{"id":220,"date":"2025-01-29T19:05:10","date_gmt":"2025-01-30T01:05:10","guid":{"rendered":"https:\/\/choicebodytalk.ca\/wellness\/?page_id=220"},"modified":"2025-01-29T19:56:06","modified_gmt":"2025-01-30T01:56:06","slug":"forms","status":"publish","type":"page","link":"https:\/\/choicebodytalk.ca\/wellness\/forms\/","title":{"rendered":"Form"},"content":{"rendered":"<p>[et_pb_section fb_built=&#8221;1&#8243; fullwidth=&#8221;on&#8221; next_background_color=&#8221;#899862&#8243; _builder_version=&#8221;4.16&#8243; bottom_divider_style=&#8221;slant&#8221; bottom_divider_flip=&#8221;horizontal&#8221; global_colors_info=&#8221;{}&#8221;][et_pb_fullwidth_header title=&#8221;Suzi Cook&#8221; subhead=&#8221;Certified BodyTalk Practitioner&#8221; text_orientation=&#8221;center&#8221; background_overlay_color=&#8221;rgba(52,81,104,0.8)&#8221; _builder_version=&#8221;4.27.4&#8243; title_font=&#8221;Lato|700|||||||&#8221; title_font_size=&#8221;46px&#8221; title_line_height=&#8221;1.5em&#8221; content_font=&#8221;Lato||||||||&#8221; content_font_size=&#8221;20px&#8221; content_line_height=&#8221;1.8em&#8221; subhead_font=&#8221;Lato|700|||||||&#8221; subhead_font_size=&#8221;25px&#8221; subhead_line_height=&#8221;1.5em&#8221; background_color=&#8221;#345168&#8243; use_background_color_gradient=&#8221;on&#8221; background_color_gradient_stops=&#8221;#345168 5%|rgba(255,255,255,0) 100%&#8221; background_image=&#8221;https:\/\/choicebodytalk.ca\/wellness\/wp-content\/uploads\/waves.jpg&#8221; custom_margin=&#8221;|||&#8221; custom_padding=&#8221;5vw||150px||false&#8221; animation_style=&#8221;slide&#8221; animation_direction=&#8221;top&#8221; animation_intensity_slide=&#8221;2%&#8221; title_font_size_tablet=&#8221;36px&#8221; title_font_size_phone=&#8221;&#8221; title_font_size_last_edited=&#8221;on|phone&#8221; global_colors_info=&#8221;{}&#8221; button_one_text_size__hover_enabled=&#8221;off&#8221; button_two_text_size__hover_enabled=&#8221;off&#8221; button_one_text_color__hover_enabled=&#8221;off&#8221; button_two_text_color__hover_enabled=&#8221;off&#8221; button_one_border_width__hover_enabled=&#8221;off&#8221; button_two_border_width__hover_enabled=&#8221;off&#8221; button_one_border_color__hover_enabled=&#8221;off&#8221; button_two_border_color__hover_enabled=&#8221;off&#8221; button_one_border_radius__hover_enabled=&#8221;off&#8221; button_two_border_radius__hover_enabled=&#8221;off&#8221; button_one_letter_spacing__hover_enabled=&#8221;off&#8221; button_two_letter_spacing__hover_enabled=&#8221;off&#8221; button_one_bg_color__hover_enabled=&#8221;off&#8221; button_two_bg_color__hover_enabled=&#8221;off&#8221;]<\/p>\n<p>Helping you heal<\/p>\n<p>[\/et_pb_fullwidth_header][\/et_pb_section][et_pb_section fb_built=&#8221;1&#8243; next_background_color=&#8221;#345168&#8243; admin_label=&#8221;Quote&#8221; _builder_version=&#8221;4.27.4&#8243; background_color=&#8221;#899862&#8243; custom_padding=&#8221;||150px||false&#8221; bottom_divider_style=&#8221;slant&#8221; bottom_divider_flip=&#8221;horizontal&#8221; global_colors_info=&#8221;{}&#8221;][et_pb_row _builder_version=&#8221;4.16&#8243; global_colors_info=&#8221;{}&#8221;][et_pb_column type=&#8221;4_4&#8243; _builder_version=&#8221;4.16&#8243; custom_padding=&#8221;|||&#8221; global_colors_info=&#8221;{}&#8221; custom_padding__hover=&#8221;|||&#8221;][et_pb_text _builder_version=&#8221;4.27.4&#8243; text_font=&#8221;Caveat|700|||||||&#8221; text_text_color=&#8221;#ffffff&#8221; text_font_size=&#8221;47px&#8221; text_line_height=&#8221;1.5em&#8221; header_font=&#8221;||||||||&#8221; text_orientation=&#8221;center&#8221; max_width=&#8221;800px&#8221; module_alignment=&#8221;center&#8221; text_font_size_tablet=&#8221;36px&#8221; text_font_size_phone=&#8221;26px&#8221; text_font_size_last_edited=&#8221;on|phone&#8221; global_colors_info=&#8221;{}&#8221;]<\/p>\n<p>Hi, I&#8217;m Suzi. I&#8217;m excited that we get to work together to create the next step in your journey to living the life you want to be living.<\/p>\n<p>[\/et_pb_text][\/et_pb_column][\/et_pb_row][et_pb_row _builder_version=&#8221;4.16&#8243; global_colors_info=&#8221;{}&#8221;][et_pb_column type=&#8221;4_4&#8243; _builder_version=&#8221;4.16&#8243; custom_padding=&#8221;|||&#8221; global_colors_info=&#8221;{}&#8221; custom_padding__hover=&#8221;|||&#8221;][et_pb_text _builder_version=&#8221;4.27.4&#8243; text_font=&#8221;Lato||||||||&#8221; text_font_size=&#8221;18px&#8221; text_line_height=&#8221;1.8em&#8221; link_font=&#8221;||||||||&#8221; ul_font=&#8221;||||||||&#8221; ol_font=&#8221;||||||||&#8221; quote_font=&#8221;||||||||&#8221; header_font=&#8221;||||||||&#8221; header_2_font=&#8221;Lato|700|||||||&#8221; header_2_font_size=&#8221;30px&#8221; header_2_letter_spacing=&#8221;1px&#8221; header_2_line_height=&#8221;1.5em&#8221; animation_style=&#8221;slide&#8221; animation_direction=&#8221;bottom&#8221; animation_intensity_slide=&#8221;5%&#8221; hover_enabled=&#8221;0&#8243; header_2_font_size_tablet=&#8221;&#8221; header_2_font_size_phone=&#8221;22px&#8221; header_2_font_size_last_edited=&#8221;on|phone&#8221; global_colors_info=&#8221;{}&#8221; text_text_color=&#8221;#000000&#8243; sticky_enabled=&#8221;0&#8243;]<\/p>\n<h2>Information and Consent Form<\/h2>\n<div class=\"forminator-ui forminator-custom-form forminator-custom-form-219 forminator-design--flat  forminator_ajax\" data-forminator-render=\"0\" data-form=\"forminator-module-219\" data-uid=\"69e2eb061f06c\"><br\/><\/div><form\n\t\t\t\tid=\"forminator-module-219\"\n\t\t\t\tclass=\"forminator-ui forminator-custom-form forminator-custom-form-219 forminator-design--flat  forminator_ajax\"\n\t\t\t\tmethod=\"post\"\n\t\t\t\tdata-forminator-render=\"0\"\n\t\t\t\tdata-form-id=\"219\"\n\t\t\t\t\n\t\t\t\tdata-design=\"flat\"\n\t\t\t\t\n\t\t\t\t\n\t\t\t\t\n\t\t\t\tdata-grid=\"open\"\n\t\t\t\t\n\t\t\t\t\n\t\t\t\tstyle=\"display: none;\"\n\t\t\t\t\n\t\t\t\tdata-uid=\"69e2eb061f06c\"\n\t\t\t><div role=\"alert\" aria-live=\"polite\" class=\"forminator-response-message forminator-error\" aria-hidden=\"true\"><\/div><div class=\"forminator-row\"><div id=\"name-1\" class=\"forminator-field-name forminator-col forminator-col-12 \"><div class=\"forminator-row forminator-no-margin\" data-multiple=\"true\"><div class=\"forminator-col forminator-col-md-6\"><div class=\"forminator-field\"><label for=\"forminator-field-first-name-1_69e2eb061f06c\" id=\"forminator-field-first-name-1_69e2eb061f06c-label\" class=\"forminator-label\">First Name <span class=\"forminator-required\">*<\/span><\/label><input type=\"text\" name=\"name-1-first-name\" placeholder=\"E.g. Pat\" id=\"forminator-field-first-name-1_69e2eb061f06c\" class=\"forminator-input\" aria-required=\"true\" data-multi=\"1\" value=\"\" \/><\/div><\/div><div class=\"forminator-col forminator-col-md-6\"><div class=\"forminator-field\"><label for=\"forminator-field-last-name-1_69e2eb061f06c\" id=\"forminator-field-last-name-1_69e2eb061f06c-label\" class=\"forminator-label\">Last Name <span class=\"forminator-required\">*<\/span><\/label><input type=\"text\" name=\"name-1-last-name\" placeholder=\"E.g. Doe\" id=\"forminator-field-last-name-1_69e2eb061f06c\" class=\"forminator-input\" aria-required=\"true\" data-multi=\"1\" value=\"\" \/><\/div><\/div><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"phone-1\" class=\"forminator-field-phone forminator-col forminator-col-6 \"><div class=\"forminator-field\"><label for=\"forminator-field-phone-1_69e2eb061f06c\" id=\"forminator-field-phone-1_69e2eb061f06c-label\" class=\"forminator-label\">Primary Phone Number <span class=\"forminator-required\">*<\/span><\/label><input type=\"text\" name=\"phone-1\" value=\"\" placeholder=\"E.g. +1 300 400 5000\" id=\"forminator-field-phone-1_69e2eb061f06c\" class=\"forminator-input forminator-field--phone\" data-required=\"1\" aria-required=\"true\" autocomplete=\"off\" \/><\/div><\/div><div id=\"phone-2\" class=\"forminator-field-phone forminator-col forminator-col-6 \"><div class=\"forminator-field\"><label for=\"forminator-field-phone-2_69e2eb061f06c\" id=\"forminator-field-phone-2_69e2eb061f06c-label\" class=\"forminator-label\">Secondary Phone Number<\/label><input type=\"text\" name=\"phone-2\" value=\"\" placeholder=\"E.g. +1 300 400 5000\" id=\"forminator-field-phone-2_69e2eb061f06c\" class=\"forminator-input forminator-field--phone\" data-required=\"\" aria-required=\"false\" autocomplete=\"off\" \/><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"email-1\" class=\"forminator-field-email forminator-col forminator-col-12 \"><div class=\"forminator-field\"><label for=\"forminator-field-email-1_69e2eb061f06c\" id=\"forminator-field-email-1_69e2eb061f06c-label\" class=\"forminator-label\">Email Address <span class=\"forminator-required\">*<\/span><\/label><input type=\"email\" name=\"email-1\" value=\"\" placeholder=\"E.g. john@doe.com\" id=\"forminator-field-email-1_69e2eb061f06c\" class=\"forminator-input forminator-email--field\" data-required=\"1\" aria-required=\"true\" \/><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"address-1\" class=\"forminator-field-address forminator-col forminator-col-12 \"><div class=\"forminator-row\"><div id=\"address-1-street_address\" class=\"forminator-col\"><div class=\"forminator-field\"><label for=\"forminator-field-address-1-street_address_69e2eb061f06c\" id=\"forminator-field-address-1-street_address_69e2eb061f06c-label\" class=\"forminator-label\">Street Address <span class=\"forminator-required\">*<\/span><\/label><input type=\"text\" name=\"address-1-street_address\" placeholder=\"E.g. 42 Wallaby Way\" id=\"forminator-field-address-1-street_address_69e2eb061f06c\" class=\"forminator-input\" data-required=\"1\" aria-required=\"true\" value=\"\" \/><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"address-1-address_line\" class=\"forminator-col\"><div class=\"forminator-field\"><label for=\"forminator-field-address-1-address_line_69e2eb061f06c\" id=\"forminator-field-address-1-address_line_69e2eb061f06c-label\" class=\"forminator-label\">Apartment, suite, etc<\/label><input type=\"text\" name=\"address-1-address_line\" placeholder=\"\" id=\"forminator-field-address-1-address_line_69e2eb061f06c\" class=\"forminator-input\" data-required=\"\" aria-required=\"false\" value=\"\" \/><\/div><\/div><\/div><div class=\"forminator-row\" data-multiple=\"true\"><div id=\"address-1-city\" class=\"forminator-col forminator-col-6\"><div class=\"forminator-field\"><label for=\"forminator-field-address-1-city_69e2eb061f06c\" id=\"forminator-field-address-1-city_69e2eb061f06c-label\" class=\"forminator-label\">City <span class=\"forminator-required\">*<\/span><\/label><input type=\"text\" name=\"address-1-city\" placeholder=\"E.g. Sydney\" id=\"forminator-field-address-1-city_69e2eb061f06c\" class=\"forminator-input\" data-required=\"1\" aria-required=\"true\" value=\"\" \/><\/div><\/div><div id=\"address-1-state\" class=\"forminator-col forminator-col-6\"><div class=\"forminator-field\"><label for=\"forminator-field-address-1-state_69e2eb061f06c\" id=\"forminator-field-address-1-state_69e2eb061f06c-label\" class=\"forminator-label\">State\/Province<\/label><input type=\"text\" name=\"address-1-state\" placeholder=\"E.g. New South Wales\" id=\"forminator-field-address-1-state_69e2eb061f06c\" class=\"forminator-input\" data-required=\"\" aria-required=\"false\" value=\"\" \/><\/div><\/div><\/div><div class=\"forminator-row\" data-multiple=\"true\"><div id=\"address-1-zip\" class=\"forminator-col forminator-col-6\"><div class=\"forminator-field\"><label for=\"forminator-field-address-1-zip_69e2eb061f06c\" id=\"forminator-field-address-1-zip_69e2eb061f06c-label\" class=\"forminator-label\">ZIP \/ Postal Code<\/label><input type=\"text\" name=\"address-1-zip\" placeholder=\"E.g. 2000\" id=\"forminator-field-address-1-zip_69e2eb061f06c\" class=\"forminator-input\" value=\"\" \/><\/div><\/div><div id=\"address-1-country\" class=\"forminator-col forminator-col-6\"><div class=\"forminator-field\"><label for=\"forminator-field-219__field--address-1-country_69e2eb061f06c\" id=\"forminator-field-219__field--address-1-country_69e2eb061f06c-label\" class=\"forminator-label\">Country <span class=\"forminator-required\">*<\/span><\/label><select name=\"address-1-country\" id=\"forminator-field-219__field--address-1-country_69e2eb061f06c\" class=\"forminator-select2\" data-search=\"true\" data-placeholder=\"Select country\" data-default-value=\"\"><option value=\"\" data-country-code=\"\" selected=\"selected\"><\/option><option value=\"Afghanistan\" data-country-code=\"AF\" >Afghanistan<\/option><option value=\"Albania\" data-country-code=\"AL\" >Albania<\/option><option value=\"Algeria\" data-country-code=\"DZ\" >Algeria<\/option><option value=\"American Samoa\" data-country-code=\"AS\" >American Samoa<\/option><option value=\"Andorra\" data-country-code=\"AD\" >Andorra<\/option><option value=\"Angola\" data-country-code=\"AO\" >Angola<\/option><option value=\"Anguilla\" data-country-code=\"AI\" >Anguilla<\/option><option value=\"Antarctica\" data-country-code=\"AQ\" >Antarctica<\/option><option value=\"Antigua and Barbuda\" data-country-code=\"AG\" >Antigua and Barbuda<\/option><option value=\"Argentina\" data-country-code=\"AR\" >Argentina<\/option><option value=\"Armenia\" data-country-code=\"AM\" >Armenia<\/option><option value=\"Australia\" data-country-code=\"AU\" >Australia<\/option><option value=\"Aruba\" data-country-code=\"AW\" >Aruba<\/option><option value=\"Austria\" data-country-code=\"AT\" >Austria<\/option><option value=\"Azerbaijan\" data-country-code=\"AZ\" >Azerbaijan<\/option><option value=\"Bahamas\" data-country-code=\"BS\" >Bahamas<\/option><option value=\"Bahrain\" data-country-code=\"BH\" >Bahrain<\/option><option value=\"Bangladesh\" data-country-code=\"BD\" >Bangladesh<\/option><option value=\"Barbados\" data-country-code=\"BB\" >Barbados<\/option><option value=\"Belarus\" data-country-code=\"BY\" >Belarus<\/option><option value=\"Belgium\" data-country-code=\"BE\" >Belgium<\/option><option value=\"Belize\" data-country-code=\"BZ\" >Belize<\/option><option value=\"Benin\" data-country-code=\"BJ\" >Benin<\/option><option value=\"Bermuda\" data-country-code=\"BM\" >Bermuda<\/option><option value=\"Bhutan\" data-country-code=\"BT\" >Bhutan<\/option><option value=\"Bolivia\" data-country-code=\"BO\" >Bolivia<\/option><option value=\"Bosnia and Herzegovina\" data-country-code=\"BA\" >Bosnia and Herzegovina<\/option><option value=\"Botswana\" data-country-code=\"BW\" >Botswana<\/option><option value=\"Bouvet Island\" data-country-code=\"BV\" >Bouvet Island<\/option><option value=\"Brazil\" data-country-code=\"BR\" >Brazil<\/option><option value=\"British Indian Ocean Territory\" data-country-code=\"IO\" >British Indian Ocean Territory<\/option><option value=\"Brunei\" data-country-code=\"BN\" >Brunei<\/option><option value=\"Bulgaria\" data-country-code=\"BG\" >Bulgaria<\/option><option value=\"Burkina Faso\" data-country-code=\"BF\" >Burkina Faso<\/option><option value=\"Burundi\" data-country-code=\"BI\" >Burundi<\/option><option value=\"Cambodia\" data-country-code=\"KH\" >Cambodia<\/option><option value=\"Cameroon\" data-country-code=\"CM\" >Cameroon<\/option><option value=\"Canada\" data-country-code=\"CA\" >Canada<\/option><option value=\"Cabo Verde\" data-country-code=\"CV\" >Cabo Verde<\/option><option value=\"Cayman Islands\" data-country-code=\"KY\" >Cayman Islands<\/option><option value=\"Central African Republic\" data-country-code=\"CF\" >Central African Republic<\/option><option value=\"Chad\" data-country-code=\"TD\" >Chad<\/option><option value=\"Chile\" data-country-code=\"CL\" >Chile<\/option><option value=\"China, People's Republic of\" data-country-code=\"CN\" >China, People's Republic of<\/option><option value=\"Christmas Island\" data-country-code=\"CX\" >Christmas Island<\/option><option value=\"Cocos Islands\" data-country-code=\"CC\" >Cocos Islands<\/option><option value=\"Colombia\" data-country-code=\"CO\" >Colombia<\/option><option value=\"Comoros\" data-country-code=\"KM\" >Comoros<\/option><option value=\"Congo, Democratic Republic of the\" data-country-code=\"CD\" >Congo, Democratic Republic of the<\/option><option value=\"Congo, Republic of the\" data-country-code=\"CG\" >Congo, Republic of the<\/option><option value=\"Cook Islands\" data-country-code=\"CK\" >Cook Islands<\/option><option value=\"Costa Rica\" data-country-code=\"CR\" >Costa Rica<\/option><option value=\"C\u00f4te d'Ivoire\" data-country-code=\"CI\" >C\u00f4te d'Ivoire<\/option><option value=\"Croatia\" data-country-code=\"HR\" >Croatia<\/option><option value=\"Cuba\" data-country-code=\"CU\" >Cuba<\/option><option value=\"Cura\u00e7ao\" data-country-code=\"CW\" >Cura\u00e7ao<\/option><option value=\"Cyprus\" data-country-code=\"CY\" >Cyprus<\/option><option value=\"Czech Republic\" data-country-code=\"CZ\" >Czech Republic<\/option><option value=\"Denmark\" data-country-code=\"DK\" >Denmark<\/option><option