{"id":22314,"date":"2023-01-26T11:30:18","date_gmt":"2023-01-26T16:30:18","guid":{"rendered":"http:\/\/www.sciontario.org\/services\/reference-dun-nouveau-client\/references-professionnelles\/"},"modified":"2024-08-27T16:59:59","modified_gmt":"2024-08-27T20:59:59","slug":"references-professionnelles","status":"publish","type":"page","link":"https:\/\/www.sciontario.org\/fr\/services\/reference-dun-nouveau-client\/references-professionnelles\/","title":{"rendered":"R\u00e9f\u00e9rences professionnelles"},"content":{"rendered":"\t\t<div data-elementor-type=\"wp-page\" data-elementor-id=\"22314\" class=\"elementor elementor-22314 elementor-17780\" wpc-filter-elementor-widget=\"1\" data-elementor-post-type=\"page\">\n\t\t\t\t<div class=\"elementor-element elementor-element-900796b e-flex e-con-boxed e-con e-parent\" data-id=\"900796b\" data-element_type=\"container\" data-e-type=\"container\" data-settings=\"{&quot;background_background&quot;:&quot;classic&quot;}\">\n\t\t\t\t\t<div class=\"e-con-inner\">\n\t\t<div class=\"elementor-element elementor-element-15dc06a e-con-full e-flex e-con e-child\" data-id=\"15dc06a\" data-element_type=\"container\" data-e-type=\"container\">\n\t\t\t\t<div class=\"elementor-element elementor-element-fcfec8f elementor-widget elementor-widget-heading\" data-id=\"fcfec8f\" data-element_type=\"widget\" data-e-type=\"widget\" data-widget_type=\"heading.default\">\n\t\t\t\t<div class=\"elementor-widget-container\">\n\t\t\t\t\t<h1 class=\"elementor-heading-title elementor-size-default\">R\u00e9f\u00e9rences professionnelles<\/h1>\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t<div class=\"elementor-element elementor-element-95626cd elementor-widget elementor-widget-heading\" data-id=\"95626cd\" data-element_type=\"widget\" data-e-type=\"widget\" data-widget_type=\"heading.default\">\n\t\t\t\t<div class=\"elementor-widget-container\">\n\t\t\t\t\t<h2 class=\"elementor-heading-title elementor-size-default\">Formulaire d'information du client<\/h2>\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t<div class=\"elementor-element elementor-element-13f3052 e-con-full elementor-hidden-mobile e-flex e-con e-child\" data-id=\"13f3052\" data-element_type=\"container\" data-e-type=\"container\">\n\t\t\t\t<\/div>\n\t\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t<div class=\"elementor-element elementor-element-b03df8f e-flex e-con-boxed e-con e-parent\" data-id=\"b03df8f\" data-element_type=\"container\" data-e-type=\"container\" data-settings=\"{&quot;background_background&quot;:&quot;classic&quot;}\">\n\t\t\t\t\t<div class=\"e-con-inner\">\n\t\t<div class=\"elementor-element elementor-element-a38829d e-con-full e-flex e-con e-child\" data-id=\"a38829d\" data-element_type=\"container\" data-e-type=\"container\">\n\t\t\t\t<div class=\"elementor-element elementor-element-34c9b8b elementor-widget elementor-widget-text-editor\" data-id=\"34c9b8b\" data-element_type=\"widget\" data-e-type=\"widget\" data-widget_type=\"text-editor.default\">\n\t\t\t\t<div class=\"elementor-widget-container\">\n\t\t\t\t\t\t\t\t\t<p data-wahfont=\"16\">Si vous \u00eates un professionnel de la sant\u00e9 ou un membre du personnel d&rsquo;un organisme communautaire et que vous souhaitez nous adresser un patient\/client pour qu&rsquo;il ait acc\u00e8s \u00e0 nos services et \u00e0 notre soutien, veuillez remplir le formulaire ci-dessous.<\/p>\n<p data-wahfont=\"16\">Si vous ne parvenez pas \u00e0 envoyer ce formulaire, t\u00e9l\u00e9chargez la version <a role=\"link\" href=\"https:\/\/sciontario.org\/wp-content\/uploads\/Centralized-Referral-Form-Feb.-2024-CS.pdf\" target=\"_blank\" rel=\"noopener noreferrer\" data-wahfont=\"16\">PDF \u00e0 remplir<\/a> et envoyez-la \u00e0 l&rsquo;adresse suivante <a role=\"link\" href=\"mailto:referrals@sciontario.org\" data-wahfont=\"16\"><span class=\"s1\" data-wahfont=\"16\">referrals@sciontario.org<\/span><\/a><span data-wahfont=\"16\">.<\/span><\/p>\n\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t<div class=\"elementor-element elementor-element-852eb9b e-con-full e-flex e-con e-child\" data-id=\"852eb9b\" data-element_type=\"container\" data-e-type=\"container\">\n\t\t<div class=\"elementor-element elementor-element-cd50662 e-con-full e-flex e-con e-child\" data-id=\"cd50662\" data-element_type=\"container\" data-e-type=\"container\" data-settings=\"{&quot;background_background&quot;:&quot;classic&quot;}\">\n\t\t\t\t<div class=\"elementor-element elementor-element-2125f3d elementor-widget elementor-widget-spacer\" data-id=\"2125f3d\" data-element_type=\"widget\" data-e-type=\"widget\" data-widget_type=\"spacer.default\">\n\t\t\t\t<div class=\"elementor-widget-container\">\n\t\t\t\t\t\t\t<div class=\"elementor-spacer\">\n\t\t\t<div class=\"elementor-spacer-inner\"><\/div>\n\t\t<\/div>\n\t\t\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t<div class=\"elementor-element elementor-element-4a8c3b7 e-flex e-con-boxed e-con e-parent\" data-id=\"4a8c3b7\" data-element_type=\"container\" data-e-type=\"container\" data-settings=\"{&quot;background_background&quot;:&quot;classic&quot;}\">\n\t\t\t\t\t<div class=\"e-con-inner\">\n\t\t<div class=\"elementor-element elementor-element-223b09f e-con-full e-flex e-con e-child\" data-id=\"223b09f\" data-element_type=\"container\" data-e-type=\"container\">\n\t\t\t\t<div class=\"elementor-element elementor-element-7b426a4 elementor-widget elementor-widget-shortcode\" data-id=\"7b426a4\" data-element_type=\"widget\" data-e-type=\"widget\" data-widget_type=\"shortcode.default\">\n\t\t\t\t<div class=\"elementor-widget-container\">\n\t\t\t\t\t\t\t<div class=\"elementor-shortcode\"><script>\nvar gform;gform||(document.addEventListener(\"gform_main_scripts_loaded\",function(){gform.scriptsLoaded=!0}),document.addEventListener(\"gform\/theme\/scripts_loaded\",function(){gform.themeScriptsLoaded=!0}),window.addEventListener(\"DOMContentLoaded\",function(){gform.domLoaded=!0}),gform={domLoaded:!1,scriptsLoaded:!1,themeScriptsLoaded:!1,isFormEditor:()=>\"function\"==typeof InitializeEditor,callIfLoaded:function(o){return!(!gform.domLoaded||!gform.scriptsLoaded||!gform.themeScriptsLoaded&&!gform.isFormEditor()||(gform.isFormEditor()&&console.warn(\"The use of gform.initializeOnLoaded() is deprecated in the form editor context and will be removed in Gravity Forms 3.1.