{"id":316,"date":"2023-01-20T16:06:58","date_gmt":"2023-01-20T22:06:58","guid":{"rendered":"https:\/\/staging5.nsd.tech\/?page_id=316"},"modified":"2025-02-27T12:31:51","modified_gmt":"2025-02-27T18:31:51","slug":"nccmh-referral-form","status":"publish","type":"page","link":"https:\/\/staging5.nsd.tech\/es\/aurora\/nccmh-referral-form\/","title":{"rendered":"NCCMH Referral Form (Adults) &#8211; Aurora"},"content":{"rendered":"<div id=\"cs-content\" class=\"cs-content\"><div class=\"x-section e316-e1 m8s-0\"><div class=\"x-row x-container max width e316-e2 m8s-1 m8s-2\"><div class=\"x-row-inner\"><div class=\"x-col e316-e3 m8s-3 NsdSpacerSmallAll\"><script type=\"text\/javascript\">\n\/* <![CDATA[ *\/\nvar 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#112337;--gf-ctrl-label-color-secondary: #112337;--gf-ctrl-choice-size: var(--gf-ctrl-choice-size-md);--gf-ctrl-checkbox-check-size: var(--gf-ctrl-checkbox-check-size-md);--gf-ctrl-radio-check-size: var(--gf-ctrl-radio-check-size-md);--gf-ctrl-btn-font-size: var(--gf-ctrl-btn-font-size-md);--gf-ctrl-btn-padding-x: var(--gf-ctrl-btn-padding-x-md);--gf-ctrl-btn-size: var(--gf-ctrl-btn-size-md);--gf-ctrl-btn-border-color-secondary: #686e77;--gf-ctrl-file-btn-bg-color-hover: #EBEBEB;--gf-field-img-choice-size: var(--gf-field-img-choice-size-md);--gf-field-img-choice-card-space: var(--gf-field-img-choice-card-space-md);--gf-field-img-choice-check-ind-size: var(--gf-field-img-choice-check-ind-size-md);--gf-field-img-choice-check-ind-icon-size: var(--gf-field-img-choice-check-ind-icon-size-md);--gf-field-pg-steps-number-color: rgba(17, 35, 55, 0.8);}<\/style>\n                        <div class='gform_heading'>\n                            <h2 class=\"gform_title\">Newcomer Collaborative Community Mental Health Program Referral Form<\/h2>\n                            <p class='gform_description'><p>The Newcomer Collaborative Community Mental Health Program is designed to support the mental health needs of all newcomers, regardless of status and time in Canada, who have experienced moderate-to-severe trauma. For more information about the program, please contact our Program Coordinator, Sara Warkentin, at s.warkentin@resiliacentre.com<\/p><\/p>\n                        <\/div><form method='post' enctype='multipart\/form-data' target='gform_ajax_frame_317' id='gform_317'  action='\/es\/wp-json\/wp\/v2\/pages\/316' data-formid='317' novalidate>\n        <div id='gf_progressbar_wrapper_317' class='gf_progressbar_wrapper' data-start-at-zero=''>\n        \t<p class=\"gf_progressbar_title\">Paso <span class='gf_step_current_page'>1<\/span> de <span class='gf_step_page_count'>3<\/span><span class='gf_step_page_name'><\/span>\n        \t<\/p>\n            <div class='gf_progressbar gf_progressbar_blue' aria-hidden='true'>\n                <div class='gf_progressbar_percentage percentbar_blue percentbar_33' style='width:33%;'><span>33%<\/span><\/div>\n            <\/div><\/div>\n                        <div class='gform-body gform_body'><div id='gform_page_317_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_317' class='gform_fields top_label form_sublabel_below description_below validation_below'><div id=\"field_317_265\" class=\"gfield gfield--type-honeypot gform_validation_container field_sublabel_below gfield--has-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_317_265'>URL<\/label><div class='ginput_container'><input name='input_265' id='input_317_265' type='text' value='' autocomplete='new-password'\/><\/div><div class='gfield_description' id='gfield_description_317_265'>Este campo es un campo de validaci\u00f3n y debe quedar sin cambios.<\/div><\/div><div id=\"field_317_196\" 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\">Referral Information<\/h3><\/div><fieldset id=\"field_317_230\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-full gf_list_3col 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' >Please identify yourself by answering the following questions:<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Obligatorio)<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_317_230'>\n\t\t\t<div class='gchoice gchoice_317_230_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_230' type='radio' value='Third Choice'  id='choice_317_230_0' onchange='gformToggleRadioOther( this )'  tabindex='1'  \/>\n\t\t\t\t\t<label for='choice_317_230_0' id='label_317_230_0' class='gform-field-label gform-field-label--type-inline'>I am referring myself<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_317_230_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_230' type='radio' value='First Choice'  id='choice_317_230_1' onchange='gformToggleRadioOther( this )'  tabindex='2'  \/>\n\t\t\t\t\t<label for='choice_317_230_1' id='label_317_230_1' class='gform-field-label gform-field-label--type-inline'>I am referring a friend, family member, or community member<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_317_230_2'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_230' type='radio' value='Second Choice'  id='choice_317_230_2' onchange='gformToggleRadioOther( this )'  tabindex='3'  \/>\n\t\t\t\t\t<label for='choice_317_230_2' id='label_317_230_2' class='gform-field-label gform-field-label--type-inline'>I am a service provider, referring one of my clients<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_317_231\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-full CONSENTS 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' >All individuals and families should be aware of and consent to the referral being made on their behalf for therapy services. Have you spoken to the individual or family about this referral and received their consent?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Obligatorio)<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_317_231'>\n\t\t\t<div class='gchoice gchoice_317_231_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_231' type='radio' value='0421'  id='choice_317_231_0' onchange='gformToggleRadioOther( this )'  tabindex='4'  \/>\n\t\t\t\t\t<label for='choice_317_231_0' id='label_317_231_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_317_231_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_231' type='radio' value='N'  id='choice_317_231_1' onchange='gformToggleRadioOther( this )'  tabindex='5'  \/>\n\t\t\t\t\t<label for='choice_317_231_1' id='label_317_231_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_317_233\" 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 ensure you speak with all individuals and families first and obtain their consent before proceeding with this referral.<\/div><\/div>\n                    <\/div>\n                    <div class='gform-page-footer gform_page_footer top_label'>\n                         <input type='button' id='gform_next_button_317_232' class='gform_next_button gform-theme-button button' onclick='gform.submission.handleButtonClick(this);' data-submission-type='next' value='Next' tabindex='6' \/> \n                    <\/div>\n                <\/div>\n                <div id='gform_page_317_2' class='gform_page' data-js='page-field-id-232' style='display:none;'>\n                    <div class='gform_page_fields'>\n                        <div id='gform_fields_317_2' class='gform_fields top_label form_sublabel_below description_below validation_below'><div id=\"field_317_260\" 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\">Referral Information<\/h3><\/div><div id=\"field_317_261\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-half REFERCONT_NAME gf_hide_charleft 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_317_261'>Referring Individual Name<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Obligatorio)<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_261' id='input_317_261' type='text' value='' class='large' maxlength='50'  tabindex='7' placeholder='(in case more information is needed)' aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_317_262\" class=\"gfield gfield--type-select gfield--input-type-select gfield--width-half REFERCONT_RELATION 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_317_262'>Relation to Referred Person<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Obligatorio)<\/span><\/span><\/label><div class='ginput_container ginput_container_select'><select name='input_262' id='input_317_262' class='large gfield_select' tabindex='8'   aria-required=\"true\" aria-invalid=\"false\" autocomplete=\"new-password\"><option value='' ><\/option><option value='59' >Community Member<\/option><option value='19' >Friend<\/option><option value='54' >Family<\/option><\/select><\/div><\/div><div id=\"field_317_263\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-half REFERCONT_TELE1 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_317_263'>Referring Phone<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Obligatorio)<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_263' id='input_317_263' type='text' value='' class='large'   tabindex='9' placeholder='___-___-____' aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_317_264\" class=\"gfield gfield--type-email gfield--input-type-email gfield--width-half REFERCONT_EMAIL gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible gpev-field\"  data-field-class=\"gpev-field\" ><label class='gfield_label gform-field-label' for='input_317_264'>Referring Email<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Obligatorio)<\/span><\/span><\/label><div class='ginput_container ginput_container_email'>\n                            <input name='input_264' id='input_317_264' type='email' value='' class='large' tabindex='10'   aria-required=\"true\" aria-invalid=\"false\"  \/>\n                        <\/div><\/div><div id=\"field_317_242\" 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\">Agency Information<\/h3><\/div><div id=\"field_317_198\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-third REFERCONT_ORG gf_hide_charleft field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_317_198'>Name of Referring Agency<\/label><div class='ginput_container ginput_container_text'><input name='input_198' id='input_317_198' type='text' value='' class='large' maxlength='100'  tabindex='11'   aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_317_204\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-third REFERCONT_NAME gf_hide_charleft 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_317_204'>Referring Individual<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Obligatorio)<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_204' id='input_317_204' type='text' value='' class='large' maxlength='50'  tabindex='12' placeholder='(in case more information is needed)' aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_317_206\" class=\"gfield gfield--type-select gfield--input-type-select gfield--width-third REFERCONT_RELATION 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_317_206'>Individual relation to