value=\"Djibouti\" data-country-code=\"DJ\" >Djibouti<\/option><option value=\"Dominica\" data-country-code=\"DM\" >Dominica<\/option><option value=\"Dominican Republic\" data-country-code=\"DO\" >Dominican Republic<\/option><option value=\"East Timor\" data-country-code=\"TL\" >East Timor<\/option><option value=\"Ecuador\" data-country-code=\"EC\" >Ecuador<\/option><option value=\"Egypt\" data-country-code=\"EG\" >Egypt<\/option><option value=\"El Salvador\" data-country-code=\"SV\" >El Salvador<\/option><option value=\"Equatorial Guinea\" data-country-code=\"GQ\" >Equatorial Guinea<\/option><option value=\"Eritrea\" data-country-code=\"ER\" >Eritrea<\/option><option value=\"Estonia\" data-country-code=\"EE\" >Estonia<\/option><option value=\"Ethiopia\" data-country-code=\"ET\" >Ethiopia<\/option><option value=\"Falkland Islands\" data-country-code=\"FK\" >Falkland Islands<\/option><option value=\"Faroe Islands\" data-country-code=\"FO\" >Faroe Islands<\/option><option value=\"Fiji\" data-country-code=\"FJ\" >Fiji<\/option><option value=\"Finland\" data-country-code=\"FI\" >Finland<\/option><option value=\"France\" data-country-code=\"FR\" >France<\/option><option value=\"France, Metropolitan\" data-country-code=\"FX\" >France, Metropolitan<\/option><option value=\"French Guiana\" data-country-code=\"GF\" >French Guiana<\/option><option value=\"French Polynesia\" data-country-code=\"PF\" >French Polynesia<\/option><option value=\"French South Territories\" data-country-code=\"TF\" >French South Territories<\/option><option value=\"Gabon\" data-country-code=\"GA\" >Gabon<\/option><option value=\"Gambia\" data-country-code=\"GM\" >Gambia<\/option><option value=\"Georgia\" data-country-code=\"GE\" >Georgia<\/option><option value=\"Germany\" data-country-code=\"DE\" >Germany<\/option><option value=\"Guernsey\" data-country-code=\"GG\" >Guernsey<\/option><option value=\"Ghana\" data-country-code=\"GH\" >Ghana<\/option><option value=\"Gibraltar\" data-country-code=\"GI\" >Gibraltar<\/option><option value=\"Greece\" data-country-code=\"GR\" >Greece<\/option><option value=\"Greenland\" data-country-code=\"GL\" >Greenland<\/option><option value=\"Grenada\" data-country-code=\"GD\" >Grenada<\/option><option value=\"Guadeloupe\" data-country-code=\"GP\" >Guadeloupe<\/option><option value=\"Guam\" data-country-code=\"GU\" >Guam<\/option><option value=\"Guatemala\" data-country-code=\"GT\" >Guatemala<\/option><option value=\"Guinea\" data-country-code=\"GN\" >Guinea<\/option><option value=\"Guinea-Bissau\" data-country-code=\"GW\" >Guinea-Bissau<\/option><option value=\"Guyana\" data-country-code=\"GY\" >Guyana<\/option><option value=\"Haiti\" data-country-code=\"HT\" >Haiti<\/option><option value=\"Heard Island And Mcdonald Island\" data-country-code=\"HM\" >Heard Island And Mcdonald Island<\/option><option value=\"Honduras\" data-country-code=\"HN\" >Honduras<\/option><option value=\"Hong Kong\" data-country-code=\"HK\" >Hong Kong<\/option><option value=\"Hungary\" data-country-code=\"HU\" >Hungary<\/option><option value=\"Iceland\" data-country-code=\"IS\" >Iceland<\/option><option value=\"India\" data-country-code=\"IN\" >India<\/option><option value=\"Indonesia\" data-country-code=\"ID\" >Indonesia<\/option><option value=\"Iran\" data-country-code=\"IR\" >Iran<\/option><option value=\"Iraq\" data-country-code=\"IQ\" >Iraq<\/option><option value=\"Ireland\" data-country-code=\"IE\" >Ireland<\/option><option value=\"Israel\" data-country-code=\"IL\" >Israel<\/option><option value=\"Italy\" data-country-code=\"IT\" >Italy<\/option><option value=\"Jamaica\" data-country-code=\"JM\" >Jamaica<\/option><option value=\"Japan\" data-country-code=\"JP\" >Japan<\/option><option value=\"Jersey\" data-country-code=\"JE\" >Jersey<\/option><option value=\"Johnston Island\" data-country-code=\"JT\" >Johnston Island<\/option><option value=\"Jordan\" data-country-code=\"JO\" >Jordan<\/option><option value=\"Kazakhstan\" data-country-code=\"KZ\" >Kazakhstan<\/option><option value=\"Kenya\" data-country-code=\"KE\" >Kenya<\/option><option value=\"Kiribati\" data-country-code=\"KI\" >Kiribati<\/option><option value=\"Korea, Democratic People's Republic of\" data-country-code=\"KP\" >Korea, Democratic People's Republic of<\/option><option value=\"Korea, Republic of\" data-country-code=\"KR\" >Korea, Republic of<\/option><option value=\"Kosovo\" data-country-code=\"XK\" >Kosovo<\/option><option value=\"Kuwait\" data-country-code=\"KW\" >Kuwait<\/option><option value=\"Kyrgyzstan\" data-country-code=\"KG\" >Kyrgyzstan<\/option><option value=\"Lao People's Democratic Republic\" data-country-code=\"LA\" >Lao People's Democratic Republic<\/option><option value=\"Latvia\" data-country-code=\"LV\" >Latvia<\/option><option value=\"Lebanon\" data-country-code=\"LB\" >Lebanon<\/option><option value=\"Lesotho\" data-country-code=\"LS\" >Lesotho<\/option><option value=\"Liberia\" data-country-code=\"LR\" >Liberia<\/option><option value=\"Libya\" data-country-code=\"LY\" >Libya<\/option><option value=\"Liechtenstein\" data-country-code=\"LI\" >Liechtenstein<\/option><option value=\"Lithuania\" data-country-code=\"LT\" >Lithuania<\/option><option value=\"Luxembourg\" data-country-code=\"LU\" >Luxembourg<\/option><option value=\"Macau\" data-country-code=\"MO\" >Macau<\/option><option value=\"North Macedonia\" data-country-code=\"MK\" >North Macedonia<\/option><option value=\"Madagascar\" data-country-code=\"MG\" >Madagascar<\/option><option value=\"Malawi\" data-country-code=\"MW\" >Malawi<\/option><option value=\"Malaysia\" data-country-code=\"MY\" >Malaysia<\/option><option value=\"Maldives\" data-country-code=\"MV\" >Maldives<\/option><option value=\"Mali\" data-country-code=\"ML\" >Mali<\/option><option value=\"Malta\" data-country-code=\"MT\" >Malta<\/option><option value=\"Marshall Islands\" data-country-code=\"MH\" >Marshall Islands<\/option><option value=\"Martinique\" data-country-code=\"MQ\" >Martinique<\/option><option value=\"Mauritania\" data-country-code=\"MR\" >Mauritania<\/option><option value=\"Mauritius\" data-country-code=\"MU\" >Mauritius<\/option><option value=\"Mayotte\" data-country-code=\"YT\" >Mayotte<\/option><option value=\"Mexico\" data-country-code=\"MX\" >Mexico<\/option><option value=\"Micronesia\" data-country-code=\"FM\" >Micronesia<\/option><option value=\"Moldova\" data-country-code=\"MD\" >Moldova<\/option><option value=\"Monaco\" data-country-code=\"MC\" >Monaco<\/option><option value=\"Mongolia\" data-country-code=\"MN\" >Mongolia<\/option><option value=\"Montserrat\" data-country-code=\"MS\" >Montserrat<\/option><option value=\"Montenegro\" data-country-code=\"ME\" >Montenegro<\/option><option value=\"Morocco\" data-country-code=\"MA\" >Morocco<\/option><option value=\"Mozambique\" data-country-code=\"MZ\" >Mozambique<\/option><option value=\"Myanmar\" data-country-code=\"MM\" >Myanmar<\/option><option value=\"Namibia\" data-country-code=\"NA\" >Namibia<\/option><option value=\"Nauru\" data-country-code=\"NR\" >Nauru<\/option><option value=\"Nepal\" data-country-code=\"NP\" >Nepal<\/option><option value=\"Netherlands\" data-country-code=\"NL\" >Netherlands<\/option><option value=\"Netherlands Antilles\" data-country-code=\"AN\" >Netherlands Antilles<\/option><option value=\"New Caledonia\" data-country-code=\"NC\" >New Caledonia<\/option><option value=\"New Zealand\" data-country-code=\"NZ\" >New Zealand<\/option><option value=\"Nicaragua\" data-country-code=\"NI\" >Nicaragua<\/option><option value=\"Niger\" data-country-code=\"NE\" >Niger<\/option><option value=\"Nigeria\" data-country-code=\"NG\" >Nigeria<\/option><option value=\"Niue\" data-country-code=\"NU\" >Niue<\/option><option value=\"Norfolk Island\" data-country-code=\"NF\" >Norfolk Island<\/option><option value=\"Northern Mariana Islands\" data-country-code=\"MP\" >Northern Mariana Islands<\/option><option value=\"Norway\" data-country-code=\"NO\" >Norway<\/option><option value=\"Oman\" data-country-code=\"OM\" >Oman<\/option><option value=\"Pakistan\" data-country-code=\"PK\" >Pakistan<\/option><option value=\"Palau\" data-country-code=\"PW\" >Palau<\/option><option value=\"Palestine, State of\" data-country-code=\"PS\" >Palestine, State of<\/option><option value=\"Panama\" data-country-code=\"PA\" >Panama<\/option><option value=\"Papua New Guinea\" data-country-code=\"PG\" >Papua New Guinea<\/option><option value=\"Paraguay\" data-country-code=\"PY\" >Paraguay<\/option><option value=\"Peru\" data-country-code=\"PE\" >Peru<\/option><option value=\"Philippines\" data-country-code=\"PH\" >Philippines<\/option><option value=\"Pitcairn Islands\" data-country-code=\"PN\" >Pitcairn Islands<\/option><option value=\"Poland\" data-country-code=\"PL\" >Poland<\/option><option value=\"Portugal\" data-country-code=\"PT\" >Portugal<\/option><option value=\"Puerto Rico\" data-country-code=\"PR\" >Puerto Rico<\/option><option value=\"Qatar\" data-country-code=\"QA\" >Qatar<\/option><option value=\"Reunion Island\" data-country-code=\"RE\" >Reunion Island<\/option><option value=\"Romania\" data-country-code=\"RO\" >Romania<\/option><option value=\"Russia\" data-country-code=\"RU\" >Russia<\/option><option value=\"Rwanda\" data-country-code=\"RW\" >Rwanda<\/option><option value=\"Saint Kitts and Nevis\" data-country-code=\"KN\" >Saint Kitts and Nevis<\/option><option value=\"Saint Lucia\" data-country-code=\"LC\" >Saint Lucia<\/option><option value=\"Saint Vincent and the Grenadines\" data-country-code=\"VC\" >Saint Vincent and the Grenadines<\/option><option value=\"Samoa\" data-country-code=\"WS\" >Samoa<\/option><option value=\"Saint Helena\" data-country-code=\"SH\" >Saint Helena<\/option><option value=\"Saint Pierre & Miquelon\" data-country-code=\"PM\" >Saint Pierre & Miquelon<\/option><option value=\"San Marino\" data-country-code=\"SM\" >San Marino<\/option><option value=\"Sao Tome and Principe\" data-country-code=\"ST\" >Sao Tome and Principe<\/option><option value=\"Saudi Arabia\" data-country-code=\"SA\" >Saudi Arabia<\/option><option value=\"Senegal\" data-country-code=\"SN\" >Senegal<\/option><option value=\"Serbia\" data-country-code=\"RS\" >Serbia<\/option><option value=\"Seychelles\" data-country-code=\"SC\" >Seychelles<\/option><option value=\"Sierra Leone\" data-country-code=\"SL\" >Sierra Leone<\/option><option value=\"Singapore\" data-country-code=\"SG\" >Singapore<\/option><option value=\"Sint Maarten\" data-country-code=\"MF\" >Sint Maarten<\/option><option value=\"Slovakia\" data-country-code=\"SK\" >Slovakia<\/option><option value=\"Slovenia\" data-country-code=\"SI\" >Slovenia<\/option><option value=\"Solomon Islands\" data-country-code=\"SB\" >Solomon Islands<\/option><option value=\"Somalia\" data-country-code=\"SO\" >Somalia<\/option><option value=\"South Africa\" data-country-code=\"ZA\" >South Africa<\/option><option value=\"South Georgia and South Sandwich\" data-country-code=\"GS\" >South Georgia and South Sandwich<\/option><option value=\"Spain\" data-country-code=\"ES\" >Spain<\/option><option value=\"Sri Lanka\" data-country-code=\"LK\" >Sri Lanka<\/option><option value=\"Stateless Persons\" data-country-code=\"XX\" >Stateless Persons<\/option><option value=\"Sudan\" data-country-code=\"SD\" >Sudan<\/option><option value=\"Sudan, South\" data-country-code=\"SS\" >Sudan, South<\/option><option value=\"Suriname\" data-country-code=\"SR\" >Suriname<\/option><option value=\"Svalbard and Jan Mayen\" data-country-code=\"SJ\" >Svalbard and Jan Mayen<\/option><option value=\"Swaziland\" data-country-code=\"SZ\" >Swaziland<\/option><option value=\"Sweden\" data-country-code=\"SE\" >Sweden<\/option><option value=\"Switzerland\" data-country-code=\"CH\" >Switzerland<\/option><option value=\"Syria\" data-country-code=\"SY\" >Syria<\/option><option value=\"Taiwan, Republic of China\" data-country-code=\"TW\" >Taiwan, Republic of China<\/option><option value=\"Tajikistan\" data-country-code=\"TJ\" >Tajikistan<\/option><option value=\"Tanzania\" data-country-code=\"TZ\" >Tanzania<\/option><option value=\"Thailand\" data-country-code=\"TH\" >Thailand<\/option><option value=\"Togo\" data-country-code=\"TG\" >Togo<\/option><option value=\"Tokelau\" data-country-code=\"TK\" >Tokelau<\/option><option value=\"Tonga\" data-country-code=\"TO\" >Tonga<\/option><option value=\"Trinidad and Tobago\" data-country-code=\"TT\" >Trinidad and Tobago<\/option><option value=\"Tunisia\" data-country-code=\"TN\" >Tunisia<\/option><option value=\"Turkey\" data-country-code=\"TR\" >Turkey<\/option><option value=\"Turkmenistan\" data-country-code=\"TM\" >Turkmenistan<\/option><option value=\"Turks And Caicos Islands\" data-country-code=\"TC\" >Turks And Caicos Islands<\/option><option value=\"Tuvalu\" data-country-code=\"TV\" >Tuvalu<\/option><option value=\"Uganda\" data-country-code=\"UG\" >Uganda<\/option><option value=\"Ukraine\" data-country-code=\"UA\" >Ukraine<\/option><option value=\"United Arab Emirates\" data-country-code=\"AE\" >United Arab Emirates<\/option><option value=\"United Kingdom\" data-country-code=\"GB\" >United Kingdom<\/option><option value=\"US Minor Outlying Islands\" data-country-code=\"UM\" >US Minor Outlying Islands<\/option><option value=\"United States of America (USA)\" data-country-code=\"US\" >United States of America (USA)<\/option><option value=\"Uruguay\" data-country-code=\"UY\" >Uruguay<\/option><option value=\"Uzbekistan\" data-country-code=\"UZ\" >Uzbekistan<\/option><option value=\"Vanuatu\" data-country-code=\"VU\" >Vanuatu<\/option><option value=\"Vatican City\" data-country-code=\"VA\" >Vatican City<\/option><option value=\"Venezuela\" data-country-code=\"VE\" >Venezuela<\/option><option value=\"Vietnam\" data-country-code=\"VN\" >Vietnam<\/option><option value=\"Virgin Islands, British\" data-country-code=\"VG\" >Virgin Islands, British<\/option><option value=\"Virgin Islands, U.S.\" data-country-code=\"VI\" >Virgin Islands, U.S.<\/option><option value=\"Wallis And Futuna Islands\" data-country-code=\"WF\" >Wallis And Futuna Islands<\/option><option value=\"Western Sahara\" data-country-code=\"EH\" >Western Sahara<\/option><option value=\"Yemen\" data-country-code=\"YE\" >Yemen<\/option><option value=\"Zambia\" data-country-code=\"ZM\" >Zambia<\/option><option value=\"Zimbabwe\" data-country-code=\"ZW\" >Zimbabwe<\/option><\/select><\/div><\/div><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"date-1\" class=\"forminator-field-date forminator-col forminator-col-12 \"><label for=\"forminator-field-date-1\" id=\"forminator-field-date-1-label\" class=\"forminator-label\">Date of Birth<\/label><div class=\"forminator-date-select\"><div class=\"forminator-row\" data-multiple=\"true\"><div id=\"date-1-month\" class=\"forminator-col\"><div class=\"forminator-field\"><label for=\"forminator-field-219__field--date-1-month_69e2eb061f06c\" id=\"forminator-field-219__field--date-1-month_69e2eb061f06c-label\" class=\"forminator-label\">Month<\/label><select name=\"date-1-month\" id=\"forminator-field-219__field--date-1-month_69e2eb061f06c\" class=\"forminator-select2\" data-format=\"mm\/dd\/yy\" data-parent=\"date-1\" aria-labelledby=\"forminator-field-219__field--date-1-month_69e2eb061f06c-label\" data-default-value=\"\"><option value=\"\" selected=\"selected\">Select month<\/option><option value=\"1\" >1<\/option><option value=\"2\" >2<\/option><option value=\"3\" >3<\/option><option value=\"4\" >4<\/option><option value=\"5\" >5<\/option><option value=\"6\" >6<\/option><option value=\"7\" >7<\/option><option value=\"8\" >8<\/option><option value=\"9\" >9<\/option><option value=\"10\" >10<\/option><option value=\"11\" >11<\/option><option value=\"12\" >12<\/option><\/select><\/div><\/div><div id=\"date-1-day\" class=\"forminator-col\"><div class=\"forminator-field\"><label for=\"forminator-field-219__field--date-1-day_69e2eb061f06c\" id=\"forminator-field-219__field--date-1-day_69e2eb061f06c-label\" class=\"forminator-label\">Day<\/label><select name=\"date-1-day\" id=\"forminator-field-219__field--date-1-day_69e2eb061f06c\" class=\"forminator-select2\" data-format=\"mm\/dd\/yy\" data-parent=\"date-1\" aria-labelledby=\"forminator-field-219__field--date-1-day_69e2eb061f06c-label\" data-default-value=\"\"><option value=\"\" selected=\"selected\">Select day<\/option><option value=\"1\" >1<\/option><option value=\"2\" >2<\/option><option value=\"3\" >3<\/option><option value=\"4\" >4<\/option><option value=\"5\" >5<\/option><option value=\"6\" >6<\/option><option value=\"7\" >7<\/option><option value=\"8\" >8<\/option><option value=\"9\" >9<\/option><option value=\"10\" >10<\/option><option value=\"11\" >11<\/option><option value=\"12\" >12<\/option><option value=\"13\" >13<\/option><option value=\"14\" >14<\/option><option value=\"15\" >15<\/option><option value=\"16\" >16<\/option><option value=\"17\" >17<\/option><option value=\"18\" >18<\/option><option value=\"19\" >19<\/option><option value=\"20\" >20<\/option><option