-section gfield--input-type-section gsection field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><h3 class=\"gsection_title\">Family Information<\/h3><\/div><fieldset id=\"field_3_48\" class=\"gfield gfield--type-name gfield--input-type-name gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' ><span class='gform-field-label__text'>Legal Guardian<\/span><span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(N\u00e9cessaire)<\/span><\/span><\/legend><div class='ginput_complex ginput_container ginput_container--name no_prefix has_first_name no_middle_name has_last_name no_suffix gf_name_has_2 ginput_container_name gform-grid-row' id='input_3_48'>\n                            \n                            <span id='input_3_48_3_container' class='name_first gform-grid-col gform-grid-col--size-auto' >\n                                                    <input type='text' name='input_48.3' id='input_3_48_3' value=''   aria-required='true'     \/>\n                                                    <label for='input_3_48_3' class='gform-field-label gform-field-label--type-sub '>Pr\u00e9nom<\/label>\n                                                <\/span>\n                            \n                            <span id='input_3_48_6_container' class='name_last gform-grid-col gform-grid-col--size-auto' >\n                                                    <input type='text' name='input_48.6' id='input_3_48_6' value=''   aria-required='true'     \/>\n                                                    <label for='input_3_48_6' class='gform-field-label gform-field-label--type-sub '>Nom<\/label>\n                                                <\/span>\n                            \n                        <\/div><\/fieldset><fieldset id=\"field_3_49\" class=\"gfield gfield--type-address gfield--input-type-address gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' ><span class='gform-field-label__text'>Address<\/span><span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(N\u00e9cessaire)<\/span><\/span><\/legend>    \n                    <div class='ginput_complex ginput_container has_street has_street2 has_city has_state has_zip ginput_container_address gform-grid-row' id='input_3_49' >\n                         <span class='ginput_full address_line_1 ginput_address_line_1 gform-grid-col' id='input_3_49_1_container' >\n                                        <input type='text' name='input_49.1' id='input_3_49_1' value=''    aria-required='true'    \/>\n                                        <label for='input_3_49_1' id='input_3_49_1_label' class='gform-field-label gform-field-label--type-sub '>Adresse postale<\/label>\n                                    <\/span><span class='ginput_full address_line_2 ginput_address_line_2 gform-grid-col' id='input_3_49_2_container' >\n                                        <input type='text' name='input_49.2' id='input_3_49_2' value=''     aria-required='false'   \/>\n                                        <label for='input_3_49_2' id='input_3_49_2_label' class='gform-field-label gform-field-label--type-sub '>Adresse ligne 2<\/label>\n                                    <\/span><span class='ginput_left address_city ginput_address_city gform-grid-col' id='input_3_49_3_container' >\n                                    <input type='text' name='input_49.3' id='input_3_49_3' value=''    aria-required='true'    \/>\n                                    <label for='input_3_49_3' id='input_3_49_3_label' class='gform-field-label gform-field-label--type-sub '>Ville<\/label>\n                                 <\/span><span class='ginput_right address_state ginput_address_state gform-grid-col' id='input_3_49_4_container' >\n                                        <select name='input_49.4' id='input_3_49_4'     aria-required='true'    ><option value='' ><\/option><option value='Alberta' >Alberta<\/option><option value='Colombie-Britannique' >Colombie-Britannique<\/option><option value='Manitoba' >Manitoba<\/option><option value='Nouveau-Brunswick' >Nouveau-Brunswick<\/option><option value='Terre-Neuve-et-Labrador' >Terre-Neuve-et-Labrador<\/option><option value='Territoires du Nord-Ouest' >Territoires du Nord-Ouest<\/option><option value='Nouvelle-\u00c9cosse' >Nouvelle-\u00c9cosse<\/option><option value='Nunavut' >Nunavut<\/option><option value='Ontario' selected='selected'>Ontario<\/option><option value='\u00cele du Prince-\u00c9douard' >\u00cele du Prince-\u00c9douard<\/option><option value='Qu\u00e9bec' >Qu\u00e9bec<\/option><option value='Saskatchewan' >Saskatchewan<\/option><option value='Yukon' >Yukon<\/option><\/select>\n                                        <label for='input_3_49_4' id='input_3_49_4_label' class='gform-field-label gform-field-label--type-sub '>Province<\/label>\n                                      <\/span><span class='ginput_left address_zip ginput_address_zip gform-grid-col' id='input_3_49_5_container' >\n                                    <input type='text' name='input_49.5' id='input_3_49_5' value=''    aria-required='true'    \/>\n                                    <label for='input_3_49_5' id='input_3_49_5_label' class='gform-field-label gform-field-label--type-sub '>Code postal<\/label>\n                                <\/span><input type='hidden' class='gform_hidden' name='input_49.6' id='input_3_49_6' value='CA' \/>\n                    <div class='gf_clear gf_clear_complex'><\/div>\n                <\/div><\/fieldset><div id=\"field_3_229\" class=\"gfield gfield--type-email gfield--input-type-email gfield--width-third gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_3_229'><span class='gform-field-label__text'>Email<\/span><span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(N\u00e9cessaire)<\/span><\/span><\/label><div class='ginput_container ginput_container_email'>\n                            <input name='input_229' id='input_3_229' type='email' value='' class='large'    aria-required=\"true\" aria-invalid=\"false\"  \/>\n                        <\/div><\/div><div id=\"field_3_227\" class=\"gfield gfield--type-phone gfield--input-type-phone gfield--phone-format-international gfield--width-third gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_3_227'><span class='gform-field-label__text'>Home\/Main<\/span><span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(N\u00e9cessaire)<\/span><\/span><\/label><div class='ginput_container ginput_container_phone'><input name='input_227' id='input_3_227' type='tel' value='' class='large'   aria-required=\"true\" aria-invalid=\"false\"    \/><\/div><\/div><div id=\"field_3_228\" class=\"gfield gfield--type-phone gfield--input-type-phone gfield--phone-format-international gfield--width-third field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_3_228'><span class='gform-field-label__text'>Work\/Other<\/span><\/label><div class='ginput_container ginput_container_phone'><input name='input_228' id='input_3_228' type='tel' value='' class='large'    aria-invalid=\"false\"    \/><\/div><\/div><div id=\"field_3_52\" class=\"gfield gfield--type-section gfield--input-type-section gsection field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><h3 class=\"gsection_title\">Parent 1<\/h3><\/div><fieldset id=\"field_3_51\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield--input-type-checkbox gfield--width-full field_sublabel_below gfield--no-description field_description_below hidden_label field_validation_below gfield_visibility_visible gfield--choice-align-vertical\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' ><span class='gform-field-label__text'>Same as Legal Guardian<\/span><\/legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox ' id='input_3_51'><div class='gchoice gchoice_3_51_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_51.1' type='checkbox'  value='Same as Legal Guardian'  id='choice_3_51_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_3_51_1' id='label_3_51_1' class='gform-field-label gform-field-label--type-inline'>Same as Legal Guardian<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_3_53\" class=\"gfield gfield--type-address gfield--input-type-address gfield--width-full field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' ><span class='gform-field-label__text'>Address<\/span><\/legend>    \n                    <div class='ginput_complex ginput_container has_street has_street2 has_city has_state has_zip ginput_container_address gform-grid-row' id='input_3_53' >\n                         <span class='ginput_full address_line_1 ginput_address_line_1 gform-grid-col' id='input_3_53_1_container' >\n                                        <input type='text' name='input_53.1' id='input_3_53_1' value=''    aria-required='false'    \/>\n                                        <label for='input_3_53_1' id='input_3_53_1_label' class='gform-field-label gform-field-label--type-sub '>Adresse postale<\/label>\n                                    <\/span><span class='ginput_full address_line_2 ginput_address_line_2 gform-grid-col' id='input_3_53_2_container' >\n                                        <input type='text' name='input_53.2' id='input_3_53_2' value=''     aria-required='false'   \/>\n                                        <label for='input_3_53_2' id='input_3_53_2_label' class='gform-field-label gform-field-label--type-sub '>Adresse ligne 2<\/label>\n                                    <\/span><span class='ginput_left address_city ginput_address_city gform-grid-col' id='input_3_53_3_container' >\n                                    <input type='text' name='input_53.3' id='input_3_53_3' value=''    aria-required='false'    \/>\n                                    <label for='input_3_53_3' id='input_3_53_3_label' class='gform-field-label gform-field-label--type-sub '>Ville<\/label>\n                                 <\/span><span class='ginput_right address_state ginput_address_state gform-grid-col' id='input_3_53_4_container' >\n                                        <select name='input_53.4' id='input_3_53_4'     aria-required='false'    ><option value='' ><\/option><option value='Alberta' >Alberta<\/option><option value='Colombie-Britannique' >Colombie-Britannique<\/option><option value='Manitoba' >Manitoba<\/option><option value='Nouveau-Brunswick' >Nouveau-Brunswick<\/option><option value='Terre-Neuve-et-Labrador' >Terre-Neuve-et-Labrador<\/option><option value='Territoires du Nord-Ouest' >Territoires du Nord-Ouest<\/option><option value='Nouvelle-\u00c9cosse' >Nouvelle-\u00c9cosse<\/option><option value='Nunavut' >Nunavut<\/option><option value='Ontario' selected='selected'>Ontario<\/option><option value='\u00cele du Prince-\u00c9douard' >\u00cele du Prince-\u00c9douard<\/option><option value='Qu\u00e9bec' >Qu\u00e9bec<\/option><option value='Saskatchewan' >Saskatchewan<\/option><option value='Yukon' >Yukon<\/option><\/select>\n                                        <label for='input_3_53_4' id='input_3_53_4_label' class='gform-field-label gform-field-label--type-sub '>Province<\/label>\n                                      <\/span><span class='ginput_left address_zip ginput_address_zip gform-grid-col' id='input_3_53_5_container' >\n                                    <input type='text' name='input_53.5' id='input_3_53_5' value=''    aria-required='false'    \/>\n                                    <label for='input_3_53_5' id='input_3_53_5_label' class='gform-field-label gform-field-label--type-sub '>Code postal<\/label>\n                                <\/span><input type='hidden' class='gform_hidden' name='input_53.6' id='input_3_53_6' value='CA' \/>\n                    <div class='gf_clear gf_clear_complex'><\/div>\n                <\/div><\/fieldset><fieldset id=\"field_3_50\" class=\"gfield gfield--type-name gfield--input-type-name gfield--width-full field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' ><span class='gform-field-label__text'>Parent&#039;s Name<\/span><\/legend><div class='ginput_complex ginput_container ginput_container--name no_prefix has_first_name no_middle_name has_last_name no_suffix gf_name_has_2 ginput_container_name gform-grid-row' id='input_3_50'>\n                            \n                            <span id='input_3_50_3_container' class='name_first gform-grid-col gform-grid-col--size-auto' >\n                                                    <input type='text' name='input_50.3' id='input_3_50_3' value=''   aria-required='false'     \/>\n                                                    <label for='input_3_50_3' class='gform-field-label gform-field-label--type-sub '>Pr\u00e9nom<\/label>\n                                                <\/span>\n                            \n                            <span id='input_3_50_6_container' class='name_last gform-grid-col gform-grid-col--size-auto' >\n                                                    <input type='text' name='input_50.6' id='input_3_50_6' value=''   aria-required='false'     \/>\n                                                    <label for='input_3_50_6' class='gform-field-label gform-field-label--type-sub '>Nom<\/label>\n                                                <\/span>\n                            \n                        <\/div><\/fieldset><div id=\"field_3_54\" class=\"gfield gfield--type-phone gfield--input-type-phone gfield--phone-format-international gfield--width-third field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_3_54'><span class='gform-field-label__text'>Home Phone<\/span><\/label><div class='ginput_container ginput_container_phone'><input name='input_54' id='input_3_54' type='tel' value='' class='large'    aria-invalid=\"false\"    \/><\/div><\/div><div id=\"field_3_55\" class=\"gfield gfield--type-phone gfield--input-type-phone gfield--phone-format-international gfield--width-third field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_3_55'><span class='gform-field-label__text'>Work Phone<\/span><\/label><div class='ginput_container ginput_container_phone'><input name='input_55' id='input_3_55' type='tel' value='' class='large'    aria-invalid=\"false\"    \/><\/div><\/div><div id=\"field_3_56\" class=\"gfield gfield--type-phone gfield--input-type-phone gfield--phone-format-international gfield--width-third field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_3_56'><span class='gform-field-label__text'>Cell Phone<\/span><\/label><div class='ginput_container ginput_container_phone'><input name='input_56' id='input_3_56' type='tel' value='' class='large'    aria-invalid=\"false\"    \/><\/div><\/div><div id=\"field_3_57\" class=\"gfield gfield--type-section gfield--input-type-section gsection field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><h3 class=\"gsection_title\">Parent 2<\/h3><\/div><fieldset id=\"field_3_58\" class=\"gfield gfield--type-name gfield--input-type-name gfield--width-full field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' ><span class='gform-field-label__text'>Parent&#039;s Name<\/span><\/legend><div class='ginput_complex ginput_container ginput_container--name no_prefix has_first_name no_middle_name has_last_name no_suffix gf_name_has_2 ginput_container_name gform-grid-row' id='input_3_58'>\n                            \n                            <span id='input_3_58_3_container' class='name_first gform-grid-col gform-grid-col--size-auto' >\n                                                    <input type='text' name='input_58.3' id='input_3_58_3' value=''   aria-required='false'     \/>\n                                                    <label for='input_3_58_3' class='gform-field-label gform-field-label--type-sub '>Pr\u00e9nom<\/label>\n                                                <\/span>\n                            \n                            <span id='input_3_58_6_container' class='name_last gform-grid-col gform-grid-col--size-auto' >\n                                                    <input type='text' name='input_58.6' id='input_3_58_6' value=''   aria-required='false'     \/>\n                                                    <label for='input_3_58_6' class='gform-field-label gform-field-label--type-sub '>Nom<\/label>\n                                                <\/span>\n                            \n                        <\/div><\/fieldset><fieldset id=\"field_3_60\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield--input-type-checkbox gfield--width-full field_sublabel_below gfield--no-description field_description_below hidden_label field_validation_below gfield_visibility_visible gfield--choice-align-vertical\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' ><span class='gform-field-label__text'>Same as Above<\/span><\/legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox ' id='input_3_60'><div class='gchoice gchoice_3_60_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_60.1' type='checkbox'  value='Same as Above'  id='choice_3_60_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_3_60_1' id='label_3_60_1' class='gform-field-label gform-field-label--type-inline'>Same as Above<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_3_61\" class=\"gfield gfield--type-address gfield--input-type-address gfield--width-full field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' ><span class='gform-field-label__text'>Address<\/span><\/legend>    \n                    <div class='ginput_complex ginput_container has_street has_street2 has_city has_state has_zip ginput_container_address gform-grid-row' id='input_3_61' >\n                         <span class='ginput_full address_line_1 ginput_address_line_1 gform-grid-col' id='input_3_61_1_container' >\n                                        <input type='text' name='input_61.1' id='input_3_61_1' value=''    aria-required='false'    \/>\n                                        <label for='input_3_61_1' id='input_3_61_1_label' class='gform-field-label gform-field-label--type-sub '>Adresse postale<\/label>\n                                    <\/span><span class='ginput_full address_line_2 ginput_address_line_2 gform-grid-col' id='input_3_61_2_container' >\n                                        <input type='text' name='input_61.2' id='input_3_61_2' value=''     aria-required='false'   \/>\n                                        <label for='input_3_61_2' id='input_3_61_2_label' class='gform-field-label gform-field-label--type-sub '>Adresse ligne 2<\/label>\n                                    <\/span><span class='ginput_left address_city ginput_address_city gform-grid-col' id='input_3_61_3_container' >\n                                    <input type='text' name='input_61.3' id='input_3_61_3' value=''    aria-required='false'    \/>\n                                    <label for='input_3_61_3' id='input_3_61_3_label' class='gform-field-label gform-field-label--type-sub '>Ville<\/label>\n                                 <\/span><span class='ginput_right address_state ginput_address_state gform-grid-col' id='input_3_61_4_container' >\n                                        <select name='input_61.4' id='input_3_61_4'     aria-required='false'    ><option value='' ><\/option><option value='Alberta' >Alberta<\/option><option value='Colombie-Britannique' >Colombie-Britannique<\/option><option value='Manitoba' >Manitoba<\/option><option value='Nouveau-Brunswick' >Nouveau-Brunswick<\/option><option value='Terre-Neuve-et-Labrador' >Terre-Neuve-et-Labrador<\/option><option value='Territoires du Nord-Ouest' >Territoires du Nord-Ouest<\/option><option value='Nouvelle-\u00c9cosse' >Nouvelle-\u00c9cosse<\/option><option value='Nunavut' >Nunavut<\/option><option value='Ontario' selected='selected'>Ontario<\/option><option value='\u00cele du Prince-\u00c9douard' >\u00cele du Prince-\u00c9douard<\/option><option value='Qu\u00e9bec' >Qu\u00e9bec<\/option><option value='Saskatchewan' >Saskatchewan<\/option><option value='Yukon' >Yukon<\/option><\/select>\n                                        <label for='input_3_61_4' id='input_3_61_4_label' class='gform-field-label gform-field-label--type-sub '>Province<\/label>\n                                      <\/span><span class='ginput_left address_zip ginput_address_zip gform-grid-col' id='input_3_61_5_container' >\n                                    <input type='text' name='input_61.5' id='input_3_61_5' value=''    aria-required='false'    \/>\n                                    <label for='input_3_61_5' id='input_3_61_5_label' class='gform-field-label gform-field-label--type-sub '>Code postal<\/label>\n                                <\/span><input type='hidden' class='gform_hidden' name='input_61.6' id='input_3_61_6' value='CA' \/>\n                    <div class='gf_clear gf_clear_complex'><\/div>\n                <\/div><\/fieldset><div id=\"field_3_62\" class=\"gfield gfield--type-phone gfield--input-type-phone gfield--phone-format-international gfield--width-third field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_3_62'><span class='gform-field-label__text'>Home Phone<\/span><\/label><div class='ginput_container ginput_container_phone'><input name='input_62' id='input_3_62' type='tel' value='' class='large'    aria-invalid=\"false\"    \/><\/div><\/div><div id=\"field_3_63\" class=\"gfield gfield--type-phone gfield--input-type-phone gfield--phone-format-international gfield--width-third field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_3_63'><span class='gform-field-label__text'>Work Phone<\/span><\/label><div class='ginput_container ginput_container_phone'><input name='input_63' id='input_3_63' type='tel' value='' class='large'    aria-invalid=\"false\"    \/><\/div><\/div><div id=\"field_3_64\" class=\"gfield gfield--type-phone gfield--input-type-phone gfield--phone-format-international gfield--width-third field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_3_64'><span class='gform-field-label__text'>Cell Phone<\/span><\/label><div class='ginput_container ginput_container_phone'><input name='input_64' id='input_3_64' type='tel' value='' class='large'    aria-invalid=\"false\"    \/><\/div><\/div><div id=\"field_3_65\" class=\"gfield gfield--type-form gfield--input-type-form gform-theme__no-reset--children gfield--width-full field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_3_65'><span class='gform-field-label__text'>Siblings<\/span><\/label><div class=\"gpnf-nested-entries-container ginput_container\">\n\n\t<table class=\"gpnf-nested-entries\">\n\n\t\t<thead>\n\t\t<tr>\n\t\t\t\t\t\t\t<th scope=\"col\" class=\"gpnf-field-1\">\n\t\t\t\t\tName\t\t\t\t<\/th>\n\t\t\t\t\t\t\t<th scope=\"col\" class=\"gpnf-field-3\">\n\t\t\t\t\tDate\t\t\t\t<\/th>\n\t\t\t\t\t\t\t<th scope=\"col\" class=\"gpnf-field-4\">\n\t\t\t\t\tRelationship\t\t\t\t<\/th>\n\t\t\t\t\t\t<th scope=\"col\" class=\"gpnf-row-actions\"><span class=\"screen-reader-text\">Actions<\/span><\/th>\n\t\t<\/tr>\n\t\t<\/thead>\n\n\t\t<tbody data-bind=\"visible: entries().length, foreach: entries\">\n\t\t<tr data-bind=\"attr: { 'data-entryid': id }\">\n\t\t\t\t\t\t\t<td class=\"gpnf-field\"\n\t\t\t\t\tdata-bind=\"html: f1.label, attr: { 'data-value': f1.label }\"\n\t\t\t\t\tdata-heading=\"Name\"\n\t\t\t\t>&nbsp;<\/td>\n\t\t\t\t\t\t\t<td class=\"gpnf-field\"\n\t\t\t\t\tdata-bind=\"html: f3.label, attr: { 'data-value': f3.label }\"\n\t\t\t\t\tdata-heading=\"Date\"\n\t\t\t\t>&nbsp;<\/td>\n\t\t\t\t\t\t\t<td class=\"gpnf-field\"\n\t\t\t\t\tdata-bind=\"html: f4.label, attr: { 'data-value': f4.label }\"\n\t\t\t\t\tdata-heading=\"Relationship\"\n\t\t\t\t>&nbsp;<\/td>\n\t\t\t\t\t\t<td class=\"gpnf-row-actions\" style=\"display: none;\" data-bind=\"visible: true\">\n\t\t\t\t<ul>\n\t\t\t\t\t<li class=\"edit\"><button type=\"button\" class=\"edit-button gform-theme-button--secondary\" data-bind=\"click: $parent.editEntry, attr: { 'aria-label': 'Edit Sibling {0} where Name is {1}.'.gformFormat( $index() + 1, f1.label ) }\">Modifier<\/button><\/li>\n\t\t\t\t\t\t\t\t\t\t<li class=\"delete\"><button type=\"button\" class=\"delete-button gform-theme-button--simple gform-theme-button--size-md\" data-bind=\"click: $parent.deleteEntry, attr: { 'aria-label': 'Delete Sibling {0} where Name is {1}.'.gformFormat( $index() + 1, f1.label ) }\">Supprimer<\/button><\/li>\n\t\t\t\t<\/ul>\n\t\t\t<\/td>\n\t\t<\/tr>\n\t\t<\/tbody>\n\n\t\t<tbody data-bind=\"visible: entries().length <= 0\">\n\t\t<tr class=\"gpnf-no-entries\" data-bind=\"visible: entries().length <= 0\" style=\"display: none;\">\n\t\t\t<td colspan=\"4\">\n\t\t\t\tIl n\u2019y a aucun(e) <span>Siblings.<\/span>\t\t\t<\/td>\n\t\t<\/tr>\n\t\t<\/tbody>\n\n\t<\/table>\n\n\t<button type=\"button\" class=\"gpnf-add-entry\"\n\t\t        data-formid=\"3\"\n\t\t        data-nestedformid=\"5\"\n\t\t\t\tdata-bind=\"attr: { disabled: isMaxed }, css: { 'gf-default-disabled': isMaxed }\"\n\t\t\t\t>\n\t\t\t\tAjouter Sibling\n\t\t\t<\/button>\t\n\t\t\t<p class=\"gpnf-add-entry-max\" data-bind=\"visible: isMaxed\" style=\"display: none;\">\n\t\t\t\tLe nombre maximal a \u00e9t\u00e9 atteint.