\"),o(),0))},initializeOnLoaded:function(o){gform.callIfLoaded(o)||(document.addEventListener(\"gform_main_scripts_loaded\",()=>{gform.scriptsLoaded=!0,gform.callIfLoaded(o)}),document.addEventListener(\"gform\/theme\/scripts_loaded\",()=>{gform.themeScriptsLoaded=!0,gform.callIfLoaded(o)}),window.addEventListener(\"DOMContentLoaded\",()=>{gform.domLoaded=!0,gform.callIfLoaded(o)}))},hooks:{action:{},filter:{}},addAction:function(o,r,e,t){gform.addHook(\"action\",o,r,e,t)},addFilter:function(o,r,e,t){gform.addHook(\"filter\",o,r,e,t)},doAction:function(o){gform.doHook(\"action\",o,arguments)},applyFilters:function(o){return gform.doHook(\"filter\",o,arguments)},removeAction:function(o,r){gform.removeHook(\"action\",o,r)},removeFilter:function(o,r,e){gform.removeHook(\"filter\",o,r,e)},addHook:function(o,r,e,t,n){null==gform.hooks[o][r]&&(gform.hooks[o][r]=[]);var d=gform.hooks[o][r];null==n&&(n=r+\"_\"+d.length),gform.hooks[o][r].push({tag:n,callable:e,priority:t=null==t?10:t})},doHook:function(r,o,e){var t;if(e=Array.prototype.slice.call(e,1),null!=gform.hooks[r][o]&&((o=gform.hooks[r][o]).sort(function(o,r){return o.priority-r.priority}),o.forEach(function(o){\"function\"!=typeof(t=o.callable)&&(t=window[t]),\"action\"==r?t.apply(null,e):e[0]=t.apply(null,e)})),\"filter\"==r)return e[0]},removeHook:function(o,r,t,n){var e;null!=gform.hooks[o][r]&&(e=(e=gform.hooks[o][r]).filter(function(o,r,e){return!!(null!=n&&n!=o.tag||null!=t&&t!=o.priority)}),gform.hooks[o][r]=e)}});\n<\/script>\n\n                <div class='gf_browser_gecko gform_wrapper gravity-theme gform-theme--no-framework' data-form-theme='gravity-theme' data-form-index='0' id='gform_wrapper_1' style='display:none'><div id='gf_1' class='gform_anchor' tabindex='-1'><\/div><form method='post' enctype='multipart\/form-data' target='gform_ajax_frame_1' id='gform_1'  action='\/fr\/wp-json\/wp\/v2\/pages\/22314#gf_1' data-formid='1' novalidate>\n                        <div class='gform-body gform_body'><div id='gform_fields_1' class='gform_fields top_label form_sublabel_below description_below validation_below'><div id=\"field_1_23\" class=\"gfield gfield--type-section gsection field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><h3 class=\"gsection_title\">Informations sur le client<\/h3><\/div><div id=\"field_1_1\" class=\"gfield gfield--type-date gfield--input-type-datepicker gfield--datepicker-no-icon gfield--width-full field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_1_1'>Date de r\u00e9f\u00e9rence (aaaa\/mm\/jj)<\/label><div class='ginput_container ginput_container_date'>\n                            <input name='input_1' id='input_1_1' type='text' value='' class='datepicker gform-datepicker ymd_slash datepicker_no_icon gdatepicker-no-icon'   placeholder='jj\/mm\/aaaa' aria-describedby=\"input_1_1_date_format\" aria-invalid=\"false\" \/>\n                            <span id='input_1_1_date_format' class='screen-reader-text'>AAAA slash MM slash JJ<\/span>\n                        <\/div>\n                        <input type='hidden' id='gforms_calendar_icon_input_1_1' class='gform_hidden' value='https:\/\/www.sciontario.org\/wp-content\/plugins\/gravityforms\/images\/datepicker\/datepicker.svg'\/><\/div><div id=\"field_1_3\" class=\"gfield gfield--type-text gfield--width-half field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_1_3'>Nom du client<\/label><div class='ginput_container ginput_container_text'><input name='input_3' id='input_1_3' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_1_4\" class=\"gfield gfield--type-text gfield--width-half field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_1_4'>Pr\u00e9nom du client<\/label><div class='ginput_container ginput_container_text'><input name='input_4' id='input_1_4' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_1_5\" class=\"gfield gfield--type-text gfield--width-half field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_1_5'>Pronom<\/label><div class='ginput_container ginput_container_text'><input name='input_5' id='input_1_5' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_1_6\" class=\"gfield gfield--type-text gfield--width-half field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_1_6'>Nom pr\u00e9f\u00e9r\u00e9<\/label><div class='ginput_container ginput_container_text'><input name='input_6' id='input_1_6' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/div><fieldset id=\"field_1_8\" class=\"gfield gfield--type-radio gfield--type-choice gfield--width-half field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >Genre<\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_1_8'>\n\t\t\t<div class='gchoice gchoice_1_8_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_8' type='radio' value='Homme'  id='choice_1_8_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_1_8_0' id='label_1_8_0' class='gform-field-label gform-field-label--type-inline'>Homme<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_1_8_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_8' type='radio' value='Femme'  id='choice_1_8_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_1_8_1' id='label_1_8_1' class='gform-field-label gform-field-label--type-inline'>Femme<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_1_9\" class=\"gfield gfield--type-date gfield--input-type-datepicker gfield--datepicker-no-icon gfield--width-half field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_1_9'>Date de naissance (jj\/mm\/aaaa)<\/label><div class='ginput_container ginput_container_date'>\n                            <input name='input_9' id='input_1_9' type='text' value='' class='datepicker gform-datepicker dmy datepicker_no_icon gdatepicker-no-icon'   placeholder='jj\/mm\/aaaa' aria-describedby=\"input_1_9_date_format\" aria-invalid=\"false\" \/>\n                            <span id='input_1_9_date_format' class='screen-reader-text'>JJ slash MM slash AAAA<\/span>\n                        <\/div>\n                        <input type='hidden' id='gforms_calendar_icon_input_1_9' class='gform_hidden' value='https:\/\/www.sciontario.org\/wp-content\/plugins\/gravityforms\/images\/datepicker\/datepicker.svg'\/><\/div><div id=\"field_1_10\" class=\"gfield gfield--type-text gfield--width-half field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_1_10'>Carte de sant\u00e9<\/label><div class='ginput_container ginput_container_text'><input name='input_10' id='input_1_10' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_1_11\" class=\"gfield gfield--type-text gfield--width-half field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_1_11'>Version #<\/label><div class='ginput_container ginput_container_text'><input name='input_11' id='input_1_11' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_1_12\" class=\"gfield gfield--type-email gfield--width-full