value=\"21\" >21<\/option><option value=\"22\" >22<\/option><option value=\"23\" >23<\/option><option value=\"24\" >24<\/option><option value=\"25\" >25<\/option><option value=\"26\" >26<\/option><option value=\"27\" >27<\/option><option value=\"28\" >28<\/option><option value=\"29\" >29<\/option><option value=\"30\" >30<\/option><option value=\"31\" >31<\/option><\/select><\/div><\/div><div id=\"date-1-year\" class=\"forminator-col\"><div class=\"forminator-field\"><label for=\"forminator-field-219__field--date-1-year_69e2eb061f06c\" id=\"forminator-field-219__field--date-1-year_69e2eb061f06c-label\" class=\"forminator-label\">Year<\/label><select name=\"date-1-year\" id=\"forminator-field-219__field--date-1-year_69e2eb061f06c\" class=\"forminator-select2\" data-format=\"mm\/dd\/yy\" data-parent=\"date-1\" aria-labelledby=\"forminator-field-219__field--date-1-year_69e2eb061f06c-label\" data-default-value=\"2026\"><option value=\"\" >Select Year<\/option><option value=\"2126\" >2126<\/option><option value=\"2125\" >2125<\/option><option value=\"2124\" >2124<\/option><option value=\"2123\" >2123<\/option><option value=\"2122\" >2122<\/option><option value=\"2121\" >2121<\/option><option value=\"2120\" >2120<\/option><option value=\"2119\" >2119<\/option><option value=\"2118\" >2118<\/option><option value=\"2117\" >2117<\/option><option value=\"2116\" >2116<\/option><option value=\"2115\" >2115<\/option><option value=\"2114\" >2114<\/option><option value=\"2113\" >2113<\/option><option value=\"2112\" >2112<\/option><option value=\"2111\" >2111<\/option><option value=\"2110\" >2110<\/option><option value=\"2109\" >2109<\/option><option value=\"2108\" >2108<\/option><option value=\"2107\" >2107<\/option><option value=\"2106\" >2106<\/option><option value=\"2105\" >2105<\/option><option value=\"2104\" >2104<\/option><option value=\"2103\" >2103<\/option><option value=\"2102\" >2102<\/option><option value=\"2101\" >2101<\/option><option value=\"2100\" >2100<\/option><option value=\"2099\" >2099<\/option><option value=\"2098\" >2098<\/option><option value=\"2097\" >2097<\/option><option value=\"2096\" >2096<\/option><option value=\"2095\" >2095<\/option><option value=\"2094\" >2094<\/option><option value=\"2093\" >2093<\/option><option value=\"2092\" >2092<\/option><option value=\"2091\" >2091<\/option><option value=\"2090\" >2090<\/option><option value=\"2089\" >2089<\/option><option value=\"2088\" >2088<\/option><option value=\"2087\" >2087<\/option><option value=\"2086\" >2086<\/option><option value=\"2085\" >2085<\/option><option value=\"2084\" >2084<\/option><option value=\"2083\" >2083<\/option><option value=\"2082\" >2082<\/option><option value=\"2081\" >2081<\/option><option value=\"2080\" >2080<\/option><option value=\"2079\" >2079<\/option><option value=\"2078\" >2078<\/option><option value=\"2077\" >2077<\/option><option value=\"2076\" >2076<\/option><option value=\"2075\" >2075<\/option><option value=\"2074\" >2074<\/option><option value=\"2073\" >2073<\/option><option value=\"2072\" >2072<\/option><option value=\"2071\" >2071<\/option><option value=\"2070\" >2070<\/option><option value=\"2069\" >2069<\/option><option value=\"2068\" >2068<\/option><option value=\"2067\" >2067<\/option><option value=\"2066\" >2066<\/option><option value=\"2065\" >2065<\/option><option value=\"2064\" >2064<\/option><option value=\"2063\" >2063<\/option><option value=\"2062\" >2062<\/option><option value=\"2061\" >2061<\/option><option value=\"2060\" >2060<\/option><option value=\"2059\" >2059<\/option><option value=\"2058\" >2058<\/option><option value=\"2057\" >2057<\/option><option value=\"2056\" >2056<\/option><option value=\"2055\" >2055<\/option><option value=\"2054\" >2054<\/option><option value=\"2053\" >2053<\/option><option value=\"2052\" >2052<\/option><option value=\"2051\" >2051<\/option><option value=\"2050\" >2050<\/option><option value=\"2049\" >2049<\/option><option value=\"2048\" >2048<\/option><option value=\"2047\" >2047<\/option><option value=\"2046\" >2046<\/option><option value=\"2045\" >2045<\/option><option value=\"2044\" >2044<\/option><option value=\"2043\" >2043<\/option><option value=\"2042\" >2042<\/option><option value=\"2041\" >2041<\/option><option value=\"2040\" >2040<\/option><option value=\"2039\" >2039<\/option><option value=\"2038\" >2038<\/option><option value=\"2037\" >2037<\/option><option value=\"2036\" >2036<\/option><option value=\"2035\" >2035<\/option><option value=\"2034\" >2034<\/option><option value=\"2033\" >2033<\/option><option value=\"2032\" >2032<\/option><option value=\"2031\" >2031<\/option><option value=\"2030\" >2030<\/option><option value=\"2029\" >2029<\/option><option value=\"2028\" >2028<\/option><option value=\"2027\" >2027<\/option><option value=\"2026\" selected=\"selected\">2026<\/option><option value=\"2025\" >2025<\/option><option value=\"2024\" >2024<\/option><option value=\"2023\" >2023<\/option><option value=\"2022\" >2022<\/option><option value=\"2021\" >2021<\/option><option value=\"2020\" >2020<\/option><option value=\"2019\" >2019<\/option><option value=\"2018\" >2018<\/option><option value=\"2017\" >2017<\/option><option value=\"2016\" >2016<\/option><option value=\"2015\" >2015<\/option><option value=\"2014\" >2014<\/option><option value=\"2013\" >2013<\/option><option value=\"2012\" >2012<\/option><option value=\"2011\" >2011<\/option><option value=\"2010\" >2010<\/option><option value=\"2009\" >2009<\/option><option value=\"2008\" >2008<\/option><option value=\"2007\" >2007<\/option><option value=\"2006\" >2006<\/option><option value=\"2005\" >2005<\/option><option value=\"2004\" >2004<\/option><option value=\"2003\" >2003<\/option><option value=\"2002\" >2002<\/option><option value=\"2001\" >2001<\/option><option value=\"2000\" >2000<\/option><option value=\"1999\" >1999<\/option><option value=\"1998\" >1998<\/option><option value=\"1997\" >1997<\/option><option value=\"1996\" >1996<\/option><option value=\"1995\" >1995<\/option><option value=\"1994\" >1994<\/option><option value=\"1993\" >1993<\/option><option value=\"1992\" >1992<\/option><option value=\"1991\" >1991<\/option><option value=\"1990\" >1990<\/option><option value=\"1989\" >1989<\/option><option value=\"1988\" >1988<\/option><option value=\"1987\" >1987<\/option><option value=\"1986\" >1986<\/option><option value=\"1985\" >1985<\/option><option value=\"1984\" >1984<\/option><option value=\"1983\" >1983<\/option><option value=\"1982\" >1982<\/option><option value=\"1981\" >1981<\/option><option value=\"1980\" >1980<\/option><option value=\"1979\" >1979<\/option><option value=\"1978\" >1978<\/option><option value=\"1977\" >1977<\/option><option value=\"1976\" >1976<\/option><option value=\"1975\" >1975<\/option><option value=\"1974\" >1974<\/option><option value=\"1973\" >1973<\/option><option value=\"1972\" >1972<\/option><option value=\"1971\" >1971<\/option><option value=\"1970\" >1970<\/option><option value=\"1969\" >1969<\/option><option value=\"1968\" >1968<\/option><option value=\"1967\" >1967<\/option><option value=\"1966\" >1966<\/option><option value=\"1965\" >1965<\/option><option value=\"1964\" >1964<\/option><option value=\"1963\" >1963<\/option><option value=\"1962\" >1962<\/option><option value=\"1961\" >1961<\/option><option value=\"1960\" >1960<\/option><option value=\"1959\" >1959<\/option><option value=\"1958\" >1958<\/option><option value=\"1957\" >1957<\/option><option value=\"1956\" >1956<\/option><option value=\"1955\" >1955<\/option><option value=\"1954\" >1954<\/option><option value=\"1953\" >1953<\/option><option value=\"1952\" >1952<\/option><option value=\"1951\" >1951<\/option><option value=\"1950\" >1950<\/option><option value=\"1949\" >1949<\/option><option value=\"1948\" >1948<\/option><option value=\"1947\" >1947<\/option><option value=\"1946\" >1946<\/option><option value=\"1945\" >1945<\/option><option value=\"1944\" >1944<\/option><option value=\"1943\" >1943<\/option><option value=\"1942\" >1942<\/option><option value=\"1941\" >1941<\/option><option value=\"1940\" >1940<\/option><option value=\"1939\" >1939<\/option><option value=\"1938\" >1938<\/option><option value=\"1937\" >1937<\/option><option value=\"1936\" >1936<\/option><option value=\"1935\" >1935<\/option><option value=\"1934\" >1934<\/option><option value=\"1933\" >1933<\/option><option value=\"1932\" >1932<\/option><option value=\"1931\" >1931<\/option><option value=\"1930\" >1930<\/option><option value=\"1929\" >1929<\/option><option value=\"1928\" >1928<\/option><option value=\"1927\" >1927<\/option><option value=\"1926\" >1926<\/option><\/select><\/div><\/div><\/div><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"radio-1\" class=\"forminator-field-radio forminator-col forminator-col-6 \"><div role=\"radiogroup\" class=\"forminator-field\" aria-labelledby=\"forminator-radiogroup-69e2eb061f06c-label\"><span id=\"forminator-radiogroup-69e2eb061f06c-label\" class=\"forminator-label\">Referred By<\/span><label id=\"forminator-field-radio-1-label-1\" for=\"forminator-field-radio-1-1-69e2eb061f06c\" class=\"forminator-radio\" title=\"Not referred\"><input type=\"radio\" name=\"radio-1\" value=\"Not-referred\" id=\"forminator-field-radio-1-1-69e2eb061f06c\" aria-labelledby=\"forminator-field-radio-1-label-1\" data-calculation=\"0\" checked=\"checked\"  data-hidden-behavior=\"zero\"\/><span class=\"forminator-radio-bullet\" aria-hidden=\"true\"><\/span><span class=\"forminator-radio-label\">Not referred<\/span><\/label><label id=\"forminator-field-radio-1-label-2\" for=\"forminator-field-radio-1-2-69e2eb061f06c\" class=\"forminator-radio\" title=\"Other\"><input type=\"radio\" name=\"radio-1\" value=\"two\" id=\"forminator-field-radio-1-2-69e2eb061f06c\" aria-labelledby=\"forminator-field-radio-1-label-2\" data-calculation=\"0\"   data-hidden-behavior=\"zero\"\/><span class=\"forminator-radio-bullet\" aria-hidden=\"true\"><\/span><span class=\"forminator-radio-label\">Other<\/span><\/label><\/div><\/div><div id=\"text-3\" class=\"forminator-field-text forminator-col forminator-col-6 \"><div class=\"forminator-field\"><label for=\"forminator-field-text-3_69e2eb061f06c\" id=\"forminator-field-text-3_69e2eb061f06c-label\" class=\"forminator-label\">Other:<\/label><input type=\"text\" name=\"text-3\" value=\"\" placeholder=\"\" id=\"forminator-field-text-3_69e2eb061f06c\" class=\"forminator-input forminator-name--field\" data-required=\"\" \/><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"textarea-1\" class=\"forminator-field-textarea forminator-col forminator-col-12 \"><div class=\"forminator-field\"><label for=\"forminator-field-textarea-1_69e2eb061f06c\" id=\"forminator-field-textarea-1_69e2eb061f06c-label\" class=\"forminator-label\">Describe the problem(s) for which you seek help. Please include dates when each problem occurred:<\/label><textarea name=\"textarea-1\" placeholder=\"\" id=\"forminator-field-textarea-1_69e2eb061f06c\" class=\"forminator-textarea\" rows=\"6\" style=\"min-height:140px;\" ><\/textarea><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"textarea-4\" class=\"forminator-field-textarea forminator-col forminator-col-12 \"><div class=\"forminator-field\"><label for=\"forminator-field-textarea-4_69e2eb061f06c\" id=\"forminator-field-textarea-4_69e2eb061f06c-label\" class=\"forminator-label\">What daily activities are you finding difficult or are limited because of your above complaints?<\/label><textarea name=\"textarea-4\" placeholder=\"\" id=\"forminator-field-textarea-4_69e2eb061f06c\" class=\"forminator-textarea\" rows=\"6\" style=\"min-height:140px;\" ><\/textarea><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"textarea-6\" class=\"forminator-field-textarea forminator-col forminator-col-12 \"><div class=\"forminator-field\"><label for=\"forminator-field-textarea-6_69e2eb061f06c\" id=\"forminator-field-textarea-6_69e2eb061f06c-label\" class=\"forminator-label\">What are your goals from BodyTalk?<\/label><textarea name=\"textarea-6\" placeholder=\"\" id=\"forminator-field-textarea-6_69e2eb061f06c\" class=\"forminator-textarea\" rows=\"6\" style=\"min-height:140px;\" ><\/textarea><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"textarea-7\" class=\"forminator-field-textarea forminator-col forminator-col-12 \"><div class=\"forminator-field\"><label for=\"forminator-field-textarea-7_69e2eb061f06c\" id=\"forminator-field-textarea-7_69e2eb061f06c-label\" class=\"forminator-label\">Please list any other kind of healthcare professional you are seeing for this\/these problem(s):<\/label><textarea name=\"textarea-7\" placeholder=\"\" id=\"forminator-field-textarea-7_69e2eb061f06c\" class=\"forminator-textarea\" rows=\"6\" style=\"min-height:140px;\" ><\/textarea><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"checkbox-1\" class=\"forminator-field-checkbox forminator-col forminator-col-12 \"><div role=\"group\" class=\"forminator-field\" aria-labelledby=\"forminator-checkbox-group-69e2eb061f06c-label\"><span id=\"forminator-checkbox-group-69e2eb061f06c-label\" class=\"forminator-label\">Please check any of the following feelings you have experienced in the last few months.<\/span><label id=\"forminator-field-checkbox-1-1-69e2eb061f06c-label\" for=\"forminator-field-checkbox-1-1-69e2eb061f06c\" class=\"forminator-checkbox forminator-checkbox-inline\" title=\"Abused\"><input type=\"checkbox\" name=\"checkbox-1[]\" value=\"one\" id=\"forminator-field-checkbox-1-1-69e2eb061f06c\" aria-labelledby=\"forminator-field-checkbox-1-1-69e2eb061f06c-label\" data-calculation=\"0\"   data-hidden-behavior=\"zero\"\/><span class=\"forminator-checkbox-box\" aria-hidden=\"true\"><\/span><span class=\"forminator-checkbox-label\">Abused<\/span><\/label><label id=\"forminator-field-checkbox-1-2-69e2eb061f06c-label\" for=\"forminator-field-checkbox-1-2-69e2eb061f06c\" class=\"forminator-checkbox forminator-checkbox-inline\" title=\"Criticized\"><input type=\"checkbox\" name=\"checkbox-1[]\" value=\"two\" id=\"forminator-field-checkbox-1-2-69e2eb061f06c\" aria-labelledby=\"forminator-field-checkbox-1-2-69e2eb061f06c-label\" data-calculation=\"0\"   data-hidden-behavior=\"zero\"\/><span class=\"forminator-checkbox-box\" aria-hidden=\"true\"><\/span><span class=\"forminator-checkbox-label\">Criticized<\/span><\/label><label id=\"forminator-field-checkbox-1-3-69e2eb061f06c-label\" for=\"forminator-field-checkbox-1-3-69e2eb061f06c\" class=\"forminator-checkbox forminator-checkbox-inline\" title=\"Overworked\"><input type=\"checkbox\" name=\"checkbox-1[]\" value=\"Overworked\" id=\"forminator-field-checkbox-1-3-69e2eb061f06c\" aria-labelledby=\"forminator-field-checkbox-1-3-69e2eb061f06c-label\" data-calculation=\"0\"   data-hidden-behavior=\"zero\"\/><span class=\"forminator-checkbox-box\" aria-hidden=\"true\"><\/span><span class=\"forminator-checkbox-label\">Overworked<\/span><\/label><label id=\"forminator-field-checkbox-1-4-69e2eb061f06c-label\" for=\"forminator-field-checkbox-1-4-69e2eb061f06c\" class=\"forminator-checkbox forminator-checkbox-inline\" title=\"Paralyzed\"><input type=\"checkbox\" name=\"checkbox-1[]\" value=\"Paralyzed\" id=\"forminator-field-checkbox-1-4-69e2eb061f06c\" aria-labelledby=\"forminator-field-checkbox-1-4-69e2eb061f06c-label\" data-calculation=\"0\"   data-hidden-behavior=\"zero\"\/><span class=\"forminator-checkbox-box\" aria-hidden=\"true\"><\/span><span class=\"forminator-checkbox-label\">Paralyzed<\/span><\/label><label id=\"forminator-field-checkbox-1-5-69e2eb061f06c-label\" for=\"forminator-field-checkbox-1-5-69e2eb061f06c\" class=\"forminator-checkbox forminator-checkbox-inline\" title=\"Depressed\"><input type=\"checkbox\" name=\"checkbox-1[]\" value=\"Depressed\" id=\"forminator-field-checkbox-1-5-69e2eb061f06c\" aria-labelledby=\"forminator-field-checkbox-1-5-69e2eb061f06c-label\" data-calculation=\"0\"   data-hidden-behavior=\"zero\"\/><span class=\"forminator-checkbox-box\" aria-hidden=\"true\"><\/span><span class=\"forminator-checkbox-label\">Depressed<\/span><\/label><label id=\"forminator-field-checkbox-1-6-69e2eb061f06c-label\" for=\"forminator-field-checkbox-1-6-69e2eb061f06c\" class=\"forminator-checkbox forminator-checkbox-inline\" title=\"Rejected\"><input type=\"checkbox\" name=\"checkbox-1[]\" value=\"Rejected\" id=\"forminator-field-checkbox-1-6-69e2eb061f06c\" aria-labelledby=\"forminator-field-checkbox-1-6-69e2eb061f06c-label\" data-calculation=\"0\"   data-hidden-behavior=\"zero\"\/><span class=\"forminator-checkbox-box\" aria-hidden=\"true\"><\/span><span class=\"forminator-checkbox-label\">Rejected<\/span><\/label><label id=\"forminator-field-checkbox-1-7-69e2eb061f06c-label\" for=\"forminator-field-checkbox-1-7-69e2eb061f06c\" class=\"forminator-checkbox forminator-checkbox-inline\" title=\"Despair\"><input type=\"checkbox\" name=\"checkbox-1[]\" value=\"Despair\" id=\"forminator-field-checkbox-1-7-69e2eb061f06c\" aria-labelledby=\"forminator-field-checkbox-1-7-69e2eb061f06c-label\" data-calculation=\"0\"   