\n\t\t\t<\/p>\n<\/div>\n<input type=\"hidden\"\n                name=\"input_65\"\n                id=\"input_3_65\"\n                data-bind=\"value: entryIds\"\n                value=\"\" \/><\/div><div id=\"field_3_66\" class=\"gfield gfield--type-form gfield--input-type-form gform-theme__no-reset--children gfield--width-full field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_3_66'><span class='gform-field-label__text'>Other Significant Support<\/span><\/label><div class=\"gpnf-nested-entries-container ginput_container\">\n\n\t<table class=\"gpnf-nested-entries\">\n\n\t\t<thead>\n\t\t<tr>\n\t\t\t\t\t\t\t<th scope=\"col\" class=\"gpnf-field-1\">\n\t\t\t\t\tName\t\t\t\t<\/th>\n\t\t\t\t\t\t\t<th scope=\"col\" class=\"gpnf-field-4\">\n\t\t\t\t\tRelationship\t\t\t\t<\/th>\n\t\t\t\t\t\t\t<th scope=\"col\" class=\"gpnf-field-7\">\n\t\t\t\t\tPhone\t\t\t\t<\/th>\n\t\t\t\t\t\t\t<th scope=\"col\" class=\"gpnf-field-6\">\n\t\t\t\t\tEmail\t\t\t\t<\/th>\n\t\t\t\t\t\t<th scope=\"col\" class=\"gpnf-row-actions\"><span class=\"screen-reader-text\">Actions<\/span><\/th>\n\t\t<\/tr>\n\t\t<\/thead>\n\n\t\t<tbody data-bind=\"visible: entries().length, foreach: entries\">\n\t\t<tr data-bind=\"attr: { 'data-entryid': id }\">\n\t\t\t\t\t\t\t<td class=\"gpnf-field\"\n\t\t\t\t\tdata-bind=\"html: f1.label, attr: { 'data-value': f1.label }\"\n\t\t\t\t\tdata-heading=\"Name\"\n\t\t\t\t>&nbsp;<\/td>\n\t\t\t\t\t\t\t<td class=\"gpnf-field\"\n\t\t\t\t\tdata-bind=\"html: f4.label, attr: { 'data-value': f4.label }\"\n\t\t\t\t\tdata-heading=\"Relationship\"\n\t\t\t\t>&nbsp;<\/td>\n\t\t\t\t\t\t\t<td class=\"gpnf-field\"\n\t\t\t\t\tdata-bind=\"html: f7.label, attr: { 'data-value': f7.label }\"\n\t\t\t\t\tdata-heading=\"Phone\"\n\t\t\t\t>&nbsp;<\/td>\n\t\t\t\t\t\t\t<td class=\"gpnf-field\"\n\t\t\t\t\tdata-bind=\"html: f6.label, attr: { 'data-value': f6.label }\"\n\t\t\t\t\tdata-heading=\"Email\"\n\t\t\t\t>&nbsp;<\/td>\n\t\t\t\t\t\t<td class=\"gpnf-row-actions\" style=\"display: none;\" data-bind=\"visible: true\">\n\t\t\t\t<ul>\n\t\t\t\t\t<li class=\"edit\"><button type=\"button\" class=\"edit-button gform-theme-button--secondary\" data-bind=\"click: $parent.editEntry, attr: { 'aria-label': 'Edit Support {0} where Name is {1}.'.gformFormat( $index() + 1, f1.label ) }\">Modifier<\/button><\/li>\n\t\t\t\t\t\t\t\t\t\t<li class=\"delete\"><button type=\"button\" class=\"delete-button gform-theme-button--simple gform-theme-button--size-md\" data-bind=\"click: $parent.deleteEntry, attr: { 'aria-label': 'Delete Support {0} where Name is {1}.'.gformFormat( $index() + 1, f1.label ) }\">Supprimer<\/button><\/li>\n\t\t\t\t<\/ul>\n\t\t\t<\/td>\n\t\t<\/tr>\n\t\t<\/tbody>\n\n\t\t<tbody data-bind=\"visible: entries().length <= 0\">\n\t\t<tr class=\"gpnf-no-entries\" data-bind=\"visible: entries().length <= 0\" style=\"display: none;\">\n\t\t\t<td colspan=\"5\">\n\t\t\t\tIl n\u2019y a aucun(e) <span>Supports.<\/span>\t\t\t<\/td>\n\t\t<\/tr>\n\t\t<\/tbody>\n\n\t<\/table>\n\n\t<button type=\"button\" class=\"gpnf-add-entry\"\n\t\t        data-formid=\"3\"\n\t\t        data-nestedformid=\"6\"\n\t\t\t\tdata-bind=\"attr: { disabled: isMaxed }, css: { 'gf-default-disabled': isMaxed }\"\n\t\t\t\t>\n\t\t\t\tAjouter Support\n\t\t\t<\/button>\t\n\t\t\t<p class=\"gpnf-add-entry-max\" data-bind=\"visible: isMaxed\" style=\"display: none;\">\n\t\t\t\tLe nombre maximal a \u00e9t\u00e9 atteint.\n\t\t\t<\/p>\n<\/div>\n<input type=\"hidden\"\n                name=\"input_66\"\n                id=\"input_3_66\"\n                data-bind=\"value: entryIds\"\n                value=\"\" \/><\/div><\/div>\n                    <\/div>\n                    <div class='gform-page-footer gform_page_footer top_label'>\n                        <button type='button' id='gform_previous_button_3_67' class='gform_previous_button gform-theme-button gform-theme-button--secondary button' onclick='gform.submission.handleButtonClick(this);' data-submission-type='previous' >Previous<\/button> <button type='button' id='gform_next_button_3_67' class='gform_next_button gform-theme-button button' onclick='gform.submission.handleButtonClick(this);' data-submission-type='next' >Next<\/button> <button type='button'  id='gform_save_3_5_link' onclick='gform.submission.handleButtonClick(this);' data-submission-type='save-continue' class='gform_save_link gform-theme-button gform-theme-button--secondary button'  ><svg aria-hidden=\"true\" focusable=\"false\" width=\"16\" height=\"16\" fill=\"none\" xmlns=\"http:\/\/www.w3.org\/2000\/svg\"><path fill-rule=\"evenodd\" clip-rule=\"evenodd\" d=\"M0 8a4 4 0 004 4h3v3a1 1 0 102 0v-3h3a4 4 0 100-8 4 4 0 10-8 0 4 4 0 00-4 4zm9 4H7V7.414L5.707 8.707a1 1 0 01-1.414-1.414l3-3a1 1 0 011.414 0l3 3a1 1 0 01-1.414 1.414L9 7.414V12z\" fill=\"#6B7280\"\/><\/svg> Save and Continue Later<\/button>\n                    <\/div>\n                <\/div>\n                <div id='gform_page_3_5' class='gform_page' data-js='page-field-id-67' style='display:none;'>\n                    <div class='gform_page_fields'>\n                        <div id='gform_fields_3_5' class='gform_fields top_label form_sublabel_below description_below validation_below'><div id=\"field_3_68\" class=\"gfield gfield--type-section gfield--input-type-section gsection field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><h3 class=\"gsection_title\">Health &amp; Medical Information<\/h3><\/div><div id=\"field_3_69\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_3_69'><span class='gform-field-label__text'>Health Concerns (e.g. allergies, asthmas, etc.)<\/span><span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(N\u00e9cessaire)<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_69' id='input_3_69' type='text' value='' class='large'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_3_70\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-full field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_3_70'><span class='gform-field-label__text'>Accessibility \/ Physical Disabilities<\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_70' id='input_3_70' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_3_71\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-full field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_3_71'><span class='gform-field-label__text'>Diet \/ Nutrition Recommended by DR or RN<\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_71' id='input_3_71' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_3_72\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-half gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_3_72'><span class='gform-field-label__text'>Health Card N\u00b0<\/span><span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(N\u00e9cessaire)<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_72' id='input_3_72' type='text' value='' class='large'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_3_73\" class=\"gfield gfield--type-date gfield--input-type-date gfield--input-type-datepicker gfield--datepicker-default-icon gfield--width-half gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_3_73'><span class='gform-field-label__text'>Expiry Date<\/span><span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(N\u00e9cessaire)<\/span><\/span><\/label><div class='ginput_container ginput_container_date'>\n\t\t\t\t\t<input\n\t\t\t\t\tplaceholder='mm\/jj\/aaaa'\n\t\t\t\t\tid='input_3_73'\n\t\t\t\t\tclass='datepicker gform-datepicker mdy datepicker_with_icon gdatepicker_with_icon'\n\t\t\t\t\ttype='text'\n\t\t\t\t\tname='input_73'\n\t\t\t\t\tvalue=''\n\t\t\t\t\t \n\t\t\t\t\taria-invalid=\"false\" \n\t\t\t\t\taria-required=\"true\"\n\t\t\t\t\t \n\t\t\t\t\t\n\t\t\t\t\tdata-mask=\"99\/99\/9999\"\n\t\t\t\t\t\/>\n\t\t\t\t<kbd id='keyboardHint_input_3_73' hidden class='down'><\/kbd>\n\t\t\t\t<button type='button' id='datepicker_toggle_input_3_73' class='gform-datepicker-toggle gform-datepicker-toggle--default accCalendar aria-date-picker gform-button gform-theme-button gform-theme-button--simple gform-theme-button--simple-in-ctrl' aria-expanded='false' aria-controls='input_3_73' aria-label='Expiry Date: Choose date on calendar' >\n\t\t\t\t\t\t\t<span class=\"gform-calendar-icon gform-datepicker-toggle-icon gform-datepicker-toggle-icon--default dashicons dashicons-calendar-alt\" aria-hidden=\"true\"><\/span>\n\t\t\t\t\t\t<\/button>\n\t\t\t<\/div><\/div><div id=\"field_3_74\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-half gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_3_74'><span class='gform-field-label__text'>Height<\/span><span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(N\u00e9cessaire)<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_74' id='input_3_74' type='text' value='' class='large'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_3_75\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-half gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_3_75'><span class='gform-field-label__text'>Weight (lbs)<\/span><span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(N\u00e9cessaire)<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_75' id='input_3_75' type='text' value='' class='large'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_3_77\" class=\"gfield gfield--type-section gfield--input-type-section gsection field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><h3 class=\"gsection_title\">Family Physician<\/h3><\/div><fieldset id=\"field_3_78\" class=\"gfield gfield--type-name gfield--input-type-name gfield--width-two-thirds field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' ><span class='gform-field-label__text'>Name<\/span><\/legend><div class='ginput_complex ginput_container ginput_container--name no_prefix has_first_name no_middle_name has_last_name no_suffix gf_name_has_2 ginput_container_name gform-grid-row' id='input_3_78'>\n                            \n                            <span id='input_3_78_3_container' class='name_first gform-grid-col gform-grid-col--size-auto' >\n                                                    <input type='text' name='input_78.3' id='input_3_78_3' value=''   aria-required='false'     \/>\n                                                    <label for='input_3_78_3' class='gform-field-label gform-field-label--type-sub '>Pr\u00e9nom<\/label>\n                                                <\/span>\n                            \n                            <span id='input_3_78_6_container' class='name_last gform-grid-col gform-grid-col--size-auto' >\n                                                    <input type='text' name='input_78.6' id='input_3_78_6' value=''   aria-required='false'     \/>\n                                                    <label for='input_3_78_6' class='gform-field-label gform-field-label--type-sub '>Nom<\/label>\n                                                <\/span>\n                            \n                        <\/div><\/fieldset><div id=\"field_3_79\" class=\"gfield gfield--type-phone gfield--input-type-phone gfield--phone-format-international gfield--width-third field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_3_79'><span class='gform-field-label__text'>Phone<\/span><\/label><div class='ginput_container ginput_container_phone'><input name='input_79' id='input_3_79' type='tel' value='' class='large'    aria-invalid=\"false\"    \/><\/div><\/div><div id=\"field_3_80\" class=\"gfield gfield--type-date gfield--input-type-date gfield--input-type-datepicker gfield--datepicker-default-icon gfield--width-quarter field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_3_80'><span class='gform-field-label__text'>Last Medical<\/span><\/label><div class='ginput_container ginput_container_date'>\n\t\t\t\t\t<input\n\t\t\t\t\tplaceholder='mm\/jj\/aaaa'\n\t\t\t\t\tid='input_3_80'\n\t\t\t\t\tclass='datepicker gform-datepicker mdy datepicker_with_icon gdatepicker_with_icon'\n\t\t\t\t\ttype='text'\n\t\t\t\t\tname='input_80'\n\t\t\t\t\tvalue=''\n\t\t\t\t\t \n\t\t\t\t\taria-invalid=\"false\" \n\t\t\t\t\t\n\t\t\t\t\t \n\t\t\t\t\t\n\t\t\t\t\tdata-mask=\"99\/99\/9999\"\n\t\t\t\t\t\/>\n\t\t\t\t<kbd id='keyboardHint_input_3_80' hidden class='down'><\/kbd>\n\t\t\t\t<button type='button' id='datepicker_toggle_input_3_80' class='gform-datepicker-toggle gform-datepicker-toggle--default accCalendar aria-date-picker gform-button gform-theme-button gform-theme-button--simple gform-theme-button--simple-in-ctrl' aria-expanded='false' aria-controls='input_3_80' aria-label='Last Medical: Choose date on calendar' >\n\t\t\t\t\t\t\t<span class=\"gform-calendar-icon gform-datepicker-toggle-icon gform-datepicker-toggle-icon--default dashicons dashicons-calendar-alt\" aria-hidden=\"true\"><\/span>\n\t\t\t\t\t\t<\/button>\n\t\t\t<\/div><\/div><fieldset id=\"field_3_81\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield--input-type-checkbox gfield--width-three-quarter field_sublabel_below gfield--no-description field_description_below hidden_label field_validation_below gfield_visibility_visible gfield--choice-align-vertical\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' ><span class='gform-field-label__text'>Last Medical - Unknown<\/span><\/legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox ' id='input_3_81'><div class='gchoice gchoice_3_81_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_81.1' type='checkbox'  value='Unknown'  id='choice_3_81_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_3_81_1' id='label_3_81_1' class='gform-field-label gform-field-label--type-inline'>Unknown<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_3_82\" class=\"gfield gfield--type-section gfield--input-type-section gsection field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><h3 class=\"gsection_title\">Dentist<\/h3><\/div><fieldset id=\"field_3_83\" class=\"gfield gfield--type-name gfield--input-type-name gfield--width-two-thirds field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' ><span class='gform-field-label__text'>Name<\/span><\/legend><div class='ginput_complex ginput_container ginput_container--name no_prefix has_first_name no_middle_name has_last_name no_suffix gf_name_has_2 ginput_container_name gform-grid-row' id='input_3_83'>\n                            \n                            <span id='input_3_83_3_container' class='name_first gform-grid-col gform-grid-col--size-auto' >\n                                                    <input type='text' name='input_83.3' id='input_3_83_3' value=''   aria-required='false'     \/>\n                                                    <label for='input_3_83_3' class='gform-field-label gform-field-label--type-sub '>Pr\u00e9nom<\/label>\n                                                <\/span>\n                            \n                            <span id='input_3_83_6_container' class='name_last gform-grid-col gform-grid-col--size-auto' >\n                                                    <input type='text' name='input_83.6' id='input_3_83_6' value=''   aria-required='false'     \/>\n                                                    <label for='input_3_83_6' class='gform-field-label gform-field-label--type-sub '>Nom<\/label>\n                                                <\/span>\n                            \n                        <\/div><\/fieldset><div id=\"field_3_84\" class=\"gfield gfield--type-phone gfield--input-type-phone gfield--phone-format-international gfield--width-third field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_3_84'><span class='gform-field-label__text'>Phone<\/span><\/label><div class='ginput_container ginput_container_phone'><input name='input_84' id='input_3_84' type='tel' value='' class='large'    aria-invalid=\"false\"    \/><\/div><\/div><div id=\"field_3_85\" class=\"gfield gfield--type-date gfield--input-type-date gfield--input-type-datepicker gfield--datepicker-default-icon gfield--width-quarter field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_3_85'><span class='gform-field-label__text'>Last Dental<\/span><\/label><div class='ginput_container ginput_container_date'>\n\t\t\t\t\t<input\n\t\t\t\t\tplaceholder='mm\/jj\/aaaa'\n\t\t\t\t\tid='input_3_85'\n\t\t\t\t\tclass='datepicker gform-datepicker mdy datepicker_with_icon gdatepicker_with_icon'\n\t\t\t\t\ttype='text'\n\t\t\t\t\tname='input_85'\n\t\t\t\t\tvalue=''\n\t\t\t\t\t \n\t\t\t\t\taria-invalid=\"false\" \n\t\t\t\t\t\n\t\t\t\t\t \n\t\t\t\t\t\n\t\t\t\t\tdata-mask=\"99\/99\/9999\"\n\t\t\t\t\t\/>\n\t\t\t\t<kbd id='keyboardHint_input_3_85' hidden class='down'><\/kbd>\n\t\t\t\t<button type='button' id='datepicker_toggle_input_3_85' class='gform-datepicker-toggle gform-datepicker-toggle--default accCalendar aria-date-picker gform-button gform-theme-button gform-theme-button--simple gform-theme-button--simple-in-ctrl' aria-expanded='false' aria-controls='input_3_85' aria-label='Last Dental: Choose date on calendar' >\n\t\t\t\t\t\t\t<span class=\"gform-calendar-icon gform-datepicker-toggle-icon gform-datepicker-toggle-icon--default dashicons dashicons-calendar-alt\" aria-hidden=\"true\"><\/span>\n\t\t\t\t\t\t<\/button>\n\t\t\t<\/div><\/div><fieldset id=\"field_3_86\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield--input-type-checkbox gfield--width-three-quarter field_sublabel_below gfield--no-description field_description_below hidden_label field_validation_below gfield_visibility_visible gfield--choice-align-vertical\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' ><span class='gform-field-label__text'>Last Dental - Unknown<\/span><\/legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox ' id='input_3_86'><div class='gchoice gchoice_3_86_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_86.1' type='checkbox'  value='Unknown'  id='choice_3_86_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_3_86_1' id='label_3_86_1' class='gform-field-label gform-field-label--type-inline'>Unknown<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_3_87\" class=\"gfield gfield--type-section gfield--input-type-section gsection field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><h3 class=\"gsection_title\">Optometrist<\/h3><\/div><fieldset id=\"field_3_88\" class=\"gfield gfield--type-name gfield--input-type-name gfield--width-two-thirds field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' ><span class='gform-field-label__text'>Name<\/span><\/legend><div class='ginput_complex ginput_container ginput_container--name no_prefix has_first_name no_middle_name has_last_name no_suffix gf_name_has_2 ginput_container_name gform-grid-row' id='input_3_88'>\n                            \n                            <span id='input_3_88_3_container' class='name_first gform-grid-col gform-grid-col--size-auto' >\n                                                    <input type='text' name='input_88.3' id='input_3_88_3' value=''   aria-required='false'     \/>\n                                                    <label for='input_3_88_3' class='gform-field-label gform-field-label--type-sub '>Pr\u00e9nom<\/label>\n                                                <\/span>\n                            \n                            <span id='input_3_88_6_container' class='name_last gform-grid-col gform-grid-col--size-auto' >\n                                                    <input type='text' name='input_88.6' id='input_3_88_6' value=''   aria-required='false'     \/>\n                                                    <label for='input_3_88_6' class='gform-field-label gform-field-label--type-sub '>Nom<\/label>\n                                                <\/span>\n                            \n                        <\/div><\/fieldset><div id=\"field_3_89\" class=\"gfield gfield--type-phone gfield--input-type-phone gfield--phone-format-international gfield--width-third field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_3_89'><span class='gform-field-label__text'>Phone<\/span><\/label><div class='ginput_container ginput_container_phone'><input name='input_89' id='input_3_89' type='tel' value='' class='large'    aria-invalid=\"false\"    \/><\/div><\/div><div id=\"field_3_90\" class=\"gfield gfield--type-date gfield--input-type-date gfield--input-type-datepicker gfield--datepicker-default-icon gfield--width-quarter field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_3_90'><span class='gform-field-label__text'>Last Optical<\/span><\/label><div class='ginput_container ginput_container_date'>\n\t\t\t\t\t<input\n\t\t\t\t\tplaceholder='mm\/jj\/aaaa'\n\t\t\t\t\tid='input_3_90'\n\t\t\t\t\tclass='datepicker gform-datepicker mdy datepicker_with_icon gdatepicker_with_icon'\n\t\t\t\t\ttype='text'\n\t\t\t\t\tname='input_90'\n\t\t\t\t\tvalue=''\n\t\t\t\t\t \n\t\t\t\t\taria-invalid=\"false\" \n\t\t\t\t\t\n\t\t\t\t\t \n\t\t\t\t\t\n\t\t\t\t\tdata-mask=\"99\/99\/9999\"\n\t\t\t\t\t\/>\n\t\t\t\t<kbd id='keyboardHint_input_3_90' hidden class='down'><\/kbd>\n\t\t\t\t<button type='button' id='datepicker_toggle_input_3_90' class='gform-datepicker-toggle gform-datepicker-toggle--default accCalendar aria-date-picker gform-button gform-theme-button gform-theme-button--simple gform-theme-button--simple-in-ctrl' aria-expanded='false' aria-controls='input_3_90' aria-label='Last Optical: Choose date on calendar' >\n\t\t\t\t\t\t\t<span class=\"gform-calendar-icon gform-datepicker-toggle-icon gform-datepicker-toggle-icon--default dashicons dashicons-calendar-alt\" aria-hidden=\"true\"><\/span>\n\t\t\t\t\t\t<\/button>\n\t\t\t<\/div><\/div><fieldset id=\"field_3_91\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield--input-type-checkbox gfield--width-three-quarter field_sublabel_below gfield--no-description field_description_below hidden_label field_validation_below gfield_visibility_visible gfield--choice-align-vertical\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' ><span class='gform-field-label__text'>Last Optical - Unknown<\/span><\/legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox ' id='input_3_91'><div class='gchoice gchoice_3_91_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_91.1' type='checkbox'  value='Unknown'  id='choice_3_91_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_3_91_1' id='label_3_91_1' class='gform-field-label gform-field-label--type-inline'>Unknown<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><\/div>\n                    <\/div>\n                    <div class='gform-page-footer gform_page_footer top_label'>\n                        <button type='button' id='gform_previous_button_3_92' class='gform_previous_button gform-theme-button gform-theme-button--secondary button' onclick='gform.submission.handleButtonClick(this);' data-submission-type='previous' >Previous<\/button> <button type='button' id='gform_next_button_3_92' class='gform_next_button gform-theme-button button' onclick='gform.submission.handleButtonClick(this);' data-submission-type='next' >Next<\/button> <button type='button'  id='gform_save_3_6_link' onclick='gform.submission.handleButtonClick(this);' data-submission-type='save-continue' class='gform_save_link gform-theme-button gform-theme-button--secondary button'  ><svg aria-hidden=\"true\" focusable=\"false\" width=\"16\" height=\"16\" fill=\"none\" xmlns=\"http:\/\/www.w3.org\/2000\/svg\"><path fill-rule=\"evenodd\" clip-rule=\"evenodd\" d=\"M0 8a4 4 0 004 4h3v3a1 1 0 102 0v-3h3a4 4 0 100-8 4 4 0 10-8 0 4 4 0 00-4 4zm9 4H7V7.414L5.707 8.707a1 1 0 01-1.414-1.414l3-3a1 1 0 011.414 0l3 3a1 1 0 01-1.414 1.414L9 7.414V12z\" fill=\"#6B7280\"\/><\/svg> Save and Continue Later<\/button>\n                    <\/div>\n                <\/div>\n                <div id='gform_page_3_6' class='gform_page' data-js='page-field-id-92' style='display:none;'>\n                    <div class='gform_page_fields'>\n                        <div id='gform_fields_3_6' class='gform_fields top_label form_sublabel_below description_below validation_below'><div id=\"field_3_93\" class=\"gfield gfield--type-section gfield--input-type-section gsection field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><h3 class=\"gsection_title\">Insurance Provider<\/h3><\/div><div id=\"field_3_95\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-half field_sublabel_below gfield--has-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_3_95'><span class='gform-field-label__text'>Broker<\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_95' id='input_3_95' type='text' value='' class='large'  aria-describedby=\"gfield_description_3_95\"    aria-invalid=\"false\"   \/><\/div><div class='gfield_description' id='gfield_description_3_95'>ie:  Cooperators, Intact ...<\/div><\/div><div id=\"field_3_96\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-half field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_3_96'><span class='gform-field-label__text'>Policy Number<\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_96' id='input_3_96' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_3_97\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-full field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_3_97'><span class='gform-field-label__text'>Status Card Number (if applicable)<\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_97' id='input_3_97' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_3_98\" class=\"gfield gfield--type-form gfield--input-type-form gform-theme__no-reset--children gfield--width-full field_sublabel_below gfield--has-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_3_98'><span class='gform-field-label__text'>Specialist(s)<\/span><\/label><div class='gfield_description' id='gfield_description_3_98'>(e.g. Psychiatrist, Speech Pathologist, Occupational Therapist, etc.)