client<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Obligatorio)<\/span><\/span><\/label><div class='ginput_container ginput_container_select'><select name='input_206' id='input_317_206' class='large gfield_select' tabindex='13'   aria-required=\"true\" aria-invalid=\"false\" autocomplete=\"new-password\"><option value='' ><\/option><option value='57' >Service Provider<\/option><option value='58' >Sponsor<\/option><option value='59' >Community Member<\/option><option value='60' >Teacher<\/option><option value='19' >Friend<\/option><option value='54' >Family<\/option><option value='33' >Other<\/option><\/select><\/div><\/div><div id=\"field_317_203\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-third REFERCONT_TELE1 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_317_203'>Referring Phone<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Obligatorio)<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_203' id='input_317_203' type='text' value='' class='large'   tabindex='14' placeholder='___-___-____' aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_317_205\" class=\"gfield gfield--type-email gfield--input-type-email gfield--width-third REFERCONT_EMAIL gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible gpev-field\"  data-field-class=\"gpev-field\" ><label class='gfield_label gform-field-label' for='input_317_205'>Referring Email<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Obligatorio)<\/span><\/span><\/label><div class='ginput_container ginput_container_email'>\n                            <input name='input_205' id='input_317_205' type='email' value='' class='large' tabindex='15'   aria-required=\"true\" aria-invalid=\"false\"  \/>\n                        <\/div><\/div><div id=\"field_317_67\" 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\">Client Information<\/h3><\/div><div id=\"field_317_27\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-third FIRST_NAME gf_hide_charleft 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_317_27'>First Name<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Obligatorio)<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_27' id='input_317_27' type='text' value='' class='large' maxlength='50'  tabindex='16'  aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_317_30\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-third LAST_NAME gf_hide_charleft 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_317_30'>Last Name<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Obligatorio)<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_30' id='input_317_30' type='text' value='' class='large' maxlength='50'  tabindex='17'  aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_317_15\" class=\"gfield gfield--type-date gfield--input-type-date gfield--input-type-datepicker gfield--datepicker-no-icon gfield--width-third DATE_BIRTH gcldf-field gcldf-field-date gcldf-date-format-dmy_dash gfield_trigger_change 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_317_15'>Date of Birth<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Obligatorio)<\/span><\/span><\/label><div class='ginput_container ginput_container_date'>\n                            <input name='input_15' id='input_317_15' type='text' value='' class='datepicker gform-datepicker dmy_dash datepicker_no_icon gdatepicker-no-icon' tabindex='18'  placeholder='dd-mm-aaaa' aria-describedby=\"input_317_15_date_format\" aria-invalid=\"false\" aria-required=\"true\"\/>\n                            <span id='input_317_15_date_format' class='screen-reader-text'>DD barra MM barra AAAA<\/span>\n                        <\/div>\n                        <input type='hidden' id='gforms_calendar_icon_input_317_15' class='gform_hidden' value='https:\/\/staging5.nsd.tech\/wp-content\/plugins\/gravityforms\/images\/datepicker\/datepicker.svg'\/><\/div><div id=\"field_317_234\" 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\">Parent \/ Legal Guardian Information<\/h3><div class='gsection_description' id='gfield_description_317_234'>For referrals of children and youth age 17 and younger, we require the names and contact information for ALL legal guardians, as they all must consent to the child or youth receiving therapy.<\/div><\/div><div id=\"field_317_236\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-third EMER_NAME gf_hide_charleft 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_317_236'>Full Name (Parent\/Legal Guardian 1)<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Obligatorio)<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_236' id='input_317_236' type='text' value='' class='large' maxlength='50'  tabindex='19'  aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_317_238\" class=\"gfield gfield--type-email gfield--input-type-email gfield--width-third EMER_EMAIL gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible gpev-field\"  data-field-class=\"gpev-field\" ><label class='gfield_label gform-field-label' for='input_317_238'>Email<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Obligatorio)<\/span><\/span><\/label><div class='ginput_container ginput_container_email'>\n                            <input name='input_238' id='input_317_238' type='email' value='' class='large' tabindex='20'   aria-required=\"true\" aria-invalid=\"false\"  \/>\n                        <\/div><\/div><div id=\"field_317_239\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-third EMER_TELE1 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_317_239'>Phone<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Obligatorio)<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_239' id='input_317_239' type='text' value='' class='large'   tabindex='21' placeholder='___-___-____' aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_317_255\" class=\"gfield gfield--type-select gfield--input-type-select gfield--width-five-twelfths EMER_RELATION 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_317_255'>Relation<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Obligatorio)<\/span><\/span><\/label><div class='ginput_container ginput_container_select'><select name='input_255' id='input_317_255' class='large gfield_select' tabindex='22'   aria-required=\"true\" aria-invalid=\"false\" autocomplete=\"new-password\"><option value='' ><\/option><option value='15' >Father<\/option><option value='27' >Mother<\/option><option value='24' >Grandparent<\/option><option value='25' >Legal Guardian<\/option><option value='32' >No Relation<\/option><\/select><\/div><\/div><div id=\"field_317_241\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-seven-twelfths EMER_ADDRESS gf_hide_charleft 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_317_241'>Address<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Obligatorio)<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_241' id='input_317_241' type='text' value='' class='large' maxlength='200'  tabindex='23'  aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_317_243\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-third EMER2_NAME gf_hide_charleft field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_317_243'>Full Name (Parent\/Legal Guardian 2)<\/label><div class='ginput_container ginput_container_text'><input name='input_243' id='input_317_243' type='text' value='' class='large' maxlength='50'  tabindex='24'   aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_317_244\" class=\"gfield gfield--type-email gfield--input-type-email gfield--width-third EMER2_EMAIL field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible gpev-field\"  data-field-class=\"gpev-field\" ><label class='gfield_label gform-field-label' for='input_317_244'>Email<\/label><div class='ginput_container ginput_container_email'>\n                            <input name='input_244' id='input_317_244' type='email' value='' class='large' tabindex='25'    aria-invalid=\"false\"  \/>\n                        <\/div><\/div><div id=\"field_317_245\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-third EMER2_TELE field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_317_245'>Phone<\/label><div class='ginput_container ginput_container_text'><input name='input_245' id='input_317_245' type='text' value='' class='large'   tabindex='26' placeholder='___-___-____'  aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_317_240\" class=\"gfield gfield--type-select gfield--input-type-select gfield--width-five-twelfths EMER2_RELATION field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_317_240'>Relation<\/label><div class='ginput_container ginput_container_select'><select name='input_240' id='input_317_240' class='large gfield_select' tabindex='27'    aria-invalid=\"false\" autocomplete=\"new-password\"><option value='' ><\/option><option value='15' >Father<\/option><option value='27' >Mother<\/option><option value='24' >Grandparent<\/option><option value='25' >Legal Guardian<\/option><option value='32' >No Relation<\/option><\/select><\/div><\/div><div id=\"field_317_247\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-seven-twelfths EMER2_ADDRESS gf_hide_charleft field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_317_247'>Address<\/label><div class='ginput_container ginput_container_text'><input name='input_247' id='input_317_247' type='text' value='' class='large' maxlength='200'  tabindex='28'   aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_317_250\" class=\"gfield gfield--type-select gfield--input-type-select gfield--width-full GENREMARKS 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_317_250'>If parents\/legal guardians do not live together, are separated, or divorced, please describe the custody arrangement:<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Obligatorio)<\/span><\/span><\/label><div class='ginput_container ginput_container_select'><select name='input_250' id='input_317_250' class='large gfield_select' tabindex='29'   aria-required=\"true\" aria-invalid=\"false\" ><option value='' ><\/option><option value='Joint court ordered custody' >Joint court ordered custody<\/option><option value='Joint custody by mutual agreement' >Joint custody by mutual agreement<\/option><option value='Sole custody' >Sole custody<\/option><option value='Current legal custody proceedings' >Current legal custody proceedings<\/option><option value='Current legal custody proceedings' >Current legal custody proceedings<\/option><option value='Custody not yet established' >Custody not yet established<\/option><option value='Not relevant \u2013 Parents live together' >Not relevant \u2013 Parents live together<\/option><\/select><\/div><\/div><div id=\"field_317_235\" 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\">Client information continued<\/h3><\/div><div id=\"field_317_249\" class=\"gfield gfield--type-section gfield--input-type-section gsection field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_hidden\"  ><div class=\"admin-hidden-markup\"><i class=\"gform-icon gform-icon--hidden\" aria-hidden=\"true\" title=\"Este campo est\u00e1 oculto cuando se visualiza el formulario\"><\/i><span>Este campo est\u00e1 oculto cuando se visualiza el formulario<\/span><\/div><h3 class=\"gsection_title\"><\/h3><\/div><div id=\"field_317_180\" class=\"gfield gfield--type-email gfield--input-type-email gfield--width-third EMAIL gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible gpev-field\"  data-field-class=\"gpev-field\" ><label class='gfield_label gform-field-label' for='input_317_180'>Email<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Obligatorio)<\/span><\/span><\/label><div class='ginput_container ginput_container_email'>\n                            <input name='input_180' id='input_317_180' type='email' value='' class='large' tabindex='30'   aria-required=\"true\" aria-invalid=\"false\"  \/>\n                        <\/div><\/div><div id=\"field_317_56\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-third TELE1 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_317_56'>Primary Phone<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Obligatorio)<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_56' id='input_317_56' type='text' value='' class='large'   tabindex='31' placeholder='___-___-____' aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_317_194\" class=\"gfield gfield--type-select gfield--input-type-select gfield--width-third CONSENTS field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_317_194'>Can we leave a message?