data-hidden-behavior=\"zero\"\/><span class=\"forminator-checkbox-box\" aria-hidden=\"true\"><\/span><span class=\"forminator-checkbox-label\">Despair<\/span><\/label><label id=\"forminator-field-checkbox-1-8-69e2eb061f06c-label\" for=\"forminator-field-checkbox-1-8-69e2eb061f06c\" class=\"forminator-checkbox forminator-checkbox-inline\" title=\"Helpless\"><input type=\"checkbox\" name=\"checkbox-1[]\" value=\"Helpless\" id=\"forminator-field-checkbox-1-8-69e2eb061f06c\" aria-labelledby=\"forminator-field-checkbox-1-8-69e2eb061f06c-label\" data-calculation=\"0\"   data-hidden-behavior=\"zero\"\/><span class=\"forminator-checkbox-box\" aria-hidden=\"true\"><\/span><span class=\"forminator-checkbox-label\">Helpless<\/span><\/label><label id=\"forminator-field-checkbox-1-9-69e2eb061f06c-label\" for=\"forminator-field-checkbox-1-9-69e2eb061f06c\" class=\"forminator-checkbox forminator-checkbox-inline\" title=\"Hopeless\"><input type=\"checkbox\" name=\"checkbox-1[]\" value=\"Hopeless\" id=\"forminator-field-checkbox-1-9-69e2eb061f06c\" aria-labelledby=\"forminator-field-checkbox-1-9-69e2eb061f06c-label\" data-calculation=\"0\"   data-hidden-behavior=\"zero\"\/><span class=\"forminator-checkbox-box\" aria-hidden=\"true\"><\/span><span class=\"forminator-checkbox-label\">Hopeless<\/span><\/label><label id=\"forminator-field-checkbox-1-10-69e2eb061f06c-label\" for=\"forminator-field-checkbox-1-10-69e2eb061f06c\" class=\"forminator-checkbox forminator-checkbox-inline\" title=\"Paranoid\"><input type=\"checkbox\" name=\"checkbox-1[]\" value=\"Paranoid\" id=\"forminator-field-checkbox-1-10-69e2eb061f06c\" aria-labelledby=\"forminator-field-checkbox-1-10-69e2eb061f06c-label\" data-calculation=\"0\"   data-hidden-behavior=\"zero\"\/><span class=\"forminator-checkbox-box\" aria-hidden=\"true\"><\/span><span class=\"forminator-checkbox-label\">Paranoid<\/span><\/label><label id=\"forminator-field-checkbox-1-11-69e2eb061f06c-label\" for=\"forminator-field-checkbox-1-11-69e2eb061f06c\" class=\"forminator-checkbox forminator-checkbox-inline\" title=\"Overwhelmed\"><input type=\"checkbox\" name=\"checkbox-1[]\" value=\"Overwhelmed\" id=\"forminator-field-checkbox-1-11-69e2eb061f06c\" aria-labelledby=\"forminator-field-checkbox-1-11-69e2eb061f06c-label\" data-calculation=\"0\"   data-hidden-behavior=\"zero\"\/><span class=\"forminator-checkbox-box\" aria-hidden=\"true\"><\/span><span class=\"forminator-checkbox-label\">Overwhelmed<\/span><\/label><label id=\"forminator-field-checkbox-1-12-69e2eb061f06c-label\" for=\"forminator-field-checkbox-1-12-69e2eb061f06c\" class=\"forminator-checkbox forminator-checkbox-inline\" title=\"Muddled\"><input type=\"checkbox\" name=\"checkbox-1[]\" value=\"Muddled\" id=\"forminator-field-checkbox-1-12-69e2eb061f06c\" aria-labelledby=\"forminator-field-checkbox-1-12-69e2eb061f06c-label\" data-calculation=\"0\"   data-hidden-behavior=\"zero\"\/><span class=\"forminator-checkbox-box\" aria-hidden=\"true\"><\/span><span class=\"forminator-checkbox-label\">Muddled<\/span><\/label><label id=\"forminator-field-checkbox-1-13-69e2eb061f06c-label\" for=\"forminator-field-checkbox-1-13-69e2eb061f06c\" class=\"forminator-checkbox forminator-checkbox-inline\" title=\"Persecuted\"><input type=\"checkbox\" name=\"checkbox-1[]\" value=\"Persecuted\" id=\"forminator-field-checkbox-1-13-69e2eb061f06c\" aria-labelledby=\"forminator-field-checkbox-1-13-69e2eb061f06c-label\" data-calculation=\"0\"   data-hidden-behavior=\"zero\"\/><span class=\"forminator-checkbox-box\" aria-hidden=\"true\"><\/span><span class=\"forminator-checkbox-label\">Persecuted<\/span><\/label><label id=\"forminator-field-checkbox-1-14-69e2eb061f06c-label\" for=\"forminator-field-checkbox-1-14-69e2eb061f06c\" class=\"forminator-checkbox forminator-checkbox-inline\" title=\"Guilty\"><input type=\"checkbox\" name=\"checkbox-1[]\" value=\"Guilty\" id=\"forminator-field-checkbox-1-14-69e2eb061f06c\" aria-labelledby=\"forminator-field-checkbox-1-14-69e2eb061f06c-label\" data-calculation=\"0\"   data-hidden-behavior=\"zero\"\/><span class=\"forminator-checkbox-box\" aria-hidden=\"true\"><\/span><span class=\"forminator-checkbox-label\">Guilty<\/span><\/label><label id=\"forminator-field-checkbox-1-15-69e2eb061f06c-label\" for=\"forminator-field-checkbox-1-15-69e2eb061f06c\" class=\"forminator-checkbox forminator-checkbox-inline\" title=\"Easily irritated\"><input type=\"checkbox\" name=\"checkbox-1[]\" value=\"Easily-irritated\" id=\"forminator-field-checkbox-1-15-69e2eb061f06c\" aria-labelledby=\"forminator-field-checkbox-1-15-69e2eb061f06c-label\" data-calculation=\"0\"   data-hidden-behavior=\"zero\"\/><span class=\"forminator-checkbox-box\" aria-hidden=\"true\"><\/span><span class=\"forminator-checkbox-label\">Easily irritated<\/span><\/label><label id=\"forminator-field-checkbox-1-16-69e2eb061f06c-label\" for=\"forminator-field-checkbox-1-16-69e2eb061f06c\" class=\"forminator-checkbox forminator-checkbox-inline\" title=\"Anxious\"><input type=\"checkbox\" name=\"checkbox-1[]\" value=\"Anxious\" id=\"forminator-field-checkbox-1-16-69e2eb061f06c\" aria-labelledby=\"forminator-field-checkbox-1-16-69e2eb061f06c-label\" data-calculation=\"0\"   data-hidden-behavior=\"zero\"\/><span class=\"forminator-checkbox-box\" aria-hidden=\"true\"><\/span><span class=\"forminator-checkbox-label\">Anxious<\/span><\/label><label id=\"forminator-field-checkbox-1-17-69e2eb061f06c-label\" for=\"forminator-field-checkbox-1-17-69e2eb061f06c\" class=\"forminator-checkbox forminator-checkbox-inline\" title=\"Sad\"><input type=\"checkbox\" name=\"checkbox-1[]\" value=\"Sad\" id=\"forminator-field-checkbox-1-17-69e2eb061f06c\" aria-labelledby=\"forminator-field-checkbox-1-17-69e2eb061f06c-label\" data-calculation=\"0\"   data-hidden-behavior=\"zero\"\/><span class=\"forminator-checkbox-box\" aria-hidden=\"true\"><\/span><span class=\"forminator-checkbox-label\">Sad<\/span><\/label><label id=\"forminator-field-checkbox-1-18-69e2eb061f06c-label\" for=\"forminator-field-checkbox-1-18-69e2eb061f06c\" class=\"forminator-checkbox forminator-checkbox-inline\" title=\"Grieving\"><input type=\"checkbox\" name=\"checkbox-1[]\" value=\"Grieving\" id=\"forminator-field-checkbox-1-18-69e2eb061f06c\" aria-labelledby=\"forminator-field-checkbox-1-18-69e2eb061f06c-label\" data-calculation=\"0\"   data-hidden-behavior=\"zero\"\/><span class=\"forminator-checkbox-box\" aria-hidden=\"true\"><\/span><span class=\"forminator-checkbox-label\">Grieving<\/span><\/label><label id=\"forminator-field-checkbox-1-19-69e2eb061f06c-label\" for=\"forminator-field-checkbox-1-19-69e2eb061f06c\" class=\"forminator-checkbox forminator-checkbox-inline\" title=\"Unable to grieve\"><input type=\"checkbox\" name=\"checkbox-1[]\" value=\"Unable-to-grieve\" id=\"forminator-field-checkbox-1-19-69e2eb061f06c\" aria-labelledby=\"forminator-field-checkbox-1-19-69e2eb061f06c-label\" data-calculation=\"0\"   data-hidden-behavior=\"zero\"\/><span class=\"forminator-checkbox-box\" aria-hidden=\"true\"><\/span><span class=\"forminator-checkbox-label\">Unable to grieve<\/span><\/label><label id=\"forminator-field-checkbox-1-20-69e2eb061f06c-label\" for=\"forminator-field-checkbox-1-20-69e2eb061f06c\" class=\"forminator-checkbox forminator-checkbox-inline\" title=\"Apprehensive\"><input type=\"checkbox\" name=\"checkbox-1[]\" value=\"Apprehensive\" id=\"forminator-field-checkbox-1-20-69e2eb061f06c\" aria-labelledby=\"forminator-field-checkbox-1-20-69e2eb061f06c-label\" data-calculation=\"0\"   data-hidden-behavior=\"zero\"\/><span class=\"forminator-checkbox-box\" aria-hidden=\"true\"><\/span><span class=\"forminator-checkbox-label\">Apprehensive<\/span><\/label><label id=\"forminator-field-checkbox-1-21-69e2eb061f06c-label\" for=\"forminator-field-checkbox-1-21-69e2eb061f06c\" class=\"forminator-checkbox forminator-checkbox-inline\" title=\"Agitated\"><input type=\"checkbox\" name=\"checkbox-1[]\" value=\"Agitated\" id=\"forminator-field-checkbox-1-21-69e2eb061f06c\" aria-labelledby=\"forminator-field-checkbox-1-21-69e2eb061f06c-label\" data-calculation=\"0\"   data-hidden-behavior=\"zero\"\/><span class=\"forminator-checkbox-box\" aria-hidden=\"true\"><\/span><span class=\"forminator-checkbox-label\">Agitated<\/span><\/label><label id=\"forminator-field-checkbox-1-22-69e2eb061f06c-label\" for=\"forminator-field-checkbox-1-22-69e2eb061f06c\" class=\"forminator-checkbox forminator-checkbox-inline\" title=\"Uneasy\"><input type=\"checkbox\" name=\"checkbox-1[]\" value=\"Uneasy\" id=\"forminator-field-checkbox-1-22-69e2eb061f06c\" aria-labelledby=\"forminator-field-checkbox-1-22-69e2eb061f06c-label\" data-calculation=\"0\"   data-hidden-behavior=\"zero\"\/><span class=\"forminator-checkbox-box\" aria-hidden=\"true\"><\/span><span class=\"forminator-checkbox-label\">Uneasy<\/span><\/label><label id=\"forminator-field-checkbox-1-23-69e2eb061f06c-label\" for=\"forminator-field-checkbox-1-23-69e2eb061f06c\" class=\"forminator-checkbox forminator-checkbox-inline\" title=\"Distress\"><input type=\"checkbox\" name=\"checkbox-1[]\" value=\"Distress\" id=\"forminator-field-checkbox-1-23-69e2eb061f06c\" aria-labelledby=\"forminator-field-checkbox-1-23-69e2eb061f06c-label\" data-calculation=\"0\"   data-hidden-behavior=\"zero\"\/><span class=\"forminator-checkbox-box\" aria-hidden=\"true\"><\/span><span class=\"forminator-checkbox-label\">Distress<\/span><\/label><label id=\"forminator-field-checkbox-1-24-69e2eb061f06c-label\" for=\"forminator-field-checkbox-1-24-69e2eb061f06c\" class=\"forminator-checkbox forminator-checkbox-inline\" title=\"Fearful\"><input type=\"checkbox\" name=\"checkbox-1[]\" value=\"Fearful\" id=\"forminator-field-checkbox-1-24-69e2eb061f06c\" aria-labelledby=\"forminator-field-checkbox-1-24-69e2eb061f06c-label\" data-calculation=\"0\"   data-hidden-behavior=\"zero\"\/><span class=\"forminator-checkbox-box\" aria-hidden=\"true\"><\/span><span class=\"forminator-checkbox-label\">Fearful<\/span><\/label><label id=\"forminator-field-checkbox-1-25-69e2eb061f06c-label\" for=\"forminator-field-checkbox-1-25-69e2eb061f06c\" class=\"forminator-checkbox forminator-checkbox-inline\" title=\"Impatient\"><input type=\"checkbox\" name=\"checkbox-1[]\" value=\"Impatient\" id=\"forminator-field-checkbox-1-25-69e2eb061f06c\" aria-labelledby=\"forminator-field-checkbox-1-25-69e2eb061f06c-label\" data-calculation=\"0\"   data-hidden-behavior=\"zero\"\/><span class=\"forminator-checkbox-box\" aria-hidden=\"true\"><\/span><span class=\"forminator-checkbox-label\">Impatient<\/span><\/label><label id=\"forminator-field-checkbox-1-26-69e2eb061f06c-label\" for=\"forminator-field-checkbox-1-26-69e2eb061f06c\" class=\"forminator-checkbox forminator-checkbox-inline\" title=\"Intimidated\"><input type=\"checkbox\" name=\"checkbox-1[]\" value=\"Intimidated\" id=\"forminator-field-checkbox-1-26-69e2eb061f06c\" aria-labelledby=\"forminator-field-checkbox-1-26-69e2eb061f06c-label\" data-calculation=\"0\"   data-hidden-behavior=\"zero\"\/><span class=\"forminator-checkbox-box\" aria-hidden=\"true\"><\/span><span class=\"forminator-checkbox-label\">Intimidated<\/span><\/label><label id=\"forminator-field-checkbox-1-27-69e2eb061f06c-label\" for=\"forminator-field-checkbox-1-27-69e2eb061f06c\" class=\"forminator-checkbox forminator-checkbox-inline\" title=\"Restless\"><input type=\"checkbox\" name=\"checkbox-1[]\" value=\"Restless\" id=\"forminator-field-checkbox-1-27-69e2eb061f06c\" aria-labelledby=\"forminator-field-checkbox-1-27-69e2eb061f06c-label\" data-calculation=\"0\"   data-hidden-behavior=\"zero\"\/><span class=\"forminator-checkbox-box\" aria-hidden=\"true\"><\/span><span class=\"forminator-checkbox-label\">Restless<\/span><\/label><label id=\"forminator-field-checkbox-1-28-69e2eb061f06c-label\" for=\"forminator-field-checkbox-1-28-69e2eb061f06c\" class=\"forminator-checkbox forminator-checkbox-inline\" title=\"Panic\"><input type=\"checkbox\" name=\"checkbox-1[]\" value=\"Panic\" id=\"forminator-field-checkbox-1-28-69e2eb061f06c\" aria-labelledby=\"forminator-field-checkbox-1-28-69e2eb061f06c-label\" data-calculation=\"0\"   data-hidden-behavior=\"zero\"\/><span class=\"forminator-checkbox-box\" aria-hidden=\"true\"><\/span><span class=\"forminator-checkbox-label\">Panic<\/span><\/label><label id=\"forminator-field-checkbox-1-29-69e2eb061f06c-label\" for=\"forminator-field-checkbox-1-29-69e2eb061f06c\" class=\"forminator-checkbox forminator-checkbox-inline\" title=\"Intolerant\"><input type=\"checkbox\" name=\"checkbox-1[]\" value=\"Intolerant\" id=\"forminator-field-checkbox-1-29-69e2eb061f06c\" aria-labelledby=\"forminator-field-checkbox-1-29-69e2eb061f06c-label\" data-calculation=\"0\"   data-hidden-behavior=\"zero\"\/><span class=\"forminator-checkbox-box\" aria-hidden=\"true\"><\/span><span class=\"forminator-checkbox-label\">Intolerant<\/span><\/label><label id=\"forminator-field-checkbox-1-30-69e2eb061f06c-label\" for=\"forminator-field-checkbox-1-30-69e2eb061f06c\" class=\"forminator-checkbox forminator-checkbox-inline\" title=\"Uncertainty\"><input type=\"checkbox\" name=\"checkbox-1[]\" value=\"Uncertainty\" id=\"forminator-field-checkbox-1-30-69e2eb061f06c\" aria-labelledby=\"forminator-field-checkbox-1-30-69e2eb061f06c-label\" data-calculation=\"0\"   data-hidden-behavior=\"zero\"\/><span class=\"forminator-checkbox-box\" aria-hidden=\"true\"><\/span><span class=\"forminator-checkbox-label\">Uncertainty<\/span><\/label><label id=\"forminator-field-checkbox-1-31-69e2eb061f06c-label\" for=\"forminator-field-checkbox-1-31-69e2eb061f06c\" class=\"forminator-checkbox forminator-checkbox-inline\" title=\"Aggravated\"><input type=\"checkbox\" name=\"checkbox-1[]\" value=\"Aggravated\" id=\"forminator-field-checkbox-1-31-69e2eb061f06c\" aria-labelledby=\"forminator-field-checkbox-1-31-69e2eb061f06c-label\" data-calculation=\"0\"   data-hidden-behavior=\"zero\"\/><span class=\"forminator-checkbox-box\" aria-hidden=\"true\"><\/span><span class=\"forminator-checkbox-label\">Aggravated<\/span><\/label><label id=\"forminator-field-checkbox-1-32-69e2eb061f06c-label\" for=\"forminator-field-checkbox-1-32-69e2eb061f06c\" class=\"forminator-checkbox forminator-checkbox-inline\" title=\"Annoyed\"><input type=\"checkbox\" name=\"checkbox-1[]\" value=\"Annoyed\" id=\"forminator-field-checkbox-1-32-69e2eb061f06c\" aria-labelledby=\"forminator-field-checkbox-1-32-69e2eb061f06c-label\" data-calculation=\"0\"   data-hidden-behavior=\"zero\"\/><span class=\"forminator-checkbox-box\" aria-hidden=\"true\"><\/span><span class=\"forminator-checkbox-label\">Annoyed<\/span><\/label><label id=\"forminator-field-checkbox-1-33-69e2eb061f06c-label\" for=\"forminator-field-checkbox-1-33-69e2eb061f06c\" class=\"forminator-checkbox forminator-checkbox-inline\" title=\"Angry\"><input type=\"checkbox\" name=\"checkbox-1[]\" value=\"Angry\" id=\"forminator-field-checkbox-1-33-69e2eb061f06c\" aria-labelledby=\"forminator-field-checkbox-1-33-69e2eb061f06c-label\" data-calculation=\"0\"   data-hidden-behavior=\"zero\"\/><span class=\"forminator-checkbox-box\" aria-hidden=\"true\"><\/span><span class=\"forminator-checkbox-label\">Angry<\/span><\/label><label id=\"forminator-field-checkbox-1-34-69e2eb061f06c-label\" for=\"forminator-field-checkbox-1-34-69e2eb061f06c\" class=\"forminator-checkbox forminator-checkbox-inline\" title=\"Outraged\"><input type=\"checkbox\" name=\"checkbox-1[]\" value=\"Outraged\" id=\"forminator-field-checkbox-1-34-69e2eb061f06c\" aria-labelledby=\"forminator-field-checkbox-1-34-69e2eb061f06c-label\" data-calculation=\"0\"   data-hidden-behavior=\"zero\"\/><span class=\"forminator-checkbox-box\" aria-hidden=\"true\"><\/span><span class=\"forminator-checkbox-label\">Outraged<\/span><\/label><label id=\"forminator-field-checkbox-1-35-69e2eb061f06c-label\" for=\"forminator-field-checkbox-1-35-69e2eb061f06c\" class=\"forminator-checkbox forminator-checkbox-inline\" title=\"Nervous\"><input type=\"checkbox\" name=\"checkbox-1[]\" value=\"Nervous\" id=\"forminator-field-checkbox-1-35-69e2eb061f06c\" aria-labelledby=\"forminator-field-checkbox-1-35-69e2eb061f06c-label\" data-calculation=\"0\"   data-hidden-behavior=\"zero\"\/><span class=\"forminator-checkbox-box\" aria-hidden=\"true\"><\/span><span class=\"forminator-checkbox-label\">Nervous<\/span><\/label><label id=\"forminator-field-checkbox-1-36-69e2eb061f06c-label\" for=\"forminator-field-checkbox-1-36-69e2eb061f06c\" class=\"forminator-checkbox forminator-checkbox-inline\" title=\"Worried\"><input type=\"checkbox\" name=\"checkbox-1[]\" value=\"Worried\" id=\"forminator-field-checkbox-1-36-69e2eb061f06c\" aria-labelledby=\"forminator-field-checkbox-1-36-69e2eb061f06c-label\" data-calculation=\"0\"   data-hidden-behavior=\"zero\"\/><span class=\"forminator-checkbox-box\" aria-hidden=\"true\"><\/span><span class=\"forminator-checkbox-label\">Worried<\/span><\/label><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"radio-2\" class=\"forminator-field-radio forminator-col forminator-col-12 \"><div role=\"radiogroup\" class=\"forminator-field\" aria-labelledby=\"forminator-radiogroup-69e2eb061f06c-label\"><span id=\"forminator-radiogroup-69e2eb061f06c-label\" class=\"forminator-label\">My family stress is:<\/span><label id=\"forminator-field-radio-2-label-1\" for=\"forminator-field-radio-2-1-69e2eb061f06c\" class=\"forminator-radio forminator-radio-inline\" title=\"None\"><input type=\"radio\" name=\"radio-2\" value=\"none\" id=\"forminator-field-radio-2-1-69e2eb061f06c\" aria-labelledby=\"forminator-field-radio-2-label-1\" data-calculation=\"0\"   data-hidden-behavior=\"zero\"\/><span class=\"forminator-radio-bullet\" aria-hidden=\"true\"><\/span><span class=\"forminator-radio-label\">None<\/span><\/label><label id=\"forminator-field-radio-2-label-2\" for=\"forminator-field-radio-2-2-69e2eb061f06c\" class=\"forminator-radio forminator-radio-inline\" title=\"Minimal\"><input type=\"radio\" name=\"radio-2\" value=\"minimal\" id=\"forminator-field-radio-2-2-69e2eb061f06c\" aria-labelledby=\"forminator-field-radio-2-label-2\" data-calculation=\"0\"   data-hidden-behavior=\"zero\"\/><span class=\"forminator-radio-bullet\" aria-hidden=\"true\"><\/span><span class=\"forminator-radio-label\">Minimal<\/span><\/label><label id=\"forminator-field-radio-2-label-3\" for=\"forminator-field-radio-2-3-69e2eb061f06c\" class=\"forminator-radio forminator-radio-inline\" title=\"Moderate\"><input type=\"radio\" name=\"radio-2\" value=\"moderate\" id=\"forminator-field-radio-2-3-69e2eb061f06c\" aria-labelledby=\"forminator-field-radio-2-label-3\" data-calculation=\"0\"   data-hidden-behavior=\"zero\"\/><span class=\"forminator-radio-bullet\" aria-hidden=\"true\"><\/span><span class=\"forminator-radio-label\">Moderate<\/span><\/label><label id=\"forminator-field-radio-2-label-4\" for=\"forminator-field-radio-2-4-69e2eb061f06c\" class=\"forminator-radio forminator-radio-inline\" title=\"Severe\"><input type=\"radio\" name=\"radio-2\" value=\"severe\" id=\"forminator-field-radio-2-4-69e2eb061f06c\" aria-labelledby=\"forminator-field-radio-2-label-4\" data-calculation=\"0\"   data-hidden-behavior=\"zero\"\/><span class=\"forminator-radio-bullet\" aria-hidden=\"true\"><\/span><span class=\"forminator-radio-label\">Severe<\/span><\/label><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"radio-3\" class=\"forminator-field-radio forminator-col forminator-col-12 \"><div role=\"radiogroup\" class=\"forminator-field\" aria-labelledby=\"forminator-radiogroup-69e2eb061f06c-label\"><span id=\"forminator-radiogroup-69e2eb061f06c-label\" class=\"forminator-label\">My relationship stress is:<\/span><label id=\"forminator-field-radio-3-label-1\" for=\"forminator-field-radio-3-1-69e2eb061f06c\" class=\"forminator-radio forminator-radio-inline\" title=\"None\"><input type=\"radio\" name=\"radio-3\" value=\"none\" id=\"forminator-field-radio-3-1-69e2eb061f06c\" aria-labelledby=\"forminator-field-radio-3-label-1\" data-calculation=\"0\"   data-hidden-behavior=\"zero\"\/><span class=\"forminator-radio-bullet\" aria-hidden=\"true\"><\/span><span class=\"forminator-radio-label\">None<\/span><\/label><label id=\"forminator-field-radio-3-label-2\" for=\"forminator-field-radio-3-2-69e2eb061f06c\" class=\"forminator-radio forminator-radio-inline\" title=\"Minimal\"><input type=\"radio\" name=\"radio-3\" value=\"minimal\" id=\"forminator-field-radio-3-2-69e2eb061f06c\" aria-labelledby=\"forminator-field-radio-3-label-2\" data-calculation=\"0\"   data-hidden-behavior=\"zero\"\/><span class=\"forminator-radio-bullet\" aria-hidden=\"true\"><\/span><span class=\"forminator-radio-label\">Minimal<\/span><\/label><label id=\"forminator-field-radio-3-label-3\" for=\"forminator-field-radio-3-3-69e2eb061f06c\" class=\"forminator-radio forminator-radio-inline\" title=\"Moderate\"><input type=\"radio\" name=\"radio-3\" value=\"moderate\" id=\"forminator-field-radio-3-3-69e2eb061f06c\" aria-labelledby=\"forminator-field-radio-3-label-3\" data-calculation=\"0\"   data-hidden-behavior=\"zero\"\/><span class=\"forminator-radio-bullet\" aria-hidden=\"true\"><\/span><span class=\"forminator-radio-label\">Moderate<\/span><\/label><label id=\"forminator-field-radio-3-label-4\" for=\"forminator-field-radio-3-4-69e2eb061f06c\" class=\"forminator-radio forminator-radio-inline\" title=\"Severe\"><input type=\"radio\" name=\"radio-3\" value=\"severe\" id=\"forminator-field-radio-3-4-69e2eb061f06c\" aria-labelledby=\"forminator-field-radio-3-label-4\" data-calculation=\"0\"   data-hidden-behavior=\"zero\"\/><span class=\"forminator-radio-bullet\" aria-hidden=\"true\"><\/span><span class=\"forminator-radio-label\">Severe<\/span><\/label><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"radio-4\" class=\"forminator-field-radio forminator-col forminator-col-12 \"><div role=\"radiogroup\" class=\"forminator-field\" aria-labelledby=\"forminator-radiogroup-69e2eb061f06c-label\"><span id=\"forminator-radiogroup-69e2eb061f06c-label\" class=\"forminator-label\">My work stress is:<\/span><label id=\"forminator-field-radio-4-label-1\" for=\"forminator-field-radio-4-1-69e2eb061f06c\" class=\"forminator-radio forminator-radio-inline\" title=\"None\"><input type=\"radio\" name=\"radio-4\" value=\"none\" id=\"forminator-field-radio-4-1-69e2eb061f06c\" aria-labelledby=\"forminator-field-radio-4-label-1\" data-calculation=\"0\"   data-hidden-behavior=\"zero\"\/><span class=\"forminator-radio-bullet\" aria-hidden=\"true\"><\/span><span class=\"forminator-radio-label\">None<\/span><\/label><label id=\"forminator-field-radio-4-label-2\" for=\"forminator-field-radio-4-2-69e2eb061f06c\" class=\"forminator-radio forminator-radio-inline\" title=\"Minimal\"><input type=\"radio\" name=\"radio-4\" value=\"minimal\" id=\"forminator-field-radio-4-2-69e2eb061f06c\" aria-labelledby=\"forminator-field-radio-4-label-2\" data-calculation=\"0\"   data-hidden-behavior=\"zero\"\/><span class=\"forminator-radio-bullet\" aria-hidden=\"true\"><\/span><span class=\"forminator-radio-label\">Minimal<\/span><\/label><label id=\"forminator-field-radio-4-label-3\" for=\"forminator-field-radio-4-3-69e2eb061f06c\" class=\"forminator-radio forminator-radio-inline\" title=\"Moderate\"><input type=\"radio\" name=\"radio-4\" value=\"moderate\" id=\"forminator-field-radio-4-3-69e2eb061f06c\" aria-labelledby=\"forminator-field-radio-4-label-3\" data-calculation=\"0\"   data-hidden-behavior=\"zero\"\/><span class=\"forminator-radio-bullet\" aria-hidden=\"true\"><\/span><span class=\"forminator-radio-label\">Moderate<\/span><\/label><label id=\"forminator-field-radio-4-label-4\" for=\"forminator-field-radio-4-4-69e2eb061f06c\" class=\"forminator-radio forminator-radio-inline\" title=\"Severe\"><input type=\"radio\" name=\"radio-4\" value=\"severe\" id=\"forminator-field-radio-4-4-69e2eb061f06c\" aria-labelledby=\"forminator-field-radio-4-label-4\" data-calculation=\"0\"   data-hidden-behavior=\"zero\"\/><span class=\"forminator-radio-bullet\" aria-hidden=\"true\"><\/span><span class=\"forminator-radio-label\">Severe<\/span><\/label><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"radio-5\" class=\"forminator-field-radio forminator-col forminator-col-12 \"><div role=\"radiogroup\" class=\"forminator-field\" aria-labelledby=\"forminator-radiogroup-69e2eb061f06c-label\"><span id=\"forminator-radiogroup-69e2eb061f06c-label\" class=\"forminator-label\">My financial stress is:<\/span><label id=\"forminator-field-radio-5-label-1\" for=\"forminator-field-radio-5-1-69e2eb061f06c\" class=\"forminator-radio forminator-radio-inline\" title=\"None\"><input type=\"radio\" name=\"radio-5\" value=\"none\" id=\"forminator-field-radio-5-1-69e2eb061f06c\" aria-labelledby=\"forminator-field-radio-5-label-1\" data-calculation=\"0\"   data-hidden-behavior=\"zero\"\/><span class=\"forminator-radio-bullet\" aria-hidden=\"true\"><\/span><span class=\"forminator-radio-label\">None<\/span><\/label><label id=\"forminator-field-radio-5-label-2\" for=\"forminator-field-radio-5-2-69e2eb061f06c\" class=\"forminator-radio forminator-radio-inline\" title=\"Minimal\"><input type=\"radio\" name=\"radio-5\" value=\"minimal\" id=\"forminator-field-radio-5-2-69e2eb061f06c\" aria-labelledby=\"forminator-field-radio-5-label-2\" data-calculation=\"0\"   data-hidden-behavior=\"zero\"\/><span class=\"forminator-radio-bullet\" aria-hidden=\"true\"><\/span><span class=\"forminator-radio-label\">Minimal<\/span><\/label><label id=\"forminator-field-radio-5-label-3\" for=\"forminator-field-radio-5-3-69e2eb061f06c\" class=\"forminator-radio forminator-radio-inline\" title=\"Moderate\"><input type=\"radio\" name=\"radio-5\" value=\"moderate\" id=\"forminator-field-radio-5-3-69e2eb061f06c\" aria-labelledby=\"forminator-field-radio-5-label-3\" data-calculation=\"0\"   data-hidden-behavior=\"zero\"\/><span class=\"forminator-radio-bullet\" aria-hidden=\"true\"><\/span><span class=\"forminator-radio-label\">Moderate<\/span><\/label><label id=\"forminator-field-radio-5-label-4\" for=\"forminator-field-radio-5-4-69e2eb061f06c\" class=\"forminator-radio forminator-radio-inline\" title=\"Severe\"><input type=\"radio\" name=\"radio-5\" value=\"severe\" id=\"forminator-field-radio-5-4-69e2eb061f06c\" aria-labelledby=\"forminator-field-radio-5-label-4\" data-calculation=\"0\"   data-hidden-behavior=\"zero\"\/><span class=\"forminator-radio-bullet\" aria-hidden=\"true\"><\/span><span class=\"forminator-radio-label\">Severe<\/span><\/label><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"radio-6\" class=\"forminator-field-radio forminator-col forminator-col-12 \"><div role=\"radiogroup\" class=\"forminator-field\" aria-labelledby=\"forminator-radiogroup-69e2eb061f06c-label\"><span id=\"forminator-radiogroup-69e2eb061f06c-label\" class=\"forminator-label\">My health stress is:<\/span><label id=\"forminator-field-radio-6-label-1\" for=\"forminator-field-radio-6-1-69e2eb061f06c\" class=\"forminator-radio forminator-radio-inline\" title=\"None\"><input type=\"radio\" name=\"radio-6\" value=\"none\" id=\"forminator-field-radio-6-1-69e2eb061f06c\" aria-labelledby=\"forminator-field-radio-6-label-1\" data-calculation=\"0\"   data-hidden-behavior=\"zero\"\/><span class=\"forminator-radio-bullet\" aria-hidden=\"true\"><\/span><span class=\"forminator-radio-label\">None<\/span><\/label><label id=\"forminator-field-radio-6-label-2\" for=\"forminator-field-radio-6-2-69e2eb061f06c\" class=\"forminator-radio forminator-radio-inline\" title=\"Minimal\"><input type=\"radio\" name=\"radio-6\" value=\"minimal\" id=\"forminator-field-radio-6-2-69e2eb061f06c\" aria-labelledby=\"forminator-field-radio-6-label-2\" data-calculation=\"0\"   data-hidden-behavior=\"zero\"\/><span class=\"forminator-radio-bullet\" aria-hidden=\"true\"><\/span><span class=\"forminator-radio-label\">Minimal<\/span><\/label><label id=\"forminator-field-radio-6-label-3\" for=\"forminator-field-radio-6-3-69e2eb061f06c\" class=\"forminator-radio forminator-radio-inline\" title=\"Moderate\"><input type=\"radio\" name=\"radio-6\" value=\"moderate\" id=\"forminator-field-radio-6-3-69e2eb061f06c\" aria-labelledby=\"forminator-field-radio-6-label-3\" data-calculation=\"0\"   data-hidden-behavior=\"zero\"\/><span class=\"forminator-radio-bullet\" aria-hidden=\"true\"><\/span><span class=\"forminator-radio-label\">Moderate<\/span><\/label><label id=\"forminator-field-radio-6-label-4\" for=\"forminator-field-radio-6-4-69e2eb061f06c\" class=\"forminator-radio forminator-radio-inline\" title=\"Severe\"><input type=\"radio\" name=\"radio-6\" value=\"severe\" id=\"forminator-field-radio-6-4-69e2eb061f06c\" aria-labelledby=\"forminator-field-radio-6-label-4\" data-calculation=\"0\"   data-hidden-behavior=\"zero\"\/><span class=\"forminator-radio-bullet\" aria-hidden=\"true\"><\/span><span class=\"forminator-radio-label\">Severe<\/span><\/label><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"radio-7\" class=\"forminator-field-radio forminator-col forminator-col-12 \"><div role=\"radiogroup\" class=\"forminator-field\" aria-labelledby=\"forminator-radiogroup-69e2eb061f06c-label\"><span id=\"forminator-radiogroup-69e2eb061f06c-label\" class=\"forminator-label\">Do you have chronic or acute pain\/discomfort in your body?<\/span><label id=\"forminator-field-radio-7-label-1\" for=\"forminator-field-radio-7-1-69e2eb061f06c\" class=\"forminator-radio\" title=\"Yes\"><input type=\"radio\" name=\"radio-7\" value=\"one\" id=\"forminator-field-radio-7-1-69e2eb061f06c\" aria-labelledby=\"forminator-field-radio-7-label-1\" data-calculation=\"0\"   data-hidden-behavior=\"zero\"\/><span class=\"forminator-radio-bullet\" aria-hidden=\"true\"><\/span><span class=\"forminator-radio-label\">Yes<\/span><\/label><label id=\"forminator-field-radio-7-label-2\" for=\"forminator-field-radio-7-2-69e2eb061f06c\" class=\"forminator-radio\" title=\"No\"><input type=\"radio\" name=\"radio-7\" value=\"two\" id=\"forminator-field-radio-7-2-69e2eb061f06c\" aria-labelledby=\"forminator-field-radio-7-label-2\" data-calculation=\"0\" checked=\"checked\"  data-hidden-behavior=\"zero\"\/><span class=\"forminator-radio-bullet\" aria-hidden=\"true\"><\/span><span class=\"forminator-radio-label\">No<\/span><\/label><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"textarea-10\" class=\"forminator-field-textarea forminator-col forminator-col-12 \"><div class=\"forminator-field\"><label for=\"forminator-field-textarea-10_69e2eb061f06c\" id=\"forminator-field-textarea-10_69e2eb061f06c-label\" class=\"forminator-label\">Please describe location, type of pain, and rate the pain from 1-10 with 1 being barely there and 10 being unbearable. List all areas of concern.<\/label><textarea name=\"textarea-10\" placeholder=\"Example: right back of shoulder, chronic tightness and aching, usual pain is 3 topping out at 6 some days\" id=\"forminator-field-textarea-10_69e2eb061f06c\" class=\"forminator-textarea\" rows=\"6\" style=\"min-height:140px;\" ><\/textarea><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"textarea-11\" class=\"forminator-field-textarea forminator-col forminator-col-12 \"><div class=\"forminator-field\"><label for=\"forminator-field-textarea-11_69e2eb061f06c\" id=\"forminator-field-textarea-11_69e2eb061f06c-label\" class=\"forminator-label\">Is there anything else you would like to share?<\/label><textarea name=\"textarea-11\" placeholder=\"\" id=\"forminator-field-textarea-11_69e2eb061f06c\" class=\"forminator-textarea\" rows=\"6\" style=\"min-height:140px;\" ><\/textarea><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"html-5\" class=\"forminator-field-html forminator-col forminator-col-12 \"><div class=\"forminator-field forminator-merge-tags\" data-field=\"html-5\"><label class=\"forminator-label\">Consent<\/label><p>I, {name-1-first-name} {name-1-last-name}, understand that the BodyTalk session(s) provided by Suzi Cook, Certified BodyTalk Practitioner is intended to enhance relaxation, increase communication within the areas of the body, and to educate me to possible energetic or emotional blocks that may create pain and disease. BodyTalk is non-invasive, safe, and objective. It utilizes the body\u2019s own innate intelligence to reestablish communication within itself. I understand that BodyTalk is not a substitute for medical treatment or medications. I am aware that the BodyTalk Practitioner does not diagnose illness or disease nor does the Practitioner prescribe medications.