<\/div><div class=\"gpnf-nested-entries-container ginput_container\">\n\n\t<table class=\"gpnf-nested-entries\">\n\n\t\t<thead>\n\t\t<tr>\n\t\t\t\t\t\t\t<th scope=\"col\" class=\"gpnf-field-1\">\n\t\t\t\t\tName\t\t\t\t<\/th>\n\t\t\t\t\t\t\t<th scope=\"col\" class=\"gpnf-field-4\">\n\t\t\t\t\tSpeciality\t\t\t\t<\/th>\n\t\t\t\t\t\t\t<th scope=\"col\" class=\"gpnf-field-5\">\n\t\t\t\t\tPhone\t\t\t\t<\/th>\n\t\t\t\t\t\t<th scope=\"col\" class=\"gpnf-row-actions\"><span class=\"screen-reader-text\">Actions<\/span><\/th>\n\t\t<\/tr>\n\t\t<\/thead>\n\n\t\t<tbody data-bind=\"visible: entries().length, foreach: entries\">\n\t\t<tr data-bind=\"attr: { 'data-entryid': id }\">\n\t\t\t\t\t\t\t<td class=\"gpnf-field\"\n\t\t\t\t\tdata-bind=\"html: f1.label, attr: { 'data-value': f1.label }\"\n\t\t\t\t\tdata-heading=\"Name\"\n\t\t\t\t>&nbsp;<\/td>\n\t\t\t\t\t\t\t<td class=\"gpnf-field\"\n\t\t\t\t\tdata-bind=\"html: f4.label, attr: { 'data-value': f4.label }\"\n\t\t\t\t\tdata-heading=\"Speciality\"\n\t\t\t\t>&nbsp;<\/td>\n\t\t\t\t\t\t\t<td class=\"gpnf-field\"\n\t\t\t\t\tdata-bind=\"html: f5.label, attr: { 'data-value': f5.label }\"\n\t\t\t\t\tdata-heading=\"Phone\"\n\t\t\t\t>&nbsp;<\/td>\n\t\t\t\t\t\t<td class=\"gpnf-row-actions\" style=\"display: none;\" data-bind=\"visible: true\">\n\t\t\t\t<ul>\n\t\t\t\t\t<li class=\"edit\"><button type=\"button\" class=\"edit-button gform-theme-button--secondary\" data-bind=\"click: $parent.editEntry, attr: { 'aria-label': 'Edit Specialist {0} where Name is {1}.'.gformFormat( $index() + 1, f1.label ) }\">Modifier<\/button><\/li>\n\t\t\t\t\t\t\t\t\t\t<li class=\"delete\"><button type=\"button\" class=\"delete-button gform-theme-button--simple gform-theme-button--size-md\" data-bind=\"click: $parent.deleteEntry, attr: { 'aria-label': 'Delete Specialist {0} where Name is {1}.'.gformFormat( $index() + 1, f1.label ) }\">Supprimer<\/button><\/li>\n\t\t\t\t<\/ul>\n\t\t\t<\/td>\n\t\t<\/tr>\n\t\t<\/tbody>\n\n\t\t<tbody data-bind=\"visible: entries().length <= 0\">\n\t\t<tr class=\"gpnf-no-entries\" data-bind=\"visible: entries().length <= 0\" style=\"display: none;\">\n\t\t\t<td colspan=\"4\">\n\t\t\t\tIl n\u2019y a aucun(e) <span>Specialists.<\/span>\t\t\t<\/td>\n\t\t<\/tr>\n\t\t<\/tbody>\n\n\t<\/table>\n\n\t<button type=\"button\" class=\"gpnf-add-entry\"\n\t\t        data-formid=\"3\"\n\t\t        data-nestedformid=\"7\"\n\t\t\t\tdata-bind=\"attr: { disabled: isMaxed }, css: { 'gf-default-disabled': isMaxed }\"\n\t\t\t\t>\n\t\t\t\tAjouter Specialist\n\t\t\t<\/button>\t\n\t\t\t<p class=\"gpnf-add-entry-max\" data-bind=\"visible: isMaxed\" style=\"display: none;\">\n\t\t\t\tLe nombre maximal a \u00e9t\u00e9 atteint.\n\t\t\t<\/p>\n<\/div>\n<input type=\"hidden\"\n                name=\"input_98\"\n                id=\"input_3_98\"\n                data-bind=\"value: entryIds\"\n                value=\"\" \/><\/div><div id=\"field_3_99\" class=\"gfield gfield--type-form gfield--input-type-form gform-theme__no-reset--children gfield--width-full field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_3_99'><span class='gform-field-label__text'>Medication(s)<\/span><\/label><div class=\"gpnf-nested-entries-container ginput_container\">\n\n\t<table class=\"gpnf-nested-entries\">\n\n\t\t<thead>\n\t\t<tr>\n\t\t\t\t\t\t\t<th scope=\"col\" class=\"gpnf-field-4\">\n\t\t\t\t\tMedication\t\t\t\t<\/th>\n\t\t\t\t\t\t\t<th scope=\"col\" class=\"gpnf-field-6\">\n\t\t\t\t\tPrescribed by\t\t\t\t<\/th>\n\t\t\t\t\t\t\t<th scope=\"col\" class=\"gpnf-field-7\">\n\t\t\t\t\tLast Reviewed\t\t\t\t<\/th>\n\t\t\t\t\t\t<th scope=\"col\" class=\"gpnf-row-actions\"><span class=\"screen-reader-text\">Actions<\/span><\/th>\n\t\t<\/tr>\n\t\t<\/thead>\n\n\t\t<tbody data-bind=\"visible: entries().length, foreach: entries\">\n\t\t<tr data-bind=\"attr: { 'data-entryid': id }\">\n\t\t\t\t\t\t\t<td class=\"gpnf-field\"\n\t\t\t\t\tdata-bind=\"html: f4.label, attr: { 'data-value': f4.label }\"\n\t\t\t\t\tdata-heading=\"Medication\"\n\t\t\t\t>&nbsp;<\/td>\n\t\t\t\t\t\t\t<td class=\"gpnf-field\"\n\t\t\t\t\tdata-bind=\"html: f6.label, attr: { 'data-value': f6.label }\"\n\t\t\t\t\tdata-heading=\"Prescribed by\"\n\t\t\t\t>&nbsp;<\/td>\n\t\t\t\t\t\t\t<td class=\"gpnf-field\"\n\t\t\t\t\tdata-bind=\"html: f7.label, attr: { 'data-value': f7.label }\"\n\t\t\t\t\tdata-heading=\"Last Reviewed\"\n\t\t\t\t>&nbsp;<\/td>\n\t\t\t\t\t\t<td class=\"gpnf-row-actions\" style=\"display: none;\" data-bind=\"visible: true\">\n\t\t\t\t<ul>\n\t\t\t\t\t<li class=\"edit\"><button type=\"button\" class=\"edit-button gform-theme-button--secondary\" data-bind=\"click: $parent.editEntry, attr: { 'aria-label': 'Edit Medication {0} where Medication is {1}.'.gformFormat( $index() + 1, f4.label ) }\">Modifier<\/button><\/li>\n\t\t\t\t\t\t\t\t\t\t<li class=\"delete\"><button type=\"button\" class=\"delete-button gform-theme-button--simple gform-theme-button--size-md\" data-bind=\"click: $parent.deleteEntry, attr: { 'aria-label': 'Delete Medication {0} where Medication is {1}.'.gformFormat( $index() + 1, f4.label ) }\">Supprimer<\/button><\/li>\n\t\t\t\t<\/ul>\n\t\t\t<\/td>\n\t\t<\/tr>\n\t\t<\/tbody>\n\n\t\t<tbody data-bind=\"visible: entries().length <= 0\">\n\t\t<tr class=\"gpnf-no-entries\" data-bind=\"visible: entries().length <= 0\" style=\"display: none;\">\n\t\t\t<td colspan=\"4\">\n\t\t\t\tIl n\u2019y a aucun(e) <span>Medications.<\/span>\t\t\t<\/td>\n\t\t<\/tr>\n\t\t<\/tbody>\n\n\t<\/table>\n\n\t<button type=\"button\" class=\"gpnf-add-entry\"\n\t\t        data-formid=\"3\"\n\t\t        data-nestedformid=\"8\"\n\t\t\t\tdata-bind=\"attr: { disabled: isMaxed }, css: { 'gf-default-disabled': isMaxed }\"\n\t\t\t\t>\n\t\t\t\tAjouter Medication\n\t\t\t<\/button>\t\n\t\t\t<p class=\"gpnf-add-entry-max\" data-bind=\"visible: isMaxed\" style=\"display: none;\">\n\t\t\t\tLe nombre maximal a \u00e9t\u00e9 atteint.\n\t\t\t<\/p>\n<\/div>\n<input type=\"hidden\"\n                name=\"input_99\"\n                id=\"input_3_99\"\n                data-bind=\"value: entryIds\"\n                value=\"\" \/><\/div><div id=\"field_3_100\" class=\"gfield gfield--type-section gfield--input-type-section gsection field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><h3 class=\"gsection_title\">Immunizations<\/h3><\/div><div id=\"field_3_102\" class=\"gfield gfield--type-html gfield--input-type-html gfield--width-third gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  >Tripple (Diptheria, Tetanus, Polio)<\/div><div id=\"field_3_103\" class=\"gfield gfield--type-date gfield--input-type-date gfield--input-type-datepicker gfield--datepicker-default-icon gfield--width-third field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_3_103'><span class='gform-field-label__text'>Date (if known)<\/span><\/label><div class='ginput_container ginput_container_date'>\n\t\t\t\t\t<input\n\t\t\t\t\tplaceholder='mm\/jj\/aaaa'\n\t\t\t\t\tid='input_3_103'\n\t\t\t\t\tclass='datepicker gform-datepicker mdy datepicker_with_icon gdatepicker_with_icon'\n\t\t\t\t\ttype='text'\n\t\t\t\t\tname='input_103'\n\t\t\t\t\tvalue=''\n\t\t\t\t\t \n\t\t\t\t\taria-invalid=\"false\" \n\t\t\t\t\t\n\t\t\t\t\t \n\t\t\t\t\t\n\t\t\t\t\tdata-mask=\"99\/99\/9999\"\n\t\t\t\t\t\/>\n\t\t\t\t<kbd id='keyboardHint_input_3_103' hidden class='down'><\/kbd>\n\t\t\t\t<button type='button' id='datepicker_toggle_input_3_103' class='gform-datepicker-toggle gform-datepicker-toggle--default accCalendar aria-date-picker gform-button gform-theme-button gform-theme-button--simple gform-theme-button--simple-in-ctrl' aria-expanded='false' aria-controls='input_3_103' aria-label='Date (if known): Choose date on calendar' >\n\t\t\t\t\t\t\t<span class=\"gform-calendar-icon gform-datepicker-toggle-icon gform-datepicker-toggle-icon--default dashicons dashicons-calendar-alt\" aria-hidden=\"true\"><\/span>\n\t\t\t\t\t\t<\/button>\n\t\t\t<\/div><\/div><fieldset id=\"field_3_104\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gf_list_3col gfield--width-third field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible gfield--choice-align-columns\"  ><legend class='gfield_label gform-field-label' ><span class='gform-field-label__text'>Up to Date<\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_3_104'>\n\t\t\t<div class='gchoice gchoice_3_104_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_104' type='radio' value='Yes'  id='choice_3_104_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_3_104_0' id='label_3_104_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_3_104_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_104' type='radio' value='No'  id='choice_3_104_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_3_104_1' id='label_3_104_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_3_104_2'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_104' type='radio' value='Unknown'  id='choice_3_104_2' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_3_104_2' id='label_3_104_2' class='gform-field-label gform-field-label--type-inline'>Unknown<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_3_105\" class=\"gfield gfield--type-html gfield--input-type-html gfield--width-third gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><b>MMR<\/b> (Measles, Mumps, Rubella)<\/div><div id=\"field_3_106\" class=\"gfield gfield--type-date gfield--input-type-date gfield--input-type-datepicker gfield--datepicker-default-icon gfield--width-third field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_3_106'><span class='gform-field-label__text'>Date (if known)<\/span><\/label><div class='ginput_container ginput_container_date'>\n\t\t\t\t\t<input\n\t\t\t\t\tplaceholder='mm\/jj\/aaaa'\n\t\t\t\t\tid='input_3_106'\n\t\t\t\t\tclass='datepicker gform-datepicker mdy datepicker_with_icon gdatepicker_with_icon'\n\t\t\t\t\ttype='text'\n\t\t\t\t\tname='input_106'\n\t\t\t\t\tvalue=''\n\t\t\t\t\t \n\t\t\t\t\taria-invalid=\"false\" \n\t\t\t\t\t\n\t\t\t\t\t \n\t\t\t\t\t\n\t\t\t\t\tdata-mask=\"99\/99\/9999\"\n\t\t\t\t\t\/>\n\t\t\t\t<kbd id='keyboardHint_input_3_106' hidden class='down'><\/kbd>\n\t\t\t\t<button type='button' id='datepicker_toggle_input_3_106' class='gform-datepicker-toggle gform-datepicker-toggle--default accCalendar aria-date-picker gform-button gform-theme-button gform-theme-button--simple gform-theme-button--simple-in-ctrl' aria-expanded='false' aria-controls='input_3_106' aria-label='Date (if known): Choose date on calendar' >\n\t\t\t\t\t\t\t<span class=\"gform-calendar-icon gform-datepicker-toggle-icon gform-datepicker-toggle-icon--default dashicons dashicons-calendar-alt\" aria-hidden=\"true\"><\/span>\n\t\t\t\t\t\t<\/button>\n\t\t\t<\/div><\/div><fieldset id=\"field_3_107\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gf_list_3col gfield--width-third field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible gfield--choice-align-columns\"  ><legend class='gfield_label gform-field-label' ><span class='gform-field-label__text'>Up to Date<\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_3_107'>\n\t\t\t<div class='gchoice gchoice_3_107_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_107' type='radio' value='Yes'  id='choice_3_107_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_3_107_0' id='label_3_107_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_3_107_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_107' type='radio' value='No'  id='choice_3_107_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_3_107_1' id='label_3_107_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_3_107_2'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_107' type='radio' value='Unknown'  id='choice_3_107_2' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_3_107_2' id='label_3_107_2' class='gform-field-label gform-field-label--type-inline'>Unknown<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_3_108\" class=\"gfield gfield--type-html gfield--input-type-html gfield--width-third gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><b>Tuberculin Test<\/b><\/div><div id=\"field_3_109\" class=\"gfield gfield--type-date gfield--input-type-date gfield--input-type-datepicker gfield--datepicker-default-icon gfield--width-third field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_3_109'><span class='gform-field-label__text'>Date (if known)<\/span><\/label><div class='ginput_container ginput_container_date'>\n\t\t\t\t\t<input\n\t\t\t\t\tplaceholder='mm\/jj\/aaaa'\n\t\t\t\t\tid='input_3_109'\n\t\t\t\t\tclass='datepicker gform-datepicker mdy datepicker_with_icon gdatepicker_with_icon'\n\t\t\t\t\ttype='text'\n\t\t\t\t\tname='input_109'\n\t\t\t\t\tvalue=''\n\t\t\t\t\t \n\t\t\t\t\taria-invalid=\"false\" \n\t\t\t\t\t\n\t\t\t\t\t \n\t\t\t\t\t\n\t\t\t\t\tdata-mask=\"99\/99\/9999\"\n\t\t\t\t\t\/>\n\t\t\t\t<kbd id='keyboardHint_input_3_109' hidden class='down'><\/kbd>\n\t\t\t\t<button type='button' id='datepicker_toggle_input_3_109' class='gform-datepicker-toggle gform-datepicker-toggle--default accCalendar aria-date-picker gform-button gform-theme-button gform-theme-button--simple gform-theme-button--simple-in-ctrl' aria-expanded='false' aria-controls='input_3_109' aria-label='Date (if known): Choose date on calendar' >\n\t\t\t\t\t\t\t<span class=\"gform-calendar-icon gform-datepicker-toggle-icon gform-datepicker-toggle-icon--default dashicons dashicons-calendar-alt\" aria-hidden=\"true\"><\/span>\n\t\t\t\t\t\t<\/button>\n\t\t\t<\/div><\/div><fieldset id=\"field_3_110\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gf_list_3col gfield--width-third field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible gfield--choice-align-columns\"  ><legend class='gfield_label gform-field-label' ><span class='gform-field-label__text'>Results<\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_3_110'>\n\t\t\t<div class='gchoice gchoice_3_110_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_110' type='radio' value='Negative'  id='choice_3_110_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_3_110_0' id='label_3_110_0' class='gform-field-label gform-field-label--type-inline'>Negative<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_3_110_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_110' type='radio' value='Positive'  id='choice_3_110_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_3_110_1' id='label_3_110_1' class='gform-field-label gform-field-label--type-inline'>Positive<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_3_110_2'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_110' type='radio' value='Unknown'  id='choice_3_110_2' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_3_110_2' id='label_3_110_2' class='gform-field-label gform-field-label--type-inline'>Unknown<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_3_111\" class=\"gfield gfield--type-html gfield--input-type-html gfield--width-third gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><b>Covid-19 Vaccination<\/b><\/div><div id=\"field_3_112\" class=\"gfield gfield--type-date gfield--input-type-date gfield--input-type-datepicker gfield--datepicker-default-icon gfield--width-third field_sublabel_below gfield--has-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_3_112'><span class='gform-field-label__text'>Date (if known)<\/span><\/label><div class='ginput_container ginput_container_date'>\n\t\t\t\t\t<input\n\t\t\t\t\tplaceholder='mm\/jj\/aaaa'\n\t\t\t\t\tid='input_3_112'\n\t\t\t\t\tclass='datepicker gform-datepicker mdy datepicker_with_icon gdatepicker_with_icon'\n\t\t\t\t\ttype='text'\n\t\t\t\t\tname='input_112'\n\t\t\t\t\tvalue=''\n\t\t\t\t\taria-describedby=\"gfield_description_3_112\" \n\t\t\t\t\taria-invalid=\"false\" \n\t\t\t\t\t\n\t\t\t\t\t \n\t\t\t\t\t\n\t\t\t\t\tdata-mask=\"99\/99\/9999\"\n\t\t\t\t\t\/>\n\t\t\t\t<kbd id='keyboardHint_input_3_112' hidden class='down'><\/kbd>\n\t\t\t\t<button type='button' id='datepicker_toggle_input_3_112' class='gform-datepicker-toggle gform-datepicker-toggle--default accCalendar aria-date-picker gform-button gform-theme-button gform-theme-button--simple gform-theme-button--simple-in-ctrl' aria-expanded='false' aria-controls='input_3_112' aria-label='Date (if known): Choose date on calendar' >\n\t\t\t\t\t\t\t<span class=\"gform-calendar-icon gform-datepicker-toggle-icon gform-datepicker-toggle-icon--default dashicons dashicons-calendar-alt\" aria-hidden=\"true\"><\/span>\n\t\t\t\t\t\t<\/button>\n\t\t\t<\/div><div class='gfield_description' id='gfield_description_3_112'>(last dose)<\/div><\/div><fieldset id=\"field_3_118\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield--input-type-checkbox gf_list_4col gfield--width-third field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible gfield--choice-align-columns\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' ><span class='gform-field-label__text'>Doses<\/span><\/legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox ' id='input_3_118'><div class='gchoice gchoice_3_118_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_118.1' type='checkbox'  value='1'  id='choice_3_118_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_3_118_1' id='label_3_118_1' class='gform-field-label gform-field-label--type-inline'>1<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_3_118_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_118.2' type='checkbox'  value='2'  id='choice_3_118_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_3_118_2' id='label_3_118_2' class='gform-field-label gform-field-label--type-inline'>2<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_3_118_3'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_118.3' type='checkbox'  value='3'  id='choice_3_118_3'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_3_118_3' id='label_3_118_3' class='gform-field-label gform-field-label--type-inline'>3<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_3_118_4'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_118.4' type='checkbox'  value='4'  id='choice_3_118_4'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_3_118_4' id='label_3_118_4' class='gform-field-label gform-field-label--type-inline'>4<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_3_114\" class=\"gfield gfield--type-html gfield--input-type-html gfield--width-third gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><b>Other<\/b> (specify)<\/div><div id=\"field_3_115\" class=\"gfield gfield--type-date gfield--input-type-date gfield--input-type-datepicker gfield--datepicker-default-icon gfield--width-third field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_3_115'><span class='gform-field-label__text'>Date (if known)<\/span><\/label><div class='ginput_container ginput_container_date'>\n\t\t\t\t\t<input\n\t\t\t\t\tplaceholder='mm\/jj\/aaaa'\n\t\t\t\t\tid='input_3_115'\n\t\t\t\t\tclass='datepicker gform-datepicker mdy datepicker_with_icon gdatepicker_with_icon'\n\t\t\t\t\ttype='text'\n\t\t\t\t\tname='input_115'\n\t\t\t\t\tvalue=''\n\t\t\t\t\t \n\t\t\t\t\taria-invalid=\"false\" \n\t\t\t\t\t\n\t\t\t\t\t \n\t\t\t\t\t\n\t\t\t\t\tdata-mask=\"99\/99\/9999\"\n\t\t\t\t\t\/>\n\t\t\t\t<kbd id='keyboardHint_input_3_115' hidden class='down'><\/kbd>\n\t\t\t\t<button type='button' id='datepicker_toggle_input_3_115' class='gform-datepicker-toggle gform-datepicker-toggle--default accCalendar aria-date-picker gform-button gform-theme-button gform-theme-button--simple gform-theme-button--simple-in-ctrl' aria-expanded='false' aria-controls='input_3_115' aria-label='Date (if known): Choose date on calendar' >\n\t\t\t\t\t\t\t<span class=\"gform-calendar-icon gform-datepicker-toggle-icon gform-datepicker-toggle-icon--default dashicons dashicons-calendar-alt\" aria-hidden=\"true\"><\/span>\n\t\t\t\t\t\t<\/button>\n\t\t\t<\/div><\/div><div id=\"field_3_117\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-third field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_3_117'><span class='gform-field-label__text'>Notes<\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_117' id='input_3_117' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/div><\/div>\n                    <\/div>\n                    <div class='gform-page-footer gform_page_footer top_label'>\n                        <button type='button' id='gform_previous_button_3_119' class='gform_previous_button gform-theme-button gform-theme-button--secondary button' onclick='gform.submission.handleButtonClick(this);' data-submission-type='previous' >Previous<\/button> <button type='button' id='gform_next_button_3_119' class='gform_next_button gform-theme-button button' onclick='gform.submission.handleButtonClick(this);' data-submission-type='next' >Next<\/button> <button type='button'  id='gform_save_3_7_link' onclick='gform.submission.handleButtonClick(this);' data-submission-type='save-continue' class='gform_save_link gform-theme-button gform-theme-button--secondary button'  ><svg aria-hidden=\"true\" focusable=\"false\" width=\"16\" height=\"16\" fill=\"none\" xmlns=\"http:\/\/www.w3.org\/2000\/svg\"><path fill-rule=\"evenodd\" clip-rule=\"evenodd\" d=\"M0 8a4 4 0 004 4h3v3a1 1 0 102 0v-3h3a4 4 0 100-8 4 4 0 10-8 0 4 4 0 00-4 4zm9 4H7V7.414L5.707 8.707a1 1 0 01-1.414-1.414l3-3a1 1 0 011.414 0l3 3a1 1 0 01-1.414 1.414L9 7.414V12z\" fill=\"#6B7280\"\/><\/svg> Save and Continue Later<\/button>\n                    <\/div>\n                <\/div>\n                <div id='gform_page_3_7' class='gform_page' data-js='page-field-id-119' style='display:none;'>\n                    <div class='gform_page_fields'>\n                        <div id='gform_fields_3_7' class='gform_fields top_label form_sublabel_below description_below validation_below'><div id=\"field_3_120\" class=\"gfield gfield--type-section gfield--input-type-section gsection field_sublabel_below gfield--has-description field_description_below field_validation_below gfield_visibility_visible\"  ><h3 class=\"gsection_title\">Guardianship Status (Legal Custody)<\/h3><div class='gsection_description' id='gfield_description_3_120'>Please submit legal documentation<\/div><\/div><fieldset id=\"field_3_121\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gf_list_2col gfield--width-half gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible gfield--choice-align-columns\"  ><legend class='gfield_label gform-field-label' ><span class='gform-field-label__text'>Status<\/span><span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(N\u00e9cessaire)<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_3_121'>\n\t\t\t<div class='gchoice gchoice_3_121_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_121' type='radio' value='Parental'  id='choice_3_121_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_3_121_0' id='label_3_121_0' class='gform-field-label gform-field-label--type-inline'>Parental<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_3_121_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_121' type='radio' value='Joint Custody'  id='choice_3_121_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_3_121_1' id='label_3_121_1' class='gform-field-label gform-field-label--type-inline'>Joint Custody<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_3_121_2'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_121' type='radio' value='Single Parent'  id='choice_3_121_2' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_3_121_2' id='label_3_121_2' class='gform-field-label gform-field-label--type-inline'>Single Parent<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_3_121_3'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_121' type='radio' value='Parental &amp; CAS (Temporary Care Agreement)'  id='choice_3_121_3' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_3_121_3' id='label_3_121_3' class='gform-field-label gform-field-label--type-inline'>Parental &amp; CAS (Temporary Care Agreement)<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_3_121_4'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_121' type='radio' value='CAS \/ SAE'  id='choice_3_121_4' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_3_121_4' id='label_3_121_4' class='gform-field-label gform-field-label--type-inline'>CAS \/ SAE<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_3_121_5'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_121' type='radio' value='Independent'  id='choice_3_121_5' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_3_121_5' id='label_3_121_5' class='gform-field-label gform-field-label--type-inline'>Independent<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_3_121_6'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_121' type='radio' value='Other (Specify)'  id='choice_3_121_6' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_3_121_6' id='label_3_121_6' class='gform-field-label gform-field-label--type-inline'>Other (Specify)<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_3_122\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-half field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_3_122'><span class='gform-field-label__text'>Name<\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_122' id='input_3_122' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/div><fieldset id=\"field_3_123\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield--input-type-checkbox gfield--width-half field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible gfield--choice-align-vertical\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' ><span class='gform-field-label__text'>CAS<\/span><\/legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox ' id='input_3_123'><div class='gchoice gchoice_3_123_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_123.1' type='checkbox'  value='Crown Ward'  id='choice_3_123_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_3_123_1' id='label_3_123_1' class='gform-field-label gform-field-label--type-inline'>Crown Ward<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_3_123_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_123.2' type='checkbox'  value='Extended Society Care'  id='choice_3_123_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_3_123_2' id='label_3_123_2' class='gform-field-label gform-field-label--type-inline'>Extended Society Care<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_3_123_3'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_123.3' type='checkbox'  value='Interim Society Care'  id='choice_3_123_3'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_3_123_3' id='label_3_123_3' class='gform-field-label gform-field-label--type-inline'>Interim Society Care<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_3_123_4'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_123.4' type='checkbox'  value='Custody during adjournment'  id='choice_3_123_4'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_3_123_4' id='label_3_123_4' class='gform-field-label gform-field-label--type-inline'>Custody during adjournment<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_3_123_5'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_123.5' type='checkbox'  value='Customary Care Agreement'  id='choice_3_123_5'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_3_123_5' id='label_3_123_5' class='gform-field-label gform-field-label--type-inline'>Customary Care Agreement<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_3_124\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-half field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_3_124'><span class='gform-field-label__text'>Other<\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_124' id='input_3_124' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/div><\/div>\n                    <\/div>\n                    <div class='gform-page-footer gform_page_footer top_label'>\n                        <button type='button' id='gform_previous_button_3_125' class='gform_previous_button gform-theme-button gform-theme-button--secondary button' onclick='gform.submission.handleButtonClick(this);' data-submission-type='previous' >Previous<\/button> <button type='button' id='gform_next_button_3_125' class='gform_next_button gform-theme-button button' onclick='gform.submission.handleButtonClick(this);' data-submission-type='next' >Next<\/button> <button type='button'  id='gform_save_3_8_link' onclick='gform.submission.handleButtonClick(this);' data-submission-type='save-continue' class='gform_save_link gform-theme-button gform-theme-button--secondary button'  ><svg aria-hidden=\"true\" focusable=\"false\" width=\"16\" height=\"16\" fill=\"none\" xmlns=\"http:\/\/www.w3.org\/2000\/svg\"><path fill-rule=\"evenodd\" clip-rule=\"evenodd\" d=\"M0 8a4 4 0 004 4h3v3a1 1 0 102 0v-3h3a4 4 0 100-8 4 4 0 10-8 0 4 4 0 00-4 4zm9 4H7V7.414L5.707 8.707a1 1 0 01-1.414-1.414l3-3a1 1 0 011.414 0l3 3a1 1 0 01-1.414 1.414L9 7.414V12z\" fill=\"#6B7280\"\/><\/svg> Save and Continue Later<\/button>\n                    <\/div>\n                <\/div>\n                <div id='gform_page_3_8' class='gform_page' data-js='page-field-id-125' style='display:none;'>\n                    <div class='gform_page_fields'>\n                        <div id='gform_fields_3_8' class='gform_fields top_label form_sublabel_below description_below validation_below'><div id=\"field_3_126\" class=\"gfield gfield--type-section gfield--input-type-section gsection field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><h3 class=\"gsection_title\">Youth&#039;s Current Living Situation<\/h3><\/div><fieldset id=\"field_3_127\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-quarter field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible gfield--choice-align-vertical\"  ><legend class='gfield_label gform-field-label' ><span class='gform-field-label__text'>Location<\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_3_127'>\n\t\t\t<div class='gchoice gchoice_3_127_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_127' type='radio' value='Family'  id='choice_3_127_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_3_127_0' id='label_3_127_0' class='gform-field-label gform-field-label--type-inline'>Family<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_3_127_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_127' type='radio' value='Children&#039;s Aid Society'  id='choice_3_127_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_3_127_1' id='label_3_127_1' class='gform-field-label gform-field-label--type-inline'>Children's Aid Society<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_3_127_2'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_127' type='radio' value='Friend&#039;s Home'  id='choice_3_127_2' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_3_127_2' id='label_3_127_2' class='gform-field-label gform-field-label--type-inline'>Friend's Home<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_3_127_3'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_127' type='radio' value='Homeless or Hostel'  id='choice_3_127_3' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_3_127_3' id='label_3_127_3' class='gform-field-label gform-field-label--type-inline'>Homeless or Hostel<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_3_127_4'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_127' type='radio' value='Hospital, Treatment Facility - Medical'  id='choice_3_127_4' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_3_127_4' id='label_3_127_4' class='gform-field-label gform-field-label--type-inline'>Hospital, Treatment Facility - Medical<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_3_127_5'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_127' type='radio' value='In Detention'  id='choice_3_127_5' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_3_127_5' id='label_3_127_5' class='gform-field-label gform-field-label--type-inline'>In Detention<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_3_127_6'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_127' type='radio' value='Other (specify)'  id='choice_3_127_6' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_3_127_6' id='label_3_127_6' class='gform-field-label gform-field-label--type-inline'>Other (specify)<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_3_128\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-quarter field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible gfield--choice-align-vertical\"  ><legend class='gfield_label gform-field-label' ><span class='gform-field-label__text'>With<\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_3_128'>\n\t\t\t<div class='gchoice gchoice_3_128_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_128' type='radio' value='Parent(s)'  id='choice_3_128_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_3_128_0' id='label_3_128_0' class='gform-field-label gform-field-label--type-inline'>Parent(s)<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_3_128_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_128' type='radio' value='Kin'  id='choice_3_128_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_3_128_1' id='label_3_128_1' class='gform-field-label gform-field-label--type-inline'>Kin<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_3_129\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield--input-type-checkbox gfield--width-quarter field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible gfield--choice-align-vertical\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' ><span class='gform-field-label__text'>Adopted?<\/span><\/legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox ' id='input_3_129'><div class='gchoice gchoice_3_129_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_129.1' type='checkbox'  value='Yes'  id='choice_3_129_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_3_129_1' id='label_3_129_1' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_3_130\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-quarter field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible gfield--choice-align-vertical\"  ><legend class='gfield_label gform-field-label' ><span class='gform-field-label__text'>Home<\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_3_130'>\n\t\t\t<div class='gchoice gchoice_3_130_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_130' type='radio' value='Foster Home'  id='choice_3_130_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_3_130_0' id='label_3_130_0' class='gform-field-label gform-field-label--type-inline'>Foster Home<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_3_130_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_130' type='radio' value='Group Home'  id='choice_3_130_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_3_130_1' id='label_3_130_1' class='gform-field-label gform-field-label--type-inline'>Group Home<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><\/div>\n                    <\/div>\n                    <div class='gform-page-footer gform_page_footer top_label'>\n                        <button type='button' id='gform_previous_button_3_131' class='gform_previous_button gform-theme-button gform-theme-button--secondary button' onclick='gform.submission.handleButtonClick(this);' data-submission-type='previous' >Previous<\/button> <button type='button' id='gform_next_button_3_131' class='gform_next_button gform-theme-button button' onclick='gform.submission.handleButtonClick(this);' data-submission-type='next' >Next<\/button> <button type='button'  id='gform_save_3_9_link' onclick='gform.submission.handleButtonClick(this);' data-submission-type='save-continue' class='gform_save_link gform-theme-button gform-theme-button--secondary button'  ><svg aria-hidden=\"true\" focusable=\"false\" width=\"16\" height=\"16\" fill=\"none\" xmlns=\"http:\/\/www.w3.org\/2000\/svg\"><path fill-rule=\"evenodd\" clip-rule=\"evenodd\" d=\"M0 8a4 4 0 004 4h3v3a1 1 0 102 0v-3h3a4 4 0 100-8 4 4 0 10-8 0 4 4 0 00-4 4zm9 4H7V7.414L5.707 8.707a1 1 0 01-1.414-1.414l3-3a1 1 0 011.414 0l3 3a1 1 0 01-1.414 1.414L9 7.414V12z\" fill=\"#6B7280\"\/><\/svg> Save and Continue Later<\/button>\n                    <\/div>\n                <\/div>\n                <div id='gform_page_3_9' class='gform_page' data-js='page-field-id-131' style='display:none;'>\n                    <div class='gform_page_fields'>\n                        <div id='gform_fields_3_9' class='gform_fields top_label form_sublabel_below description_below validation_below'><div id=\"field_3_132\" class=\"gfield gfield--type-section gfield--input-type-section gsection field_sublabel_below gfield--has-description field_description_below field_validation_below gfield_visibility_visible\"  ><h3 class=\"gsection_title\">Family Income<\/h3><div class='gsection_description' id='gfield_description_3_132'>*The information provided will help us better serve and meet the needs of various socio-economic groups<\/div><\/div><fieldset id=\"field_3_133\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield--input-type-checkbox gf_list_3col gfield--width-full field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible gfield--choice-align-columns\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' ><span class='gform-field-label__text'>Please indicate what the income level of the youth\u2019s family\/caregiver was last year.<\/span><\/legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox ' id='input_3_133'><div class='gchoice gchoice_3_133_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_133.1' type='checkbox'  value='$0 - $29,999'  id='choice_3_133_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_3_133_1' id='label_3_133_1' class='gform-field-label gform-field-label--type-inline'>$0 - $29,999<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_3_133_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_133.2' type='checkbox'  value='$30,000 - $59,999'  id='choice_3_133_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_3_133_2' id='label_3_133_2' class='gform-field-label gform-field-label--type-inline'>$30,000 - $59,999<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_3_133_3'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_133.3' type='checkbox'  value='$60,000 - $89,999'  id='choice_3_133_3'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_3_133_3' id='label_3_133_3' class='gform-field-label gform-field-label--type-inline'>$60,000 - $89,999<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_3_133_4'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_133.4' type='checkbox'  value='$90,000 - $119,999'  id='choice_3_133_4'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_3_133_4' id='label_3_133_4' class='gform-field-label gform-field-label--type-inline'>$90,000 - $119,999<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_3_133_5'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_133.5' type='checkbox'  value='$120,000 - $149,999'  id='choice_3_133_5'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_3_133_5' id='label_3_133_5' class='gform-field-label gform-field-label--type-inline'>$120,000 - $149,999<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_3_133_6'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_133.6' type='checkbox'  value='$150,000 or more'  id='choice_3_133_6'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_3_133_6' id='label_3_133_6' class='gform-field-label gform-field-label--type-inline'>$150,000 or more<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_3_133_7'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_133.7' type='checkbox'  value='Prefer not to answer'  id='choice_3_133_7'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_3_133_7' id='label_3_133_7' class='gform-field-label gform-field-label--type-inline'>Prefer not to answer<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_3_134\" class=\"gfield gfield--type-section gfield--input-type-section gsection field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><h3 class=\"gsection_title\">History of Family or Caregiver Involvement<\/h3><\/div><div id=\"field_3_135\" class=\"gfield gfield--type-textarea gfield--input-type-textarea gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_3_135'><span class='gform-field-label__text'>Please provide a brief synopsis of the youth\u2019s family relationships and their history, including guardianship history if status has changed over time.<\/span><span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(N\u00e9cessaire)<\/span><\/span><\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_135' id='input_3_135' class='textarea large'     aria-required=\"true\" aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/div><\/div>\n                    <\/div>\n                    <div class='gform-page-footer gform_page_footer top_label'>\n                        <button type='button' id='gform_previous_button_3_136' class='gform_previous_button gform-theme-button gform-theme-button--secondary button' onclick='gform.submission.handleButtonClick(this);' data-submission-type='previous' >Previous<\/button> <button type='button' id='gform_next_button_3_136' class='gform_next_button gform-theme-button button' onclick='gform.submission.handleButtonClick(this);' data-submission-type='next' >Next<\/button> <button type='button'  id='gform_save_3_10_link' onclick='gform.submission.handleButtonClick(this);' data-submission-type='save-continue' class='gform_save_link gform-theme-button gform-theme-button--secondary button'  ><svg aria-hidden=\"true\" focusable=\"false\" width=\"16\" height=\"16\" fill=\"none\" xmlns=\"http:\/\/www.w3.org\/2000\/svg\"><path fill-rule=\"evenodd\" clip-rule=\"evenodd\" d=\"M0 8a4 4 0 004 4h3v3a1 1 0 102 0v-3h3a4 4 0 100-8 4 4 0 10-8 0 4 4 0 00-4 4zm9 4H7V7.414L5.707 8.707a1 1 0 01-1.414-1.414l3-3a1 1 0 011.414 0l3 3a1 1 0 01-1.414 1.414L9 7.414V12z\" fill=\"#6B7280\"\/><\/svg> Save and Continue Later<\/button>\n                    <\/div>\n                <\/div>\n                <div id='gform_page_3_10' class='gform_page' data-js='page-field-id-136' style='display:none;'>\n                    <div class='gform_page_fields'>\n                        <div id='gform_fields_3_10' class='gform_fields top_label form_sublabel_below description_below validation_below'><div id=\"field_3_138\" class=\"gfield gfield--type-section gfield--input-type-section gsection field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><h3 class=\"gsection_title\">Place of Birth &amp; Legal Status<\/h3><\/div><fieldset id=\"field_3_139\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-third field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible gfield--choice-align-vertical\"  ><legend class='gfield_label gform-field-label' ><span class='gform-field-label__text'>Location<\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_3_139'>\n\t\t\t<div class='gchoice gchoice_3_139_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_139' type='radio' value='Canada'  id='choice_3_139_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_3_139_0' id='label_3_139_0' class='gform-field-label gform-field-label--type-inline'>Canada<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_3_139_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_139' type='radio' value='Outside of Canada'  id='choice_3_139_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_3_139_1' id='label_3_139_1' class='gform-field-label gform-field-label--type-inline'>Outside of Canada<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_3_139_2'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_139' type='radio' value='Citizen'  id='choice_3_139_2' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_3_139_2' id='label_3_139_2' class='gform-field-label gform-field-label--type-inline'>Citizen<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_3_139_3'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_139' type='radio' value='Refugee'  id='choice_3_139_3' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_3_139_3' id='label_3_139_3' class='gform-field-label gform-field-label--type-inline'>Refugee<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_3_140\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-third field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_3_140'><span class='gform-field-label__text'>Specify Country<\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_140' id='input_3_140' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_3_141\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-third field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_3_141'><span class='gform-field-label__text'>Legal Status<\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_141' id='input_3_141' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/div><\/div>\n                    <\/div>\n                    <div class='gform-page-footer gform_page_footer top_label'>\n                        <button type='button' id='gform_previous_button_3_142' class='gform_previous_button gform-theme-button gform-theme-button--secondary button' onclick='gform.submission.handleButtonClick(this);' data-submission-type='previous' >Previous<\/button> <button type='button' id='gform_next_button_3_142' class='gform_next_button gform-theme-button button' onclick='gform.submission.handleButtonClick(this);' data-submission-type='next' >Next<\/button> <button type='button'  id='gform_save_3_11_link' onclick='gform.submission.handleButtonClick(this);' data-submission-type='save-continue' class='gform_save_link gform-theme-button gform-theme-button--secondary button'  ><svg aria-hidden=\"true\" focusable=\"false\" width=\"16\" height=\"16\" fill=\"none\" xmlns=\"http:\/\/www.w3.org\/2000\/svg\"><path fill-rule=\"evenodd\" clip-rule=\"evenodd\" d=\"M0 8a4 4 0 004 4h3v3a1 1 0 102 0v-3h3a4 4 0 100-8 4 4 0 10-8 0 4 4 0 00-4 4zm9 4H7V7.414L5.707 8.707a1 1 0 01-1.414-1.414l3-3a1 1 0 011.414 0l3 3a1 1 0 01-1.414 1.414L9 7.414V12z\" fill=\"#6B7280\"\/><\/svg> Save and Continue Later<\/button>\n                    <\/div>\n                <\/div>\n                <div id='gform_page_3_11' class='gform_page' data-js='page-field-id-142' style='display:none;'>\n                    <div class='gform_page_fields'>\n                        <div id='gform_fields_3_11' class='gform_fields top_label form_sublabel_below description_below validation_below'><div id=\"field_3_143\" class=\"gfield gfield--type-section gfield--input-type-section gsection field_sublabel_below gfield--has-description field_description_below field_validation_below gfield_visibility_visible\"  ><h3 class=\"gsection_title\">Youth\u2019s Race<\/h3><div class='gsection_description' id='gfield_description_3_143'>*A set of values that best represents a group of people who possess similar and distinct physical characteristics<\/div><\/div><fieldset id=\"field_3_145\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield--input-type-checkbox gfield--width-half gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible gfield--choice-align-vertical\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' ><span class='gform-field-label__text'>Please choose all that apply<\/span><span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(N\u00e9cessaire)<\/span><\/span><\/legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox ' id='input_3_145'><div class='gchoice gchoice_3_145_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_145.1' type='checkbox'  value='Black (e.g. African, Afro-Caribbean, African-Canadian, etc. descent)'  id='choice_3_145_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_3_145_1' id='label_3_145_1' class='gform-field-label gform-field-label--type-inline'>Black (e.g. African, Afro-Caribbean, African-Canadian, etc. descent)<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_3_145_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_145.2' type='checkbox'  value='East Asian (eg. Chinese, Korean, Japanese, Taiwanese, etc. descent)'  id='choice_3_145_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_3_145_2' id='label_3_145_2' class='gform-field-label gform-field-label--type-inline'>East Asian (eg. Chinese, Korean, Japanese, Taiwanese, etc. descent)<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_3_145_3'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_145.3' type='checkbox'  value='Latino (e.g. Latin American, Hispanic, etc. descent)'  id='choice_3_145_3'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_3_145_3' id='label_3_145_3' class='gform-field-label gform-field-label--type-inline'>Latino (e.g. Latin American, Hispanic, etc. descent)<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_3_145_4'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_145.4' type='checkbox'  value='Middle Eastern (e.g. Arab, Persian, West Asian, Afghan, Egyptian, Iranian, etc. decent)'  id='choice_3_145_4'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_3_145_4' id='label_3_145_4' class='gform-field-label gform-field-label--type-inline'>Middle Eastern (e.g. Arab, Persian, West Asian, Afghan, Egyptian, Iranian, etc. decent)<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_3_145_5'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_145.5' type='checkbox'  value='Indigeneous (First Nations, M\u00e9tis and\/or Inuit decent)'  id='choice_3_145_5'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_3_145_5' id='label_3_145_5' class='gform-field-label gform-field-label--type-inline'>Indigeneous (First Nations, M\u00e9tis and\/or Inuit decent)<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_3_145_6'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_145.6' type='checkbox'  value='South Asian (e.g. East Indian, Pakistani, Sri Lankan, Indo-Caribbean, etc. decent)'  id='choice_3_145_6'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_3_145_6' id='label_3_145_6' class='gform-field-label gform-field-label--type-inline'>South Asian (e.g. East Indian, Pakistani, Sri Lankan, Indo-Caribbean, etc. decent)<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_3_145_7'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_145.7' type='checkbox'  value='Southeast Asian (Filipino, Vietnamese, Cambodian, Thai, other Southeast Asian, etc. descent)'  id='choice_3_145_7'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_3_145_7' id='label_3_145_7' class='gform-field-label gform-field-label--type-inline'>Southeast Asian (Filipino, Vietnamese, Cambodian, Thai, other Southeast Asian, etc. descent)<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_3_145_8'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_145.8' type='checkbox'  value='White (e.g. European, North American, Western, etc. descent)'  id='choice_3_145_8'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_3_145_8' id='label_3_145_8' class='gform-field-label gform-field-label--type-inline'>White (e.g. European, North American, Western, etc. descent)<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_3_145_9'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_145.9' type='checkbox'  