<\/label><div class='ginput_container ginput_container_select'><select name='input_194' id='input_317_194' class='large gfield_select' tabindex='32'    aria-invalid=\"false\" ><option value='' ><\/option><option value='0420' >Yes<\/option><option value='0463' >No<\/option><\/select><\/div><\/div><div id=\"field_317_65\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-third POSTALCODE 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_317_65'>Postal Code<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Obligatorio)<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_65' id='input_317_65' type='text' value='' class='large'   tabindex='33'  aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_317_6\" class=\"gfield gfield--type-select gfield--input-type-select gfield--width-third GENDER 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_317_6'>Gender<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Obligatorio)<\/span><\/span><\/label><div class='ginput_container ginput_container_select'><select name='input_6' id='input_317_6' class='large gfield_select' tabindex='34'   aria-required=\"true\" aria-invalid=\"false\" ><option value=''  class='gf_placeholder'>\u2000<\/option><option value='F' >Female<\/option><option value='M' >Male<\/option><option value='X' >Other<\/option><option value='U' >Prefer not to disclose<\/option><\/select><\/div><\/div><div id=\"field_317_217\" class=\"gfield gfield--type-select gfield--input-type-select gfield--width-third PRONOUNS field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_317_217'>Pronouns<\/label><div class='ginput_container ginput_container_select'><select name='input_217' id='input_317_217' class='large gfield_select' tabindex='35'    aria-invalid=\"false\" ><option value='' ><\/option><option value='0079' >She\/Her<\/option><option value='0078' >He\/Him<\/option><option value='0080' >They\/Them<\/option><option value='0118' >Other<\/option><\/select><\/div><\/div><div id=\"field_317_66\" class=\"gfield gfield--type-select gfield--input-type-select gfield--width-third PROVINCE 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_317_66'>Province<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Obligatorio)<\/span><\/span><\/label><div class='ginput_container ginput_container_select'><select name='input_66' id='input_317_66' class='large gfield_select' tabindex='36'   aria-required=\"true\" aria-invalid=\"false\" ><option value='' selected='selected' class='gf_placeholder'>\u2003<\/option><option value='04003' >Manitoba<\/option><\/select><\/div><\/div><div id=\"field_317_172\" class=\"gfield gfield--type-select gfield--input-type-select gfield--width-third CITY 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_317_172'>City<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Obligatorio)<\/span><\/span><\/label><div class='ginput_container ginput_container_select'><select name='input_172' id='input_317_172' class='large gfield_select' tabindex='37'   aria-required=\"true\" aria-invalid=\"false\" ><option value='' selected='selected' class='gf_placeholder'>\u2002<\/option><option value='0400301188' >Winnipeg<\/option><option value='0400301019' >Brandon<\/option><option value='0400301128' >Portage la Prairie<\/option><option value='0400301176' >Thompson<\/option><option value='0400301143' >Selkirk<\/option><option value='0400301167' >Steinbach<\/option><option value='0400301187' >Winkler<\/option><option value='0400301001' >Agassiz Provincial Forest<\/option><option value='0400301002' >Alexander<\/option><option value='0400301003' >Alonsa<\/option><option value='0400301004' >Altona<\/option><option value='0400301199' >Anola<\/option><option value='0400301005' >Arborg<\/option><option value='0400301006' >Ashern<\/option><option value='0400301201' >Aubigny<\/option><option value='0400301007' >Austin<\/option><option value='0400301008' >Baldur<\/option><option value='0400301009' >Basswood<\/option><option value='0400301010' >Beausejour<\/option><option value='0400301011' >Belmont<\/option><option value='0400301012' >Benito<\/option><option value='0400301013' >Berens River<\/option><option value='0400301014' >Beulah<\/option><option value='0400301015' >Binscarth<\/option><option value='0400301197' >Birnie<\/option><option value='0400301016' >Birtle<\/option><option value='0400301017' >Bissett<\/option><option value='0400301202' >Blumenort<\/option><option value='0400301018' >Boissevain<\/option><option value='0400301020' >Brochet<\/option><option value='0400301021' >Brookdale<\/option><option value='0400301203' >Brunkild<\/option><option value='0400301022' >Camperville<\/option><option value='0400301023' >Carberry<\/option><option value='0400301024' >Carman<\/option><option value='0400301025' >Cartwright<\/option><option value='0400301026' >Churchill<\/option><option value='0400301204' >Cooks Creek<\/option><option value='0400301027' >Cormorant<\/option><option value='0400301028' >Cowan<\/option><option value='0400301029' >Cranberry Portage<\/option><option value='0400301030' >Crandall<\/option><option value='0400301031' >Cross Lake<\/option><option value='0400301032' >Crystal City<\/option><option value='0400301033' >Cypress River<\/option><option value='0400301034' >Darlingford<\/option><option value='0400301035' >Dauphin<\/option><option value='0400301036' >Deloraine<\/option><option value='0400301037' >Dominion City<\/option><option value='0400301192' >Dufresne<\/option><option value='0400301038' >Dugald<\/option><option value='0400301205' >East Braintree<\/option><option value='0400301039' >Easterville<\/option><option value='0400301040' >Eddystone<\/option><option value='0400301198' >Eden<\/option><option value='0400301041' >Edwin<\/option><option value='0400301042' >Elgin<\/option><option value='0400301043' >Elie<\/option><option value='0400301044' >Elkhorn<\/option><option value='0400301045' >Elm Creek<\/option><option value='0400301206' >Elma<\/option><option value='0400301046' >Emerson<\/option><option value='0400301047' >Erickson<\/option><option value='0400301048' >Eriksdale<\/option><option value='0400301049' >Ethelbert<\/option><option value='0400301050' >Falcon Lake<\/option><option value='0400301051' >Fisher Branch<\/option><option value='0400301052' >Fisher River<\/option><option value='0400301053' >Flin Flon<\/option><option value='0400301054' >Fork River<\/option><option value='0400301055' >Foxwarren<\/option><option value='0400301207' >Fraserwood<\/option><option value='0400301208' >Gardenton<\/option><option value='0400301056' >Gilbert Plains<\/option><option value='0400301057' >Gillam<\/option><option value='0400301058' >Gimli<\/option><option value='0400301209' >Giroux<\/option><option value='0400301059' >Gladstone<\/option><option value='0400301060' >Glenboro<\/option><option value='0400301061' >Glenella<\/option><option value='0400301062' >Gods Lake Narrows<\/option><option value='0400301063' >Grand Beach<\/option><option value='0400301064' >Grand Rapids<\/option><option value='0400301065' >Grandview<\/option><option value='0400301066' >Gretna<\/option><option value='0400301195' >Grunthal<\/option><option value='0400301067' >Gypsumville<\/option><option value='0400301068' >Hadashville<\/option><option value='0400301069' >Hamiota<\/option><option value='0400301070' >Hartney<\/option><option value='0400301210' >Hazelridge<\/option><option value='0400301071' >Hecla<\/option><option value='0400301211' >Hodgson<\/option><option value='0400301072' >Holland<\/option><option value='0400301212' >Ile Des Chenes<\/option><option value='0400301073' >Ilford<\/option><option value='0400301074' >Inwood<\/option><option value='0400301075' >Island Lake<\/option><option value='0400301076' >Kelwood<\/option><option value='0400301077' >Kenton<\/option><option value='0400301078' >Killarney<\/option><option value='0400301196' >Kleefeld<\/option><option value='0400301213' >Komarno<\/option><option value='0400301079' >La Broquerie<\/option><option value='0400301194' >La Salle<\/option><option value='0400301080' >Lac Brochet<\/option><option value='0400301081' >Lac du Bonnet<\/option><option value='0400301214' >Landmark<\/option><option value='0400301082' >Langruth<\/option><option value='0400301083' >Leaf Rapids<\/option><option value='0400301084' >Libau<\/option><option value='0400301215' >Linden<\/option><option value='0400301085' >Little Grand Rapids<\/option><option value='0400301086' >Lockport<\/option><option value='0400301193' >Lorette<\/option><option value='0400301216' >Lowe Farm<\/option><option value='0400301087' >Lundar<\/option><option value='0400301088' >Lynn Lake<\/option><option value='0400301089' >MacGregor<\/option><option value='0400301090' >Mafeking<\/option><option value='0400301091' >Manigotagan<\/option><option value='0400301092' >Manitou<\/option><option value='0400301217' >Marchand<\/option><option value='0400301093' >McAuley<\/option><option value='0400301094' >McCreary<\/option><option value='0400301095' >Melita<\/option><option value='0400301096' >Miami<\/option><option value='0400301218' >Middlebro<\/option><option value='0400301097' >Miniota<\/option><option value='0400301098' >Minnedosa<\/option><option value='0400301099' >Minto<\/option><option value='0400301100' >Moose Lake<\/option><option value='0400301101' >Morden<\/option><option value='0400301102' >Morris<\/option><option value='0400301103' >Neepawa<\/option><option value='0400301104' >Nelson House<\/option><option value='0400301105' >Newdale<\/option><option value='0400301106' >Niverville<\/option><option