field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_1_12'>Courriel du client<\/label><div class='ginput_container ginput_container_email'>\n                            <input name='input_12' id='input_1_12' type='email' value='' class='large'     aria-invalid=\"false\"  \/>\n                        <\/div><\/div><fieldset id=\"field_1_13\" class=\"gfield gfield--type-address field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Adresse du domicile<\/legend>    \n                    <div class='ginput_complex ginput_container has_street has_street2 has_city has_state has_zip ginput_container_address gform-grid-row' id='input_1_13' >\n                         <span class='ginput_full address_line_1 ginput_address_line_1 gform-grid-col' id='input_1_13_1_container' >\n                                        <input type='text' name='input_13.1' id='input_1_13_1' value=''    aria-required='false'    \/>\n                                        <label for='input_1_13_1' id='input_1_13_1_label' class='gform-field-label gform-field-label--type-sub '>Adresse postale<\/label>\n                                    <\/span><span class='ginput_full address_line_2 ginput_address_line_2 gform-grid-col' id='input_1_13_2_container' >\n                                        <input type='text' name='input_13.2' id='input_1_13_2' value=''     aria-required='false'   \/>\n                                        <label for='input_1_13_2' id='input_1_13_2_label' class='gform-field-label gform-field-label--type-sub '>Num\u00e9ro de la suite\/unit\u00e9<\/label>\n                                    <\/span><span class='ginput_left address_city ginput_address_city gform-grid-col' id='input_1_13_3_container' >\n                                    <input type='text' name='input_13.3' id='input_1_13_3' value=''    aria-required='false'    \/>\n                                    <label for='input_1_13_3' id='input_1_13_3_label' class='gform-field-label gform-field-label--type-sub '>Ville<\/label>\n                                 <\/span><span class='ginput_right address_state ginput_address_state gform-grid-col' id='input_1_13_4_container' >\n                                        <select name='input_13.4' id='input_1_13_4'     aria-required='false'    ><option value='' selected='selected'><\/option><option value='Alberta' >Alberta<\/option><option value='Colombie-Britannique' >Colombie-Britannique<\/option><option value='Manitoba' >Manitoba<\/option><option value='Nouveau-Brunswick' >Nouveau-Brunswick<\/option><option value='Terre-Neuve-et-Labrador' >Terre-Neuve-et-Labrador<\/option><option value='Territoires du Nord-Ouest' >Territoires du Nord-Ouest<\/option><option value='Nouvelle-\u00c9cosse' >Nouvelle-\u00c9cosse<\/option><option value='Nunavut' >Nunavut<\/option><option value='Ontario' >Ontario<\/option><option value='\u00cele du Prince-\u00c9douard' >\u00cele du Prince-\u00c9douard<\/option><option value='Qu\u00e9bec' >Qu\u00e9bec<\/option><option value='Saskatchewan' >Saskatchewan<\/option><option value='Yukon' >Yukon<\/option><\/select>\n                                        <label for='input_1_13_4' id='input_1_13_4_label' class='gform-field-label gform-field-label--type-sub '>Province<\/label>\n                                      <\/span><span class='ginput_left address_zip ginput_address_zip gform-grid-col' id='input_1_13_5_container' >\n                                    <input type='text' name='input_13.5' id='input_1_13_5' value=''    aria-required='false'    \/>\n                                    <label for='input_1_13_5' id='input_1_13_5_label' class='gform-field-label gform-field-label--type-sub '>Code postal<\/label>\n                                <\/span><input type='hidden' class='gform_hidden' name='input_13.6' id='input_1_13_6' value='Canada' \/>\n                    <div class='gf_clear gf_clear_complex'><\/div>\n                <\/div><\/fieldset><div id=\"field_1_14\" class=\"gfield gfield--type-phone gfield--width-half field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_1_14'>Num\u00e9ro de t\u00e9l\u00e9phone principal<\/label><div class='ginput_container ginput_container_phone'><input name='input_14' id='input_1_14' type='tel' value='' class='large'    aria-invalid=\"false\"   \/><\/div><\/div><fieldset id=\"field_1_82\" class=\"gfield gfield--type-radio gfield--type-choice gfield--width-half field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >T\u00e9l\u00e9phone principal Type<\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_1_82'>\n\t\t\t<div class='gchoice gchoice_1_82_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_82' type='radio' value='Accueil'  id='choice_1_82_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_1_82_0' id='label_1_82_0' class='gform-field-label gform-field-label--type-inline'>Accueil<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_1_82_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_82' type='radio' value='Cellule'  id='choice_1_82_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_1_82_1' id='label_1_82_1' class='gform-field-label gform-field-label--type-inline'>Cellule<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_1_15\" class=\"gfield gfield--type-phone gfield--width-half field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_1_15'>Num\u00e9ro de t\u00e9l\u00e9phone secondaire<\/label><div class='ginput_container ginput_container_phone'><input name='input_15' id='input_1_15' type='tel' value='' class='large'    aria-invalid=\"false\"   \/><\/div><\/div><fieldset id=\"field_1_81\" class=\"gfield gfield--type-radio gfield--type-choice gfield--width-half field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >Type de t\u00e9l\u00e9phone secondaire<\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_1_81'>\n\t\t\t<div class='gchoice gchoice_1_81_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_81' type='radio' value='Accueil'  id='choice_1_81_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_1_81_0' id='label_1_81_0' class='gform-field-label gform-field-label--type-inline'>Accueil<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_1_81_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_81' type='radio' value='Cellule'  id='choice_1_81_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_1_81_1' id='label_1_81_1' class='gform-field-label gform-field-label--type-inline'>Cellule<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_1_16\" class=\"gfield gfield--type-text gfield--width-half field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_1_16'>Langue