value='Prefer not to answer'  id='choice_3_145_9'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_3_145_9' id='label_3_145_9' class='gform-field-label gform-field-label--type-inline'>Prefer not to answer<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_3_145_11'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_145.11' type='checkbox'  value='Another race category'  id='choice_3_145_11'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_3_145_11' id='label_3_145_11' class='gform-field-label gform-field-label--type-inline'>Another race category<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_3_146\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-half field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_3_146'><span class='gform-field-label__text'>Specify<\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_146' id='input_3_146' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_3_147\" class=\"gfield gfield--type-section gfield--input-type-section gsection field_sublabel_below gfield--has-description field_description_below field_validation_below gfield_visibility_visible\"  ><h3 class=\"gsection_title\">Additional Diversity Identification &amp; Needs<\/h3><div class='gsection_description' id='gfield_description_3_147'>Please identify, if applicable, any other diversity identification. Indicate any special needs or accommodations the youth may\nrequire with respect to their religious\/spiritual needs, their gender identification and\/or their ethnic\/cultural identification (food\npreferences for meals and snacks, cultural activities, celebration of religious holidays, or other cultural traditions or practices)<\/div><\/div><div id=\"field_3_148\" class=\"gfield gfield--type-textarea gfield--input-type-textarea gfield--width-full field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_3_148'><span class='gform-field-label__text'>Additional Needs<\/span><\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_148' id='input_3_148' class='textarea large'      aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/div><\/div>\n                    <\/div>\n                    <div class='gform-page-footer gform_page_footer top_label'>\n                        <button type='button' id='gform_previous_button_3_20' class='gform_previous_button gform-theme-button gform-theme-button--secondary button' onclick='gform.submission.handleButtonClick(this);' data-submission-type='previous' >Previous<\/button> <button type='button' id='gform_next_button_3_20' class='gform_next_button gform-theme-button button' onclick='gform.submission.handleButtonClick(this);' data-submission-type='next' >Next<\/button> <button type='button'  id='gform_save_3_12_link' onclick='gform.submission.handleButtonClick(this);' data-submission-type='save-continue' class='gform_save_link gform-theme-button gform-theme-button--secondary button'  ><svg aria-hidden=\"true\" focusable=\"false\" width=\"16\" height=\"16\" fill=\"none\" xmlns=\"http:\/\/www.w3.org\/2000\/svg\"><path fill-rule=\"evenodd\" clip-rule=\"evenodd\" d=\"M0 8a4 4 0 004 4h3v3a1 1 0 102 0v-3h3a4 4 0 100-8 4 4 0 10-8 0 4 4 0 00-4 4zm9 4H7V7.414L5.707 8.707a1 1 0 01-1.414-1.414l3-3a1 1 0 011.414 0l3 3a1 1 0 01-1.414 1.414L9 7.414V12z\" fill=\"#6B7280\"\/><\/svg> Save and Continue Later<\/button>\n                    <\/div>\n                <\/div>\n                <div id='gform_page_3_12' class='gform_page' data-js='page-field-id-20' style='display:none;'>\n                    <div class='gform_page_fields'>\n                        <div id='gform_fields_3_12' class='gform_fields top_label form_sublabel_below description_below validation_below'><div id=\"field_3_150\" class=\"gfield gfield--type-section gfield--input-type-section gsection field_sublabel_below gfield--has-description field_description_below field_validation_below gfield_visibility_visible\"  ><h3 class=\"gsection_title\">Youth\u2019s Ethnic &amp; Cultural Identification<\/h3><div class='gsection_description' id='gfield_description_3_150'>* The information provided will help us better serve and meet the needs of various ethno cultural groups<\/div><\/div><fieldset id=\"field_3_152\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gf_list_2col gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible gfield--choice-align-columns\"  ><legend class='gfield_label gform-field-label' ><span class='gform-field-label__text'>Please select<\/span><span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(N\u00e9cessaire)<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_3_152'>\n\t\t\t<div class='gchoice gchoice_3_152_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_152' type='radio' value='Indigenous'  id='choice_3_152_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_3_152_0' id='label_3_152_0' class='gform-field-label gform-field-label--type-inline'>Indigenous<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_3_152_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_152' type='radio' value='North American'  id='choice_3_152_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_3_152_1' id='label_3_152_1' class='gform-field-label gform-field-label--type-inline'>North American<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_3_152_2'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_152' type='radio' value='British Isles (e.g. Irish, Scottish, English)'  id='choice_3_152_2' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_3_152_2' id='label_3_152_2' class='gform-field-label gform-field-label--type-inline'>British Isles (e.g. Irish, Scottish, English)<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_3_152_3'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_152' type='radio' value='French (e.g. Acadian, French)'  id='choice_3_152_3' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_3_152_3' id='label_3_152_3' class='gform-field-label gform-field-label--type-inline'>French (e.g. Acadian, French)<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_3_152_4'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_152' type='radio' value='Western European (e.g. Austrian, Belgian, Dutch, German, Swiss)'  id='choice_3_152_4' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_3_152_4' id='label_3_152_4' class='gform-field-label gform-field-label--type-inline'>Western European (e.g. Austrian, Belgian, Dutch, German, Swiss)<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_3_152_5'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_152' type='radio' value='Northern European (e.g. Danish, Finnish, Icelandic, Norwegian, Swedish)'  id='choice_3_152_5' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_3_152_5' id='label_3_152_5' class='gform-field-label gform-field-label--type-inline'>Northern European (e.g. Danish, Finnish, Icelandic, Norwegian, Swedish)<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_3_152_6'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_152' type='radio' value='Eastern European (e.g. Czech, Hungarian, Latvian, Polish, etc.)'  id='choice_3_152_6' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_3_152_6' id='label_3_152_6' class='gform-field-label gform-field-label--type-inline'>Eastern European (e.g. Czech, Hungarian, Latvian, Polish, etc.)<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_3_152_7'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_152' type='radio' value='Southern European (e.g. Bulgarian, Croatian, Greek, Italian, Portuguese, etc.)'  id='choice_3_152_7' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_3_152_7' id='label_3_152_7' class='gform-field-label gform-field-label--type-inline'>Southern European (e.g. Bulgarian, Croatian, Greek, Italian, Portuguese, etc.)<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_3_152_8'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_152' type='radio' value='Other European (Jewish)'  id='choice_3_152_8' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_3_152_8' id='label_3_152_8' class='gform-field-label gform-field-label--type-inline'>Other European (Jewish)<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_3_152_9'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_152' type='radio' value='Caribbean (e.g. Guyanese, Jamaican, Haitian, Puerto Rican, etc.)'  id='choice_3_152_9' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_3_152_9' id='label_3_152_9' class='gform-field-label gform-field-label--type-inline'>Caribbean (e.g. Guyanese, Jamaican, Haitian, Puerto Rican, etc.)<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_3_152_10'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_152' type='radio' value='Latin, Central and South American (e.g. Mexican, Columbian, Peruvian, etc.)'  id='choice_3_152_10' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_3_152_10' id='label_3_152_10' class='gform-field-label gform-field-label--type-inline'>Latin, Central and South American (e.g. Mexican, Columbian, Peruvian, etc.)<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_3_152_11'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_152' type='radio' value='African (e.g. Congolese, Somali, Nigerian, South African, etc.)'  id='choice_3_152_11' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_3_152_11' id='label_3_152_11' class='gform-field-label gform-field-label--type-inline'>African (e.g. Congolese, Somali, Nigerian, South African, etc.)<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_3_152_12'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_152' type='radio' value='West Asian (e.g. Afghan, Armenian, Iranian, etc.)'  id='choice_3_152_12' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_3_152_12' id='label_3_152_12' class='gform-field-label gform-field-label--type-inline'>West Asian (e.g. Afghan, Armenian, Iranian, etc.)<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_3_152_13'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_152' type='radio' value='South Asian (e.g. Bangladeshi, East Indian, Pakistani, Sri Lankan, etc.)'  id='choice_3_152_13' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_3_152_13' id='label_3_152_13' class='gform-field-label gform-field-label--type-inline'>South Asian (e.g. Bangladeshi, East Indian, Pakistani, Sri Lankan, etc.)<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_3_152_14'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_152' type='radio' value='Oceania (e.g. Australian, New Zealander, Pacific Islander)'  id='choice_3_152_14' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_3_152_14' id='label_3_152_14' class='gform-field-label gform-field-label--type-inline'>Oceania (e.g. Australian, New Zealander, Pacific Islander)<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_3_152_15'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_152' type='radio' value='Unknown'  id='choice_3_152_15' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_3_152_15' id='label_3_152_15' class='gform-field-label gform-field-label--type-inline'>Unknown<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_3_152_16'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_152' type='radio' value='Prefer not to answer'  id='choice_3_152_16' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_3_152_16' id='label_3_152_16' class='gform-field-label gform-field-label--type-inline'>Prefer not to answer<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_3_152_17'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_152' type='radio' value='Another race category'  id='choice_3_152_17' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_3_152_17' id='label_3_152_17' class='gform-field-label gform-field-label--type-inline'>Another race category<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_3_153\" class=\"gfield gfield--type-textarea gfield--input-type-textarea gfield--width-full field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_3_153'><span class='gform-field-label__text'>Additional information or details<\/span><\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_153' id='input_3_153' class='textarea small'      aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/div><\/div>\n                    <\/div>\n                    <div class='gform-page-footer gform_page_footer top_label'>\n                        <button type='button' id='gform_previous_button_3_154' class='gform_previous_button gform-theme-button gform-theme-button--secondary button' onclick='gform.submission.handleButtonClick(this);' data-submission-type='previous' >Previous<\/button> <button type='button' id='gform_next_button_3_154' class='gform_next_button gform-theme-button button' onclick='gform.submission.handleButtonClick(this);' data-submission-type='next' >Next<\/button> <button type='button'  id='gform_save_3_13_link' onclick='gform.submission.handleButtonClick(this);' data-submission-type='save-continue' class='gform_save_link gform-theme-button gform-theme-button--secondary button'  ><svg aria-hidden=\"true\" focusable=\"false\" width=\"16\" height=\"16\" fill=\"none\" xmlns=\"http:\/\/www.w3.org\/2000\/svg\"><path fill-rule=\"evenodd\" clip-rule=\"evenodd\" d=\"M0 8a4 4 0 004 4h3v3a1 1 0 102 0v-3h3a4 4 0 100-8 4 4 0 10-8 0 4 4 0 00-4 4zm9 4H7V7.414L5.707 8.707a1 1 0 01-1.414-1.414l3-3a1 1 0 011.414 0l3 3a1 1 0 01-1.414 1.414L9 7.414V12z\" fill=\"#6B7280\"\/><\/svg> Save and Continue Later<\/button>\n                    <\/div>\n                <\/div>\n                <div id='gform_page_3_13' class='gform_page' data-js='page-field-id-154' style='display:none;'>\n                    <div class='gform_page_fields'>\n                        <div id='gform_fields_3_13' class='gform_fields top_label form_sublabel_below description_below validation_below'><div id=\"field_3_155\" class=\"gfield gfield--type-section gfield--input-type-section gsection field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><h3 class=\"gsection_title\">Current &amp; Historical Diagnoses<\/h3><\/div><div id=\"field_3_157\" class=\"gfield gfield--type-form gfield--input-type-form gform-theme__no-reset--children gfield--width-full field_sublabel_below gfield--no-description field_description_below hidden_label field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_3_157'><span class='gform-field-label__text'>Please Enter<\/span><\/label><div class=\"gpnf-nested-entries-container ginput_container\">\n\n\t<table class=\"gpnf-nested-entries\">\n\n\t\t<thead>\n\t\t<tr>\n\t\t\t\t\t\t\t<th scope=\"col\" class=\"gpnf-field-4\">\n\t\t\t\t\tYouth\u2019s Mental Health and Neuro-Developmental Diagnoses\t\t\t\t<\/th>\n\t\t\t\t\t\t\t<th scope=\"col\" class=\"gpnf-field-6\">\n\t\t\t\t\tDiagnosing Professional\t\t\t\t<\/th>\n\t\t\t\t\t\t\t<th scope=\"col\" class=\"gpnf-field-7\">\n\t\t\t\t\tDate\t\t\t\t<\/th>\n\t\t\t\t\t\t<th scope=\"col\" class=\"gpnf-row-actions\"><span class=\"screen-reader-text\">Actions<\/span><\/th>\n\t\t<\/tr>\n\t\t<\/thead>\n\n\t\t<tbody data-bind=\"visible: entries().length, foreach: entries\">\n\t\t<tr data-bind=\"attr: { 'data-entryid': id }\">\n\t\t\t\t\t\t\t<td class=\"gpnf-field\"\n\t\t\t\t\tdata-bind=\"html: f4.label, attr: { 'data-value': f4.label }\"\n\t\t\t\t\tdata-heading=\"Youth\u2019s Mental Health and Neuro-Developmental Diagnoses\"\n\t\t\t\t>&nbsp;<\/td>\n\t\t\t\t\t\t\t<td class=\"gpnf-field\"\n\t\t\t\t\tdata-bind=\"html: f6.label, attr: { 'data-value': f6.label }\"\n\t\t\t\t\tdata-heading=\"Diagnosing Professional\"\n\t\t\t\t>&nbsp;<\/td>\n\t\t\t\t\t\t\t<td class=\"gpnf-field\"\n\t\t\t\t\tdata-bind=\"html: f7.label, attr: { 'data-value': f7.label }\"\n\t\t\t\t\tdata-heading=\"Date\"\n\t\t\t\t>&nbsp;<\/td>\n\t\t\t\t\t\t<td class=\"gpnf-row-actions\" style=\"display: none;\" data-bind=\"visible: true\">\n\t\t\t\t<ul>\n\t\t\t\t\t<li class=\"edit\"><button type=\"button\" class=\"edit-button gform-theme-button--secondary\" data-bind=\"click: $parent.editEntry, attr: { 'aria-label': 'Edit Diagnosis {0} where Youth\u2019s Mental Health and Neuro-Developmental Diagnoses is {1}.'.gformFormat( $index() + 1, f4.label ) }\">Modifier<\/button><\/li>\n\t\t\t\t\t\t\t\t\t\t<li class=\"delete\"><button type=\"button\" class=\"delete-button gform-theme-button--simple gform-theme-button--size-md\" data-bind=\"click: $parent.deleteEntry, attr: { 'aria-label': 'Delete Diagnosis {0} where Youth\u2019s Mental Health and Neuro-Developmental Diagnoses is {1}.'.gformFormat( $index() + 1, f4.label ) }\">Supprimer<\/button><\/li>\n\t\t\t\t<\/ul>\n\t\t\t<\/td>\n\t\t<\/tr>\n\t\t<\/tbody>\n\n\t\t<tbody data-bind=\"visible: entries().length <= 0\">\n\t\t<tr class=\"gpnf-no-entries\" data-bind=\"visible: entries().length <= 0\" style=\"display: none;\">\n\t\t\t<td colspan=\"4\">\n\t\t\t\tIl n\u2019y a aucun(e) <span>Diagnoses.<\/span>\t\t\t<\/td>\n\t\t<\/tr>\n\t\t<\/tbody>\n\n\t<\/table>\n\n\t<button type=\"button\" class=\"gpnf-add-entry\"\n\t\t        data-formid=\"3\"\n\t\t        data-nestedformid=\"9\"\n\t\t\t\tdata-bind=\"attr: { disabled: isMaxed }, css: { 'gf-default-disabled': isMaxed }\"\n\t\t\t\t>\n\t\t\t\tAjouter Diagnosis\n\t\t\t<\/button>\t\n\t\t\t<p class=\"gpnf-add-entry-max\" data-bind=\"visible: isMaxed\" style=\"display: none;\">\n\t\t\t\tLe nombre maximal a \u00e9t\u00e9 atteint.\n\t\t\t<\/p>\n<\/div>\n<input type=\"hidden\"\n                name=\"input_157\"\n                id=\"input_3_157\"\n                data-bind=\"value: entryIds\"\n                value=\"\" \/><\/div><div id=\"field_3_156\" class=\"gfield gfield--type-textarea gfield--input-type-textarea gfield--width-full field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_3_156'><span class='gform-field-label__text'>Please add any additional explanation or comments regarding the information provided above for the youth&#039;s diagnoses, if applicable:<\/span><\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_156' id='input_3_156' class='textarea medium'      aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/div><\/div>\n                    <\/div>\n                    <div class='gform-page-footer gform_page_footer top_label'>\n                        <button type='button' id='gform_previous_button_3_158' class='gform_previous_button gform-theme-button gform-theme-button--secondary button' onclick='gform.submission.handleButtonClick(this);' data-submission-type='previous' >Previous<\/button> <button type='button' id='gform_next_button_3_158' class='gform_next_button gform-theme-button button' onclick='gform.submission.handleButtonClick(this);' data-submission-type='next' >Next<\/button> <button type='button'  id='gform_save_3_14_link' onclick='gform.submission.handleButtonClick(this);' data-submission-type='save-continue' class='gform_save_link gform-theme-button gform-theme-button--secondary button'  ><svg aria-hidden=\"true\" focusable=\"false\" width=\"16\" height=\"16\" fill=\"none\" xmlns=\"http:\/\/www.w3.org\/2000\/svg\"><path fill-rule=\"evenodd\" clip-rule=\"evenodd\" d=\"M0 8a4 4 0 004 4h3v3a1 1 0 102 0v-3h3a4 4 0 100-8 4 4 0 10-8 0 4 4 0 00-4 4zm9 4H7V7.414L5.707 8.707a1 1 0 01-1.414-1.414l3-3a1 1 0 011.414 0l3 3a1 1 0 01-1.414 1.414L9 7.414V12z\" fill=\"#6B7280\"\/><\/svg> Save and Continue Later<\/button>\n                    <\/div>\n                <\/div>\n                <div id='gform_page_3_14' class='gform_page' data-js='page-field-id-158' style='display:none;'>\n                    <div class='gform_page_fields'>\n                        <div id='gform_fields_3_14' class='gform_fields top_label form_sublabel_below description_below validation_below'><div id=\"field_3_159\" class=\"gfield gfield--type-section gfield--input-type-section gsection field_sublabel_below gfield--has-description field_description_below field_validation_below gfield_visibility_visible\"  ><h3 class=\"gsection_title\">Current Primary Presenting Problem Areas<\/h3><div class='gsection_description' id='gfield_description_3_159'>Please check category that apply; choosing as many that apply<\/div><\/div><fieldset id=\"field_3_160\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield--input-type-checkbox gfield--width-third field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible gfield--choice-align-vertical\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' ><span class='gform-field-label__text'>School &amp; Learning<\/span><\/legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox ' id='input_3_160'><div class='gchoice gchoice_3_160_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_160.1' type='checkbox'  value='Truancy'  id='choice_3_160_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_3_160_1' id='label_3_160_1' class='gform-field-label gform-field-label--type-inline'>Truancy<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_3_160_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_160.2' type='checkbox'  value='School Phobia'  id='choice_3_160_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_3_160_2' id='label_3_160_2' class='gform-field-label gform-field-label--type-inline'>School Phobia<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_3_160_3'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_160.3' type='checkbox'  value='Under Achievement'  id='choice_3_160_3'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_3_160_3' id='label_3_160_3' class='gform-field-label gform-field-label--type-inline'>Under Achievement<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_3_160_4'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_160.4' type='checkbox'  value='Learning Problems'  id='choice_3_160_4'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_3_160_4' id='label_3_160_4' class='gform-field-label gform-field-label--type-inline'>Learning Problems<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_3_160_5'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_160.5' type='checkbox'  value='Learning Disability'  id='choice_3_160_5'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_3_160_5' id='label_3_160_5' class='gform-field-label gform-field-label--type-inline'>Learning Disability<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_3_160_6'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_160.6' type='checkbox'  value='Not in School'  id='choice_3_160_6'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_3_160_6' id='label_3_160_6' class='gform-field-label gform-field-label--type-inline'>Not in School<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_3_160_7'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_160.7' type='checkbox'  value='Other'  id='choice_3_160_7'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_3_160_7' id='label_3_160_7' class='gform-field-label gform-field-label--type-inline'>Other<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_3_162\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-third field_sublabel_below gfield--has-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_3_162'><span class='gform-field-label__text'>Other<\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_162' id='input_3_162' type='text' value='' class='large'  aria-describedby=\"gfield_description_3_162\"    aria-invalid=\"false\"   \/><\/div><div class='gfield_description' id='gfield_description_3_162'>Please Specify<\/div><\/div><fieldset id=\"field_3_161\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield--input-type-checkbox gfield--width-third field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible gfield--choice-align-vertical\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' ><span class='gform-field-label__text'>Victimization<\/span><\/legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox ' id='input_3_161'><div class='gchoice gchoice_3_161_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_161.1' type='checkbox'  value='Sexual Abuse (Suspected)'  id='choice_3_161_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_3_161_1' id='label_3_161_1' class='gform-field-label gform-field-label--type-inline'>Sexual Abuse (Suspected)<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_3_161_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_161.2' type='checkbox'  value='Physical Abuse (Suspected)'  id='choice_3_161_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_3_161_2' id='label_3_161_2' class='gform-field-label gform-field-label--type-inline'>Physical Abuse (Suspected)<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_3_161_3'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_161.3' type='checkbox'  value='Emotional Abuse \/ Bullying'  id='choice_3_161_3'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_3_161_3' id='label_3_161_3' class='gform-field-label gform-field-label--type-inline'>Emotional Abuse \/ Bullying<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_3_161_4'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_161.4' type='checkbox'  value='Neglect'  id='choice_3_161_4'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_3_161_4' id='label_3_161_4' class='gform-field-label gform-field-label--type-inline'>Neglect<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_3_161_5'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_161.5' type='checkbox'  value='Sexual Abuse (Verified)'  id='choice_3_161_5'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_3_161_5' id='label_3_161_5' class='gform-field-label gform-field-label--type-inline'>Sexual Abuse (Verified)<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_3_161_6'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_161.6' type='checkbox'  value='Physical Abuse(Verified)'  id='choice_3_161_6'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_3_161_6' id='label_3_161_6' class='gform-field-label gform-field-label--type-inline'>Physical Abuse(Verified)<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_3_163\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-half field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_3_163'><span class='gform-field-label__text'>Age (Sexual Abuse)<\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_163' id='input_3_163' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_3_164\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-half field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_3_164'><span class='gform-field-label__text'>By whom (Sexual Abuse)<\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_164' id='input_3_164' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_3_165\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-half field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_3_165'><span class='gform-field-label__text'>Age (Physical Abuse)<\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_165' id='input_3_165' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_3_166\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-half field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_3_166'><span class='gform-field-label__text'>By whom (Physical Abuse)<\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_166' id='input_3_166' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/div><fieldset id=\"field_3_167\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield--input-type-checkbox gfield--width-half field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible gfield--choice-align-vertical\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' ><span class='gform-field-label__text'>Disruptive Behaviour<\/span><\/legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox ' id='input_3_167'><div class='gchoice gchoice_3_167_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_167.1' type='checkbox'  value='Aggression (Verbal)'  id='choice_3_167_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_3_167_1' id='label_3_167_1' class='gform-field-label gform-field-label--type-inline'>Aggression (Verbal)<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_3_167_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_167.2' type='checkbox'  value='Aggression (Physical)'  id='choice_3_167_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_3_167_2' id='label_3_167_2' class='gform-field-label gform-field-label--type-inline'>Aggression (Physical)<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_3_167_3'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_167.3' type='checkbox'  value='Running'  id='choice_3_167_3'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_3_167_3' id='label_3_167_3' class='gform-field-label gform-field-label--type-inline'>Running<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_3_167_4'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_167.4' type='checkbox'  value='Fire Setting'  id='choice_3_167_4'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_3_167_4' id='label_3_167_4' class='gform-field-label gform-field-label--type-inline'>Fire Setting<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_3_167_5'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_167.5' type='checkbox'  value='Stealing'  id='choice_3_167_5'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_3_167_5' id='label_3_167_5' class='gform-field-label gform-field-label--type-inline'>Stealing<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_3_167_6'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_167.6' type='checkbox'  value='Destruction of Property'  id='choice_3_167_6'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_3_167_6' id='label_3_167_6' class='gform-field-label gform-field-label--type-inline'>Destruction of Property<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_3_167_7'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_167.7' type='checkbox'  value='Sexual Acting Out'  id='choice_3_167_7'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_3_167_7' id='label_3_167_7' class='gform-field-label gform-field-label--type-inline'>Sexual Acting Out<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_3_167_8'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_167.8' type='checkbox'  value='Substance Abuse'  id='choice_3_167_8'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_3_167_8' id='label_3_167_8' class='gform-field-label gform-field-label--type-inline'>Substance Abuse<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_3_167_9'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_167.9' type='checkbox'  value='Defiance'  id='choice_3_167_9'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_3_167_9' id='label_3_167_9' class='gform-field-label gform-field-label--type-inline'>Defiance<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_3_167_11'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_167.11' type='checkbox'  value='Self Control'  id='choice_3_167_11'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_3_167_11' id='label_3_167_11' class='gform-field-label gform-field-label--type-inline'>Self Control<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_3_167_12'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_167.12' type='checkbox'  value='Bullying'  id='choice_3_167_12'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_3_167_12' id='label_3_167_12' class='gform-field-label gform-field-label--type-inline'>Bullying<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_3_168\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield--input-type-checkbox gfield--width-half field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible gfield--choice-align-vertical\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' ><span class='gform-field-label__text'>Thought, Perception and Mood Disturbances<\/span><\/legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox ' id='input_3_168'><div class='gchoice gchoice_3_168_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_168.1' type='checkbox'  value='Disturbances in Thought Process'  id='choice_3_168_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_3_168_1' id='label_3_168_1' class='gform-field-label gform-field-label--type-inline'>Disturbances in Thought Process<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_3_168_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_168.2' type='checkbox'  value='Anxiety or Depression'  id='choice_3_168_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_3_168_2' id='label_3_168_2' class='gform-field-label gform-field-label--type-inline'>Anxiety or Depression<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_3_168_3'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_168.3' type='checkbox'  value='Continued Excited Mood'  id='choice_3_168_3'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_3_168_3' id='label_3_168_3' class='gform-field-label gform-field-label--type-inline'>Continued Excited Mood<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_3_168_4'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_168.4' type='checkbox'  value='Self Harm'  id='choice_3_168_4'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_3_168_4' id='label_3_168_4' class='gform-field-label gform-field-label--type-inline'>Self Harm<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_3_168_5'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_168.5' type='checkbox'  value='Severe Mood Swings or Reactivity'  id='choice_3_168_5'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_3_168_5' id='label_3_168_5' class='gform-field-label gform-field-label--type-inline'>Severe Mood Swings or Reactivity<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_3_168_6'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_168.6' type='checkbox'  value='Suicidal Ideation'  id='choice_3_168_6'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_3_168_6' id='label_3_168_6' class='gform-field-label gform-field-label--type-inline'>Suicidal Ideation<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_3_168_7'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_168.7' type='checkbox'  value='Suicidal Gestures or Attempts'  id='choice_3_168_7'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_3_168_7' id='label_3_168_7' class='gform-field-label gform-field-label--type-inline'>Suicidal Gestures or Attempts<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_3_169\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-full field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_3_169'><span class='gform-field-label__text'>Primary Presenting Problem Areas Additional Comments:<\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_169' id='input_3_169' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/div><fieldset id=\"field_3_170\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield--input-type-checkbox gfield--width-third field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible gfield--choice-align-vertical\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' ><span class='gform-field-label__text'>Family Issues \/ Concerns \/ Dynamics<\/span><\/legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox ' id='input_3_170'><div class='gchoice gchoice_3_170_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_170.1' type='checkbox'  value='Lack of Family Support to Provide Care'  id='choice_3_170_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_3_170_1' id='label_3_170_1' class='gform-field-label gform-field-label--type-inline'>Lack of Family Support to Provide Care<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_3_170_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_170.2' type='checkbox'  value='Family Conflict or Distress'  id='choice_3_170_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_3_170_2' id='label_3_170_2' class='gform-field-label gform-field-label--type-inline'>Family Conflict or Distress<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_3_170_3'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_170.3' type='checkbox'  value='Parent-Child Conflict'  id='choice_3_170_3'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_3_170_3' id='label_3_170_3' class='gform-field-label gform-field-label--type-inline'>Parent-Child Conflict<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_3_170_4'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_170.4' type='checkbox'  value='Substance Abuse'  id='choice_3_170_4'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_3_170_4' id='label_3_170_4' class='gform-field-label gform-field-label--type-inline'>Substance Abuse<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_3_170_5'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_170.5' type='checkbox'  value='Physical or Mental Health Issues'  id='choice_3_170_5'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_3_170_5' id='label_3_170_5' class='gform-field-label gform-field-label--type-inline'>Physical or Mental Health Issues<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_3_170_6'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_170.6' type='checkbox'  value='Other'  id='choice_3_170_6'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_3_170_6' id='label_3_170_6' class='gform-field-label gform-field-label--type-inline'>Other<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_3_171\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-third field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_3_171'><span class='gform-field-label__text'>Other<\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_171' id='input_3_171' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/div><fieldset id=\"field_3_172\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield--input-type-checkbox gfield--width-third field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible gfield--choice-align-vertical\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' ><span class='gform-field-label__text'>Physical \/ Sensory Status<\/span><\/legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox ' id='input_3_172'><div class='gchoice gchoice_3_172_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_172.1' type='checkbox'  value='Neurological or Severe Brain Damage'  id='choice_3_172_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_3_172_1' id='label_3_172_1' class='gform-field-label gform-field-label--type-inline'>Neurological or Severe Brain Damage<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_3_172_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_172.2' type='checkbox'  value='Enuresis'  id='choice_3_172_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_3_172_2' id='label_3_172_2' class='gform-field-label gform-field-label--type-inline'>Enuresis<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_3_172_3'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_172.3' type='checkbox'  value='Encopresis'  id='choice_3_172_3'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_3_172_3' id='label_3_172_3' class='gform-field-label gform-field-label--type-inline'>Encopresis<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_3_172_4'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_172.4' type='checkbox'  value='Sensory Deficits or Disorders'  id='choice_3_172_4'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_3_172_4' id='label_3_172_4' class='gform-field-label gform-field-label--type-inline'>Sensory Deficits or Disorders<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_3_172_5'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_172.5' type='checkbox'  value='Sleep Disturbances'  id='choice_3_172_5'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_3_172_5' id='label_3_172_5' class='gform-field-label gform-field-label--type-inline'>Sleep Disturbances<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_3_172_6'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_172.6' type='checkbox'  value='Psycho-Physiological'  id='choice_3_172_6'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_3_172_6' id='label_3_172_6' class='gform-field-label gform-field-label--type-inline'>Psycho-Physiological<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_3_172_7'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_172.7' type='checkbox'  value='Physical Disability'  id='choice_3_172_7'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_3_172_7' id='label_3_172_7' class='gform-field-label gform-field-label--type-inline'>Physical Disability<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_3_173\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield--input-type-checkbox gfield--width-half field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible gfield--choice-align-vertical\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' ><span class='gform-field-label__text'>Intellectual \/ Adaptive \/ Functional<\/span><\/legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox ' id='input_3_173'><div class='gchoice gchoice_3_173_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_173.1' type='checkbox'  value='Deficits in Intellectual Function'  id='choice_3_173_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_3_173_1' id='label_3_173_1' class='gform-field-label gform-field-label--type-inline'>Deficits in Intellectual Function<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_3_173_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_173.2' type='checkbox'  value='Deficits in Life Skills'  id='choice_3_173_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_3_173_2' id='label_3_173_2' class='gform-field-label gform-field-label--type-inline'>Deficits in Life Skills<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_3_173_3'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_173.3' type='checkbox'  value='Development Delays'  id='choice_3_173_3'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_3_173_3' id='label_3_173_3' class='gform-field-label gform-field-label--type-inline'>Development Delays<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_3_174\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield--input-type-checkbox gfield--width-half field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible gfield--choice-align-vertical\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' ><span class='gform-field-label__text'>Social Withdraw<\/span><\/legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox ' id='input_3_174'><div class='gchoice gchoice_3_174_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_174.1' type='checkbox'  value='Lack of Peer Friendship'  id='choice_3_174_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_3_174_1' id='label_3_174_1' class='gform-field-label gform-field-label--type-inline'>Lack of Peer Friendship<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_3_174_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_174.2' type='checkbox'  value='Lack of Adult Relationships'  id='choice_3_174_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_3_174_2' id='label_3_174_2' class='gform-field-label gform-field-label--type-inline'>Lack of Adult Relationships<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_3_174_3'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_174.3' type='checkbox'  value='Social Isolation'  id='choice_3_174_3'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_3_174_3' id='label_3_174_3' class='gform-field-label gform-field-label--type-inline'>Social Isolation<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><\/div>\n                    <\/div>\n                    <div class='gform-page-footer gform_page_footer top_label'>\n                        <button type='button' id='gform_previous_button_3_176' class='gform_previous_button gform-theme-button gform-theme-button--secondary button' onclick='gform.submission.handleButtonClick(this);' data-submission-type='previous' >Previous<\/button> <button type='button' id='gform_next_button_3_176' class='gform_next_button gform-theme-button button' onclick='gform.submission.handleButtonClick(this);' data-submission-type='next' >Next<\/button> <button type='button'  id='gform_save_3_15_link' onclick='gform.submission.handleButtonClick(this);' data-submission-type='save-continue' class='gform_save_link gform-theme-button gform-theme-button--secondary button'  ><svg aria-hidden=\"true\" focusable=\"false\" width=\"16\" height=\"16\" fill=\"none\" xmlns=\"http:\/\/www.w3.org\/2000\/svg\"><path fill-rule=\"evenodd\" clip-rule=\"evenodd\" d=\"M0 8a4 4 0 004 4h3v3a1 1 0 102 0v-3h3a4 4 0 100-8 4 4 0 10-8 0 4 4 0 00-4 4zm9 4H7V7.414L5.707 8.707a1 1 0 01-1.414-1.414l3-3a1 1 0 011.414 0l3 3a1 1 0 01-1.414 1.414L9 7.414V12z\" fill=\"#6B7280\"\/><\/svg> Save and Continue Later<\/button>\n                    <\/div>\n                <\/div>\n                <div id='gform_page_3_15' class='gform_page' data-js='page-field-id-176' style='display:none;'>\n                    <div class='gform_page_fields'>\n                        <div id='gform_fields_3_15' class='gform_fields top_label form_sublabel_below description_below validation_below'><div id=\"field_3_175\" class=\"gfield gfield--type-section gfield--input-type-section gsection field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><h3 class=\"gsection_title\">Service Involvement<\/h3><\/div><div id=\"field_3_177\" class=\"gfield gfield--type-html gfield--input-type-html gfield--width-three-quarter gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><strong>Please indicate:<\/strong><br\/>\na) if the youth or any family members are currently or have received services from the RSC and<br\/>\nb) if so, when and through which RSC program\/service.<\/div><fieldset id=\"field_3_178\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield--input-type-checkbox gfield--width-quarter field_sublabel_below gfield--no-description field_description_below hidden_label field_validation_below gfield_visibility_visible gfield--choice-align-vertical\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' ><span class='gform-field-label__text'>N\/A<\/span><\/legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox ' id='input_3_178'><div class='gchoice gchoice_3_178_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_178.1' type='checkbox'  value='N\/A'  id='choice_3_178_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_3_178_1' id='label_3_178_1' class='gform-field-label gform-field-label--type-inline'>N\/A<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_3_179\" class=\"gfield gfield--type-textarea gfield--input-type-textarea gfield--width-full field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_3_179'><span class='gform-field-label__text'>Please Describe<\/span><\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_179' id='input_3_179' class='textarea large'      aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/div><\/div>\n                    <\/div>\n                    <div class='gform-page-footer gform_page_footer top_label'>\n                        <button type='button' id='gform_previous_button_3_180' class='gform_previous_button gform-theme-button gform-theme-button--secondary button' onclick='gform.submission.handleButtonClick(this);' data-submission-type='previous' >Previous<\/button> <button type='button' id='gform_next_button_3_180' class='gform_next_button gform-theme-button button' onclick='gform.submission.handleButtonClick(this);' data-submission-type='next' >Next<\/button> <button type='button'  id='gform_save_3_16_link' onclick='gform.submission.handleButtonClick(this);' data-submission-type='save-continue' class='gform_save_link gform-theme-button gform-theme-button--secondary button'  ><svg aria-hidden=\"true\" focusable=\"false\" width=\"16\" height=\"16\" fill=\"none\" xmlns=\"http:\/\/www.w3.org\/2000\/svg\"><path fill-rule=\"evenodd\" clip-rule=\"evenodd\" d=\"M0 8a4 4 0 004 4h3v3a1 1 0 102 0v-3h3a4 4 0 100-8 4 4 0 10-8 0 4 4 0 00-4 4zm9 4H7V7.414L5.707 8.707a1 1 0 01-1.414-1.414l3-3a1 1 0 011.414 0l3 3a1 1 0 01-1.414 1.414L9 7.414V12z\" fill=\"#6B7280\"\/><\/svg> Save and Continue Later<\/button>\n                    <\/div>\n                <\/div>\n                <div id='gform_page_3_16' class='gform_page' data-js='page-field-id-180' style='display:none;'>\n                    <div class='gform_page_fields'>\n                        <div id='gform_fields_3_16' class='gform_fields top_label form_sublabel_below description_below validation_below'><div id=\"field_3_181\" class=\"gfield gfield--type-section gfield--input-type-section gsection field_sublabel_below gfield--has-description field_description_below field_validation_below gfield_visibility_visible\"  ><h3 class=\"gsection_title\">Placement History (Current and Historical)<\/h3><div class='gsection_description' id='gfield_description_3_181'>Please list current and historical service involvement, other than placements<\/div><\/div><div id=\"field_3_182\" class=\"gfield gfield--type-form gfield--input-type-form gform-theme__no-reset--children gfield--width-full field_sublabel_below gfield--no-description field_description_below hidden_label field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_3_182'><span class='gform-field-label__text'>Untitled<\/span><\/label><div class=\"gpnf-nested-entries-container ginput_container\">\n\n\t<table class=\"gpnf-nested-entries\">\n\n\t\t<thead>\n\t\t<tr>\n\t\t\t\t\t\t\t<th scope=\"col\" class=\"gpnf-field-4\">\n\t\t\t\t\tOrganization \/ Caregiver\t\t\t\t<\/th>\n\t\t\t\t\t\t\t<th scope=\"col\" class=\"gpnf-field-6\">\n\t\t\t\t\tPlacement Type\t\t\t\t<\/th>\n\t\t\t\t\t\t\t<th scope=\"col\" class=\"gpnf-field-7\">\n\t\t\t\t\tStart Date\t\t\t\t<\/th>\n\t\t\t\t\t\t\t<th scope=\"col\" class=\"gpnf-field-8\">\n\t\t\t\t\tEnd Date\t\t\t\t<\/th>\n\t\t\t\t\t\t<th scope=\"col\" class=\"gpnf-row-actions\"><span class=\"screen-reader-text\">Actions<\/span><\/th>\n\t\t<\/tr>\n\t\t<\/thead>\n\n\t\t<tbody data-bind=\"visible: entries().length, foreach: entries\">\n\t\t<tr data-bind=\"attr: { 'data-entryid': id }\">\n\t\t\t\t\t\t\t<td class=\"gpnf-field\"\n\t\t\t\t\tdata-bind=\"html: f4.label, attr: { 'data-value': f4.label }\"\n\t\t\t\t\tdata-heading=\"Organization \/ Caregiver\"\n\t\t\t\t>&nbsp;<\/td>\n\t\t\t\t\t\t\t<td class=\"gpnf-field\"\n\t\t\t\t\tdata-bind=\"html: f6.label, attr: { 'data-value': f6.label }\"\n\t\t\t\t\tdata-heading=\"Placement Type\"\n\t\t\t\t>&nbsp;<\/td>\n\t\t\t\t\t\t\t<td class=\"gpnf-field\"\n\t\t\t\t\tdata-bind=\"html: f7.label, attr: { 'data-value': f7.label }\"\n\t\t\t\t\tdata-heading=\"Start Date\"\n\t\t\t\t>&nbsp;<\/td>\n\t\t\t\t\t\t\t<td class=\"gpnf-field\"\n\t\t\t\t\tdata-bind=\"html: f8.label, attr: { 'data-value': f8.label }\"\n\t\t\t\t\tdata-heading=\"End Date\"\n\t\t\t\t>&nbsp;<\/td>\n\t\t\t\t\t\t<td class=\"gpnf-row-actions\" style=\"display: none;\" data-bind=\"visible: true\">\n\t\t\t\t<ul>\n\t\t\t\t\t<li class=\"edit\"><button type=\"button\" class=\"edit-button gform-theme-button--secondary\" data-bind=\"click: $parent.editEntry, attr: { 'aria-label': 'Edit Entry {0} where Organization \/ Caregiver is {1}.'