value='0400301107' >Norway House<\/option><option value='0400301108' >Notre Dame de Lourdes<\/option><option value='0400301109' >Oak Lake<\/option><option value='0400301110' >Oak River<\/option><option value='0400301219' >Oakbank<\/option><option value='0400301111' >Oakville<\/option><option value='0400301112' >Ochre River<\/option><option value='0400301220' >Otterburne<\/option><option value='0400301113' >Oxford House<\/option><option value='0400301221' >Pansy<\/option><option value='0400301114' >Peguis<\/option><option value='0400301115' >Pelican Rapids<\/option><option value='0400301116' >Pikwitonei<\/option><option value='0400301117' >Pilot Mound<\/option><option value='0400301118' >Pinawa<\/option><option value='0400301119' >Pine Dock<\/option><option value='0400301120' >Pine Falls<\/option><option value='0400301121' >Pine River<\/option><option value='0400301122' >Piney<\/option><option value='0400301123' >Plum Coulee<\/option><option value='0400301124' >Plumas<\/option><option value='0400301125' >Pointe du Bois<\/option><option value='0400301126' >Poplar River<\/option><option value='0400301127' >Poplarfield<\/option><option value='0400301222' >Prawda<\/option><option value='0400301223' >Randolph<\/option><option value='0400301129' >Rapid City<\/option><option value='0400301130' >Rathwell<\/option><option value='0400301131' >Red Sucker Lake<\/option><option value='0400301132' >Rennie<\/option><option value='0400301133' >Reston<\/option><option value='0400301224' >Richer<\/option><option value='0400301134' >Rivers<\/option><option value='0400301135' >Riverton<\/option><option value='0400301136' >Roblin<\/option><option value='0400301137' >Roland<\/option><option value='0400301138' >Rorketon<\/option><option value='0400301225' >Rosa<\/option><option value='0400301226' >Roseau River<\/option><option value='0400301227' >Rosenort<\/option><option value='0400301228' >Rosewood<\/option><option value='0400301139' >Rossburn<\/option><option value='0400301140' >Russell<\/option><option value='0400301229' >Sandilands<\/option><option value='0400301141' >Sandy Lake<\/option><option value='0400301142' >Sanford<\/option><option value='0400301230' >Sarto<\/option><option value='0400301231' >Schanzenfeld<\/option><option value='0400301232' >Seven Sister Falls<\/option><option value='0400301144' >Shamattawa<\/option><option value='0400301145' >Shilo<\/option><option value='0400301146' >Shoal Lake<\/option><option value='0400301147' >Sidney<\/option><option value='0400301148' >Sifton<\/option><option value='0400301149' >Snow Lake<\/option><option value='0400301150' >Snowflake<\/option><option value='0400301151' >Somerset<\/option><option value='0400301152' >Souris<\/option><option value='0400301153' >South Indian Lake<\/option><option value='0400301233' >South Junction<\/option><option value='0400301154' >Sperling<\/option><option value='0400301155' >Split Lake<\/option><option value='0400301156' >Sprague<\/option><option value='0400301234' >St. Adolphe<\/option><option value='0400301158' >St. Claude<\/option><option value='0400301159' >St. Francois Xavier<\/option><option value='0400301160' >St. Jean Baptiste<\/option><option value='0400301161' >St. Laurent<\/option><option value='0400301162' >St. Lazare<\/option><option value='0400301235' >St. Malo<\/option><option value='0400301163' >Starbuck<\/option><option value='0400301164' >Ste. Agathe<\/option><option value='0400301236' >Ste. Anne<\/option><option value='0400301165' >Ste. Rose du Lac<\/option><option value='0400301166' >Steep Rock<\/option><option value='0400301168' >Stonewall<\/option><option value='0400301157' >St-Pierre-Jolys<\/option><option value='0400301169' >Strathclair<\/option><option value='0400301237' >Sundown<\/option><option value='0400301170' >Swan Lake<\/option><option value='0400301171' >Swan River<\/option><option value='0400301172' >Tadoule Lake<\/option><option value='0400301173' >Teulon<\/option><option value='0400301174' >The Pas<\/option><option value='0400301175' >Thicket Portage<\/option><option value='0400301238' >Tolstoi<\/option><option value='0400301239' >Tourond<\/option><option value='0400301177' >Treherne<\/option><option value='0400301240' >Tyndale<\/option><option value='0400301241' >Vassar<\/option><option value='0400301178' >Virden<\/option><option value='0400301179' >Vita<\/option><option value='0400301180' >Waasagomach<\/option><option value='0400301181' >Wabowden<\/option><option value='0400301182' >Wanless<\/option><option value='0400301183' >Wasagaming<\/option><option value='0400301184' >Waterhen<\/option><option value='0400301185' >Wawanesa<\/option><option value='0400301186' >Whitemouth<\/option><option value='0400301189' >Winnipeg Beach<\/option><option value='0400301190' >Winnipegosis<\/option><option value='0400301242' >Woodlands<\/option><option value='0400301243' >Woodmore<\/option><option value='0400301191' >Woodridge<\/option><option value='0400301244' >Zhoda<\/option><\/select><\/div><\/div><div id=\"field_317_159\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-third ADDRESS1 gf_hide_charleft 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_317_159'>Address<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Obligatorio)<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_159' id='input_317_159' type='text' value='' class='large' maxlength='200'  tabindex='38'  aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_317_93\" class=\"gfield gfield--type-date gfield--input-type-date gfield--input-type-datepicker gfield--datepicker-no-icon gfield--width-third DATE_ARRIVAL 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_317_93'>Date of Arrival<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Obligatorio)<\/span><\/span><\/label><div class='ginput_container ginput_container_date'>\n                            <input name='input_93' id='input_317_93' type='text' value='' class='datepicker gform-datepicker dmy_dash datepicker_no_icon gdatepicker-no-icon' tabindex='39'  placeholder='dd-mm-aaaa' aria-describedby=\"input_317_93_date_format\" aria-invalid=\"false\" aria-required=\"true\"\/>\n                            <span id='input_317_93_date_format' class='screen-reader-text'>DD barra MM barra AAAA<\/span>\n                        <\/div>\n                        <input type='hidden' id='gforms_calendar_icon_input_317_93' class='gform_hidden' value='https:\/\/staging5.nsd.tech\/wp-content\/plugins\/gravityforms\/images\/datepicker\/datepicker.svg'\/><\/div><div id=\"field_317_229\" class=\"gfield gfield--type-select gfield--input-type-select gfield--width-third CAN_STATUS 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_317_229'>Status in Canada<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Obligatorio)<\/span><\/span><\/label><div class='ginput_container ginput_container_select'><select name='input_229' id='input_317_229' class='large gfield_select' tabindex='40'   aria-required=\"true\" aria-invalid=\"false\" ><option value='' ><\/option><option value='0001' >Canadian Citizen<\/option><option value='0002' >Government Assisted Refugees (GAR)<\/option><option value='0003' >Permanent Resident<\/option><option value='0006' >Refugee Claimant (RC)<\/option><option value='0007' >Student - Study Permit<\/option><option value='0016' >Work Permit<\/option><option value='0018' >Ukraine CUAET Permit<\/option><option value='0022' >Private Sponsored Refugees (PSR)<\/option><option value='0023' >Blended Visa Office-Referred Program (BVOR)<\/option><\/select><\/div><\/div><div id=\"field_317_52\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-third FOSSIDNO field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_317_52'>UCI \/ PR Number (Optional)<\/label><div class='ginput_container ginput_container_text'><input name='input_52' id='input_317_52' type='text' value='' class='large'   tabindex='41'   aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_317_50\" class=\"gfield gfield--type-select gfield--input-type-select gfield--width-third CNT_CITIZENSHIP 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_317_50'>Country of Origin<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Obligatorio)<\/span><\/span><\/label><div class='ginput_container ginput_container_select'><select name='input_50' id='input_317_50' class='large gfield_select' tabindex='42'   aria-required=\"true\" aria-invalid=\"false\" ><option value='' selected='selected' class='gf_placeholder'>\u2000<\/option><option value='002' >Afghanistan<\/option><option value='003' >Albania<\/option><option value='004' >Alderney<\/option><option value='005' >Algeria<\/option><option value='006' >American Samoa<\/option><option value='007' >Andorra<\/option><option value='008' >Angola<\/option><option value='009' >Anguilla<\/option><option value='010' >Antigua and Barbuda<\/option><option value='011' >Argentina<\/option><option value='012' >Armenia<\/option><option value='014' >Australia<\/option><option value='015' >Austria<\/option><option value='016' >Azerbaijan<\/option><option value='017' >Bahamas<\/option><option value='018' >Bahrain<\/option><option value='019' >Bangladesh<\/option><option value='020' >Barbados<\/option><option value='021' >Belarus<\/option><option value='022' >Belgium<\/option><option value='023' >Belize<\/option><option value='024' >Benin<\/option><option value='025' >Bermuda<\/option><option value='026' >Bhutan<\/option><option value='027' >Bolivia<\/option><option value='028' >Bophuthatswana<\/option><option value='029' >Bosnia and Herzegovina<\/option><option value='030' >Botswana<\/option><option value='031' >Brazil<\/option><option value='033' >British Virgin Islands<\/option><option value='034' >Brunei<\/option><option value='035' >Bulgaria<\/option><option value='036' >Burkina Faso<\/option><option value='037' >Myanmar (formerly Burma)<\/option><option value='038' >Burundi<\/option><option value='039' >Cameroon<\/option><option value='040' >Canada<\/option><option value='041' >Canary Islands<\/option><option value='042' >Cabo Verde<\/option><option value='043' >Cayman Islands<\/option><option value='044' >Central African Republic<\/option><option value='045' >Chad<\/option><option value='047' >Chile<\/option><option value='048' >China (PRC)<\/option><option value='049' >Colombia<\/option><option value='050' >Comoros<\/option><option value='051' >Congo Democratic Republic of<\/option><option value='052' >Congo (Congo Republic)<\/option><option value='054' >Costa Rica<\/option><option value='055' >Croatia<\/option><option value='056' >Cuba<\/option><option value='057' >Cyprus<\/option><option value='058' >Czechia (Czech Republic)<\/option><option value='059' >Denmark<\/option><option value='060' >Djibouti<\/option><option value='061' >Dominican Republic<\/option><option value='062' >Ecuador<\/option><option value='063' >Egypt<\/option><option value='064' >El Salvador<\/option><option value='065' >England<\/option><option value='066' >Equatorial Guinea<\/option><option value='067' >Eritrea<\/option><option