principale<\/label><div class='ginput_container ginput_container_text'><input name='input_16' id='input_1_16' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_1_18\" class=\"gfield gfield--type-select gfield--width-half field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_1_18'>Traducteur demand\u00e9<\/label><div class='ginput_container ginput_container_select'><select name='input_18' id='input_1_18' class='large gfield_select'     aria-invalid=\"false\" ><option value='' selected='selected' class='gf_placeholder'>Veuillez s\u00e9lectionner<\/option><option value='1' >Oui<\/option><option value='0' >Non<\/option><\/select><\/div><\/div><div id=\"field_1_19\" class=\"gfield gfield--type-text gfield--width-full field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_1_19'>Autre nom de contact<\/label><div class='ginput_container ginput_container_text'><input name='input_19' id='input_1_19' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_1_20\" class=\"gfield gfield--type-text gfield--width-half field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_1_20'>Relation<\/label><div class='ginput_container ginput_container_text'><input name='input_20' id='input_1_20' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_1_22\" class=\"gfield gfield--type-phone gfield--width-half field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_1_22'>Autre num\u00e9ro de t\u00e9l\u00e9phone de la personne \u00e0 contacter<\/label><div class='ginput_container ginput_container_phone'><input name='input_22' id='input_1_22' type='tel' value='' class='large'    aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_1_24\" class=\"gfield gfield--type-section gsection field_sublabel_below gfield--has-description field_description_below field_validation_below gfield_visibility_visible\"  ><h3 class=\"gsection_title\">Informations sur les r\u00e9f\u00e9rences<\/h3><div class='gsection_description' id='gfield_description_1_24'>(Veuillez remplir le plus grand nombre de cases possible)<\/div><\/div><fieldset id=\"field_1_25\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield--width-half field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Type de r\u00e9f\u00e9rence<\/legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox ' id='input_1_25'><div class='gchoice gchoice_1_25_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_25.1' type='checkbox'  value='communaut\u00e9'  id='choice_1_25_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_1_25_1' id='label_1_25_1' class='gform-field-label gform-field-label--type-inline'>R\u00e9f\u00e9rence communautaire<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_1_25_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_25.2' type='checkbox'  value='soins de sant\u00e9'  id='choice_1_25_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_1_25_2' id='label_1_25_2' class='gform-field-label gform-field-label--type-inline'>Orientation vers un \u00e9tablissement de soins de sant\u00e9<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_1_26\" class=\"gfield gfield--type-text gfield--width-half field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_1_26'>\u00c9tablissement\/Agence<\/label><div class='ginput_container ginput_container_text'><input name='input_26' id='input_1_26' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_1_27\" class=\"gfield gfield--type-date gfield--input-type-datepicker gfield--datepicker-no-icon gfield--width-half field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_1_27'>Date d&#039;admission (aaaa\/mm\/jj)<\/label><div class='ginput_container ginput_container_date'>\n                            <input name='input_27' id='input_1_27' type='text' value='' class='datepicker gform-datepicker ymd_slash datepicker_no_icon gdatepicker-no-icon'   placeholder='jj\/mm\/aaaa' aria-describedby=\"input_1_27_date_format\" aria-invalid=\"false\" \/>\n                            <span id='input_1_27_date_format' class='screen-reader-text'>AAAA slash MM slash JJ<\/span>\n                        <\/div>\n                        <input type='hidden' id='gforms_calendar_icon_input_1_27' class='gform_hidden' value='https:\/\/www.sciontario.org\/wp-content\/plugins\/gravityforms\/images\/datepicker\/datepicker.svg'\/><\/div><div id=\"field_1_28\" class=\"gfield gfield--type-date gfield--input-type-datepicker gfield--datepicker-no-icon gfield--width-half field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_1_28'>Date de sortie (aaaa\/mm\/jj)<\/label><div class='ginput_container ginput_container_date'>\n                            <input name='input_28' id='input_1_28' type='text' value='' class='datepicker gform-datepicker ymd_slash datepicker_no_icon gdatepicker-no-icon'   placeholder='jj\/mm\/aaaa' aria-describedby=\"input_1_28_date_format\" aria-invalid=\"false\" \/>\n                            <span id='input_1_28_date_format' class='screen-reader-text'>AAAA slash MM slash JJ<\/span>\n                        <\/div>\n                        <input type='hidden' id='gforms_calendar_icon_input_1_28' class='gform_hidden' value='https:\/\/www.sciontario.org\/wp-content\/plugins\/gravityforms\/images\/datepicker\/datepicker.svg'\/><\/div><div id=\"field_1_61\" class=\"gfield gfield--type-text gfield--width-full field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_1_61'>Num\u00e9ro de l&#039;unit\u00e9\/de la pi\u00e8ce<\/label><div class='ginput_container ginput_container_text'><input name='input_61' id='input_1_61' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_1_30\" class=\"gfield gfield--type-select gfield--width-half field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_1_30'>R\u00e9f\u00e9rence pour les membres de la famille d&#039;une personne atteinte d&#039;une LM<\/label><div class='ginput_container ginput_container_select'><select name='input_30' id='input_1_30' class='large gfield_select'     aria-invalid=\"false\" ><option value='' selected='selected' class='gf_placeholder'>Veuillez s\u00e9lectionner<\/option><option value='1' >Oui<\/option><option value='0' >Non<\/option><\/select><\/div><\/div><div id=\"field_1_31\" class=\"gfield gfield--type-text gfield--width-half field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_1_31'>Renvoy\u00e9 par :<\/label><div class='ginput_container ginput_container_text'><input name='input_31' id='input_1_31' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_1_33\" class=\"gfield gfield--type-email gfield--width-half field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_1_33'>Courriel<\/label><div class='ginput_container