.gformFormat( $index() + 1, f4.label ) }\">Modifier<\/button><\/li>\n\t\t\t\t\t\t\t\t\t\t<li class=\"delete\"><button type=\"button\" class=\"delete-button gform-theme-button--simple gform-theme-button--size-md\" data-bind=\"click: $parent.deleteEntry, attr: { 'aria-label': 'Delete Entry {0} where Organization \/ Caregiver is {1}.'.gformFormat( $index() + 1, f4.label ) }\">Supprimer<\/button><\/li>\n\t\t\t\t<\/ul>\n\t\t\t<\/td>\n\t\t<\/tr>\n\t\t<\/tbody>\n\n\t\t<tbody data-bind=\"visible: entries().length <= 0\">\n\t\t<tr class=\"gpnf-no-entries\" data-bind=\"visible: entries().length <= 0\" style=\"display: none;\">\n\t\t\t<td colspan=\"5\">\n\t\t\t\tIl n\u2019y a aucun(e) <span>Entries.<\/span>\t\t\t<\/td>\n\t\t<\/tr>\n\t\t<\/tbody>\n\n\t<\/table>\n\n\t<button type=\"button\" class=\"gpnf-add-entry\"\n\t\t        data-formid=\"3\"\n\t\t        data-nestedformid=\"10\"\n\t\t\t\tdata-bind=\"attr: { disabled: isMaxed }, css: { 'gf-default-disabled': isMaxed }\"\n\t\t\t\t>\n\t\t\t\tAjouter Entry\n\t\t\t<\/button>\t\n\t\t\t<p class=\"gpnf-add-entry-max\" data-bind=\"visible: isMaxed\" style=\"display: none;\">\n\t\t\t\tLe nombre maximal a \u00e9t\u00e9 atteint.\n\t\t\t<\/p>\n<\/div>\n<input type=\"hidden\"\n                name=\"input_182\"\n                id=\"input_3_182\"\n                data-bind=\"value: entryIds\"\n                value=\"\" \/><\/div><div id=\"field_3_185\" class=\"gfield gfield--type-section gfield--input-type-section gsection field_sublabel_below gfield--has-description field_description_below field_validation_below gfield_visibility_visible\"  ><h3 class=\"gsection_title\">Youth Criminal Justice Act Involvement (Current &amp; Historical)<\/h3><div class='gsection_description' id='gfield_description_3_185'>Please include any current or outstanding matters, such as bail conditions, probation orders, pending charges, upcoming court dates, etc.<\/div><\/div><fieldset id=\"field_3_187\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield--input-type-checkbox gfield--width-full field_sublabel_below gfield--no-description field_description_below hidden_label field_validation_below gfield_visibility_visible gfield--choice-align-vertical\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' ><span class='gform-field-label__text'>N\/A<\/span><\/legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox ' id='input_3_187'><div class='gchoice gchoice_3_187_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_187.1' type='checkbox'  value='N\/A'  id='choice_3_187_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_3_187_1' id='label_3_187_1' class='gform-field-label gform-field-label--type-inline'>N\/A<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_3_186\" class=\"gfield gfield--type-textarea gfield--input-type-textarea gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_3_186'><span class='gform-field-label__text'>Please Describe<\/span><span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(N\u00e9cessaire)<\/span><\/span><\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_186' id='input_3_186' class='textarea large'     aria-required=\"true\" aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/div><\/div>\n                    <\/div>\n                    <div class='gform-page-footer gform_page_footer top_label'>\n                        <button type='button' id='gform_previous_button_3_232' class='gform_previous_button gform-theme-button gform-theme-button--secondary button' onclick='gform.submission.handleButtonClick(this);' data-submission-type='previous' >Previous<\/button> <button type='button' id='gform_next_button_3_232' class='gform_next_button gform-theme-button button' onclick='gform.submission.handleButtonClick(this);' data-submission-type='next' >Next<\/button> <button type='button'  id='gform_save_3_17_link' onclick='gform.submission.handleButtonClick(this);' data-submission-type='save-continue' class='gform_save_link gform-theme-button gform-theme-button--secondary button'  ><svg aria-hidden=\"true\" focusable=\"false\" width=\"16\" height=\"16\" fill=\"none\" xmlns=\"http:\/\/www.w3.org\/2000\/svg\"><path fill-rule=\"evenodd\" clip-rule=\"evenodd\" d=\"M0 8a4 4 0 004 4h3v3a1 1 0 102 0v-3h3a4 4 0 100-8 4 4 0 10-8 0 4 4 0 00-4 4zm9 4H7V7.414L5.707 8.707a1 1 0 01-1.414-1.414l3-3a1 1 0 011.414 0l3 3a1 1 0 01-1.414 1.414L9 7.414V12z\" fill=\"#6B7280\"\/><\/svg> Save and Continue Later<\/button>\n                    <\/div>\n                <\/div>\n                <div id='gform_page_3_17' class='gform_page' data-js='page-field-id-232' style='display:none;'>\n                    <div class='gform_page_fields'>\n                        <div id='gform_fields_3_17' class='gform_fields top_label form_sublabel_below description_below validation_below'><div id=\"field_3_183\" class=\"gfield gfield--type-section gfield--input-type-section gsection field_sublabel_below gfield--has-description field_description_below field_validation_below gfield_visibility_visible\"  ><h3 class=\"gsection_title\">Service History<\/h3><div class='gsection_description' id='gfield_description_3_183'>Please list current and historical service involvement, other than placements<\/div><\/div><div id=\"field_3_184\" class=\"gfield gfield--type-form gfield--input-type-form gform-theme__no-reset--children gfield--width-full field_sublabel_below gfield--no-description field_description_below hidden_label field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_3_184'><span class='gform-field-label__text'>Untitled<\/span><\/label><div class=\"gpnf-nested-entries-container ginput_container\">\n\n\t<table class=\"gpnf-nested-entries\">\n\n\t\t<thead>\n\t\t<tr>\n\t\t\t\t\t\t\t<th scope=\"col\" class=\"gpnf-field-4\">\n\t\t\t\t\tOrganization \/ Service Provider Name\t\t\t\t<\/th>\n\t\t\t\t\t\t\t<th scope=\"col\" class=\"gpnf-field-6\">\n\t\t\t\t\tService Sector\t\t\t\t<\/th>\n\t\t\t\t\t\t\t<th scope=\"col\" class=\"gpnf-field-7\">\n\t\t\t\t\tStart Date\t\t\t\t<\/th>\n\t\t\t\t\t\t\t<th scope=\"col\" class=\"gpnf-field-8\">\n\t\t\t\t\tEnd Date\t\t\t\t<\/th>\n\t\t\t\t\t\t<th scope=\"col\" class=\"gpnf-row-actions\"><span class=\"screen-reader-text\">Actions<\/span><\/th>\n\t\t<\/tr>\n\t\t<\/thead>\n\n\t\t<tbody data-bind=\"visible: entries().length, foreach: entries\">\n\t\t<tr data-bind=\"attr: { 'data-entryid': id }\">\n\t\t\t\t\t\t\t<td class=\"gpnf-field\"\n\t\t\t\t\tdata-bind=\"html: f4.label, attr: { 'data-value': f4.label }\"\n\t\t\t\t\tdata-heading=\"Organization \/ Service Provider Name\"\n\t\t\t\t>&nbsp;<\/td>\n\t\t\t\t\t\t\t<td class=\"gpnf-field\"\n\t\t\t\t\tdata-bind=\"html: f6.label, attr: { 'data-value': f6.label }\"\n\t\t\t\t\tdata-heading=\"Service Sector\"\n\t\t\t\t>&nbsp;<\/td>\n\t\t\t\t\t\t\t<td class=\"gpnf-field\"\n\t\t\t\t\tdata-bind=\"html: f7.label, attr: { 'data-value': f7.label }\"\n\t\t\t\t\tdata-heading=\"Start Date\"\n\t\t\t\t>&nbsp;<\/td>\n\t\t\t\t\t\t\t<td class=\"gpnf-field\"\n\t\t\t\t\tdata-bind=\"html: f8.label, attr: { 'data-value': f8.label }\"\n\t\t\t\t\tdata-heading=\"End Date\"\n\t\t\t\t>&nbsp;<\/td>\n\t\t\t\t\t\t<td class=\"gpnf-row-actions\" style=\"display: none;\" data-bind=\"visible: true\">\n\t\t\t\t<ul>\n\t\t\t\t\t<li class=\"edit\"><button type=\"button\" class=\"edit-button gform-theme-button--secondary\" data-bind=\"click: $parent.editEntry, attr: { 'aria-label': 'Edit Entr\u00e9e {0} where Organization \/ Service Provider Name is {1}.'.gformFormat( $index() + 1, f4.label ) }\">Modifier<\/button><\/li>\n\t\t\t\t\t\t\t\t\t\t<li class=\"delete\"><button type=\"button\" class=\"delete-button gform-theme-button--simple gform-theme-button--size-md\" data-bind=\"click: $parent.deleteEntry, attr: { 'aria-label': 'Delete Entr\u00e9e {0} where Organization \/ Service Provider Name is {1}.'.gformFormat( $index() + 1, f4.label ) }\">Supprimer<\/button><\/li>\n\t\t\t\t<\/ul>\n\t\t\t<\/td>\n\t\t<\/tr>\n\t\t<\/tbody>\n\n\t\t<tbody data-bind=\"visible: entries().length <= 0\">\n\t\t<tr class=\"gpnf-no-entries\" data-bind=\"visible: entries().length <= 0\" style=\"display: none;\">\n\t\t\t<td colspan=\"5\">\n\t\t\t\tIl n\u2019y a aucun(e) <span>Entr\u00e9es.<\/span>\t\t\t<\/td>\n\t\t<\/tr>\n\t\t<\/tbody>\n\n\t<\/table>\n\n\t<button type=\"button\" class=\"gpnf-add-entry\"\n\t\t        data-formid=\"3\"\n\t\t        data-nestedformid=\"11\"\n\t\t\t\tdata-bind=\"attr: { disabled: isMaxed }, css: { 'gf-default-disabled': isMaxed }\"\n\t\t\t\t>\n\t\t\t\tAjouter Entr\u00e9e\n\t\t\t<\/button>\t\n\t\t\t<p class=\"gpnf-add-entry-max\" data-bind=\"visible: isMaxed\" style=\"display: none;\">\n\t\t\t\tLe nombre maximal a \u00e9t\u00e9 atteint.\n\t\t\t<\/p>\n<\/div>\n<input type=\"hidden\"\n                name=\"input_184\"\n                id=\"input_3_184\"\n                data-bind=\"value: entryIds\"\n                value=\"\" \/><\/div><\/div>\n                    <\/div>\n                    <div class='gform-page-footer gform_page_footer top_label'>\n                        <button type='button' id='gform_previous_button_3_188' class='gform_previous_button gform-theme-button gform-theme-button--secondary button' onclick='gform.submission.handleButtonClick(this);' data-submission-type='previous' >Previous<\/button> <button type='button' id='gform_next_button_3_188' class='gform_next_button gform-theme-button button' onclick='gform.submission.handleButtonClick(this);' data-submission-type='next' >Next<\/button> <button type='button'  id='gform_save_3_18_link' onclick='gform.submission.handleButtonClick(this);' data-submission-type='save-continue' class='gform_save_link gform-theme-button gform-theme-button--secondary button'  ><svg aria-hidden=\"true\" focusable=\"false\" width=\"16\" height=\"16\" fill=\"none\" xmlns=\"http:\/\/www.w3.org\/2000\/svg\"><path fill-rule=\"evenodd\" clip-rule=\"evenodd\" d=\"M0 8a4 4 0 004 4h3v3a1 1 0 102 0v-3h3a4 4 0 100-8 4 4 0 10-8 0 4 4 0 00-4 4zm9 4H7V7.414L5.707 8.707a1 1 0 01-1.414-1.414l3-3a1 1 0 011.414 0l3 3a1 1 0 01-1.414 1.414L9 7.414V12z\" fill=\"#6B7280\"\/><\/svg> Save and Continue Later<\/button>\n                    <\/div>\n                <\/div>\n                <div id='gform_page_3_18' class='gform_page' data-js='page-field-id-188' style='display:none;'>\n                    <div class='gform_page_fields'>\n                        <div id='gform_fields_3_18' class='gform_fields top_label form_sublabel_below description_below validation_below'><div id=\"field_3_189\" class=\"gfield gfield--type-section gfield--input-type-section gsection field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><h3 class=\"gsection_title\">Education (Current &amp; Historical)<\/h3><\/div><div id=\"field_3_190\" class=\"gfield gfield--type-form gfield--input-type-form gform-theme__no-reset--children gfield--width-full field_sublabel_below gfield--no-description field_description_below hidden_label field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_3_190'><span class='gform-field-label__text'>School, School Board, and Program<\/span><\/label><div class=\"gpnf-nested-entries-container ginput_container\">\n\n\t<table class=\"gpnf-nested-entries\">\n\n\t\t<thead>\n\t\t<tr>\n\t\t\t\t\t\t\t<th scope=\"col\" class=\"gpnf-field-4\">\n\t\t\t\t\tSchool, School Board, and Program\t\t\t\t<\/th>\n\t\t\t\t\t\t\t<th scope=\"col\" class=\"gpnf-field-6\">\n\t\t\t\t\tGrade Completed\t\t\t\t<\/th>\n\t\t\t\t\t\t\t<th scope=\"col\" class=\"gpnf-field-7\">\n\t\t\t\t\tStart Date\t\t\t\t<\/th>\n\t\t\t\t\t\t\t<th scope=\"col\" class=\"gpnf-field-8\">\n\t\t\t\t\tStart Date\t\t\t\t<\/th>\n\t\t\t\t\t\t<th scope=\"col\" class=\"gpnf-row-actions\"><span class=\"screen-reader-text\">Actions<\/span><\/th>\n\t\t<\/tr>\n\t\t<\/thead>\n\n\t\t<tbody data-bind=\"visible: entries().length, foreach: entries\">\n\t\t<tr data-bind=\"attr: { 'data-entryid': id }\">\n\t\t\t\t\t\t\t<td class=\"gpnf-field\"\n\t\t\t\t\tdata-bind=\"html: f4.label, attr: { 'data-value': f4.label }\"\n\t\t\t\t\tdata-heading=\"School, School Board, and Program\"\n\t\t\t\t>&nbsp;<\/td>\n\t\t\t\t\t\t\t<td class=\"gpnf-field\"\n\t\t\t\t\tdata-bind=\"html: f6.label, attr: { 'data-value': f6.label }\"\n\t\t\t\t\tdata-heading=\"Grade Completed\"\n\t\t\t\t>&nbsp;<\/td>\n\t\t\t\t\t\t\t<td class=\"gpnf-field\"\n\t\t\t\t\tdata-bind=\"html: f7.label, attr: { 'data-value': f7.label }\"\n\t\t\t\t\tdata-heading=\"Start Date\"\n\t\t\t\t>&nbsp;<\/td>\n\t\t\t\t\t\t\t<td class=\"gpnf-field\"\n\t\t\t\t\tdata-bind=\"html: f8.label, attr: { 'data-value': f8.label }\"\n\t\t\t\t\tdata-heading=\"Start Date\"\n\t\t\t\t>&nbsp;<\/td>\n\t\t\t\t\t\t<td class=\"gpnf-row-actions\" style=\"display: none;\" data-bind=\"visible: true\">\n\t\t\t\t<ul>\n\t\t\t\t\t<li class=\"edit\"><button type=\"button\" class=\"edit-button gform-theme-button--secondary\" data-bind=\"click: $parent.editEntry, attr: { 'aria-label': 'Edit Entry {0} where School, School Board, and Program is {1}.'.gformFormat( $index() + 1, f4.label ) }\">Modifier<\/button><\/li>\n\t\t\t\t\t\t\t\t\t\t<li class=\"delete\"><button type=\"button\" class=\"delete-button gform-theme-button--simple gform-theme-button--size-md\" data-bind=\"click: $parent.deleteEntry, attr: { 'aria-label': 'Delete Entry {0} where School, School Board, and Program is {1}.'.gformFormat( $index() + 1, f4.label ) }\">Supprimer<\/button><\/li>\n\t\t\t\t<\/ul>\n\t\t\t<\/td>\n\t\t<\/tr>\n\t\t<\/tbody>\n\n\t\t<tbody data-bind=\"visible: entries().length <= 0\">\n\t\t<tr class=\"gpnf-no-entries\" data-bind=\"visible: entries().length <= 0\" style=\"display: none;\">\n\t\t\t<td colspan=\"5\">\n\t\t\t\tIl n\u2019y a aucun(e) <span>Entries.<\/span>\t\t\t<\/td>\n\t\t<\/tr>\n\t\t<\/tbody>\n\n\t<\/table>\n\n\t<button type=\"button\" class=\"gpnf-add-entry\"\n\t\t        data-formid=\"3\"\n\t\t        data-nestedformid=\"12\"\n\t\t\t\tdata-bind=\"attr: { disabled: isMaxed }, css: { 'gf-default-disabled': isMaxed }\"\n\t\t\t\t>\n\t\t\t\tAjouter Entry\n\t\t\t<\/button>\t\n\t\t\t<p class=\"gpnf-add-entry-max\" data-bind=\"visible: isMaxed\" style=\"display: none;\">\n\t\t\t\tLe nombre maximal a \u00e9t\u00e9 atteint.\n\t\t\t<\/p>\n<\/div>\n<input type=\"hidden\"\n                name=\"input_190\"\n                id=\"input_3_190\"\n                data-bind=\"value: entryIds\"\n                value=\"\" \/><\/div><div id=\"field_3_191\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-full field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_3_191'><span class='gform-field-label__text'>Location of OSR (Ontario Student Record)<\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_191' id='input_3_191' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_3_192\" class=\"gfield gfield--type-textarea gfield--input-type-textarea gfield--width-full field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_3_192'><span class='gform-field-label__text'>Identify any additional student services or professional support services accessed, including special accommodations made to youth\u2019s attendance requirements.<\/span><\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_192' id='input_3_192' class='textarea large'      aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/div><div id=\"field_3_197\" class=\"gfield gfield--type-section gfield--input-type-section gsection field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><h3 class=\"gsection_title\">Youth &amp; Family Strengths<\/h3><\/div><div id=\"field_3_194\" class=\"gfield gfield--type-html gfield--input-type-html gfield--width-full gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><strong>Please include:<\/strong><br\/>\n<ul><li>Character strengths<\/li>\n<li>Talents, interests, skills, assets<\/li>\n<li>Relationship supports, connections,<\/li>\n<li>Strengths identified in formal assessments, reports, and\/or other professional consultations<\/li><\/ul><\/div><div id=\"field_3_195\" class=\"gfield gfield--type-textarea gfield--input-type-textarea gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_3_195'><span class='gform-field-label__text'>Please Describe<\/span><span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(N\u00e9cessaire)<\/span><\/span><\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_195' id='input_3_195' class='textarea large'     aria-required=\"true\" aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/div><\/div>\n                    <\/div>\n                    <div class='gform-page-footer gform_page_footer top_label'>\n                        <button type='button' id='gform_previous_button_3_196' class='gform_previous_button gform-theme-button gform-theme-button--secondary button' onclick='gform.submission.handleButtonClick(this);' data-submission-type='previous' >Previous<\/button> <button type='button' id='gform_next_button_3_196' class='gform_next_button gform-theme-button button' onclick='gform.submission.handleButtonClick(this);' data-submission-type='next' >Next<\/button> <button type='button'  id='gform_save_3_19_link' onclick='gform.submission.handleButtonClick(this);' data-submission-type='save-continue' class='gform_save_link gform-theme-button gform-theme-button--secondary button'  ><svg aria-hidden=\"true\" focusable=\"false\" width=\"16\" height=\"16\" fill=\"none\" xmlns=\"http:\/\/www.w3.org\/2000\/svg\"><path fill-rule=\"evenodd\" clip-rule=\"evenodd\" d=\"M0 8a4 4 0 004 4h3v3a1 1 0 102 0v-3h3a4 4 0 100-8 4 4 0 10-8 0 4 4 0 00-4 4zm9 4H7V7.414L5.707 8.707a1 1 0 01-1.414-1.414l3-3a1 1 0 011.414 0l3 3a1 1 0 01-1.414 1.414L9 7.414V12z\" fill=\"#6B7280\"\/><\/svg> Save and Continue Later<\/button>\n                    <\/div>\n                <\/div>\n                <div id='gform_page_3_19' class='gform_page' data-js='page-field-id-196' style='display:none;'>\n                    <div class='gform_page_fields'>\n                        <div id='gform_fields_3_19' class='gform_fields top_label form_sublabel_below description_below validation_below'><div id=\"field_3_193\" class=\"gfield gfield--type-section gfield--input-type-section gsection field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><h3 class=\"gsection_title\">Youth &amp; Family Needs<\/h3><\/div><div id=\"field_3_202\" class=\"gfield gfield--type-html gfield--input-type-html gfield--width-full gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><strong>For effective treatment planning, please identify:<\/strong><br\/>\n<ul>\n<li>Immediate goals\/needs to be addressed in the initial phase of treatment<\/li>\n<li>What the youth and\/or family\/caregiver need in order to sustain achievements from previous services received<\/li>\n<li>What they will need from the RSC treatment team within the RSC program<\/li>\n<li>What needs they may have that can only be met outside the RSC and how those needs can be best accommodated for while the youth resides at a RSC Treatment Residence<\/li>\n<\/ul><\/div><div id=\"field_3_199\" class=\"gfield gfield--type-textarea gfield--input-type-textarea gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_3_199'><span class='gform-field-label__text'>Please Describe<\/span><span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(N\u00e9cessaire)<\/span><\/span><\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_199' id='input_3_199' class='textarea large'     aria-required=\"true\" aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/div><div id=\"field_3_231\" class=\"gfield gfield--type-textarea gfield--input-type-textarea gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_3_231'><span class='gform-field-label__text'>Applicant Objectives<\/span><span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(N\u00e9cessaire)<\/span><\/span><\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_231' id='input_3_231' class='textarea large'     aria-required=\"true\" aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/div><\/div>\n                    <\/div>\n                    <div class='gform-page-footer gform_page_footer top_label'>\n                        <button type='button' id='gform_previous_button_3_205' class='gform_previous_button gform-theme-button gform-theme-button--secondary button' onclick='gform.submission.handleButtonClick(this);' data-submission-type='previous' >Previous<\/button> <button type='button' id='gform_next_button_3_205' class='gform_next_button gform-theme-button button' onclick='gform.submission.handleButtonClick(this);' data-submission-type='next' >Next<\/button> <button type='button'  id='gform_save_3_20_link' onclick='gform.submission.handleButtonClick(this);' data-submission-type='save-continue' class='gform_save_link gform-theme-button gform-theme-button--secondary button'  ><svg aria-hidden=\"true\" focusable=\"false\" width=\"16\" height=\"16\" fill=\"none\" xmlns=\"http:\/\/www.w3.org\/2000\/svg\"><path fill-rule=\"evenodd\" clip-rule=\"evenodd\" d=\"M0 8a4 4 0 004 4h3v3a1 1 0 102 0v-3h3a4 4 0 100-8 4 4 0 10-8 0 4 4 0 00-4 4zm9 4H7V7.414L5.707 8.707a1 1 0 01-1.414-1.414l3-3a1 1 0 011.414 0l3 3a1 1 0 01-1.414 1.414L9 7.414V12z\" fill=\"#6B7280\"\/><\/svg> Save and Continue Later<\/button>\n                    <\/div>\n                <\/div>\n                <div id='gform_page_3_20' class='gform_page' data-js='page-field-id-205' style='display:none;'>\n                    <div class='gform_page_fields'>\n                        <div id='gform_fields_3_20' class='gform_fields top_label form_sublabel_below description_below validation_below'><div id=\"field_3_203\" class=\"gfield gfield--type-section gfield--input-type-section gsection field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><h3 class=\"gsection_title\">Anticipated or Recommended Discharge Plan<\/h3><\/div><div id=\"field_3_201\" class=\"gfield gfield--type-html gfield--input-type-html gfield--width-full gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  >Please provide as many details as possible regarding the anticipated&#47;recommended plan for the youth&#39;s discharge from the Roberts&#47;Smart Centre upon completion of their treatment AND the estimated timeline, expected outcomes, and needs for this plan to be successful.<\/div><div id=\"field_3_204\" class=\"gfield gfield--type-textarea gfield--input-type-textarea gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_3_204'><span class='gform-field-label__text'>Please Describe<\/span><span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(N\u00e9cessaire)<\/span><\/span><\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_204' id='input_3_204' class='textarea large'     aria-required=\"true\" aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/div><div id=\"field_3_208\" class=\"gfield gfield--type-section gfield--input-type-section gsection field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><h3 class=\"gsection_title\">Additional Information (if applicable)<\/h3><\/div><div id=\"field_3_207\" class=\"gfield gfield--type-html gfield--input-type-html gfield--width-full gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><strong>Please include:<\/strong><br\/>\n<ul>\n<li>Upcoming appointments that would need to be maintained<\/li><\/li>\n<li>On-going medical treatments the youth requires<\/li>\n<li>Anything relevant for the health and safety of the youth and the members of the treatment team: communicable diseases, significant triggers, safety protocols, imminent risks, etc.