<\/p><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"text-1\" class=\"forminator-field-text forminator-col forminator-col-6 \"><div class=\"forminator-field\"><label for=\"forminator-field-text-1_69e2eb061f06c\" id=\"forminator-field-text-1_69e2eb061f06c-label\" class=\"forminator-label\">Signature <span class=\"forminator-required\">*<\/span><\/label><input type=\"text\" name=\"text-1\" value=\"\" placeholder=\"\" id=\"forminator-field-text-1_69e2eb061f06c\" class=\"forminator-input forminator-name--field\" data-required=\"1\" \/><\/div><\/div><div id=\"html-4\" class=\"forminator-field-html forminator-col forminator-col-6 \"><div class=\"forminator-field forminator-merge-tags\" data-field=\"html-4\"><label class=\"forminator-label\">Submission Date<\/label><p>04\/17\/2026<\/p><\/div><\/div><\/div><input type=\"hidden\" name=\"referer_url\" value=\"\" \/><div class=\"forminator-row forminator-row-last\"><div class=\"forminator-col\"><div class=\"forminator-field\"><button class=\"forminator-button forminator-button-submit\">Submit Signed Consent and Client Information Form<\/button><\/div><\/div><\/div><input type=\"hidden\" id=\"forminator_nonce\" name=\"forminator_nonce\" value=\"7b38cdd9b7\" \/><input type=\"hidden\" name=\"_wp_http_referer\" value=\"\/wellness\/wp-json\/wp\/v2\/pages\/220\" \/><input type=\"hidden\" name=\"form_id\" value=\"219\"><input type=\"hidden\" name=\"page_id\" value=\"220\"><input type=\"hidden\" name=\"form_type\" value=\"default\"><input type=\"hidden\" name=\"current_url\" value=\"https:\/\/choicebodytalk.ca\/wellness\/forms\/\"><input type=\"hidden\" name=\"render_id\" value=\"0\"><input type=\"hidden\" name=\"action\" value=\"forminator_submit_form_custom-forms\"><\/form>\n<p>[\/et_pb_text][\/et_pb_column][\/et_pb_row][\/et_pb_section][et_pb_section fb_built=&#8221;1&#8243; admin_label=&#8221;Footer&#8221; _builder_version=&#8221;4.27.4&#8243; background_color=&#8221;#345168&#8243; use_background_color_gradient=&#8221;on&#8221; background_color_gradient_stops=&#8221;#345168 5%|rgba(219,219,219,0) 100%&#8221; background_color_gradient_overlays_image=&#8221;on&#8221; background_color_gradient_start=&#8221;#345168&#8243; background_color_gradient_start_position=&#8221;5%&#8221; background_color_gradient_end=&#8221;rgba(219,219,219,0)&#8221; background_image=&#8221;https:\/\/choicebodytalk.ca\/wellness\/wp-content\/uploads\/2019\/03\/footprint-1021452_1920.jpg&#8221; custom_padding=&#8221;5%||3.1%||false|false&#8221; bottom_divider_flip=&#8221;horizontal&#8221; locked=&#8221;off&#8221; global_colors_info=&#8221;{}&#8221;][et_pb_row _builder_version=&#8221;4.16&#8243; locked=&#8221;off&#8221; global_colors_info=&#8221;{}&#8221;][et_pb_column type=&#8221;4_4&#8243; _builder_version=&#8221;4.16&#8243; custom_padding=&#8221;|||&#8221; global_colors_info=&#8221;{}&#8221; custom_padding__hover=&#8221;|||&#8221;][et_pb_text admin_label=&#8221;Title&#8221; _builder_version=&#8221;4.16&#8243; text_font=&#8221;Lato||||||||&#8221; text_font_size=&#8221;18px&#8221; text_line_height=&#8221;1.8em&#8221; link_font=&#8221;||||||||&#8221; ul_font=&#8221;||||||||&#8221; ol_font=&#8221;||||||||&#8221; quote_font=&#8221;||||||||&#8221; header_font=&#8221;||||||||&#8221; header_2_font=&#8221;Lato|700|||||||&#8221; header_2_font_size=&#8221;40px&#8221; header_2_letter_spacing=&#8221;1px&#8221; header_2_line_height=&#8221;1.5em&#8221; header_3_font=&#8221;||||||||&#8221; header_4_font=&#8221;||||||||&#8221; header_5_font=&#8221;||||||||&#8221; header_6_font=&#8221;Lato|700|||||||&#8221; header_6_font_size=&#8221;18px&#8221; header_6_letter_spacing=&#8221;1px&#8221; header_6_line_height=&#8221;1.8em&#8221; text_orientation=&#8221;center&#8221; background_layout=&#8221;dark&#8221; max_width=&#8221;700px&#8221; module_alignment=&#8221;center&#8221; header_2_font_size_tablet=&#8221;&#8221; header_2_font_size_phone=&#8221;22px&#8221; header_2_font_size_last_edited=&#8221;on|phone&#8221; global_colors_info=&#8221;{}&#8221;]<\/p>\n<h2>Don&#8217;t Wait Any Longer. Start Forging Your Own Path Today!<\/h2>\n<p>[\/et_pb_text][et_pb_image src=&#8221;https:\/\/choicebodytalk.ca\/wellness\/wp-content\/uploads\/2018\/08\/Choice-letterhead.png&#8221; title_text=&#8221;Choice letterhead&#8221; _builder_version=&#8221;4.27.4&#8243; _module_preset=&#8221;default&#8221; custom_padding=&#8221;|25%||25%|false|false&#8221; global_colors_info=&#8221;{}&#8221;][\/et_pb_image][\/et_pb_column][\/et_pb_row][\/et_pb_section]<\/p>\n","protected":false},"excerpt":{"rendered":"<p>Helping you healHi, I&#8217;m Suzi. I&#8217;m excited that we get to work together to create the next step in your journey to living the life you want to be living.Information and Consent Form <div class=\"forminator-ui forminator-custom-form forminator-custom-form-219 forminator-design--flat  forminator_ajax\" data-forminator-render=\"1\" data-form=\"forminator-module-219\" data-uid=\"69e2eb0684503\"><br\/><\/div><form\n\t\t\t\tid=\"forminator-module-219\"\n\t\t\t\tclass=\"forminator-ui forminator-custom-form forminator-custom-form-219 forminator-design--flat  forminator_ajax\"\n\t\t\t\tmethod=\"post\"\n\t\t\t\tdata-forminator-render=\"1\"\n\t\t\t\tdata-form-id=\"219\"\n\t\t\t\t\n\t\t\t\tdata-design=\"flat\"\n\t\t\t\t\n\t\t\t\t\n\t\t\t\t\n\t\t\t\tdata-grid=\"open\"\n\t\t\t\t\n\t\t\t\t\n\t\t\t\tstyle=\"display: none;\"\n\t\t\t\t\n\t\t\t\tdata-uid=\"69e2eb0684503\"\n\t\t\t><div role=\"alert\" aria-live=\"polite\" class=\"forminator-response-message forminator-error\" aria-hidden=\"true\"><\/div><div class=\"forminator-row\"><div id=\"name-1\" class=\"forminator-field-name forminator-col forminator-col-12 \"><div class=\"forminator-row forminator-no-margin\" data-multiple=\"true\"><div class=\"forminator-col forminator-col-md-6\"><div class=\"forminator-field\"><label for=\"forminator-field-first-name-1_69e2eb0684503\" id=\"forminator-field-first-name-1_69e2eb0684503-label\" class=\"forminator-label\">First Name <span class=\"forminator-required\">*<\/span><\/label><input type=\"text\" name=\"name-1-first-name\" placeholder=\"E.g. Pat\" id=\"forminator-field-first-name-1_69e2eb0684503\" class=\"forminator-input\" aria-required=\"true\" data-multi=\"1\" value=\"\" \/><\/div><\/div><div class=\"forminator-col forminator-col-md-6\"><div class=\"forminator-field\"><label for=\"forminator-field-last-name-1_69e2eb0684503\" id=\"forminator-field-last-name-1_69e2eb0684503-label\" class=\"forminator-label\">Last Name <span class=\"forminator-required\">*<\/span><\/label><input type=\"text\" name=\"name-1-last-name\" placeholder=\"E.g. Doe\" id=\"forminator-field-last-name-1_69e2eb0684503\" class=\"forminator-input\" aria-required=\"true\" data-multi=\"1\" value=\"\" \/><\/div><\/div><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"phone-1\" class=\"forminator-field-phone forminator-col forminator-col-6 \"><div class=\"forminator-field\"><label for=\"forminator-field-phone-1_69e2eb0684503\" id=\"forminator-field-phone-1_69e2eb0684503-label\" class=\"forminator-label\">Primary Phone Number <span class=\"forminator-required\">*<\/span><\/label><input type=\"text\" name=\"phone-1\" value=\"\" placeholder=\"E.g. +1 300 400 5000\" id=\"forminator-field-phone-1_69e2eb0684503\" class=\"forminator-input forminator-field--phone\" data-required=\"1\" aria-required=\"true\" autocomplete=\"off\" \/><\/div><\/div><div id=\"phone-2\" class=\"forminator-field-phone forminator-col forminator-col-6 \"><div class=\"forminator-field\"><label for=\"forminator-field-phone-2_69e2eb0684503\" id=\"forminator-field-phone-2_69e2eb0684503-label\" class=\"forminator-label\">Secondary Phone Number<\/label><input type=\"text\" name=\"phone-2\" value=\"\" placeholder=\"E.g. +1 300 400 5000\" id=\"forminator-field-phone-2_69e2eb0684503\" class=\"forminator-input forminator-field--phone\" data-required=\"\" aria-required=\"false\" autocomplete=\"off\" \/><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"email-1\" class=\"forminator-field-email forminator-col forminator-col-12 \"><div class=\"forminator-field\"><label for=\"forminator-field-email-1_69e2eb0684503\" id=\"forminator-field-email-1_69e2eb0684503-label\" class=\"forminator-label\">Email Address <span class=\"forminator-required\">*<\/span><\/label><input type=\"email\" name=\"email-1\" value=\"\" placeholder=\"E.g. john@doe.com\" id=\"forminator-field-email-1_69e2eb0684503\" class=\"forminator-input forminator-email--field\" data-required=\"1\" aria-required=\"true\" \/><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"address-1\" class=\"forminator-field-address forminator-col forminator-col-12 \"><div class=\"forminator-row\"><div id=\"address-1-street_address\" class=\"forminator-col\"><div class=\"forminator-field\"><label for=\"forminator-field-address-1-street_address_69e2eb0684503\" id=\"forminator-field-address-1-street_address_69e2eb0684503-label\" class=\"forminator-label\">Street Address <span class=\"forminator-required\">*<\/span><\/label><input type=\"text\" name=\"address-1-street_address\" placeholder=\"E.g. 42 Wallaby Way\" id=\"forminator-field-address-1-street_address_69e2eb0684503\" class=\"forminator-input\" data-required=\"1\" aria-required=\"true\" value=\"\" \/><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"address-1-address_line\" class=\"forminator-col\"><div class=\"forminator-field\"><label for=\"forminator-field-address-1-address_line_69e2eb0684503\" id=\"forminator-field-address-1-address_line_69e2eb0684503-label\" class=\"forminator-label\">Apartment, suite, etc<\/label><input type=\"text\" name=\"address-1-address_line\" placeholder=\"\" id=\"forminator-field-address-1-address_line_69e2eb0684503\" class=\"forminator-input\" data-required=\"\" aria-required=\"false\" value=\"\" \/><\/div><\/div><\/div><div class=\"forminator-row\" data-multiple=\"true\"><div id=\"address-1-city\" class=\"forminator-col forminator-col-6\"><div class=\"forminator-field\"><label for=\"forminator-field-address-1-city_69e2eb0684503\" id=\"forminator-field-address-1-city_69e2eb0684503-label\" class=\"forminator-label\">City <span class=\"forminator-required\">*<\/span><\/label><input type=\"text\" name=\"address-1-city\" placeholder=\"E.g. Sydney\" id=\"forminator-field-address-1-city_69e2eb0684503\" class=\"forminator-input\" data-required=\"1\" aria-required=\"true\" value=\"\" \/><\/div><\/div><div id=\"address-1-state\" class=\"forminator-col forminator-col-6\"><div class=\"forminator-field\"><label for=\"forminator-field-address-1-state_69e2eb0684503\" id=\"forminator-field-address-1-state_69e2eb0684503-label\" class=\"forminator-label\">State\/Province<\/label><input type=\"text\" name=\"address-1-state\" placeholder=\"E.g. New South Wales\" id=\"forminator-field-address-1-state_69e2eb0684503\" class=\"forminator-input\" data-required=\"\" aria-required=\"false\" value=\"\" \/><\/div><\/div><\/div><div class=\"forminator-row\" data-multiple=\"true\"><div id=\"address-1-zip\" class=\"forminator-col forminator-col-6\"><div class=\"forminator-field\"><label for=\"forminator-field-address-1-zip_69e2eb0684503\" id=\"forminator-field-address-1-zip_69e2eb0684503-label\" class=\"forminator-label\">ZIP \/ Postal Code<\/label><input type=\"text\" name=\"address-1-zip\" placeholder=\"E.g. 2000\" id=\"forminator-field-address-1-zip_69e2eb0684503\" class=\"forminator-input\" value=\"\" \/><\/div><\/div><div id=\"address-1-country\" class=\"forminator-col forminator-col-6\"><div class=\"forminator-field\"><label for=\"forminator-field-219__field--address-1-country_69e2eb0684503\" id=\"forminator-field-219__field--address-1-country_69e2eb0684503-label\" class=\"forminator-label\">Country <span class=\"forminator-required\">*<\/span><\/label><select name=\"address-1-country\" id=\"forminator-field-219__field--address-1-country_69e2eb0684503\" class=\"forminator-select2\" data-search=\"true\" data-placeholder=\"Select country\" data-default-value=\"\"><option value=\"\" data-country-code=\"\" selected=\"selected\"><\/option><option value=\"Afghanistan\" data-country-code=\"AF\" >Afghanistan<\/option><option value=\"Albania\" data-country-code=\"AL\" >Albania<\/option><option value=\"Algeria\" data-country-code=\"DZ\" >Algeria<\/option><option value=\"American Samoa\" data-country-code=\"AS\" >American Samoa<\/option><option value=\"Andorra\" data-country-code=\"AD\" >Andorra<\/option><option value=\"Angola\" data-country-code=\"AO\" >Angola<\/option><option value=\"Anguilla\" data-country-code=\"AI\" >Anguilla<\/option><option value=\"Antarctica\" data-country-code=\"AQ\" >Antarctica<\/option><option value=\"Antigua and Barbuda\" data-country-code=\"AG\" >Antigua and Barbuda<\/option><option value=\"Argentina\" data-country-code=\"AR\" >Argentina<\/option><option value=\"Armenia\" data-country-code=\"AM\" >Armenia<\/option><option value=\"Australia\" data-country-code=\"AU\" >Australia<\/option><option value=\"Aruba\" data-country-code=\"AW\" >Aruba<\/option><option value=\"Austria\" data-country-code=\"AT\" >Austria<\/option><option value=\"Azerbaijan\" data-country-code=\"AZ\" >Azerbaijan<\/option><option value=\"Bahamas\" data-country-code=\"BS\" >Bahamas<\/option><option value=\"Bahrain\" data-country-code=\"BH\" >Bahrain<\/option><option value=\"Bangladesh\" data-country-code=\"BD\" >Bangladesh<\/option><option value=\"Barbados\" data-country-code=\"BB\" >Barbados<\/option><option value=\"Belarus\" data-country-code=\"BY\" >Belarus<\/option><option value=\"Belgium\" data-country-code=\"BE\" >Belgium<\/option><option value=\"Belize\" data-country-code=\"BZ\" >Belize<\/option><option value=\"Benin\" data-country-code=\"BJ\" >Benin<\/option><option value=\"Bermuda\" data-country-code=\"BM\" >Bermuda<\/option><option value=\"Bhutan\" data-country-code=\"BT\" >Bhutan<\/option><option value=\"Bolivia\" data-country-code=\"BO\" >Bolivia<\/option><option value=\"Bosnia and Herzegovina\" data-country-code=\"BA\" >Bosnia and Herzegovina<\/option><option value=\"Botswana\" data-country-code=\"BW\" >Botswana<\/option><option value=\"Bouvet Island\" data-country-code=\"BV\" >Bouvet Island<\/option><option value=\"Brazil\" data-country-code=\"BR\" >Brazil<\/option><option value=\"British Indian Ocean Territory\" data-country-code=\"IO\" >British Indian Ocean Territory<\/option><option value=\"Brunei\" data-country-code=\"BN\" >Brunei<\/option><option value=\"Bulgaria\" data-country-code=\"BG\" >Bulgaria<\/option><option value=\"Burkina Faso\" data-country-code=\"BF\" >Burkina Faso<\/option><option value=\"Burundi\" data-country-code=\"BI\" >Burundi<\/option><option value=\"Cambodia\" data-country-code=\"KH\" >Cambodia<\/option><option value=\"Cameroon\" data-country-code=\"CM\" >Cameroon<\/option><option value=\"Canada\" data-country-code=\"CA\" >Canada<\/option><option value=\"Cabo Verde\" data-country-code=\"CV\" >Cabo Verde<\/option><option value=\"Cayman Islands\" data-country-code=\"KY\" >Cayman Islands<\/option><option value=\"Central African Republic\" data-country-code=\"CF\" >Central African Republic<\/option><option value=\"Chad\" data-country-code=\"TD\" >Chad<\/option><option value=\"Chile\" data-country-code=\"CL\" >Chile<\/option><option value=\"China, People's Republic of\" data-country-code=\"CN\" >China, People's Republic of<\/option><option value=\"Christmas Island\" data-country-code=\"CX\" >Christmas Island<\/option><option value=\"Cocos Islands\" data-country-code=\"CC\" >Cocos Islands<\/option><option value=\"Colombia\" data-country-code=\"CO\" >Colombia<\/option><option value=\"Comoros\" data-country-code=\"KM\" >Comoros<\/option><option value=\"Congo, Democratic Republic of the\" data-country-code=\"CD\" >Congo, Democratic Republic of the<\/option><option value=\"Congo, Republic of the\" data-country-code=\"CG\" >Congo, Republic of the<\/option><option value=\"Cook Islands\" data-country-code=\"CK\" >Cook Islands<\/option><option value=\"Costa Rica\" data-country-code=\"CR\" >Costa Rica<\/option><option value=\"C\u00f4te d'Ivoire\" data-country-code=\"CI\" >C\u00f4te d'Ivoire<\/option><option value=\"Croatia\" data-country-code=\"HR\" >Croatia<\/option><option value=\"Cuba\" data-country-code=\"CU\" >Cuba<\/option><option value=\"Cura\u00e7ao\" data-country-code=\"CW\" >Cura\u00e7ao<\/option><option value=\"Cyprus\" data-country-code=\"CY\" >Cyprus<\/option><option value=\"Czech Republic\" data-country-code=\"CZ\" >Czech Republic<\/option><option value=\"Denmark\" data-country-code=\"DK\" >Denmark<\/option><option value=\"Djibouti\" data-country-code=\"DJ\" >Djibouti<\/option><option value=\"Dominica\" data-country-code=\"DM\" >Dominica<\/option><option value=\"Dominican Republic\" data-country-code=\"DO\" >Dominican Republic<\/option><option value=\"East Timor\" data-country-code=\"TL\" >East Timor<\/option><option value=\"Ecuador\" data-country-code=\"EC\" >Ecuador<\/option><option value=\"Egypt\" data-country-code=\"EG\" >Egypt<\/option><option value=\"El Salvador\" data-country-code=\"SV\" >El Salvador<\/option><option value=\"Equatorial Guinea\" data-country-code=\"GQ\" >Equatorial Guinea<\/option><option value=\"Eritrea\" data-country-code=\"ER\" >Eritrea<\/option><option value=\"Estonia\" data-country-code=\"EE\" >Estonia<\/option><option value=\"Ethiopia\" data-country-code=\"ET\" >Ethiopia<\/option><option value=\"Falkland Islands\" data-country-code=\"FK\" >Falkland Islands<\/option><option value=\"Faroe Islands\" data-country-code=\"FO\" >Faroe Islands<\/option><option value=\"Fiji\" data-country-code=\"FJ\" >Fiji<\/option><option value=\"Finland\" data-country-code=\"FI\" >Finland<\/option><option value=\"France\" data-country-code=\"FR\" >France<\/option><option value=\"France, Metropolitan\" data-country-code=\"FX\" >France, Metropolitan<\/option><option value=\"French Guiana\" data-country-code=\"GF\" >French Guiana<\/option><option value=\"French Polynesia\" data-country-code=\"PF\" >French Polynesia<\/option><option value=\"French South Territories\" data-country-code=\"TF\" >French South Territories<\/option><option value=\"Gabon\" data-country-code=\"GA\" >Gabon<\/option><option value=\"Gambia\" data-country-code=\"GM\" >Gambia<\/option><option value=\"Georgia\" data-country-code=\"GE\" >Georgia<\/option><option value=\"Germany\" data-country-code=\"DE\" >Germany<\/option><option value=\"Guernsey\" data-country-code=\"GG\" >Guernsey<\/option><option value=\"Ghana\" data-country-code=\"GH\" >Ghana<\/option><option value=\"Gibraltar\" data-country-code=\"GI\" >Gibraltar<\/option><option value=\"Greece\" data-country-code=\"GR\" >Greece<\/option><option