ginput_container_email'>\n                            <input name='input_33' id='input_1_33' type='email' value='' class='large'     aria-invalid=\"false\"  \/>\n                        <\/div><\/div><div id=\"field_1_34\" class=\"gfield gfield--type-phone gfield--width-half field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_1_34'>Contact #<\/label><div class='ginput_container ginput_container_phone'><input name='input_34' id='input_1_34' type='tel' value='' class='large'    aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_1_35\" class=\"gfield gfield--type-section gsection field_sublabel_below gfield--has-description field_description_below field_validation_below gfield_visibility_visible\"  ><h3 class=\"gsection_title\">Handicap du client<\/h3><div class='gsection_description' id='gfield_description_1_35'>(Veuillez compl\u00e9ter la section appropri\u00e9e)<\/div><\/div><div id=\"field_1_62\" class=\"gfield gfield--type-section gsection field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><h3 class=\"gsection_title\">Section A : LM<\/h3><\/div><div id=\"field_1_38\" class=\"gfield gfield--type-date gfield--input-type-datepicker gfield--datepicker-no-icon gfield--width-third field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_1_38'>Date d&#039;apparition (aaaa\/mm\/jj)<\/label><div class='ginput_container ginput_container_date'>\n                            <input name='input_38' id='input_1_38' type='text' value='' class='datepicker gform-datepicker ymd_slash datepicker_no_icon gdatepicker-no-icon'   placeholder='jj\/mm\/aaaa' aria-describedby=\"input_1_38_date_format\" aria-invalid=\"false\" \/>\n                            <span id='input_1_38_date_format' class='screen-reader-text'>AAAA slash MM slash JJ<\/span>\n                        <\/div>\n                        <input type='hidden' id='gforms_calendar_icon_input_1_38' class='gform_hidden' value='https:\/\/www.sciontario.org\/wp-content\/plugins\/gravityforms\/images\/datepicker\/datepicker.svg'\/><\/div><div id=\"field_1_69\" class=\"gfield gfield--type-select gfield--width-third field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_1_69'>Diagnostic de l\u00e9sion m\u00e9dullaire<\/label><div class='ginput_container ginput_container_select'><select name='input_69' id='input_1_69' class='large gfield_select'     aria-invalid=\"false\" ><option value='' selected='selected' class='gf_placeholder'>Veuillez s\u00e9lectionner<\/option><option value='Parapl\u00e9gie' >Parapl\u00e9gie<\/option><option value='Quadripl\u00e9gie' >Quadripl\u00e9gie<\/option><\/select><\/div><\/div><div id=\"field_1_77\" class=\"gfield gfield--type-select gfield--width-third field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_1_77'>Compl\u00e9ter<\/label><div class='ginput_container ginput_container_select'><select name='input_77' id='input_1_77' class='large gfield_select'     aria-invalid=\"false\" ><option value='' selected='selected' class='gf_placeholder'>Veuillez s\u00e9lectionner<\/option><option value='Compl\u00e9ter' >Compl\u00e9ter<\/option><option value='Incomplet' >Incomplet<\/option><\/select><\/div><\/div><div id=\"field_1_65\" class=\"gfield gfield--type-text gfield--width-third field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_1_65'>Niveau de blessure<\/label><div class='ginput_container ginput_container_text'><input name='input_65' id='input_1_65' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_1_76\" class=\"gfield gfield--type-select gfield--width-third field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_1_76'>Ventilateur utilis\u00e9<\/label><div class='ginput_container ginput_container_select'><select name='input_76' id='input_1_76' class='large gfield_select'     aria-invalid=\"false\" ><option value='' selected='selected' class='gf_placeholder'>Veuillez s\u00e9lectionner<\/option><option value='Oui' >Oui<\/option><option value='Non' >Non<\/option><\/select><\/div><\/div><div id=\"field_1_78\" class=\"gfield gfield--type-select gfield--width-third field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_1_78'>Questions relatives \u00e0 la douleur<\/label><div class='ginput_container ginput_container_select'><select name='input_78' id='input_1_78' class='large gfield_select'     aria-invalid=\"false\" ><option value='' selected='selected' class='gf_placeholder'>Veuillez s\u00e9lectionner<\/option><option value='Oui' >Oui<\/option><option value='Non' >Non<\/option><\/select><\/div><\/div><div id=\"field_1_66\" class=\"gfield gfield--type-select gfield--width-third field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_1_66'>Type de blessure<\/label><div class='ginput_container ginput_container_select'><select name='input_66' id='input_1_66' class='large gfield_select'     aria-invalid=\"false\" ><option value='' selected='selected' class='gf_placeholder'>Veuillez s\u00e9lectionner<\/option><option value='Traumatique' >Traumatique<\/option><option value='Non traumatique' >Non traumatique<\/option><\/select><\/div><\/div><div id=\"field_1_67\" class=\"gfield gfield--type-select gfield--width-third field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_1_67'>Blessures<\/label><div class='ginput_container ginput_container_select'><select name='input_67' id='input_1_67' class='large gfield_select'     aria-invalid=\"false\" ><option value='' selected='selected' class='gf_placeholder'>Veuillez s\u00e9lectionner<\/option><option value='L&#039;automne' >L&#039;automne<\/option><option value='Accident de v\u00e9hicule motoris\u00e9' >Accident de v\u00e9hicule motoris\u00e9<\/option><option value='Agression' >Agression<\/option><option value='Sports et loisirs' >Sports et loisirs<\/option><option value='Autres traumatismes' >Autres traumatismes<\/option><\/select><\/div><\/div><div id=\"field_1_68\" class=\"gfield gfield--type-select gfield--width-third field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_1_68'>Blessures<\/label><div class='ginput_container ginput_container_select'><select name='input_68' id='input_1_68' class='large gfield_select'     aria-invalid=\"false\" ><option value='' selected='selected' class='gf_placeholder'>Veuillez s\u00e9lectionner<\/option><option value='Infection' >Infection<\/option><option value='Inflammation\/d\u00e9g\u00e9n\u00e9rescence' >Inflammation\/d\u00e9g\u00e9n\u00e9rescence<\/option><option value='Le cancer' >Le cancer<\/option><option value='H\u00e9matologique ou vasculaire' >H\u00e9matologique ou vasculaire<\/option><option value='Cong\u00e9nitale' >Cong\u00e9nitale<\/option><option value='Structurel' >Structurel<\/option><option