<\/li><\/ul><\/div><div id=\"field_3_206\" class=\"gfield gfield--type-textarea gfield--input-type-textarea gfield--width-full field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_3_206'><span class='gform-field-label__text'>Please Describe<\/span><\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_206' id='input_3_206' class='textarea large'      aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/div><\/div>\n                    <\/div>\n                    <div class='gform-page-footer gform_page_footer top_label'>\n                        <button type='button' id='gform_previous_button_3_209' class='gform_previous_button gform-theme-button gform-theme-button--secondary button' onclick='gform.submission.handleButtonClick(this);' data-submission-type='previous' >Previous<\/button> <button type='button' id='gform_next_button_3_209' class='gform_next_button gform-theme-button button' onclick='gform.submission.handleButtonClick(this);' data-submission-type='next' >Next<\/button> <button type='button'  id='gform_save_3_21_link' onclick='gform.submission.handleButtonClick(this);' data-submission-type='save-continue' class='gform_save_link gform-theme-button gform-theme-button--secondary button'  ><svg aria-hidden=\"true\" focusable=\"false\" width=\"16\" height=\"16\" fill=\"none\" xmlns=\"http:\/\/www.w3.org\/2000\/svg\"><path fill-rule=\"evenodd\" clip-rule=\"evenodd\" d=\"M0 8a4 4 0 004 4h3v3a1 1 0 102 0v-3h3a4 4 0 100-8 4 4 0 10-8 0 4 4 0 00-4 4zm9 4H7V7.414L5.707 8.707a1 1 0 01-1.414-1.414l3-3a1 1 0 011.414 0l3 3a1 1 0 01-1.414 1.414L9 7.414V12z\" fill=\"#6B7280\"\/><\/svg> Save and Continue Later<\/button>\n                    <\/div>\n                <\/div>\n                <div id='gform_page_3_21' class='gform_page' data-js='page-field-id-209' style='display:none;'>\n                    <div class='gform_page_fields'>\n                        <div id='gform_fields_3_21' class='gform_fields top_label form_sublabel_below description_below validation_below'><div id=\"field_3_211\" class=\"gfield gfield--type-section gfield--input-type-section gsection field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><h3 class=\"gsection_title\">SECTION B<\/h3><\/div><div id=\"field_3_212\" class=\"gfield gfield--type-html gfield--input-type-html gfield--width-full gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><img decoding=\"async\" src=\"https:\/\/www.robertssmartcentre.com\/wp-content\/uploads\/2026\/05\/INTAKE_SECTIONB.jpg\" style=\"width: 100%; height: auto;\"\/><\/div><\/div>\n                    <\/div>\n                    <div class='gform-page-footer gform_page_footer top_label'>\n                        <button type='button' id='gform_previous_button_3_214' class='gform_previous_button gform-theme-button gform-theme-button--secondary button' onclick='gform.submission.handleButtonClick(this);' data-submission-type='previous' >Previous<\/button> <button type='button' id='gform_next_button_3_214' class='gform_next_button gform-theme-button button' onclick='gform.submission.handleButtonClick(this);' data-submission-type='next' >Next<\/button> <button type='button'  id='gform_save_3_22_link' onclick='gform.submission.handleButtonClick(this);' data-submission-type='save-continue' class='gform_save_link gform-theme-button gform-theme-button--secondary button'  ><svg aria-hidden=\"true\" focusable=\"false\" width=\"16\" height=\"16\" fill=\"none\" xmlns=\"http:\/\/www.w3.org\/2000\/svg\"><path fill-rule=\"evenodd\" clip-rule=\"evenodd\" d=\"M0 8a4 4 0 004 4h3v3a1 1 0 102 0v-3h3a4 4 0 100-8 4 4 0 10-8 0 4 4 0 00-4 4zm9 4H7V7.414L5.707 8.707a1 1 0 01-1.414-1.414l3-3a1 1 0 011.414 0l3 3a1 1 0 01-1.414 1.414L9 7.414V12z\" fill=\"#6B7280\"\/><\/svg> Save and Continue Later<\/button>\n                    <\/div>\n                <\/div>\n                <div id='gform_page_3_22' class='gform_page' data-js='page-field-id-214' style='display:none;'>\n                    <div class='gform_page_fields'>\n                        <div id='gform_fields_3_22' class='gform_fields top_label form_sublabel_below description_below validation_below'><div id=\"field_3_215\" class=\"gfield gfield--type-section gfield--input-type-section gsection field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><h3 class=\"gsection_title\">Secure Treatment Admission Criteria<\/h3><\/div><div id=\"field_3_216\" class=\"gfield gfield--type-html gfield--input-type-html gfield--width-full gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><div style=\"font-family: sans-serif; line-height: 1.5; color: #333;\">\n    <p>The Court may order that a child be committed to a Secure Treatment Program only where the Court is satisfied that:<\/p>\n\n    <ol style=\"list-style-type: lower-alpha; padding-left: 40px;\">\n        <li style=\"margin-bottom: 10px;\">the child has a mental health disorder<\/li>\n        <li style=\"margin-bottom: 10px;\">\n            the child has, as a result of the mental disorder, within forty-five days immediately preceding,\n            <ol style=\"list-style-type: lower-roman; padding-left: 40px; margin: 10px 0;\">\n                <li>the application under subsection 161 (1)<\/li>\n                <li>the child\u2019s detention or custody under the Youth Criminal Justice Act (Canada) or under the Provincial Offences Act, or<\/li>\n                <li>the child\u2019s admission to a psychiatric facility under the Mental Health Act as an involuntary patient,<\/li>\n            <\/ol>\n            caused or attempted to cause serious bodily harm to himself, herself or another person.\n        <\/li>\n        <li style=\"margin-bottom: 10px;\">\n            the child has,\n            <ol style=\"list-style-type: lower-roman; padding-left: 40px; margin: 10px 0;\">\n                <li>within the twelve months immediately preceding the application, but on another occasion than referred to in clause (b), caused, attempted to cause or by words or conduct made a substantial threat to cause serious bodily harm to himself, herself or another person, or<\/li>\n                <li>in committing the act or attempt referred to in clause (b), caused or attempted to cause a person\u2019s death;<\/li>\n            <\/ol>\n        <\/li>\n        <li style=\"margin-bottom: 10px;\">the Secure Treatment Program would be effective to prevent the child from causing or attempting to cause serious bodily harm to himself, herself or another person;<\/li>\n        <li style=\"margin-bottom: 10px;\">treatment appropriate for the child\u2019s mental disorder is available at the place of Secure Treatment to which the application relates; and<\/li>\n        <li style=\"margin-bottom: 10px;\">no less restrictive method of providing treatment appropriate for the child\u2019s mental disorder is appropriate in the circumstances.<\/li>\n    <\/ol>\n<\/div><\/div><\/div>\n                    <\/div>\n                    <div class='gform-page-footer gform_page_footer top_label'>\n                        <button type='button' id='gform_previous_button_3_217' class='gform_previous_button gform-theme-button gform-theme-button--secondary button' onclick='gform.submission.handleButtonClick(this);' data-submission-type='previous' >Previous<\/button> <button type='button' id='gform_next_button_3_217' class='gform_next_button gform-theme-button button' onclick='gform.submission.handleButtonClick(this);' data-submission-type='next' >Next<\/button> <button type='button'  id='gform_save_3_23_link' onclick='gform.submission.handleButtonClick(this);' data-submission-type='save-continue' class='gform_save_link gform-theme-button gform-theme-button--secondary button'  ><svg aria-hidden=\"true\" focusable=\"false\" width=\"16\" height=\"16\" fill=\"none\" xmlns=\"http:\/\/www.w3.org\/2000\/svg\"><path fill-rule=\"evenodd\" clip-rule=\"evenodd\" d=\"M0 8a4 4 0 004 4h3v3a1 1 0 102 0v-3h3a4 4 0 100-8 4 4 0 10-8 0 4 4 0 00-4 4zm9 4H7V7.414L5.707 8.707a1 1 0 01-1.414-1.414l3-3a1 1 0 011.414 0l3 3a1 1 0 01-1.414 1.414L9 7.414V12z\" fill=\"#6B7280\"\/><\/svg> Save and Continue Later<\/button>\n                    <\/div>\n                <\/div>\n                <div id='gform_page_3_23' class='gform_page' data-js='page-field-id-217' style='display:none;'>\n                    <div class='gform_page_fields'>\n                        <div id='gform_fields_3_23' class='gform_fields top_label form_sublabel_below description_below validation_below'><div id=\"field_3_218\" class=\"gfield gfield--type-section gfield--input-type-section gsection field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><h3 class=\"gsection_title\">Admission Criteria (B)<\/h3><\/div><div id=\"field_3_219\" class=\"gfield gfield--type-html gfield--input-type-html gfield--width-full gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  >Provide details that the child has, as a result of the mental disorder, <strong>within forty-five days <\/strong>immediately preceding, the application under subsection 161(1), <strong>OR<\/strong>\n<ul>\n<li>the child\u2019s detention or custody under the Youth Criminal Justice Act or under the Provincial Offences Act, <strong>OR<\/strong><\/li>\n<li>the child\u2019s admission to a psychiatric facility under the Mental Health Act as an involuntary patient, OR<\/li>\n<li>has caused or attempted to cause <strong>serious bodily harm to himself, herself or another person<\/strong>.<\/li><\/ul><\/div><div id=\"field_3_220\" class=\"gfield gfield--type-form gfield--input-type-form gform-theme__no-reset--children gfield--width-full field_sublabel_below gfield--no-description field_description_below hidden_label field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_3_220'><span class='gform-field-label__text'>Admission Criteria A<\/span><\/label><div class=\"gpnf-nested-entries-container ginput_container\">\n\n\t<table class=\"gpnf-nested-entries\">\n\n\t\t<thead>\n\t\t<tr>\n\t\t\t\t\t\t\t<th scope=\"col\" class=\"gpnf-field-4\">\n\t\t\t\t\tIncident\t\t\t\t<\/th>\n\t\t\t\t\t\t\t<th scope=\"col\" class=\"gpnf-field-7\">\n\t\t\t\t\tDate\t\t\t\t<\/th>\n\t\t\t\t\t\t\t<th scope=\"col\" class=\"gpnf-field-6\">\n\t\t\t\t\tOutcome\t\t\t\t<\/th>\n\t\t\t\t\t\t<th scope=\"col\" class=\"gpnf-row-actions\"><span class=\"screen-reader-text\">Actions<\/span><\/th>\n\t\t<\/tr>\n\t\t<\/thead>\n\n\t\t<tbody data-bind=\"visible: entries().length, foreach: entries\">\n\t\t<tr data-bind=\"attr: { 'data-entryid': id }\">\n\t\t\t\t\t\t\t<td class=\"gpnf-field\"\n\t\t\t\t\tdata-bind=\"html: f4.label, attr: { 'data-value': f4.label }\"\n\t\t\t\t\tdata-heading=\"Incident\"\n\t\t\t\t>&nbsp;<\/td>\n\t\t\t\t\t\t\t<td class=\"gpnf-field\"\n\t\t\t\t\tdata-bind=\"html: f7.label, attr: { 'data-value': f7.label }\"\n\t\t\t\t\tdata-heading=\"Date\"\n\t\t\t\t>&nbsp;<\/td>\n\t\t\t\t\t\t\t<td class=\"gpnf-field\"\n\t\t\t\t\tdata-bind=\"html: f6.label, attr: { 'data-value': f6.label }\"\n\t\t\t\t\tdata-heading=\"Outcome\"\n\t\t\t\t>&nbsp;<\/td>\n\t\t\t\t\t\t<td class=\"gpnf-row-actions\" style=\"display: none;\" data-bind=\"visible: true\">\n\t\t\t\t<ul>\n\t\t\t\t\t<li class=\"edit\"><button type=\"button\" class=\"edit-button gform-theme-button--secondary\" data-bind=\"click: $parent.editEntry, attr: { 'aria-label': 'Edit Entr\u00e9e {0} where Incident is {1}.'.gformFormat( $index() + 1, f4.label ) }\">Modifier<\/button><\/li>\n\t\t\t\t\t\t\t\t\t\t<li class=\"delete\"><button type=\"button\" class=\"delete-button gform-theme-button--simple gform-theme-button--size-md\" data-bind=\"click: $parent.deleteEntry, attr: { 'aria-label': 'Delete Entr\u00e9e {0} where Incident is {1}.'.gformFormat( $index() + 1, f4.label ) }\">Supprimer<\/button><\/li>\n\t\t\t\t<\/ul>\n\t\t\t<\/td>\n\t\t<\/tr>\n\t\t<\/tbody>\n\n\t\t<tbody data-bind=\"visible: entries().length <= 0\">\n\t\t<tr class=\"gpnf-no-entries\" data-bind=\"visible: entries().length <= 0\" style=\"display: none;\">\n\t\t\t<td colspan=\"4\">\n\t\t\t\tIl n\u2019y a aucun(e) <span>Entr\u00e9es.<\/span>\t\t\t<\/td>\n\t\t<\/tr>\n\t\t<\/tbody>\n\n\t<\/table>\n\n\t<button type=\"button\" class=\"gpnf-add-entry\"\n\t\t        data-formid=\"3\"\n\t\t        data-nestedformid=\"13\"\n\t\t\t\tdata-bind=\"attr: { disabled: isMaxed }, css: { 'gf-default-disabled': isMaxed }\"\n\t\t\t\t>\n\t\t\t\tAjouter Entr\u00e9e\n\t\t\t<\/button>\t\n\t\t\t<p class=\"gpnf-add-entry-max\" data-bind=\"visible: isMaxed\" style=\"display: none;\">\n\t\t\t\tLe nombre maximal a \u00e9t\u00e9 atteint.\n\t\t\t<\/p>\n<\/div>\n<input type=\"hidden\"\n                name=\"input_220\"\n                id=\"input_3_220\"\n                data-bind=\"value: entryIds\"\n                value=\"\" \/><\/div><div id=\"field_3_221\" class=\"gfield gfield--type-fileupload gfield--input-type-fileupload gfield--width-full field_sublabel_below gfield--has-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='gform_browse_button_3_221'><span class='gform-field-label__text'>Supporting Documentation<\/span><\/label><div class='ginput_container ginput_container_fileupload'><div id='gform_multifile_upload_3_221' data-settings='{&quot;runtimes&quot;:&quot;html5,flash,html4&quot;,&quot;browse_button&quot;:&quot;gform_browse_button_3_221&quot;,&quot;container&quot;:&quot;gform_multifile_upload_3_221&quot;,&quot;drop_element&quot;:&quot;gform_drag_drop_area_3_221&quot;,&quot;filelist&quot;:&quot;gform_preview_3_221&quot;,&quot;unique_names&quot;:true,&quot;file_data_name&quot;:&quot;file&quot;,&quot;url&quot;:&quot;https:\\\/\\\/www.robertssmartcentre.com\\\/fr\\\/?gf_page=fb962d61be882d5&quot;,&quot;flash_swf_url&quot;:&quot;https:\\\/\\\/www.robertssmartcentre.com\\\/wp-includes\\\/js\\\/plupload\\\/plupload.flash.swf&quot;,&quot;silverlight_xap_url&quot;:&quot;https:\\\/\\\/www.robertssmartcentre.com\\\/wp-includes\\\/js\\\/plupload\\\/plupload.silverlight.xap&quot;,&quot;filters&quot;:{&quot;mime_types&quot;:[{&quot;title&quot;:&quot;Fichiers autoris\\u00e9s&quot;,&quot;extensions&quot;:&quot;pdf,doc,docx&quot;}],&quot;max_file_size&quot;:&quot;134217728b&quot;},&quot;multipart&quot;:true,&quot;urlstream_upload&quot;:false,&quot;multipart_params&quot;:{&quot;form_id&quot;:3,&quot;field_id&quot;:221,&quot;_gform_file_upload_nonce_3_221&quot;:&quot;209b6e7ad2&quot;},&quot;gf_vars&quot;:{&quot;max_files&quot;:0,&quot;message_id&quot;:&quot;gform_multifile_messages_3_221&quot;,&quot;disallowed_extensions&quot;:[&quot;php&quot;,&quot;asp&quot;,&quot;aspx&quot;,&quot;cmd&quot;,&quot;csh&quot;,&quot;bat&quot;,&quot;html&quot;,&quot;htm&quot;,&quot;hta&quot;,&quot;jar&quot;,&quot;exe&quot;,&quot;com&quot;,&quot;js&quot;,&quot;lnk&quot;,&quot;htaccess&quot;,&quot;phar&quot;,&quot;phtml&quot;,&quot;ps1&quot;,&quot;ps2&quot;,&quot;php3&quot;,&quot;php4&quot;,&quot;php5&quot;,&quot;php6&quot;,&quot;py&quot;,&quot;rb&quot;,&quot;tmp&quot;]}}' class='gform_fileupload_multifile'>\n\t\t\t\t\t\t\t\t\t\t<div id='gform_drag_drop_area_3_221' class='gform_drop_area gform-theme-field-control'>\n\t\t\t\t\t\t\t\t\t\t\t<span class='gform_drop_instructions'>D\u00e9posez les fichiers ici ou <\/span>\n\t\t\t\t\t\t\t\t\t\t\t<button type='button' id='gform_browse_button_3_221' class='button gform_button_select_files gform-theme-button gform-theme-button--control' aria-describedby=\"gfield_upload_rules_3_221 gfield_description_3_221\"  >S\u00e9lectionnez des fichiers<\/button>\n\t\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t<\/div><span class='gfield_description gform_fileupload_rules' id='gfield_upload_rules_3_221'>Types de fichiers accept\u00e9s\u00a0: pdf, doc, docx, Taille max. des fichiers\u00a0: 128 MB.<\/span><ul class='validation_message--hidden-on-empty gform-ul-reset' id='gform_multifile_messages_3_221'><\/ul> <div id='gform_preview_3_221' class='ginput_preview_list'><\/div><\/div><div class='gfield_description' id='gfield_description_3_221'>*Please attach supporting documentation i.e. Serious Occurrence Reports (SORs), incident reports, police reports, hospital\ndischarge reports, etc.<\/div><\/div><\/div>\n                    <\/div>\n                    <div class='gform-page-footer gform_page_footer top_label'>\n                        <button type='button' id='gform_previous_button_3_222' class='gform_previous_button gform-theme-button gform-theme-button--secondary button' onclick='gform.submission.handleButtonClick(this);' data-submission-type='previous' >Previous<\/button> <button type='button' id='gform_next_button_3_222' class='gform_next_button gform-theme-button button' onclick='gform.submission.handleButtonClick(this);' data-submission-type='next' >Next<\/button> <button type='button'  id='gform_save_3_24_link' onclick='gform.submission.handleButtonClick(this);' data-submission-type='save-continue' class='gform_save_link gform-theme-button gform-theme-button--secondary button'  ><svg aria-hidden=\"true\" focusable=\"false\" width=\"16\" height=\"16\" fill=\"none\" xmlns=\"http:\/\/www.w3.org\/2000\/svg\"><path fill-rule=\"evenodd\" clip-rule=\"evenodd\" d=\"M0 8a4 4 0 004 4h3v3a1 1 0 102 0v-3h3a4 4 0 100-8 4 4 0 10-8 0 4 4 0 00-4 4zm9 4H7V7.414L5.707 8.707a1 1 0 01-1.414-1.414l3-3a1 1 0 011.414 0l3 3a1 1 0 01-1.414 1.414L9 7.414V12z\" fill=\"#6B7280\"\/><\/svg> Save and Continue Later<\/button>\n                    <\/div>\n                <\/div>\n                <div id='gform_page_3_24' class='gform_page' data-js='page-field-id-222' style='display:none;'>\n                    <div class='gform_page_fields'>\n                        <div id='gform_fields_3_24' class='gform_fields top_label form_sublabel_below description_below validation_below'><div id=\"field_3_223\" class=\"gfield gfield--type-section gfield--input-type-section gsection field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><h3 class=\"gsection_title\">Admission Criteria (C)<\/h3><\/div><div id=\"field_3_224\" class=\"gfield gfield--type-html gfield--input-type-html gfield--width-full gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><strong>Provide details that the child has, as a result of the mental disorder, in the twelve months immediately preceding the application, but on another occasion than referred to in criteria (b)<\/strong>,\n<ul>\n<li>caused, attempted to cause or by words or conduct made a substantial threat to cause serious bodily harm to himself, herself\nor another person, OR<\/li>\n<li>n committing the act or attempt referred to in criteria (b), caused or attempted to cause a person\u2019s death;<\/li>\n<\/ul><\/div><div id=\"field_3_225\" class=\"gfield gfield--type-form gfield--input-type-form gform-theme__no-reset--children gfield--width-full field_sublabel_below gfield--no-description field_description_below hidden_label field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_3_225'><span class='gform-field-label__text'>Admission Criteria (C)<\/span><\/label><div class=\"gpnf-nested-entries-container ginput_container\">\n\n\t<table class=\"gpnf-nested-entries\">\n\n\t\t<thead>\n\t\t<tr>\n\t\t\t\t\t\t\t<th scope=\"col\" class=\"gpnf-field-4\">\n\t\t\t\t\tIncident\t\t\t\t<\/th>\n\t\t\t\t\t\t\t<th scope=\"col\" class=\"gpnf-field-7\">\n\t\t\t\t\tDate\t\t\t\t<\/th>\n\t\t\t\t\t\t\t<th scope=\"col\" class=\"gpnf-field-6\">\n\t\t\t\t\tOutcome\t\t\t\t<\/th>\n\t\t\t\t\t\t<th scope=\"col\" class=\"gpnf-row-actions\"><span class=\"screen-reader-text\">Actions<\/span><\/th>\n\t\t<\/tr>\n\t\t<\/thead>\n\n\t\t<tbody data-bind=\"visible: entries().length, foreach: entries\">\n\t\t<tr data-bind=\"attr: { 'data-entryid': id }\">\n\t\t\t\t\t\t\t<td class=\"gpnf-field\"\n\t\t\t\t\tdata-bind=\"html: f4.label, attr: { 'data-value': f4.label }\"\n\t\t\t\t\tdata-heading=\"Incident\"\n\t\t\t\t>&nbsp;<\/td>\n\t\t\t\t\t\t\t<td class=\"gpnf-field\"\n\t\t\t\t\tdata-bind=\"html: f7.label, attr: { 'data-value': f7.label }\"\n\t\t\t\t\tdata-heading=\"Date\"\n\t\t\t\t>&nbsp;<\/td>\n\t\t\t\t\t\t\t<td class=\"gpnf-field\"\n\t\t\t\t\tdata-bind=\"html: f6.label, attr: { 'data-value': f6.label }\"\n\t\t\t\t\tdata-heading=\"Outcome\"\n\t\t\t\t>&nbsp;<\/td>\n\t\t\t\t\t\t<td class=\"gpnf-row-actions\" style=\"display: none;\" data-bind=\"visible: true\">\n\t\t\t\t<ul>\n\t\t\t\t\t<li class=\"edit\"><button type=\"button\" class=\"edit-button gform-theme-button--secondary\" data-bind=\"click: $parent.editEntry, attr: { 'aria-label': 'Edit Entr\u00e9e {0} where Incident is {1}.'.gformFormat( $index() + 1, f4.label ) }\">Modifier<\/button><\/li>\n\t\t\t\t\t\t\t\t\t\t<li class=\"delete\"><button type=\"button\" class=\"delete-button gform-theme-button--simple gform-theme-button--size-md\" data-bind=\"click: $parent.deleteEntry, attr: { 'aria-label': 'Delete Entr\u00e9e {0} where Incident is {1}.'.gformFormat( $index() + 1, f4.label ) }\">Supprimer<\/button><\/li>\n\t\t\t\t<\/ul>\n\t\t\t<\/td>\n\t\t<\/tr>\n\t\t<\/tbody>\n\n\t\t<tbody data-bind=\"visible: entries().length <= 0\">\n\t\t<tr class=\"gpnf-no-entries\" data-bind=\"visible: entries().length <= 0\" style=\"display: none;\">\n\t\t\t<td colspan=\"4\">\n\t\t\t\tIl n\u2019y a aucun(e) <span>Entr\u00e9es.<\/span>\t\t\t<\/td>\n\t\t<\/tr>\n\t\t<\/tbody>\n\n\t<\/table>\n\n\t<button type=\"button\" class=\"gpnf-add-entry\"\n\t\t        data-formid=\"3\"\n\t\t        data-nestedformid=\"13\"\n\t\t\t\tdata-bind=\"attr: { disabled: isMaxed }, css: { 'gf-default-disabled': isMaxed }\"\n\t\t\t\t>\n\t\t\t\tAjouter Entr\u00e9e\n\t\t\t<\/button>\t\n\t\t\t<p class=\"gpnf-add-entry-max\" data-bind=\"visible: isMaxed\" style=\"display: none;\">\n\t\t\t\tLe nombre maximal a \u00e9t\u00e9 atteint.\n\t\t\t<\/p>\n<\/div>\n<input type=\"hidden\"\n                name=\"input_225\"\n                id=\"input_3_225\"\n                data-bind=\"value: entryIds\"\n                value=\"\" \/><\/div><div id=\"field_3_226\" class=\"gfield gfield--type-fileupload gfield--input-type-fileupload gfield--width-full field_sublabel_below gfield--has-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_3_226'><span class='gform-field-label__text'>Support Documents<\/span><\/label><div class='ginput_container ginput_container_fileupload'><input type='hidden' name='MAX_FILE_SIZE' value='134217728' \/><input name='input_226' id='input_3_226' type='file' class='large' aria-describedby=\"gfield_upload_rules_3_226 gfield_description_3_226\" onchange='javascript:gformValidateFileSize( this, 134217728 );'  \/><span class='gfield_description gform_fileupload_rules' id='gfield_upload_rules_3_226'>Taille max. des fichiers\u00a0: 128 MB.<\/span><div class='gfield_description validation_message gfield_validation_message validation_message--hidden-on-empty' id='live_validation_message_3_226'><\/div> <\/div><div class='gfield_description' id='gfield_description_3_226'>*Please attach supporting documentation i.e. Serious Occurrence Reports (SORs), incident reports, police reports, hospital\ndischarge reports, etc.<\/div><\/div><\/div>\n                    <\/div>\n                    <div class='gform-page-footer gform_page_footer top_label'>\n                        <button type='button' id='gform_previous_button_3_149' class='gform_previous_button gform-theme-button gform-theme-button--secondary button' onclick='gform.submission.handleButtonClick(this);' data-submission-type='previous' >Previous<\/button> <button type='button' id='gform_next_button_3_149' class='gform_next_button gform-theme-button button' onclick='gform.submission.handleButtonClick(this);' data-submission-type='next' >Next<\/button> <button type='button'  id='gform_save_3_25_link' onclick='gform.submission.handleButtonClick(this);' data-submission-type='save-continue' class='gform_save_link gform-theme-button gform-theme-button--secondary button'  ><svg aria-hidden=\"true\" focusable=\"false\" width=\"16\" height=\"16\" fill=\"none\" xmlns=\"http:\/\/www.w3.org\/2000\/svg\"><path fill-rule=\"evenodd\" clip-rule=\"evenodd\" d=\"M0 8a4 4 0 004 4h3v3a1 1 0 102 0v-3h3a4 4 0 100-8 4 4 0 10-8 0 4 4 0 00-4 4zm9 4H7V7.414L5.707 8.707a1 1 0 01-1.414-1.414l3-3a1 1 0 011.414 0l3 3a1 1 0 01-1.414 1.414L9 7.414V12z\" fill=\"#6B7280\"\/><\/svg> Save and Continue Later<\/button>\n                    <\/div>\n                <\/div>\n                <div id='gform_page_3_25' class='gform_page' data-js='page-field-id-149' style='display:none;'>\n                    <div class='gform_page_fields'>\n                        <div id='gform_fields_3_25' class='gform_fields top_label form_sublabel_below description_below validation_below'><div id=\"field_3_13\" class=\"gfield gfield--type-html gfield--input-type-html gfield--width-full gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  >{all_fields}<\/div><div id=\"field_3_15\" class=\"gfield gfield--type-signature gfield--input-type-signature gfield--width-half gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_3_15'><span class='gform-field-label__text'>Signature<\/span><span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(N\u00e9cessaire)<\/span><\/span><\/label><input type='hidden' value='' name='input_15' id='input_3_15_signature_filename'\/><div class='gfield_signature_ui_container gform-theme__no-reset--children' ><div id='input_3_15_Container' class='gfield_signature_container ginput_container' style='height:180px; width:400px; ' ><canvas id='input_3_15' width='400' height='180' style='border-style: Dashed; border-width: 2px; border-color: #DDDDDD; background-color:#FFFFFF; cursor: url(https:\/\/www.robertssmartcentre.com\/wp-content\/plugins\/gravityformssignature\/assets\/img\/pen.cur), pointer;'><\/canvas><\/div><div id='input_3_15_toolbar' style='margin:5px 0;position:relative;height:20px;width:400px;max-width:100%;'><img id = 'input_3_15_resetbutton' src='data:image\/png;base64,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' style='cursor:pointer;float:right;height:24px;width:24px;border:0px solid transparent' alt='Clear Signature' \/ ><\/div><input type='hidden' id='input_3_15_data' name='input_3_15_data' value=''><\/div><\/div><div id=\"field_3_16\" class=\"gfield gfield--type-date gfield--input-type-date gfield--input-type-datepicker gfield--datepicker-default-icon gfield--width-half gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_3_16'><span class='gform-field-label__text'>Date<\/span><span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(N\u00e9cessaire)<\/span><\/span><\/label><div class='ginput_container ginput_container_date'>\n\t\t\t\t\t<input\n\t\t\t\t\tplaceholder='mm\/jj\/aaaa'\n\t\t\t\t\tid='input_3_16'\n\t\t\t\t\tclass='datepicker gform-datepicker mdy datepicker_with_icon gdatepicker_with_icon'\n\t\t\t\t\ttype='text'\n\t\t\t\t\tname='input_16'\n\t\t\t\t\tvalue=''\n\t\t\t\t\t \n\t\t\t\t\taria-invalid=\"false\" \n\t\t\t\t\taria-required=\"true\"\n\t\t\t\t\t \n\t\t\t\t\t\n\t\t\t\t\tdata-mask=\"99\/99\/9999\"\n\t\t\t\t\t\/>\n\t\t\t\t<kbd id='keyboardHint_input_3_16' hidden class='down'><\/kbd>\n\t\t\t\t<button type='button' id='datepicker_toggle_input_3_16' class='gform-datepicker-toggle gform-datepicker-toggle--default accCalendar aria-date-picker gform-button gform-theme-button gform-theme-button--simple gform-theme-button--simple-in-ctrl' aria-expanded='false' aria-controls='input_3_16' aria-label='Date: Choose date on calendar' >\n\t\t\t\t\t\t\t<span class=\"gform-calendar-icon gform-datepicker-toggle-icon gform-datepicker-toggle-icon--default dashicons dashicons-calendar-alt\" aria-hidden=\"true\"><\/span>\n\t\t\t\t\t\t<\/button>\n\t\t\t<\/div><\/div><div id=\"field_3_18\" class=\"gfield gfield--type-signature gfield--input-type-signature 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