value=\"Greenland\" data-country-code=\"GL\" >Greenland<\/option><option value=\"Grenada\" data-country-code=\"GD\" >Grenada<\/option><option value=\"Guadeloupe\" data-country-code=\"GP\" >Guadeloupe<\/option><option value=\"Guam\" data-country-code=\"GU\" >Guam<\/option><option value=\"Guatemala\" data-country-code=\"GT\" >Guatemala<\/option><option value=\"Guinea\" data-country-code=\"GN\" >Guinea<\/option><option value=\"Guinea-Bissau\" data-country-code=\"GW\" >Guinea-Bissau<\/option><option value=\"Guyana\" data-country-code=\"GY\" >Guyana<\/option><option value=\"Haiti\" data-country-code=\"HT\" >Haiti<\/option><option value=\"Heard Island And Mcdonald Island\" data-country-code=\"HM\" >Heard Island And Mcdonald Island<\/option><option value=\"Honduras\" data-country-code=\"HN\" >Honduras<\/option><option value=\"Hong Kong\" data-country-code=\"HK\" >Hong Kong<\/option><option value=\"Hungary\" data-country-code=\"HU\" >Hungary<\/option><option value=\"Iceland\" data-country-code=\"IS\" >Iceland<\/option><option value=\"India\" data-country-code=\"IN\" >India<\/option><option value=\"Indonesia\" data-country-code=\"ID\" >Indonesia<\/option><option value=\"Iran\" data-country-code=\"IR\" >Iran<\/option><option value=\"Iraq\" data-country-code=\"IQ\" >Iraq<\/option><option value=\"Ireland\" data-country-code=\"IE\" >Ireland<\/option><option value=\"Israel\" data-country-code=\"IL\" >Israel<\/option><option value=\"Italy\" data-country-code=\"IT\" >Italy<\/option><option value=\"Jamaica\" data-country-code=\"JM\" >Jamaica<\/option><option value=\"Japan\" data-country-code=\"JP\" >Japan<\/option><option value=\"Jersey\" data-country-code=\"JE\" >Jersey<\/option><option value=\"Johnston Island\" data-country-code=\"JT\" >Johnston Island<\/option><option value=\"Jordan\" data-country-code=\"JO\" >Jordan<\/option><option value=\"Kazakhstan\" data-country-code=\"KZ\" >Kazakhstan<\/option><option value=\"Kenya\" data-country-code=\"KE\" >Kenya<\/option><option value=\"Kiribati\" data-country-code=\"KI\" >Kiribati<\/option><option value=\"Korea, Democratic People's Republic of\" data-country-code=\"KP\" >Korea, Democratic People's Republic of<\/option><option value=\"Korea, Republic of\" data-country-code=\"KR\" >Korea, Republic of<\/option><option value=\"Kosovo\" data-country-code=\"XK\" >Kosovo<\/option><option value=\"Kuwait\" data-country-code=\"KW\" >Kuwait<\/option><option value=\"Kyrgyzstan\" data-country-code=\"KG\" >Kyrgyzstan<\/option><option value=\"Lao People's Democratic Republic\" data-country-code=\"LA\" >Lao People's Democratic Republic<\/option><option value=\"Latvia\" data-country-code=\"LV\" >Latvia<\/option><option value=\"Lebanon\" data-country-code=\"LB\" >Lebanon<\/option><option value=\"Lesotho\" data-country-code=\"LS\" >Lesotho<\/option><option value=\"Liberia\" data-country-code=\"LR\" >Liberia<\/option><option value=\"Libya\" data-country-code=\"LY\" >Libya<\/option><option value=\"Liechtenstein\" data-country-code=\"LI\" >Liechtenstein<\/option><option value=\"Lithuania\" data-country-code=\"LT\" >Lithuania<\/option><option value=\"Luxembourg\" data-country-code=\"LU\" >Luxembourg<\/option><option value=\"Macau\" data-country-code=\"MO\" >Macau<\/option><option value=\"North Macedonia\" data-country-code=\"MK\" >North Macedonia<\/option><option value=\"Madagascar\" data-country-code=\"MG\" >Madagascar<\/option><option value=\"Malawi\" data-country-code=\"MW\" >Malawi<\/option><option value=\"Malaysia\" data-country-code=\"MY\" >Malaysia<\/option><option value=\"Maldives\" data-country-code=\"MV\" >Maldives<\/option><option value=\"Mali\" data-country-code=\"ML\" >Mali<\/option><option value=\"Malta\" data-country-code=\"MT\" >Malta<\/option><option value=\"Marshall Islands\" data-country-code=\"MH\" >Marshall Islands<\/option><option value=\"Martinique\" data-country-code=\"MQ\" >Martinique<\/option><option value=\"Mauritania\" data-country-code=\"MR\" >Mauritania<\/option><option value=\"Mauritius\" data-country-code=\"MU\" >Mauritius<\/option><option value=\"Mayotte\" data-country-code=\"YT\" >Mayotte<\/option><option value=\"Mexico\" data-country-code=\"MX\" >Mexico<\/option><option value=\"Micronesia\" data-country-code=\"FM\" >Micronesia<\/option><option value=\"Moldova\" data-country-code=\"MD\" >Moldova<\/option><option value=\"Monaco\" data-country-code=\"MC\" >Monaco<\/option><option value=\"Mongolia\" data-country-code=\"MN\" >Mongolia<\/option><option value=\"Montserrat\" data-country-code=\"MS\" >Montserrat<\/option><option value=\"Montenegro\" data-country-code=\"ME\" >Montenegro<\/option><option value=\"Morocco\" data-country-code=\"MA\" >Morocco<\/option><option value=\"Mozambique\" data-country-code=\"MZ\" >Mozambique<\/option><option value=\"Myanmar\" data-country-code=\"MM\" >Myanmar<\/option><option value=\"Namibia\" data-country-code=\"NA\" >Namibia<\/option><option value=\"Nauru\" data-country-code=\"NR\" >Nauru<\/option><option value=\"Nepal\" data-country-code=\"NP\" >Nepal<\/option><option value=\"Netherlands\" data-country-code=\"NL\" >Netherlands<\/option><option value=\"Netherlands Antilles\" data-country-code=\"AN\" >Netherlands Antilles<\/option><option value=\"New Caledonia\" data-country-code=\"NC\" >New Caledonia<\/option><option value=\"New Zealand\" data-country-code=\"NZ\" >New Zealand<\/option><option value=\"Nicaragua\" data-country-code=\"NI\" >Nicaragua<\/option><option value=\"Niger\" data-country-code=\"NE\" >Niger<\/option><option value=\"Nigeria\" data-country-code=\"NG\" >Nigeria<\/option><option value=\"Niue\" data-country-code=\"NU\" >Niue<\/option><option value=\"Norfolk Island\" data-country-code=\"NF\" >Norfolk Island<\/option><option value=\"Northern Mariana Islands\" data-country-code=\"MP\" >Northern Mariana Islands<\/option><option value=\"Norway\" data-country-code=\"NO\" >Norway<\/option><option value=\"Oman\" data-country-code=\"OM\" >Oman<\/option><option value=\"Pakistan\" data-country-code=\"PK\" >Pakistan<\/option><option value=\"Palau\" data-country-code=\"PW\" >Palau<\/option><option value=\"Palestine, State of\" data-country-code=\"PS\" >Palestine, State of<\/option><option value=\"Panama\" data-country-code=\"PA\" >Panama<\/option><option value=\"Papua New Guinea\" data-country-code=\"PG\" >Papua New Guinea<\/option><option value=\"Paraguay\" data-country-code=\"PY\" >Paraguay<\/option><option value=\"Peru\" data-country-code=\"PE\" >Peru<\/option><option value=\"Philippines\" data-country-code=\"PH\" >Philippines<\/option><option value=\"Pitcairn Islands\" data-country-code=\"PN\" >Pitcairn Islands<\/option><option value=\"Poland\" data-country-code=\"PL\" >Poland<\/option><option value=\"Portugal\" data-country-code=\"PT\" >Portugal<\/option><option value=\"Puerto Rico\" data-country-code=\"PR\" >Puerto Rico<\/option><option value=\"Qatar\" data-country-code=\"QA\" >Qatar<\/option><option value=\"Reunion Island\" data-country-code=\"RE\" >Reunion Island<\/option><option value=\"Romania\" data-country-code=\"RO\" >Romania<\/option><option value=\"Russia\" data-country-code=\"RU\" >Russia<\/option><option value=\"Rwanda\" data-country-code=\"RW\" >Rwanda<\/option><option value=\"Saint Kitts and Nevis\" data-country-code=\"KN\" >Saint Kitts and Nevis<\/option><option value=\"Saint Lucia\" data-country-code=\"LC\" >Saint Lucia<\/option><option value=\"Saint Vincent and the Grenadines\" data-country-code=\"VC\" >Saint Vincent and the Grenadines<\/option><option value=\"Samoa\" data-country-code=\"WS\" >Samoa<\/option><option value=\"Saint Helena\" data-country-code=\"SH\" >Saint Helena<\/option><option value=\"Saint Pierre & Miquelon\" data-country-code=\"PM\" >Saint Pierre & Miquelon<\/option><option value=\"San Marino\" data-country-code=\"SM\" >San Marino<\/option><option value=\"Sao Tome and Principe\" data-country-code=\"ST\" >Sao Tome and Principe<\/option><option value=\"Saudi Arabia\" data-country-code=\"SA\" >Saudi Arabia<\/option><option value=\"Senegal\" data-country-code=\"SN\" >Senegal<\/option><option value=\"Serbia\" data-country-code=\"RS\" >Serbia<\/option><option value=\"Seychelles\" data-country-code=\"SC\" >Seychelles<\/option><option value=\"Sierra Leone\" data-country-code=\"SL\" >Sierra Leone<\/option><option value=\"Singapore\" data-country-code=\"SG\" >Singapore<\/option><option value=\"Sint Maarten\" data-country-code=\"MF\" >Sint Maarten<\/option><option value=\"Slovakia\" data-country-code=\"SK\" >Slovakia<\/option><option value=\"Slovenia\" data-country-code=\"SI\" >Slovenia<\/option><option value=\"Solomon Islands\" data-country-code=\"SB\" >Solomon Islands<\/option><option value=\"Somalia\" data-country-code=\"SO\" >Somalia<\/option><option value=\"South Africa\" data-country-code=\"ZA\" >South Africa<\/option><option value=\"South Georgia and South Sandwich\" data-country-code=\"GS\" >South Georgia and South Sandwich<\/option><option value=\"Spain\" data-country-code=\"ES\" >Spain<\/option><option value=\"Sri Lanka\" data-country-code=\"LK\" >Sri Lanka<\/option><option value=\"Stateless Persons\" data-country-code=\"XX\" >Stateless Persons<\/option><option value=\"Sudan\" data-country-code=\"SD\" >Sudan<\/option><option value=\"Sudan, South\" data-country-code=\"SS\" >Sudan, South<\/option><option value=\"Suriname\" data-country-code=\"SR\" >Suriname<\/option><option value=\"Svalbard and Jan Mayen\" data-country-code=\"SJ\" >Svalbard and Jan Mayen<\/option><option value=\"Swaziland\" data-country-code=\"SZ\" >Swaziland<\/option><option value=\"Sweden\" data-country-code=\"SE\" >Sweden<\/option><option value=\"Switzerland\" data-country-code=\"CH\" >Switzerland<\/option><option value=\"Syria\" data-country-code=\"SY\" >Syria<\/option><option value=\"Taiwan, Republic of China\" data-country-code=\"TW\" >Taiwan, Republic of China<\/option><option value=\"Tajikistan\" data-country-code=\"TJ\" >Tajikistan<\/option><option value=\"Tanzania\" data-country-code=\"TZ\" >Tanzania<\/option><option value=\"Thailand\" data-country-code=\"TH\" >Thailand<\/option><option value=\"Togo\" data-country-code=\"TG\" >Togo<\/option><option value=\"Tokelau\" data-country-code=\"TK\" >Tokelau<\/option><option value=\"Tonga\" data-country-code=\"TO\" >Tonga<\/option><option value=\"Trinidad and Tobago\" data-country-code=\"TT\" >Trinidad and Tobago<\/option><option value=\"Tunisia\" data-country-code=\"TN\" >Tunisia<\/option><option value=\"Turkey\" data-country-code=\"TR\" >Turkey<\/option><option value=\"Turkmenistan\" data-country-code=\"TM\" >Turkmenistan<\/option><option value=\"Turks And Caicos Islands\" data-country-code=\"TC\" >Turks And Caicos Islands<\/option><option value=\"Tuvalu\" data-country-code=\"TV\" >Tuvalu<\/option><option value=\"Uganda\" data-country-code=\"UG\" >Uganda<\/option><option value=\"Ukraine\" data-country-code=\"UA\" >Ukraine<\/option><option value=\"United Arab Emirates\" data-country-code=\"AE\" >United Arab Emirates<\/option><option value=\"United Kingdom\" data-country-code=\"GB\" >United Kingdom<\/option><option value=\"US Minor Outlying Islands\" data-country-code=\"UM\" >US Minor Outlying Islands<\/option><option value=\"United States of America (USA)\" data-country-code=\"US\" >United States of America (USA)<\/option><option value=\"Uruguay\" data-country-code=\"UY\" >Uruguay<\/option><option value=\"Uzbekistan\" data-country-code=\"UZ\" >Uzbekistan<\/option><option value=\"Vanuatu\" data-country-code=\"VU\" >Vanuatu<\/option><option value=\"Vatican City\" data-country-code=\"VA\" >Vatican City<\/option><option value=\"Venezuela\" data-country-code=\"VE\" >Venezuela<\/option><option value=\"Vietnam\" data-country-code=\"VN\" >Vietnam<\/option><option value=\"Virgin Islands, British\" data-country-code=\"VG\" >Virgin Islands, British<\/option><option value=\"Virgin Islands, U.S.\" data-country-code=\"VI\" >Virgin Islands, U.S.<\/option><option value=\"Wallis And Futuna Islands\" data-country-code=\"WF\" >Wallis And Futuna Islands<\/option><option value=\"Western Sahara\" data-country-code=\"EH\" >Western Sahara<\/option><option value=\"Yemen\" data-country-code=\"YE\" >Yemen<\/option><option value=\"Zambia\" data-country-code=\"ZM\" >Zambia<\/option><option value=\"Zimbabwe\" data-country-code=\"ZW\" >Zimbabwe<\/option><\/select><\/div><\/div><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"date-1\" class=\"forminator-field-date forminator-col forminator-col-12 \"><label for=\"forminator-field-date-1\" id=\"forminator-field-date-1-label\" class=\"forminator-label\">Date of Birth<\/label><div class=\"forminator-date-select\"><div class=\"forminator-row\" data-multiple=\"true\"><div id=\"date-1-month\" class=\"forminator-col\"><div class=\"forminator-field\"><label for=\"forminator-field-219__field--date-1-month_69e2eb0684503\" id=\"forminator-field-219__field--date-1-month_69e2eb0684503-label\" class=\"forminator-label\">Month<\/label><select name=\"date-1-month\" id=\"forminator-field-219__field--date-1-month_69e2eb0684503\" class=\"forminator-select2\" data-format=\"mm\/dd\/yy\" data-parent=\"date-1\" aria-labelledby=\"forminator-field-219__field--date-1-month_69e2eb0684503-label\" data-default-value=\"\"><option value=\"\" selected=\"selected\">Select month<\/option><option value=\"1\" >1<\/option><option value=\"2\" >2<\/option><option value=\"3\" >3<\/option><option value=\"4\" >4<\/option><option value=\"5\" >5<\/option><option value=\"6\" >6<\/option><option value=\"7\" >7<\/option><option value=\"8\" >8<\/option><option value=\"9\" >9<\/option><option value=\"10\" >10<\/option><option value=\"11\" >11<\/option><option value=\"12\" >12<\/option><\/select><\/div><\/div><div id=\"date-1-day\" class=\"forminator-col\"><div class=\"forminator-field\"><label for=\"forminator-field-219__field--date-1-day_69e2eb0684503\" id=\"forminator-field-219__field--date-1-day_69e2eb0684503-label\" class=\"forminator-label\">Day<\/label><select name=\"date-1-day\" id=\"forminator-field-219__field--date-1-day_69e2eb0684503\" class=\"forminator-select2\" data-format=\"mm\/dd\/yy\" data-parent=\"date-1\" aria-labelledby=\"forminator-field-219__field--date-1-day_69e2eb0684503-label\" data-default-value=\"\"><option value=\"\" selected=\"selected\">Select day<\/option><option value=\"1\" >1<\/option><option value=\"2\" >2<\/option><option value=\"3\" >3<\/option><option value=\"4\" >4<\/option><option value=\"5\" >5<\/option><option value=\"6\" >6<\/option><option value=\"7\" >7<\/option><option value=\"8\" >8<\/option><option value=\"9\" >9<\/option><option value=\"10\" >10<\/option><option value=\"11\" >11<\/option><option value=\"12\" >12<\/option><option value=\"13\" >13<\/option><option value=\"14\" >14<\/option><option value=\"15\" >15<\/option><option value=\"16\" >16<\/option><option value=\"17\" >17<\/option><option value=\"18\" >18<\/option><option value=\"19\" >19<\/option><option value=\"20\" >20<\/option><option value=\"21\" >21<\/option><option value=\"22\" >22<\/option><option value=\"23\" >23<\/option><option value=\"24\" >24<\/option><option value=\"25\" >25<\/option><option value=\"26\" >26<\/option><option value=\"27\" >27<\/option><option value=\"28\" >28<\/option><option value=\"29\" >29<\/option><option value=\"30\" >30<\/option><option value=\"31\" >31<\/option><\/select><\/div><\/div><div id=\"date-1-year\" class=\"forminator-col\"><div class=\"forminator-field\"><label for=\"forminator-field-219__field--date-1-year_69e2eb0684503\" id=\"forminator-field-219__field--date-1-year_69e2eb0684503-label\" class=\"forminator-label\">Year<\/label><select name=\"date-1-year\" id=\"forminator-field-219__field--date-1-year_69e2eb0684503\" class=\"forminator-select2\" data-format=\"mm\/dd\/yy\" data-parent=\"date-1\" aria-labelledby=\"forminator-field-219__field--date-1-year_69e2eb0684503-label\" data-default-value=\"2026\"><option value=\"\" >Select Year<\/option><option value=\"2126\" >2126<\/option><option value=\"2125\" >2125<\/option><option value=\"2124\" >2124<\/option><option value=\"2123\" >2123<\/option><option value=\"2122\" >2122<\/option><option value=\"2121\" >2121<\/option><option value=\"2120\" >2120<\/option><option value=\"2119\" >2119<\/option><option value=\"2118\" >2118<\/option><option value=\"2117\" >2117<\/option><option value=\"2116\" >2116<\/option><option value=\"2115\" >2115<\/option><option value=\"2114\" >2114<\/option><option value=\"2113\" >2113<\/option><option value=\"2112\" >2112<\/option><option value=\"2111\" >2111<\/option><option value=\"2110\" >2110<\/option><option value=\"2109\" >2109<\/option><option value=\"2108\" >2108<\/option><option value=\"2107\" >2107<\/option><option value=\"2106\" >2106<\/option><option value=\"2105\" >2105<\/option><option value=\"2104\" >2104<\/option><option value=\"2103\" >2103<\/option><option value=\"2102\" >2102<\/option><option value=\"2101\" >2101<\/option><option value=\"2100\" >2100<\/option><option value=\"2099\" >2099<\/option><option value=\"2098\" >2098<\/option><option value=\"2097\" >2097<\/option><option