value='Neurologique' >Neurologique<\/option><option value='Complications de la chirurgie' >Complications de la chirurgie<\/option><option value='Autre' >Autre<\/option><\/select><\/div><\/div><div id=\"field_1_73\" class=\"gfield gfield--type-text gfield--width-full field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_1_73'>Autre<\/label><div class='ginput_container ginput_container_text'><input name='input_73' id='input_1_73' type='text' value='' class='large'    placeholder='Veuillez pr\u00e9ciser'  aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_1_79\" class=\"gfield gfield--type-textarea gfield--width-full textarea-half field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_1_79'>Commentaires<\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_79' id='input_1_79' class='textarea large'      aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/div><div id=\"field_1_70\" class=\"gfield gfield--type-section gsection field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><h3 class=\"gsection_title\">Section B : Non-LM<\/h3><\/div><div id=\"field_1_71\" class=\"gfield gfield--type-select gfield--width-half field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_1_71'>Diagnostic non-LM<\/label><div class='ginput_container ginput_container_select'><select name='input_71' id='input_1_71' class='large gfield_select'     aria-invalid=\"false\" ><option value='' selected='selected' class='gf_placeholder'>Veuillez s\u00e9lectionner<\/option><option value='SLA' >SLA<\/option><option value='Arthrite' >Arthrite<\/option><option value='Amputation' >Amputation<\/option><option value='Infirmit\u00e9 motrice c\u00e9r\u00e9brale' >Infirmit\u00e9 motrice c\u00e9r\u00e9brale<\/option><option value='Maladie de Charcot Marie-Tooth' >Maladie de Charcot Marie-Tooth<\/option><option value='Polyneuropathie inflammatoire d\u00e9my\u00e9linisante chronique (PIDC)' >Polyneuropathie inflammatoire d\u00e9my\u00e9linisante chronique (PIDC)<\/option><option value='Maladie d\u00e9g\u00e9n\u00e9rative des disques' >Maladie d\u00e9g\u00e9n\u00e9rative des disques<\/option><option value='Discitis' >Discitis<\/option><option value='Syndrome de Guillain Barre (SGB)' >Syndrome de Guillain Barre (SGB)<\/option><option value='H\u00e9mipl\u00e9gie' >H\u00e9mipl\u00e9gie<\/option><option value='M\u00e9ningite' >M\u00e9ningite<\/option><option value='Scl\u00e9rose en plaques' >Scl\u00e9rose en plaques<\/option><option value='Dystrophie musculaire' >Dystrophie musculaire<\/option><option value='Ost\u00e9oporose' >Ost\u00e9oporose<\/option><option value='Polio ou syndrome post-polio' >Polio ou syndrome post-polio<\/option><option value='Polyneuropathie' >Polyneuropathie<\/option><option value='Amyotrophie spinale' >Amyotrophie spinale<\/option><option value='Autre' >Autre<\/option><\/select><\/div><\/div><div id=\"field_1_83\" class=\"gfield gfield--type-text gfield--width-half field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_1_83'>Autre<\/label><div class='ginput_container ginput_container_text'><input name='input_83' id='input_1_83' type='text' value='' class='large'    placeholder='Veuillez pr\u00e9ciser'  aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_1_84\" class=\"gfield gfield--type-textarea gfield--width-full textarea-half field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_1_84'>Commentaires<\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_84' id='input_1_84' class='textarea large'      aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/div><div id=\"field_1_72\" class=\"gfield gfield--type-section gsection field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><h3 class=\"gsection_title\"><\/h3><\/div><div id=\"field_1_41\" class=\"gfield gfield--type-textarea gfield--width-full textarea-half field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_1_41'>Existe-t-il d&#039;autres probl\u00e8mes de sant\u00e9 ?<\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_41' id='input_1_41' class='textarea large'      aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/div><div id=\"field_1_43\" class=\"gfield gfield--type-section gsection field_sublabel_below gfield--has-description field_description_below field_validation_below gfield_visibility_visible\"  ><h3 class=\"gsection_title\">\u00c9valuation de l&#039;orientation<\/h3><div class='gsection_description' id='gfield_description_1_43'>(Veuillez remplir le plus grand nombre de cases possible)<\/div><\/div><fieldset id=\"field_1_44\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield--width-third field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' >L&#039;assurance ou la CSPAAT est-elle impliqu\u00e9e ?<\/legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox ' id='input_1_44'><div class='gchoice gchoice_1_44_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_44.1' type='checkbox'  value='Assurance'  id='choice_1_44_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_1_44_1' id='label_1_44_1' class='gform-field-label gform-field-label--type-inline'>Assurance<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_1_44_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_44.2' type='checkbox'  value='CSPAAT'  id='choice_1_44_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_1_44_2' id='label_1_44_2' class='gform-field-label gform-field-label--type-inline'>CSPAAT<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_1_44_3'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_44.3' type='checkbox'  value='Aucun'  id='choice_1_44_3'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_1_44_3' id='label_1_44_3' class='gform-field-label gform-field-label--type-inline'>Aucun<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_1_44_4'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_44.4' type='checkbox'  value='Incertain'  id='choice_1_44_4'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_1_44_4' id='label_1_44_4' class='gform-field-label gform-field-label--type-inline'>Incertain<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_1_46\" class=\"gfield gfield--type-select gfield--width-third field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_1_46'>Y a-t-il un logement o\u00f9 retourner ?<\/label><div class='ginput_container ginput_container_select'><select name='input_46' id='input_1_46' class='large gfield_select'     aria-invalid=\"false\" ><option value='' selected='selected' class='gf_placeholder'>Veuillez s\u00e9lectionner<\/option><option value='Oui' >Oui<\/option><option value='Non' >Non<\/option><\/select><\/div><\/div><div id=\"field_1_47\" class=\"gfield gfield--type-select gfield--width-third field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_1_47'>Le domicile\/logement est-il accessible ?