value='068' >Estonia<\/option><option value='069' >Ethiopia<\/option><option value='071' >Germany<\/option><option value='072' >Fiji<\/option><option value='073' >Finland<\/option><option value='075' >Fr. Polynesia<\/option><option value='076' >France<\/option><option value='077' >French Guiana<\/option><option value='078' >Gabon<\/option><option value='079' >Gambia<\/option><option value='080' >Georgia<\/option><option value='081' >Ghana<\/option><option value='083' >Greece<\/option><option value='084' >Greenland<\/option><option value='085' >Grenada<\/option><option value='086' >Guadaloupe<\/option><option value='087' >Guam<\/option><option value='088' >Guatemala<\/option><option value='089' >Guinea<\/option><option value='090' >Guinea-bissau<\/option><option value='091' >Guyana<\/option><option value='092' >Haiti<\/option><option value='093' >Honduras<\/option><option value='094' >Hong Kong<\/option><option value='095' >Hungary<\/option><option value='096' >Iceland<\/option><option value='097' >India<\/option><option value='098' >Indonesia<\/option><option value='099' >Iran<\/option><option value='100' >Iraq<\/option><option value='101' >Ireland<\/option><option value='102' >Israel<\/option><option value='103' >Italy<\/option><option value='104' >Cote d Ivoire (Ivory Coast)<\/option><option value='105' >Jamaica<\/option><option value='106' >Japan<\/option><option value='107' >Jordan<\/option><option value='108' >Kampuchea Democratic<\/option><option value='109' >Kazakhstan<\/option><option value='110' >Kenya<\/option><option value='111' >Kerguelen Islands<\/option><option value='112' >Kyrgyzstan<\/option><option value='113' >Kiribati<\/option><option value='114' >Korea, North<\/option><option value='115' >Korea, South<\/option><option value='116' >Kosovo<\/option><option value='117' >Kuwait<\/option><option value='118' >Laos<\/option><option value='119' >Latvia<\/option><option value='120' >Lebanon<\/option><option value='121' >Lesotho<\/option><option value='122' >Liberia<\/option><option value='123' >Libya<\/option><option value='124' >Liechtenstein<\/option><option value='125' >Lithuania<\/option><option value='126' >Luxembourg<\/option><option value='128' >North Macedonia<\/option><option value='129' >Madagascar<\/option><option value='130' >Malawi<\/option><option value='131' >Malaysia<\/option><option value='132' >Maldives<\/option><option value='133' >Mali<\/option><option value='134' >Malta<\/option><option value='135' >Marshall Islands<\/option><option value='137' >Mauritania<\/option><option value='138' >Mauritius<\/option><option value='140' >Mexico<\/option><option value='141' >Moldova<\/option><option value='142' >Monaco<\/option><option value='143' >Mongolia<\/option><option value='144' >Montserrat<\/option><option value='145' >Morocco<\/option><option value='146' >Mozambique<\/option><option value='147' >Namibia<\/option><option value='148' >Nauru<\/option><option value='149' >Nepal<\/option><option value='150' >Netherlands<\/option><option value='153' >New Caledonia<\/option><option value='154' >New Zealand<\/option><option value='155' >Nicaragua<\/option><option value='156' >Niger<\/option><option value='157' >Nigeria<\/option><option value='158' >Northern Ireland<\/option><option value='159' >Norway<\/option><option value='160' >Pakistan<\/option><option value='161' >Palestine<\/option><option value='162' >Panama<\/option><option value='164' >Papua New Guinea<\/option><option value='165' >Paraguay<\/option><option value='166' >Peru<\/option><option value='167' >Philippines<\/option><option value='168' >Pitcairn Islands<\/option><option value='169' >Poland<\/option><option value='170' >Portugal<\/option><option value='171' >Puerto Rico<\/option><option value='172' >Qatar<\/option><option value='173' >Reunion<\/option><option value='174' >Romania<\/option><option value='175' >Russia<\/option><option value='176' >Rwanda<\/option><option value='177' >Samoa<\/option><option value='178' >San Marino<\/option><option value='179' >Sao Tome and Principe<\/option><option value='180' >Saudi Arabia<\/option><option value='181' >Scotland<\/option><option value='182' >Senegal<\/option><option value='183' >Serbia<\/option><option value='184' >Seychelles<\/option><option value='185' >Sierra Leone<\/option><option value='186' >Singapore<\/option><option value='187' >Solomon Islands<\/option><option value='188' >Somalia<\/option><option value='189' >South Africa<\/option><option value='190' >Spain<\/option><option value='191' >Sri Lanka<\/option><option value='192' >St. Helena<\/option><option value='193' >St. Kitts and Nevis<\/option><option value='194' >St. Lucia<\/option><option value='195' >St. Pierre Et Miquelon<\/option><option value='196' >St. Vincent And The Grenadines<\/option><option value='197' >Stateless<\/option><option value='198' >Sudan<\/option><option value='199' >Suriname<\/option><option value='200' >Eswatini (formerly Swaziland)<\/option><option value='201' >Sweden<\/option><option value='202' >Switzerland<\/option><option value='203' >Syria<\/option><option value='204' >Tajikistan<\/option><option value='205' >Tanzania<\/option><option value='206' >Thailand<\/option><option value='207' >Tibet<\/option><option value='208' >Togo<\/option><option value='209' >Tonga<\/option><option value='210' >Trinidad &amp; Tobago<\/option><option value='211' >Tunisia<\/option><option value='212' >Turkey<\/option><option value='213' >Turkmenistan<\/option><option value='214' >Turks &amp; Caicos<\/option><option value='215' >Tuvalu<\/option><option value='216' >U.S. Virgin Islands<\/option><option value='217' >United States of America<\/option><option value='219' >Uganda<\/option><option value='220' >Ukraine<\/option><option value='221' >United Arab Emirates<\/option><option value='223' >Uruguay<\/option><option value='224' >Uzbekistan<\/option><option value='225' >Vanuatu<\/option><option value='226' >Holy See (Vatican City)<\/option><option value='227' >Venezuela<\/option><option value='228' >Vietnam<\/option><option value='231' >Wales<\/option><option value='233' >Western Sahara<\/option><option value='234' >Yemen<\/option><option value='235' >Yugoslavia<\/option><option value='236' >Zaire (now Congo DRC)<\/option><option value='237' >Zambia<\/option><option value='238' >Zimbabwe<\/option><option value='239' >Oman<\/option><option value='240' >Sudan, South<\/option><option value='241' >United Kingdom<\/option><option value='242' >Slovenia<\/option><option value='243' >Slovakia (Slovak Republic)<\/option><option value='244' >Taiwan (ROC)<\/option><option value='245' >Cambodia<\/option><option value='246' >Dominica<\/option><option value='247' >East Timor (Timor-Leste)<\/option><option value='248' >Micronesia<\/option><option value='249' >Montenegro<\/option><option value='250' >Palau<\/option><\/select><\/div><\/div><div id=\"field_317_53\" class=\"gfield gfield--type-select gfield--input-type-select gfield--width-third PRIMARYLANG 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_317_53'>Native Language<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Obligatorio)<\/span><\/span><\/label><div class='ginput_container ginput_container_select'><select name='input_53' id='input_317_53' class='large gfield_select' tabindex='43'   aria-required=\"true\" aria-invalid=\"false\" ><option value='' selected='selected' class='gf_placeholder'>\u200e\u2000<\/option><option value='058' >English<\/option><option value='069' >French<\/option><option value='001' >Acholi<\/option><option value='002' >Ada<\/option><option value='003' >Affar<\/option><option value='004' >Afghan<\/option><option value='005' >Afrikaans<\/option><option value='006' >Aka<\/option><option value='007' >Akan<\/option><option value='212' >Aklanon<\/option><option value='008' >Akra<\/option><option value='009' >Albanian<\/option><option value='213' >American Sign Language (ASL)<\/option><option value='010' >Amharic<\/option><option value='011' >Anuak (Anywa)<\/option><option value='013' >Arabic<\/option><option value='214' >Aran<\/option><option value='014' >Armenian<\/option><option value='015' >Ashanti<\/option><option value='215' >Assamese<\/option><option value='016' >Assyrian<\/option><option value='017' >Azeri<\/option><option value='018' >Bahasa Indonesian<\/option><option value='216' >Balochi<\/option><option value='019' >Bambara<\/option><option value='020' >Bantu<\/option><option value='217' >Baule<\/option><option value='218' >Belarusian<\/option><option value='021' >Belen<\/option><option value='022' >Bemba<\/option><option value='023' >Bembe<\/option><option value='024' >Bengali<\/option><option value='025' >Beni<\/option><option value='219' >Benin<\/option><option value='026' >Berber<\/option><option value='027' >Bhari<\/option><option value='220' >Bicol\/Bikol\/Bicolano<\/option><option value='221' >Bijaiya<\/option><option value='222' >Bilen<\/option><option value='028' >Bini<\/option><option value='029' >Bisaya<\/option><option value='030' >Bissa<\/option><option value='223' >Bontok<\/option><option value='224' >Braille (translation only)<\/option><option value='031' >Breton<\/option><option value='032' >Bulgarian<\/option><option value='033' >Burmese<\/option><option value='034' >Busan<\/option><option value='035' >Busango<\/option><option value='036' >Cantonese<\/option><option value='037' >Catalan<\/option><option value='038' >Cebuano<\/option><option value='039' >Chakma<\/option><option value='040' >Chaldean<\/option><option value='041' >Chaocho<\/option><option value='225' >Chavacano<\/option><option value='042' >Chichewa<\/option><option value='043' >Chin<\/option><option value='044' >Chinese<\/option><option value='226' >Chinese - Simplified (TRANSLATION ONLY)<\/option><option value='227' >Chinese - Traditional (TRANSLATION ONLY)<\/option><option value='228' >Chiuchow<\/option><option value='045' >Chiyao<\/option><option value='046' >Chowchau<\/option><option value='229' >Concani<\/option><option value='047' >Creole<\/option><option value='048' >Croatian<\/option><option value='049' >Czech<\/option><option value='050' >Danish<\/option><option value='051' >Dari<\/option><option value='052' >Deaf-mute<\/option><option value='053' >Dinka<\/option><option value='054' >Dioula<\/option><option value='055' >Dutch<\/option><option value='230' >Dzongkha<\/option><option value='056' >Edo<\/option><option value='057' >Efik<\/option><option value='059' >Estonian<\/option><option value='060' >Ewe<\/option><option value='062' >Fang<\/option><option value='063' >Fanti<\/option><option value='064' >Farsi (Persian)<\/option><option value='316' >Filipino<\/option><option value='065' >Finnish<\/option><option value='066' >Flemish<\/option><option value='231' >Foochow<\/option><option value='067' >Fouki<\/option><option value='068' >Foullah<\/option><option value='070' >Fukinese<\/option><option value='071' >Fulani<\/option><option value='072' >Ga<\/option><option value='073' >Gaelic<\/option><option value='232' >Georgian<\/option><option