<\/label><div class='ginput_container ginput_container_select'><select name='input_47' id='input_1_47' class='large gfield_select'     aria-invalid=\"false\" ><option value='' selected='selected' class='gf_placeholder'>Veuillez s\u00e9lectionner<\/option><option value='Oui' >Oui<\/option><option value='Non' >Non<\/option><option value='Incertain' >Incertain<\/option><\/select><\/div><\/div><div id=\"field_1_48\" class=\"gfield gfield--type-select gfield--width-half field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_1_48'>Des services de soutien seront-ils n\u00e9cessaires ?<\/label><div class='ginput_container ginput_container_select'><select name='input_48' id='input_1_48' class='large gfield_select'     aria-invalid=\"false\" ><option value='' selected='selected' class='gf_placeholder'>Veuillez s\u00e9lectionner<\/option><option value='Oui' >Oui<\/option><option value='Non' >Non<\/option><\/select><\/div><\/div><div id=\"field_1_52\" class=\"gfield gfield--type-select gfield--width-half field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_1_52'>Travaillez-vous avec des organismes communautaires ?<\/label><div class='ginput_container ginput_container_select'><select name='input_52' id='input_1_52' class='large gfield_select'     aria-invalid=\"false\" ><option value='' selected='selected' class='gf_placeholder'>Veuillez s\u00e9lectionner<\/option><option value='Oui' >Oui<\/option><option value='Non' >Non<\/option><option value='Incertain' >Incertain<\/option><\/select><\/div><\/div><div id=\"field_1_51\" class=\"gfield gfield--type-text gfield--width-half field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_1_51'>Source de revenus<\/label><div class='ginput_container ginput_container_text'><input name='input_51' id='input_1_51' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_1_50\" class=\"gfield gfield--type-select gfield--width-half field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_1_50'>Le client est-il actuellement employ\u00e9 ?<\/label><div class='ginput_container ginput_container_select'><select name='input_50' id='input_1_50' class='large gfield_select'     aria-invalid=\"false\" ><option value='' selected='selected' class='gf_placeholder'>Veuillez s\u00e9lectionner<\/option><option value='Oui' >Oui<\/option><option value='Non' >Non<\/option><\/select><\/div><\/div><fieldset id=\"field_1_53\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield--width-full field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Appareils de mobilit\u00e9\/technologie de l&#039;information :<\/legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox ' id='input_1_53'><div class='gchoice gchoice_1_53_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_53.1' type='checkbox'  value='Aucun'  id='choice_1_53_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_1_53_1' id='label_1_53_1' class='gform-field-label gform-field-label--type-inline'>Aucun<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_1_53_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_53.2' type='checkbox'  value='Canne'  id='choice_1_53_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_1_53_2' id='label_1_53_2' class='gform-field-label gform-field-label--type-inline'>Canne<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_1_53_3'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_53.3' type='checkbox'  value='Marcheur'  id='choice_1_53_3'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_1_53_3' id='label_1_53_3' class='gform-field-label gform-field-label--type-inline'>Marcheur<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_1_53_4'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_53.4' type='checkbox'  value='Chaise manuelle'  id='choice_1_53_4'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_1_53_4' id='label_1_53_4' class='gform-field-label gform-field-label--type-inline'>Chaise manuelle<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_1_53_5'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_53.5' type='checkbox'  value='Ordinateur portable\/tablette'  id='choice_1_53_5'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_1_53_5' id='label_1_53_5' class='gform-field-label gform-field-label--type-inline'>Ordinateur portable\/tablette<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_1_53_6'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_53.6' type='checkbox'  value='Fauteuil \u00e9lectrique'  id='choice_1_53_6'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_1_53_6' id='label_1_53_6' class='gform-field-label gform-field-label--type-inline'>Fauteuil \u00e9lectrique<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_1_53_7'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_53.7' type='checkbox'  value='De la parole au texte'  id='choice_1_53_7'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_1_53_7' id='label_1_53_7' class='gform-field-label gform-field-label--type-inline'>De la parole au texte<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_1_53_8'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_53.8' type='checkbox'  value='Scooter'  id='choice_1_53_8'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_1_53_8' id='label_1_53_8' class='gform-field-label gform-field-label--type-inline'>Scooter<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_1_53_9'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_53.9' type='checkbox'  value='T\u00e9l\u00e9phone intelligent'  id='choice_1_53_9'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_1_53_9' id='label_1_53_9' class='gform-field-label gform-field-label--type-inline'>T\u00e9l\u00e9phone intelligent<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_1_53_11'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_53.11' type='checkbox'  value='Inconnu'  id='choice_1_53_11'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_1_53_11' id='label_1_53_11' class='gform-field-label gform-field-label--type-inline'>Inconnu<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_1_53_12'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_53.12' type='checkbox'  value='Autre'  id='choice_1_53_12'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_1_53_12' id='label_1_53_12' class='gform-field-label gform-field-label--type-inline'>Autre<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_1_54\" class=\"gfield gfield--type-text gfield--width-full field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_1_54'>Autre<\/label><div class='ginput_container ginput_container_text'><input name='input_54' id='input_1_54' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_1_57\" class=\"gfield gfield--type-textarea textarea-half field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_1_57'>Quelle(s) raison(s) justifie(nt) votre renvoi \u00e0 L\u00e9sions M\u00e9dullaires Ontario ?