value='074' >German<\/option><option value='075' >Greek<\/option><option value='076' >Guerze<\/option><option value='077' >Gujarati<\/option><option value='233' >Hainam<\/option><option value='234' >Hakha Chin<\/option><option value='078' >Hakka<\/option><option value='235' >Harara<\/option><option value='236' >Harary<\/option><option value='079' >Hargar<\/option><option value='080' >Hassanya<\/option><option value='081' >Hausa<\/option><option value='082' >Hebrew<\/option><option value='237' >Hiligaynon<\/option><option value='083' >Hindi<\/option><option value='084' >Hindko<\/option><option value='085' >Hokkin<\/option><option value='086' >Hungarian<\/option><option value='238' >Ibibio<\/option><option value='087' >Ibo<\/option><option value='239' >Icelandic<\/option><option value='240' >Igbo<\/option><option value='241' >Igorot<\/option><option value='242' >Ijaw<\/option><option value='243' >Ika<\/option><option value='244' >Ilican<\/option><option value='245' >Ilocano<\/option><option value='088' >Ilongo<\/option><option value='246' >Indonesian<\/option><option value='089' >Ishan<\/option><option value='090' >Italian<\/option><option value='247' >Itsekiri<\/option><option value='248' >Ivbiosakon<\/option><option value='091' >Izi<\/option><option value='092' >Japanese<\/option><option value='249' >Jarai<\/option><option value='093' >Javanese<\/option><option value='094' >Jolay<\/option><option value='012' >Juba Arabic<\/option><option value='095' >Kacchi<\/option><option value='250' >Kakwa<\/option><option value='096' >Kanarese<\/option><option value='097' >Kandahari<\/option><option value='098' >Kankani<\/option><option value='251' >Kannada<\/option><option value='252' >Kapampangan<\/option><option value='099' >Karen<\/option><option value='253' >Kashmiri<\/option><option value='254' >Kazakh<\/option><option value='100' >Khmer<\/option><option value='101' >Kifuliru<\/option><option value='102' >Kihavu<\/option><option value='103' >Kikongo<\/option><option value='255' >Kinyamulenge<\/option><option value='104' >Kinyarwanda<\/option><option value='105' >Kirega<\/option><option value='106' >Kirundi<\/option><option value='107' >Kiswahili<\/option><option value='256' >Kituba<\/option><option value='257' >Konkani<\/option><option value='108' >Korean<\/option><option value='109' >Krio<\/option><option value='110' >Kurdish<\/option><option value='313' >Kurmanji<\/option><option value='258' >Kyrgyz<\/option><option value='259' >La langue des signes qu\u00e9b\u00e9coise (LSQ)<\/option><option value='111' >Laotian<\/option><option value='112' >Latvian<\/option><option value='113' >Lebanese<\/option><option value='260' >Lengie<\/option><option value='114' >Lingala<\/option><option value='115' >Lithuanian<\/option><option value='116' >Lowma<\/option><option value='261' >Luganda<\/option><option value='262' >Lugishu<\/option><option value='263' >Lutoro<\/option><option value='117' >Maban<\/option><option value='118' >Macedonian<\/option><option value='264' >Macena<\/option><option value='119' >Macua<\/option><option value='120' >Mahou<\/option><option value='265' >Makonde<\/option><option value='121' >Malagasy<\/option><option value='122' >Malay<\/option><option value='123' >Malayalam<\/option><option value='124' >Maligo<\/option><option value='125' >Malinke<\/option><option value='126' >Maltese<\/option><option value='127' >Mandarin<\/option><option value='128' >Mandingo<\/option><option value='129' >Marathi<\/option><option value='311' >Masalit<\/option><option value='130' >Mashi<\/option><option value='131' >Mende<\/option><option value='132' >Mina<\/option><option value='266' >Mizo<\/option><option value='267' >Moldovan<\/option><option value='268' >Mongolian<\/option><option value='269' >Moore<\/option><option value='270' >Naandi\/Cemual<\/option><option value='271' >Ndebele<\/option><option value='133' >Nepali<\/option><option value='134' >Norwegian<\/option><option value='272' >Nubian<\/option><option value='135' >Nuer<\/option><option value='136' >Nzima<\/option><option value='273' >Oko<\/option><option value='137' >Okpe<\/option><option value='138' >Oriya<\/option><option value='139' >Oromo<\/option><option value='274' >Osal<\/option><option value='140' >Other African Languages<\/option><option value='141' >Other Chinese Dialects<\/option><option value='142' >Other European Languages<\/option><option value='143' >Other Languages<\/option><option value='144' >Other Middle Eastern Languages<\/option><option value='275' >Other Signed Languages<\/option><option value='145' >Other South Asian Languages<\/option><option value='146' >Other South East Asian Lang.<\/option><option value='276' >Otuho<\/option><option value='277' >Pahari<\/option><option value='278' >Pampango<\/option><option value='279' >Pangasinan<\/option><option value='154' >Pashto<\/option><option value='148' >Peul<\/option><option value='280' >Phuockien<\/option><option value='149' >Pidgin<\/option><option value='281' >Plautdietsch<\/option><option value='150' >Polish<\/option><option value='151' >Portuguese<\/option><option value='152' >Poular<\/option><option value='153' >Punjabi<\/option><option value='282' >Rohingya<\/option><option value='283' >Romani<\/option><option value='155' >Romanian<\/option><option value='284' >Rukiga<\/option><option value='285' >Runyankole<\/option><option value='156' >Russian<\/option><option value='286' >Rutooro<\/option><option value='157' >Samoan<\/option><option value='287' >Sango<\/option><option value='288' >Sanskrit<\/option><option value='289' >Sara<\/option><option value='158' >Scoula<\/option><option value='159' >Sechuan<\/option><option value='290' >Senufo<\/option><option value='160' >Serbian<\/option><option value='161' >Serbo-Croatian<\/option><option value='291' >Sesotho<\/option><option value='162' >Seswi<\/option><option value='163' >Seychelles<\/option><option value='292' >Shan<\/option><option value='164' >Shanghai<\/option><option value='165' >Shansai<\/option><option value='166' >Shilluk<\/option><option value='293' >Shona<\/option><option value='167' >Sign Language<\/option><option value='168' >Sindhi<\/option><option value='170' >Sinhalese<\/option><option value='171' >Slovak<\/option><option value='172' >Slovene<\/option><option value='173' >Somali<\/option><option value='312' >Songhai<\/option><option value='174' >Soninke<\/option><option value='314' >Sorani<\/option><option value='294' >Sotho<\/option><option value='175' >Soussou<\/option><option value='295' >Southern Burun<\/option><option value='176' >Spanish<\/option><option value='177' >Suesue<\/option><option value='296' >Sukuma<\/option><option value='178' >Swahili<\/option><option value='179' >Swazai<\/option><option value='180' >Swedish<\/option><option value='317' >Swiss German<\/option><option value='181' >Tagalog<\/option><option value='297' >Taichew<\/option><option value='315' >Tamasheq<\/option><option value='182' >Tamil<\/option><option value='183' >Tari<\/option><option value='298' >Tatar<\/option><option value='184' >Tatshanese<\/option><option value='185' >Telugu<\/option><option value='299' >Temne<\/option><option value='300' >Teochew<\/option><option value='186' >Thai<\/option><option value='187' >Tibetan<\/option><option value='188' >Tichiew<\/option><option value='301' >Tigre<\/option><option value='189' >Tigrigna<\/option><option value='190' >Timini<\/option><option value='191' >Tiv<\/option><option value='302' >Toishan<\/option><option value='192' >Tshiluba<\/option><option value='193' >Tsibula<\/option><option value='194' >Turkish<\/option><option value='195' >Twi<\/option><option value='318' >Uduk<\/option><option value='200' >Uhrobo<\/option><option value='196' >Uigrigma<\/option><option value='197' >Ukrainian<\/option><option value='303' >Umbundu<\/option><option value='304' >Unama<\/option><option value='198' >Unknown<\/option><option value='199' >Urdu<\/option><option value='319' >Uyghur<\/option><option value='201' >Uzbek<\/option><option value='202' >Vietnamese<\/option><option value='305' >Visayan<\/option><option value='306' >Waray<\/option><option value='203' >Welsh<\/option><option value='204' >Western Hemisphere Indian Lang<\/option><option value='205' >Wolof<\/option><option value='206' >Xhosa<\/option><option value='307' >Yako\/Loko\/Lokaa<\/option><option value='308' >Yekhee\/Afenmai\/Afemai<\/option><option value='207' >Yiboe<\/option><option value='208' >Yiddish<\/option><option value='209' >Yoruba<\/option><option value='210' >Zande<\/option><option value='309' >Zshiluba<\/option><option value='310' >Zuganda<\/option><option value='211' >Zulu<\/option><\/select><\/div><\/div><div id=\"field_317_193\" class=\"gfield gfield--type-multiselect gfield--input-type-multiselect gfield--width-third LANGS field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_317_193'>Other Languages (type to search)<\/label><div class='ginput_container ginput_container_multiselect'><select multiple='multiple'  size='7' name='input_193[]' id='input_317_193' class='large gfield_select' tabindex='44'  aria-invalid=\"false\"  ><option value='001' >Acholi<\/option><option value='002' >Ada<\/option><option value='003' >Affar<\/option><option value='004' >Afghan<\/option><option value='005' >Afrikaans<\/option><option value='006' >Aka<\/option><option value='007' >Akan<\/option><option value='212' >Aklanon<\/option><option value='008' >Akra<\/option><option value='009' >Albanian<\/option><option value='213' >American Sign Language (ASL)<\/option><option value='010' >Amharic<\/option><option value='011' >Anuak (Anywa)<\/option><option value='013' >Arabic<\/option><option value='214' >Aran<\/option><option value='014' >Armenian<\/option><option value='015' >Ashanti<\/option><option value='215' >Assamese<\/option><option value='016' >Assyrian<\/option><option value='017' >Azeri<\/option><option value='018' >Bahasa Indonesian<\/option><option value='216' >Balochi<\/option><option value='019' >Bambara<\/option><option value='020' >Bantu<\/option><option value='217' >Baule<\/option><option value='218' >Belarusian<\/option><option value='021' >Belen<\/option><option value='022' >Bemba<\/option><option value='023' >Bembe<\/option><option value='024' >Bengali<\/option><option value='025' >Beni<\/option><option value='219' >Benin<\/option><option value='026' >Berber<\/option><option value='027' >Bhari<\/option><option value='220' >Bicol\/Bikol\/Bicolano<\/option><option value='221' >Bijaiya<\/option><option value='222' >Bilen<\/option><option value='028' >Bini<\/option><option value='029' >Bisaya<\/option><option value='030' >Bissa<\/option><option value='223' >Bontok<\/option><option value='224' >Braille (translation only)<\/option><option value='031' >Breton<\/option><option value='032' >Bulgarian<\/option><option value='033' >Burmese<\/option><option value='034' >Busan<\/option><option value='035' >Busango<\/option><option value='036' >Cantonese<\/option><option value='037' >Catalan<\/option><option value='038' >Cebuano<\/option><option value='039' >Chakma<\/option><option value='040' >Chaldean<\/option><option value='041' >Chaocho<\/option><option value='225' >Chavacano<\/option><option value='042' >Chichewa<\/option><option value='043' >Chin<\/option><option value='044' >Chinese<\/option><option value='226' >Chinese - Simplified (TRANSLATION ONLY)<\/option><option value='227' >Chinese - Traditional (TRANSLATION ONLY)<\/option><option value='228' >Chiuchow<\/option><option value='045' >Chiyao<\/option><option value='046' >Chowchau<\/option><option value='229' >Concani<\/option><option value='047' >Creole<\/option><option value='048' >Croatian<\/option><option value='049' >Czech<\/option><option value='050' >Danish<\/option><option value='051' >Dari<\/option><option value='052' >Deaf-mute<\/option><option value='053' >Dinka<\/option><option value='054' >Dioula<\/option><option value='055' >Dutch<\/option><option value='230' >Dzongkha<\/option><option value='056' >Edo<\/option><option value='057' >Efik<\/option><option value='058' >English<\/option><option value='059' >Estonian<\/option><option value='060' >Ewe<\/option><option value='062' >Fang<\/option><option value='063' >Fanti<\/option><option value='064' >Farsi (Persian)<\/option><option value='316' >Filipino<\/option><option value='065' >Finnish<\/option><option value='066' >Flemish<\/option><option value='231' >Foochow<\/option><option value='067' >Fouki<\/option><option value='068' >Foullah<\/option><option value='069' >French<\/option><option value='070' >Fukinese<\/option><option value='071' >Fulani<\/option><option value='072' >Ga<\/option><option value='073' >Gaelic<\/option><option value='232' >Georgian<\/option><option value='074' >German<\/option><option value='075' >Greek<\/option><option value='076' >Guerze<\/option><option value='077' >Gujarati<\/option><option value='233' >Hainam<\/option><option value='234' >Hakha Chin<\/option><option value='078' >Hakka<\/option><option value='235' >Harara<\/option><option value='236' >Harary<\/option><option value='079' >Hargar<\/option><option value='080' >Hassanya<\/option><option value='081' >Hausa<\/option><option value='082' >Hebrew<\/option><option value='237' >Hiligaynon<\/option><option value='083' >Hindi<\/option><option value='084' >Hindko<\/option><option value='085' >Hokkin<\/option><option value='086' >Hungarian<\/option><option value='238' >Ibibio<\/option><option value='087' >Ibo<\/option><option value='239' >Icelandic<\/option><option value='240' >Igbo<\/option><option value='241' >Igorot<\/option><option value='242' >Ijaw<\/option><option value='243' >Ika<\/option><option value='244' >Ilican<\/option><option value='245' >Ilocano<\/option><option value='088' >Ilongo<\/option><option value='246' >Indonesian<\/option><option value='089' >Ishan<\/option><option value='090' >Italian<\/option><option value='247' >Itsekiri<\/option><option value='248' >Ivbiosakon<\/option><option value='091' >Izi<\/option><option value='092' >Japanese<\/option><option value='249' >Jarai<\/option><option value='093' >Javanese<\/option><option value='094' >Jolay<\/option><option value='012' >Juba Arabic<\/option><option value='095' >Kacchi<\/option><option value='250' >Kakwa<\/option><option value='096' >Kanarese<\/option><option value='097' >Kandahari<\/option><option value='098' >Kankani<\/option><option value='251' >Kannada<\/option><option value='252' >Kapampangan<\/option><option value='099' >Karen<\/option><option value='253' >Kashmiri<\/option><option value='254' >Kazakh<\/option><option value='100' >Khmer<\/option><option value='101' >Kifuliru<\/option><option value='102' >Kihavu<\/option><option value='103' >Kikongo<\/option><option value='255' >Kinyamulenge<\/option><option value='104' >Kinyarwanda<\/option><option value='105' >Kirega<\/option><option value='106' >Kirundi<\/option><option value='107' >Kiswahili<\/option><option value='256' >Kituba<\/option><option value='257' >Konkani<\/option><option value='108' >Korean<\/option><option value='109' >Krio<\/option><option value='110' >Kurdish<\/option><option value='313' >Kurmanji<\/option><option value='258' >Kyrgyz<\/option><option value='259' >La langue des signes qu\u00e9b\u00e9coise (LSQ)<\/option><option value='111' >Laotian<\/option><option value='112' >Latvian<\/option><option value='113' >Lebanese<\/option><option value='260' >Lengie<\/option><option value='114' >Lingala<\/option><option value='115' >Lithuanian<\/option><option value='116' >Lowma<\/option><option value='261' >Luganda<\/option><option value='262' >Lugishu<\/option><option value='263' >Lutoro<\/option><option value='117' >Maban<\/option><option value='118' >Macedonian<\/option><option value='264' >Macena<\/option><option value='119' >Macua<\/option><option value='120' >Mahou<\/option><option value='265' >Makonde<\/option><option value='121' >Malagasy<\/option><option value='122' >Malay<\/option><option value='123' >Malayalam<\/option><option value='124' >Maligo<\/option><option value='125' >Malinke<\/option><option value='126' >Maltese<\/option><option value='127' >Mandarin<\/option><option value='128' >Mandingo<\/option><option value='129' >Marathi<\/option><option value='311' >Masalit<\/option><option value='130' >Mashi<\/option><option value='131' >Mende<\/option><option value='132' >Mina<\/option><option value='266' >Mizo<\/option><option value='267' >Moldovan<\/option><option value='268' >Mongolian<\/option><option value='269' >Moore<\/option><option value='270' >Naandi\/Cemual<\/option><option value='271' >Ndebele<\/option><option value='133' >Nepali<\/option><option value='134' >Norwegian<\/option><option value='272' >Nubian<\/option><option value='135' >Nuer<\/option><option value='136' >Nzima<\/option><option value='273' >Oko<\/option><option value='137' >Okpe<\/option><option value='138' >Oriya<\/option><option value='139' >Oromo<\/option><option value='274' >Osal<\/option><option value='140' >Other African Languages<\/option><option value='141' >Other Chinese Dialects<\/option><option value='142' >Other European Languages<\/option><option value='143' >Other Languages<\/option><option value='144' >Other Middle Eastern Languages<\/option><option value='275' >Other Signed Languages<\/option><option value='145' >Other South Asian Languages<\/option><option value='146' >Other South East Asian Lang.<\/option><option value='276' >Otuho<\/option><option value='277' >Pahari<\/option><option value='278' >Pampango<\/option><option value='279' >Pangasinan<\/option><option value='154' >Pashto<\/option><option value='148' >Peul<\/option><option value='280' >Phuockien<\/option><option value='149' >Pidgin<\/option><option value='281' >Plautdietsch<\/option><option value='150' >Polish<\/option><option value='151' >Portuguese<\/option><option value='152' >Poular<\/option><option value='153' >Punjabi<\/option><option value='282' >Rohingya<\/option><option value='283' >Romani<\/option><option value='155' >Romanian<\/option><option value='284' >Rukiga<\/option><option value='285' >Runyankole<\/option><option value='156' >Russian<\/option><option value='286' >Rutooro<\/option><option value='157' >Samoan<\/option><option value='287' >Sango<\/option><option value='288' >Sanskrit<\/option><option value='289' >Sara<\/option><option value='158' >Scoula<\/option><option value='159' >Sechuan<\/option><option value='290' >Senufo<\/option><option value='160' >Serbian<\/option><option value='161' >Serbo-Croatian<\/option><option value='291' >Sesotho<\/option><option value='162' >Seswi<\/option><option value='163' >Seychelles<\/option><option value='292' >Shan<\/option><option value='164' >Shanghai<\/option><option value='165' >Shansai<\/option><option value='166' >Shilluk<\/option><option value='293' >Shona<\/option><option value='167' >Sign Language<\/option><option value='168' >Sindhi<\/option><option value='170' >Sinhalese<\/option><option value='171' >Slovak<\/option><option value='172' >Slovene<\/option><option value='173' >Somali<\/option><option value='312' >Songhai<\/option><option value='174' >Soninke<\/option><option value='314' >Sorani<\/option><option value='294' >Sotho<\/option><option value='175' >Soussou<\/option><option value='295' >Southern Burun<\/option><option value='176' >Spanish<\/option><option value='177' >Suesue<\/option><option value='296' >Sukuma<\/option><option value='178' >Swahili<\/option><option value='179' >Swazai<\/option><option value='180' >Swedish<\/option><option value='317' >Swiss German<\/option><option value='181' >Tagalog<\/option><option value='297' >Taichew<\/option><option value='315' >Tamasheq<\/option><option value='182' >Tamil<\/option><option value='183' >Tari<\/option><option value='298' >Tatar<\/option><option value='184' >Tatshanese<\/option><option value='185' >Telugu<\/option><option value='299' >Temne<\/option><option value='300' >Teochew<\/option><option value='186' >Thai<\/option><option value='187' >Tibetan<\/option><option value='188' >Tichiew<\/option><option value='301' >Tigre<\/option><option value='189' >Tigrigna<\/option><option value='190' >Timini<\/option><option value='191' >Tiv<\/option><option value='302' >Toishan<\/option><option value='192' >Tshiluba<\/option><option value='193' >Tsibula<\/option><option value='194' >Turkish<\/option><option value='195' >Twi<\/option><option value='318' >Uduk<\/option><option value='200' >Uhrobo<\/option><option value='196' >Uigrigma<\/option><option value='197' >Ukrainian<\/option><option value='303' >Umbundu<\/option><option value='304' >Unama<\/option><option value='198' >Unknown<\/option><option value='199' >Urdu<\/option><option value='319' >Uyghur<\/option><option value='201' >Uzbek<\/option><option value='202' >Vietnamese<\/option><option value='305' >Visayan<\/option><option value='306' >Waray<\/option><option value='203' >Welsh<\/option><option value='204' >Western Hemisphere Indian Lang<\/option><option value='205' >Wolof<\/option><option value='206' >Xhosa<\/option><option value='307' >Yako\/Loko\/Lokaa<\/option><option value='308' >Yekhee\/Afenmai\/Afemai<\/option><option value='207' >Yiboe<\/option><option value='208' >Yiddish<\/option><option value='209' >Yoruba<\/option><option value='210' >Zande<\/option><option value='309' >Zshiluba<\/option><option value='310' >Zuganda<\/option><option value='211' >Zulu<\/option><\/select><\/div><\/div><fieldset id=\"field_317_215\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-third Interpret_Required gf_list_2col 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' >Interpreter Required<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Obligatorio)<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_317_215'>\n\t\t\t<div class='gchoice gchoice_317_215_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_215' type='radio' value='Y'  id='choice_317_215_0' onchange='gformToggleRadioOther( this )'  tabindex='45'  \/>\n\t\t\t\t\t<label for='choice_317_215_0' id='label_317_215_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_317_215_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_215' type='radio' value='N'  