<\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_57' id='input_1_57' class='textarea large'      aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/div><fieldset id=\"field_1_58\" class=\"gfield gfield--type-consent gfield--type-choice field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Consentement<\/legend><div class='ginput_container ginput_container_consent'><input name='input_58.1' id='input_1_58_1' type='checkbox' value='1'    aria-invalid=\"false\"   \/> <label class=\"gform-field-label gform-field-label--type-inline gfield_consent_label\" for='input_1_58_1' >Je consens ou le client consent \u00e0 ce que la pr\u00e9sente demande soit adress\u00e9e aux programmes et services de L\u00e9sions M\u00e9dullaires Ontario.<\/label><input type='hidden' name='input_58.2' value='Je consens ou le client consent \u00e0 ce que la pr\u00e9sente demande soit adress\u00e9e aux programmes et services de L\u00e9sions M\u00e9dullaires Ontario.' class='gform_hidden' \/><input type='hidden' name='input_58.3' value='1' class='gform_hidden' \/><\/div><\/fieldset><div id=\"field_1_59\" class=\"gfield gfield--type-html gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><i>Veuillez noter qu'un appel de suivi apr\u00e8s la sortie de l'h\u00f4pital peut \u00eatre effectu\u00e9 par L\u00e9sions M\u00e9dullaires Ontario. <br> L\u00e9sions M\u00e9dullairesL\u00e9sions M\u00e9dullaires Ontario respecte la vie priv\u00e9e de ses clients. Nous prot\u00e9geons les renseignements personnels et nous nous conformons \u00e0 toutes les exigences l\u00e9gislatives en mati\u00e8re de protection de la vie priv\u00e9e. Nous ne louons pas, ne vendons pas et n'\u00e9changeons pas de renseignements. Les renseignements qui nous sont fournis serviront \u00e0 assurer la prestation des services et \u00e0 tenir les clients au courant des activit\u00e9s de Spinal Cord Injury Ontario. Les renseignements que nous recueillons sont prot\u00e9g\u00e9s en vertu de la Loi sur la protection des renseignements personnels et les documents \u00e9lectroniques (LPRPDE) et de la Loi sur la protection des renseignements personnels sur la sant\u00e9 (LPRPS).    <\/i><\/div><\/div><\/div>\n        <div class='gform-footer gform_footer top_label'> <input type='submit' id='gform_submit_button_1' class='gform_button button' onclick='gform.submission.handleButtonClick(this);' data-submission-type='submit' value='Soumettre'  \/> <input type='hidden' name='gform_ajax' value='form_id=1&amp;title=&amp;description=&amp;tabindex=0&amp;theme=gravity-theme&amp;styles=[]&amp;hash=beb3261439e1007c43af36db4e3f12d7' \/>\n            <input type='hidden' class='gform_hidden' name='gform_submission_method' data-js='gform_submission_method_1' value='iframe' \/>\n            <input type='hidden' class='gform_hidden' name='gform_theme' data-js='gform_theme_1' id='gform_theme_1' value='gravity-theme' \/>\n            <input type='hidden' class='gform_hidden' name='gform_style_settings' data-js='gform_style_settings_1' id='gform_style_settings_1' value='[]' \/>\n            <input type='hidden' class='gform_hidden' name='is_submit_1' value='1' \/>\n            <input type='hidden' class='gform_hidden' name='gform_submit' value='1' \/>\n            \n            <input type='hidden' class='gform_hidden' name='gform_currency' data-currency='CAD' value='xB1gKxUGqBWsq2c4DGJe8CxFaeoBteFxz3fFMJpBayg1X9qpNlVxfrHZzqq3FXgqV4ykrqgiRhD\/7RXOXdeU7cgcDCBF7uyVHPZskNbXdRmRRJY=' \/>\n            <input type='hidden' class='gform_hidden' name='gform_unique_id' value='' \/>\n            <input type='hidden' class='gform_hidden' name='state_1' value='WyJ7XCI4XCI6W1wiNDRmM2E2MzA1NDU4YzBkZmMxNTdlYWZlMzA5OGFhNmZcIixcImExNjRjMGNiZGE4NjJkMGIwMDk4ZmQyZjRlZGMxYzQxXCJdLFwiODJcIjpbXCJlZTZlNzE0ZTYyN2NjYjZiMTU0ZGQ5NjAyOGY2OWI1NFwiLFwiMTExZmE3ZGQ5MmJhZTdiNmI1NjcwNjUzZTRiOTY4YTNcIl0sXCI4MVwiOltcImVlNmU3MTRlNjI3Y2NiNmIxNTRkZDk2MDI4ZjY5YjU0XCIsXCIxMTFmYTdkZDkyYmFlN2I2YjU2NzA2NTNlNGI5NjhhM1wiXSxcIjU4LjFcIjpcIjUxMzA2MWQwNzYxZjI5YThlZTZmNGQ5Nzg1MjU3ZDMwXCIsXCI1OC4yXCI6XCJmY2NmNjJhZTg4NWJmMGI4MzNhODVhNjNhYjA3YjIxZVwiLFwiNTguM1wiOlwiNTEzMDYxZDA3NjFmMjlhOGVlNmY0ZDk3ODUyNTdkMzBcIn0iLCI4YWVjZTNlM2JhNDZkMjIzYzdjZGQ5NTI3ZDI3NjMxYyJd' \/>\n            <input type='hidden' autocomplete='off' class='gform_hidden' name='gform_target_page_number_1' id='gform_target_page_number_1' value='0' \/>\n            <input type='hidden' autocomplete='off' class='gform_hidden' name='gform_source_page_number_1' id='gform_source_page_number_1' value='1' \/>\n            <input type='hidden' name='gform_field_values' value='' \/>\n            \n        <\/div>\n                        <\/form>\n                        <\/div>\n\t\t                <iframe style='display:none;width:0px;height:0px;' src='about:blank' name='gform_ajax_frame_1' id='gform_ajax_frame_1' title='Cette iframe contient la logique n\u00e9cessaire pour manipuler Gravity Forms avec Ajax.'><\/iframe>\n\t\t                <script>\ngform.initializeOnLoaded( function() {gformInitSpinner( 1, 'https:\/\/www.sciontario.org\/wp-content\/plugins\/gravityforms\/images\/spinner.svg', true );jQuery('#gform_ajax_frame_1').on('load',function(){var contents = jQuery(this).contents().find('*').html();var is_postback = contents.indexOf('GF_AJAX_POSTBACK') >= 0;if(!is_postback){return;}var form_content = jQuery(this).contents().find('#gform_wrapper_1');var is_confirmation = jQuery(this).contents().find('#gform_confirmation_wrapper_1').length > 0;var is_redirect = contents.indexOf('gformRedirect(){') >= 0;var is_form = form_content.length > 0 && ! is_redirect && ! is_confirmation;var mt = parseInt(jQuery('html').css('margin-top'), 10) + parseInt(jQuery('body').css('margin-top'), 10) + 100;if(is_form){form_content.find('form').css('opacity', 0);jQuery('#gform_wrapper_1').html(form_content.html());if(form_content.hasClass('gform_validation_error')){jQuery('#gform_wrapper_1').addClass('gform_validation_error');} else {jQuery('#gform_wrapper_1').removeClass('gform_validation_error');}setTimeout( function() { \/* delay the scroll by 50 milliseconds to fix a bug in chrome *\/ jQuery(document).scrollTop(jQuery('#gform_wrapper_1').offset().top - mt); 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