id='choice_317_215_1' onchange='gformToggleRadioOther( this )'  tabindex='46'  \/>\n\t\t\t\t\t<label for='choice_317_215_1' id='label_317_215_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_317_214\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-two-thirds CLB_Proficiency gf_list_4col 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' >Client&#039;s Estimated English Level<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Obligatorio)<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_317_214'>\n\t\t\t<div class='gchoice gchoice_317_214_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_214' type='radio' value='0081'  id='choice_317_214_0' onchange='gformToggleRadioOther( this )'  tabindex='47'  \/>\n\t\t\t\t\t<label for='choice_317_214_0' id='label_317_214_0' class='gform-field-label gform-field-label--type-inline'>Minimal\/None<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_317_214_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_214' type='radio' value='0007'  id='choice_317_214_1' onchange='gformToggleRadioOther( this )'  tabindex='48'  \/>\n\t\t\t\t\t<label for='choice_317_214_1' id='label_317_214_1' class='gform-field-label gform-field-label--type-inline'>Basic<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_317_214_2'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_214' type='radio' value='0008'  id='choice_317_214_2' onchange='gformToggleRadioOther( this )'  tabindex='49'  \/>\n\t\t\t\t\t<label for='choice_317_214_2' id='label_317_214_2' class='gform-field-label gform-field-label--type-inline'>Intermediate<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_317_214_3'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_214' type='radio' value='0009'  id='choice_317_214_3' onchange='gformToggleRadioOther( this )'  tabindex='50'  \/>\n\t\t\t\t\t<label for='choice_317_214_3' id='label_317_214_3' class='gform-field-label gform-field-label--type-inline'>Advanced<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_317_256\" class=\"gfield gfield--type-select gfield--input-type-select gfield--width-full GENREMARKS 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_317_256'>Preference for services<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Obligatorio)<\/span><\/span><\/label><div class='ginput_container ginput_container_select'><select name='input_256' id='input_317_256' class='large gfield_select' tabindex='51'   aria-required=\"true\" aria-invalid=\"false\" ><option value='' ><\/option><option value='In Person Services' >In Person Services<\/option><option value='Virtual Services by video chat or phone' >Virtual Services by video chat or phone<\/option><option value='Open to both' >Open to both<\/option><\/select><\/div><\/div><div id=\"field_317_253\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-full GENREMARKS field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_317_253'>Any Preferences \/ Availability for therapy sessions<\/label><div class='ginput_container ginput_container_text'><input name='input_253' id='input_317_253' type='text' value='' class='large'   tabindex='52'   aria-invalid=\"false\"   \/><\/div><\/div><\/div>\n                    <\/div>\n                    <div class='gform-page-footer gform_page_footer top_label'>\n                        <input type='button' id='gform_previous_button_317_211' class='gform_previous_button gform-theme-button gform-theme-button--secondary button' onclick='gform.submission.handleButtonClick(this);' data-submission-type='previous' value='Previous' tabindex='53' \/> <input type='button' id='gform_next_button_317_211' class='gform_next_button gform-theme-button button' onclick='gform.submission.handleButtonClick(this);' data-submission-type='next' value='Next' tabindex='54' \/> \n                    <\/div>\n                <\/div>\n                <div id='gform_page_317_3' class='gform_page' data-js='page-field-id-211' style='display:none;'>\n                    <div class='gform_page_fields'>\n                        <div id='gform_fields_317_3' class='gform_fields top_label form_sublabel_below description_below validation_below'><div id=\"field_317_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\">Service Information<\/h3><\/div><div id=\"field_317_199\" class=\"gfield gfield--type-textarea gfield--input-type-textarea gfield--width-full GENREMARKS gf_hide_charleft show_description gfield_contains_required field_sublabel_below gfield--has-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_317_199'>Brief Description of Need for Service<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Obligatorio)<\/span><\/span><\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_199' id='input_317_199' class='textarea small' tabindex='55' aria-describedby=\"gfield_description_317_199\" maxlength='1000'  aria-required=\"true\" aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><div class='gfield_description' id='gfield_description_317_199'>What are the problems or issues which cause you (or the client you are referring) to seek therapy\/mental health support? <\/div><\/div><div id=\"field_317_200\" class=\"gfield gfield--type-textarea gfield--input-type-textarea gfield--width-full GENREMARKS gf_hide_charleft show_description field_sublabel_below gfield--has-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_317_200'>Any special considerations<\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_200' id='input_317_200' class='textarea small' tabindex='56' aria-describedby=\"gfield_description_317_200\" maxlength='1000'   aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><div class='gfield_description' id='gfield_description_317_200'>Needs for accessibility or other accommodations <\/div><\/div><div id=\"field_317_201\" class=\"gfield gfield--type-textarea gfield--input-type-textarea gfield--width-full GENREMARKS gf_hide_charleft show_description field_sublabel_below gfield--has-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_317_201'>Other services and supports involved with the individual\/family<\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_201' id='input_317_201' class='textarea small' tabindex='57' aria-describedby=\"gfield_description_317_201\" maxlength='1000'   aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><div class='gfield_description' id='gfield_description_317_201'>What other agencies or services are supporting you (or the client you are referring)? Please list names and contact information where possible. <\/div><\/div><div id=\"field_317_259\" class=\"gfield gfield--type-captcha gfield--input-type-captcha 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_317_259'>CAPTCHA<\/label><div id='input_317_259' class='ginput_container ginput_recaptcha' data-sitekey='6LdQ_KQqAAAAAOZ5dT_twxSmxS7Hk-VjwJnkXATw'  data-theme='light' data-tabindex='58'  data-badge=''><\/div><\/div><div id=\"field_317_227\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-quarter REASON exclude field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_hidden\"  ><div class=\"admin-hidden-markup\"><i class=\"gform-icon gform-icon--hidden\" aria-hidden=\"true\" title=\"Este campo est\u00e1 oculto cuando se visualiza el formulario\"><\/i><span>Este campo est\u00e1 oculto cuando se visualiza el formulario<\/span><\/div><label class='gfield_label gform-field-label' for='input_317_227'>Program (Admin Only)<\/label><div class='ginput_container ginput_container_text'><input name='input_227' id='input_317_227' type='text' value='0007' class='large'   tabindex='59'   aria-invalid=\"false\"  autocomplete=\"new-password\" \/><\/div><\/div><div id=\"field_317_45\" class=\"gfield gfield--type-date gfield--input-type-date gfield--input-type-datepicker gfield--datepicker-no-icon gfield--width-quarter DATE_VISITED exclude field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_hidden\"  ><div class=\"admin-hidden-markup\"><i class=\"gform-icon gform-icon--hidden\" aria-hidden=\"true\" title=\"Este campo est\u00e1 oculto cuando se visualiza el formulario\"><\/i><span>Este campo est\u00e1 oculto cuando se visualiza el formulario<\/span><\/div><label class='gfield_label gform-field-label' for='input_317_45'>Date Visited (Admin Only)<\/label><div class='ginput_container ginput_container_date'>\n                            <input name='input_45' id='input_317_45' type='text' value='26\/04\/2026' class='datepicker gform-datepicker dmy datepicker_no_icon gdatepicker-no-icon' tabindex='60'  placeholder='dd\/mm\/aaaa' aria-describedby=\"input_317_45_date_format\" aria-invalid=\"false\" \/>\n                            <span id='input_317_45_date_format' class='screen-reader-text'>DD barra MM barra AAAA<\/span>\n                        <\/div>\n                        <input type='hidden' id='gforms_calendar_icon_input_317_45' class='gform_hidden' value='https:\/\/staging5.nsd.tech\/wp-content\/plugins\/gravityforms\/images\/datepicker\/datepicker.svg'\/><\/div><div id=\"field_317_228\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-quarter CurrentJobStatus exclude field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_hidden\"  ><div class=\"admin-hidden-markup\"><i class=\"gform-icon gform-icon--hidden\" aria-hidden=\"true\" title=\"Este campo est\u00e1 oculto cuando se visualiza el formulario\"><\/i><span>Este campo est\u00e1 oculto cuando se visualiza el formulario<\/span><\/div><label class='gfield_label gform-field-label' for='input_317_228'>Employment Status (Admin Only)<\/label><div class='ginput_container ginput_container_text'><input name='input_228' id='input_317_228' type='text' value='0005' class='large'   tabindex='61'   aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_317_257\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-quarter OF_LANG exclude field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_hidden\"  ><div class=\"admin-hidden-markup\"><i class=\"gform-icon gform-icon--hidden\" aria-hidden=\"true\" title=\"Este campo est\u00e1 oculto cuando se visualiza el formulario\"><\/i><span>Este campo est\u00e1 oculto cuando se visualiza el formulario<\/span><\/div><label class='gfield_label gform-field-label' for='input_317_257'>Official Language (Admin Only)<\/label><div class='ginput_container ginput_container_text'><input name='input_257' id='input_317_257' type='text' value='1' class='large'   tabindex='62'   aria-invalid=\"false\"   \/><\/div><\/div><\/div><\/div>\n        <div class='gform-page-footer gform_page_footer top_label'><input type='submit' id='gform_previous_button_317' class='gform_previous_button gform-theme-button gform-theme-button--secondary button' onclick='gform.submission.handleButtonClick(this);' data-submission-type='previous' value='Previous' tabindex='63' \/> <input type='submit' id='gform_submit_button_317' class='gform_button button' onclick='gform.submission.handleButtonClick(this);' data-submission-type='submit' value='Submit' tabindex='64' \/> <input type='hidden' 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