value=\"2096\" >2096<\/option><option value=\"2095\" >2095<\/option><option value=\"2094\" >2094<\/option><option value=\"2093\" >2093<\/option><option value=\"2092\" >2092<\/option><option value=\"2091\" >2091<\/option><option value=\"2090\" >2090<\/option><option value=\"2089\" >2089<\/option><option value=\"2088\" >2088<\/option><option value=\"2087\" >2087<\/option><option value=\"2086\" >2086<\/option><option value=\"2085\" >2085<\/option><option value=\"2084\" >2084<\/option><option value=\"2083\" >2083<\/option><option value=\"2082\" >2082<\/option><option value=\"2081\" >2081<\/option><option value=\"2080\" >2080<\/option><option value=\"2079\" >2079<\/option><option value=\"2078\" >2078<\/option><option value=\"2077\" >2077<\/option><option value=\"2076\" >2076<\/option><option value=\"2075\" >2075<\/option><option value=\"2074\" >2074<\/option><option value=\"2073\" >2073<\/option><option value=\"2072\" >2072<\/option><option value=\"2071\" >2071<\/option><option value=\"2070\" >2070<\/option><option value=\"2069\" >2069<\/option><option value=\"2068\" >2068<\/option><option value=\"2067\" >2067<\/option><option value=\"2066\" >2066<\/option><option value=\"2065\" >2065<\/option><option value=\"2064\" >2064<\/option><option value=\"2063\" >2063<\/option><option value=\"2062\" >2062<\/option><option value=\"2061\" >2061<\/option><option value=\"2060\" >2060<\/option><option value=\"2059\" >2059<\/option><option value=\"2058\" >2058<\/option><option value=\"2057\" >2057<\/option><option value=\"2056\" >2056<\/option><option value=\"2055\" >2055<\/option><option value=\"2054\" >2054<\/option><option value=\"2053\" >2053<\/option><option value=\"2052\" >2052<\/option><option value=\"2051\" >2051<\/option><option value=\"2050\" >2050<\/option><option value=\"2049\" >2049<\/option><option value=\"2048\" >2048<\/option><option value=\"2047\" >2047<\/option><option value=\"2046\" >2046<\/option><option value=\"2045\" >2045<\/option><option value=\"2044\" >2044<\/option><option value=\"2043\" >2043<\/option><option value=\"2042\" >2042<\/option><option value=\"2041\" >2041<\/option><option value=\"2040\" >2040<\/option><option value=\"2039\" >2039<\/option><option value=\"2038\" >2038<\/option><option value=\"2037\" >2037<\/option><option value=\"2036\" >2036<\/option><option value=\"2035\" >2035<\/option><option value=\"2034\" >2034<\/option><option value=\"2033\" >2033<\/option><option value=\"2032\" >2032<\/option><option value=\"2031\" >2031<\/option><option value=\"2030\" >2030<\/option><option value=\"2029\" >2029<\/option><option value=\"2028\" >2028<\/option><option value=\"2027\" >2027<\/option><option value=\"2026\" selected=\"selected\">2026<\/option><option value=\"2025\" >2025<\/option><option value=\"2024\" >2024<\/option><option value=\"2023\" >2023<\/option><option value=\"2022\" >2022<\/option><option value=\"2021\" >2021<\/option><option value=\"2020\" >2020<\/option><option value=\"2019\" >2019<\/option><option value=\"2018\" >2018<\/option><option value=\"2017\" >2017<\/option><option value=\"2016\" >2016<\/option><option value=\"2015\" >2015<\/option><option value=\"2014\" >2014<\/option><option value=\"2013\" >2013<\/option><option value=\"2012\" >2012<\/option><option value=\"2011\" >2011<\/option><option value=\"2010\" >2010<\/option><option value=\"2009\" >2009<\/option><option value=\"2008\" >2008<\/option><option value=\"2007\" >2007<\/option><option value=\"2006\" >2006<\/option><option value=\"2005\" >2005<\/option><option value=\"2004\" >2004<\/option><option value=\"2003\" >2003<\/option><option value=\"2002\" >2002<\/option><option value=\"2001\" >2001<\/option><option value=\"2000\" >2000<\/option><option value=\"1999\" >1999<\/option><option value=\"1998\" >1998<\/option><option value=\"1997\" >1997<\/option><option value=\"1996\" >1996<\/option><option value=\"1995\" >1995<\/option><option value=\"1994\" >1994<\/option><option value=\"1993\" >1993<\/option><option value=\"1992\" >1992<\/option><option value=\"1991\" >1991<\/option><option value=\"1990\" >1990<\/option><option value=\"1989\" >1989<\/option><option value=\"1988\" >1988<\/option><option value=\"1987\" >1987<\/option><option value=\"1986\" >1986<\/option><option value=\"1985\" >1985<\/option><option value=\"1984\" >1984<\/option><option value=\"1983\" >1983<\/option><option value=\"1982\" >1982<\/option><option value=\"1981\" >1981<\/option><option value=\"1980\" >1980<\/option><option value=\"1979\" >1979<\/option><option value=\"1978\" >1978<\/option><option value=\"1977\" >1977<\/option><option value=\"1976\" >1976<\/option><option value=\"1975\" >1975<\/option><option value=\"1974\" >1974<\/option><option value=\"1973\" >1973<\/option><option value=\"1972\" >1972<\/option><option value=\"1971\" >1971<\/option><option value=\"1970\" >1970<\/option><option value=\"1969\" >1969<\/option><option value=\"1968\" >1968<\/option><option value=\"1967\" >1967<\/option><option value=\"1966\" >1966<\/option><option value=\"1965\" >1965<\/option><option value=\"1964\" >1964<\/option><option value=\"1963\" >1963<\/option><option value=\"1962\" >1962<\/option><option value=\"1961\" >1961<\/option><option value=\"1960\" >1960<\/option><option value=\"1959\" >1959<\/option><option value=\"1958\" >1958<\/option><option value=\"1957\" >1957<\/option><option value=\"1956\" >1956<\/option><option value=\"1955\" >1955<\/option><option value=\"1954\" >1954<\/option><option value=\"1953\" >1953<\/option><option value=\"1952\" >1952<\/option><option value=\"1951\" >1951<\/option><option value=\"1950\" >1950<\/option><option value=\"1949\" >1949<\/option><option value=\"1948\" >1948<\/option><option value=\"1947\" >1947<\/option><option value=\"1946\" >1946<\/option><option value=\"1945\" >1945<\/option><option value=\"1944\" >1944<\/option><option value=\"1943\" >1943<\/option><option value=\"1942\" >1942<\/option><option value=\"1941\" >1941<\/option><option value=\"1940\" >1940<\/option><option value=\"1939\" >1939<\/option><option value=\"1938\" >1938<\/option><option value=\"1937\" >1937<\/option><option value=\"1936\" >1936<\/option><option value=\"1935\" >1935<\/option><option value=\"1934\" >1934<\/option><option value=\"1933\" >1933<\/option><option value=\"1932\" >1932<\/option><option value=\"1931\" >1931<\/option><option value=\"1930\" >1930<\/option><option value=\"1929\" >1929<\/option><option value=\"1928\" >1928<\/option><option value=\"1927\" >1927<\/option><option value=\"1926\" >1926<\/option><\/select><\/div><\/div><\/div><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"radio-1\" class=\"forminator-field-radio forminator-col forminator-col-6 \"><div role=\"radiogroup\" class=\"forminator-field\" aria-labelledby=\"forminator-radiogroup-69e2eb0684503-label\"><span id=\"forminator-radiogroup-69e2eb0684503-label\" class=\"forminator-label\">Referred By<\/span><label id=\"forminator-field-radio-1-label-1\" for=\"forminator-field-radio-1-1-69e2eb0684503\" class=\"forminator-radio\" title=\"Not referred\"><input type=\"radio\" name=\"radio-1\" value=\"Not-referred\" id=\"forminator-field-radio-1-1-69e2eb0684503\" aria-labelledby=\"forminator-field-radio-1-label-1\" data-calculation=\"0\" checked=\"checked\"  data-hidden-behavior=\"zero\"\/><span class=\"forminator-radio-bullet\" aria-hidden=\"true\"><\/span><span class=\"forminator-radio-label\">Not referred<\/span><\/label><label id=\"forminator-field-radio-1-label-2\" for=\"forminator-field-radio-1-2-69e2eb0684503\" class=\"forminator-radio\" title=\"Other\"><input type=\"radio\" name=\"radio-1\" value=\"two\" id=\"forminator-field-radio-1-2-69e2eb0684503\" aria-labelledby=\"forminator-field-radio-1-label-2\" data-calculation=\"0\"   data-hidden-behavior=\"zero\"\/><span class=\"forminator-radio-bullet\" aria-hidden=\"true\"><\/span><span class=\"forminator-radio-label\">Other<\/span><\/label><\/div><\/div><div id=\"text-3\" class=\"forminator-field-text forminator-col forminator-col-6 \"><div class=\"forminator-field\"><label for=\"forminator-field-text-3_69e2eb0684503\" id=\"forminator-field-text-3_69e2eb0684503-label\" class=\"forminator-label\">Other:<\/label><input type=\"text\" name=\"text-3\" value=\"\" placeholder=\"\" id=\"forminator-field-text-3_69e2eb0684503\" class=\"forminator-input forminator-name--field\" data-required=\"\" \/><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"textarea-1\" class=\"forminator-field-textarea forminator-col forminator-col-12 \"><div class=\"forminator-field\"><label for=\"forminator-field-textarea-1_69e2eb0684503\" id=\"forminator-field-textarea-1_69e2eb0684503-label\" class=\"forminator-label\">Describe the problem(s) for which you seek help. Please include dates when each problem occurred:<\/label><textarea name=\"textarea-1\" placeholder=\"\" id=\"forminator-field-textarea-1_69e2eb0684503\" class=\"forminator-textarea\" rows=\"6\" style=\"min-height:140px;\" ><\/textarea><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"textarea-4\" class=\"forminator-field-textarea forminator-col forminator-col-12 \"><div class=\"forminator-field\"><label for=\"forminator-field-textarea-4_69e2eb0684503\" id=\"forminator-field-textarea-4_69e2eb0684503-label\" class=\"forminator-label\">What daily activities are you finding difficult or are limited because of your above complaints?<\/label><textarea name=\"textarea-4\" placeholder=\"\" id=\"forminator-field-textarea-4_69e2eb0684503\" class=\"forminator-textarea\" rows=\"6\" style=\"min-height:140px;\" ><\/textarea><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"textarea-6\" class=\"forminator-field-textarea forminator-col forminator-col-12 \"><div class=\"forminator-field\"><label for=\"forminator-field-textarea-6_69e2eb0684503\" id=\"forminator-field-textarea-6_69e2eb0684503-label\" class=\"forminator-label\">What are your goals from BodyTalk?<\/label><textarea name=\"textarea-6\" placeholder=\"\" id=\"forminator-field-textarea-6_69e2eb0684503\" class=\"forminator-textarea\" rows=\"6\" style=\"min-height:140px;\" ><\/textarea><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"textarea-7\" class=\"forminator-field-textarea forminator-col forminator-col-12 \"><div class=\"forminator-field\"><label for=\"forminator-field-textarea-7_69e2eb0684503\" id=\"forminator-field-textarea-7_69e2eb0684503-label\" class=\"forminator-label\">Please list any other kind of healthcare professional you are seeing for this\/these problem(s):<\/label><textarea name=\"textarea-7\" placeholder=\"\" id=\"forminator-field-textarea-7_69e2eb0684503\" class=\"forminator-textarea\" rows=\"6\" style=\"min-height:140px;\" ><\/textarea><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"checkbox-1\" class=\"forminator-field-checkbox forminator-col forminator-col-12 \"><div role=\"group\" class=\"forminator-field\" aria-labelledby=\"forminator-checkbox-group-69e2eb0684503-label\"><span id=\"forminator-checkbox-group-69e2eb0684503-label\" class=\"forminator-label\">Please check any of the following feelings you have experienced in the last few months.<\/span><label id=\"forminator-field-checkbox-1-1-69e2eb0684503-label\" for=\"forminator-field-checkbox-1-1-69e2eb0684503\" class=\"forminator-checkbox forminator-checkbox-inline\" title=\"Abused\"><input type=\"checkbox\" name=\"checkbox-1[]\" value=\"one\" id=\"forminator-field-checkbox-1-1-69e2eb0684503\" aria-labelledby=\"forminator-field-checkbox-1-1-69e2eb0684503-label\" data-calculation=\"0\"   data-hidden-behavior=\"zero\"\/><span class=\"forminator-checkbox-box\" aria-hidden=\"true\"><\/span><span class=\"forminator-checkbox-label\">Abused<\/span><\/label><label id=\"forminator-field-checkbox-1-2-69e2eb0684503-label\" for=\"forminator-field-checkbox-1-2-69e2eb0684503\" class=\"forminator-checkbox forminator-checkbox-inline\" title=\"Criticized\"><input type=\"checkbox\" name=\"checkbox-1[]\" value=\"two\" id=\"forminator-field-checkbox-1-2-69e2eb0684503\" aria-labelledby=\"forminator-field-checkbox-1-2-69e2eb0684503-label\" data-calculation=\"0\"   data-hidden-behavior=\"zero\"\/><span class=\"forminator-checkbox-box\" aria-hidden=\"true\"><\/span><span class=\"forminator-checkbox-label\">Criticized<\/span><\/label><label id=\"forminator-field-checkbox-1-3-69e2eb0684503-label\" for=\"forminator-field-checkbox-1-3-69e2eb0684503\" class=\"forminator-checkbox forminator-checkbox-inline\" title=\"Overworked\"><input type=\"checkbox\" name=\"checkbox-1[]\" value=\"Overworked\" id=\"forminator-field-checkbox-1-3-69e2eb0684503\" aria-labelledby=\"forminator-field-checkbox-1-3-69e2eb0684503-label\" data-calculation=\"0\"   data-hidden-behavior=\"zero\"\/><span class=\"forminator-checkbox-box\" aria-hidden=\"true\"><\/span><span class=\"forminator-checkbox-label\">Overworked<\/span><\/label><label id=\"forminator-field-checkbox-1-4-69e2eb0684503-label\" for=\"forminator-field-checkbox-1-4-69e2eb0684503\" class=\"forminator-checkbox forminator-checkbox-inline\" title=\"Paralyzed\"><input type=\"checkbox\" name=\"checkbox-1[]\" value=\"Paralyzed\" id=\"forminator-field-checkbox-1-4-69e2eb0684503\" aria-labelledby=\"forminator-field-checkbox-1-4-69e2eb0684503-label\" data-calculation=\"0\"   data-hidden-behavior=\"zero\"\/><span class=\"forminator-checkbox-box\" aria-hidden=\"true\"><\/span><span class=\"forminator-checkbox-label\">Paralyzed<\/span><\/label><label id=\"forminator-field-checkbox-1-5-69e2eb0684503-label\" for=\"forminator-field-checkbox-1-5-69e2eb0684503\" class=\"forminator-checkbox forminator-checkbox-inline\" title=\"Depressed\"><input type=\"checkbox\" name=\"checkbox-1[]\" value=\"Depressed\" id=\"forminator-field-checkbox-1-5-69e2eb0684503\" aria-labelledby=\"forminator-field-checkbox-1-5-69e2eb0684503-label\" data-calculation=\"0\"   data-hidden-behavior=\"zero\"\/><span class=\"forminator-checkbox-box\" aria-hidden=\"true\"><\/span><span class=\"forminator-checkbox-label\">Depressed<\/span><\/label><label id=\"forminator-field-checkbox-1-6-69e2eb0684503-label\" for=\"forminator-field-checkbox-1-6-69e2eb0684503\" class=\"forminator-checkbox forminator-checkbox-inline\" title=\"Rejected\"><input type=\"checkbox\" name=\"checkbox-1[]\" value=\"Rejected\" id=\"forminator-field-checkbox-1-6-69e2eb0684503\" aria-labelledby=\"forminator-field-checkbox-1-6-69e2eb0684503-label\" data-calculation=\"0\"   data-hidden-behavior=\"zero\"\/><span class=\"forminator-checkbox-box\" aria-hidden=\"true\"><\/span><span class=\"forminator-checkbox-label\">Rejected<\/span><\/label><label id=\"forminator-field-checkbox-1-7-69e2eb0684503-label\" for=\"forminator-field-checkbox-1-7-69e2eb0684503\" class=\"forminator-checkbox forminator-checkbox-inline\" title=\"Despair\"><input type=\"checkbox\" name=\"checkbox-1[]\" value=\"Despair\" id=\"forminator-field-checkbox-1-7-69e2eb0684503\" aria-labelledby=\"forminator-field-checkbox-1-7-69e2eb0684503-label\" data-calculation=\"0\"   data-hidden-behavior=\"zero\"\/><span class=\"forminator-checkbox-box\" aria-hidden=\"true\"><\/span><span class=\"forminator-checkbox-label\">Despair<\/span><\/label><label id=\"forminator-field-checkbox-1-8-69e2eb0684503-label\" for=\"forminator-field-checkbox-1-8-69e2eb0684503\" class=\"forminator-checkbox forminator-checkbox-inline\" title=\"Helpless\"><input type=\"checkbox\" name=\"checkbox-1[]\" value=\"Helpless\" id=\"forminator-field-checkbox-1-8-69e2eb0684503\" aria-labelledby=\"forminator-field-checkbox-1-8-69e2eb0684503-label\" data-calculation=\"0\"   data-hidden-behavior=\"zero\"\/><span class=\"forminator-checkbox-box\" aria-hidden=\"true\"><\/span><span class=\"forminator-checkbox-label\">Helpless<\/span><\/label><label id=\"forminator-field-checkbox-1-9-69e2eb0684503-label\" for=\"forminator-field-checkbox-1-9-69e2eb0684503\" class=\"forminator-checkbox forminator-checkbox-inline\" title=\"Hopeless\"><input type=\"checkbox\" name=\"checkbox-1[]\" value=\"Hopeless\" id=\"forminator-field-checkbox-1-9-69e2eb0684503\" aria-labelledby=\"forminator-field-checkbox-1-9-69e2eb0684503-label\" data-calculation=\"0\"   data-hidden-behavior=\"zero\"\/><span class=\"forminator-checkbox-box\" aria-hidden=\"true\"><\/span><span class=\"forminator-checkbox-label\">Hopeless<\/span><\/label><label id=\"forminator-field-checkbox-1-10-69e2eb0684503-label\" for=\"forminator-field-checkbox-1-10-69e2eb0684503\" class=\"forminator-checkbox forminator-checkbox-inline\" title=\"Paranoid\"><input type=\"checkbox\" name=\"checkbox-1[]\" value=\"Paranoid\" id=\"forminator-field-checkbox-1-10-69e2eb0684503\" aria-labelledby=\"forminator-field-checkbox-1-10-69e2eb0684503-label\" data-calculation=\"0\"   data-hidden-behavior=\"zero\"\/><span class=\"forminator-checkbox-box\" aria-hidden=\"true\"><\/span><span class=\"forminator-checkbox-label\">Paranoid<\/span><\/label><label id=\"forminator-field-checkbox-1-11-69e2eb0684503-label\" for=\"forminator-field-checkbox-1-11-69e2eb0684503\" class=\"forminator-checkbox forminator-checkbox-inline\" title=\"Overwhelmed\"><input type=\"checkbox\" name=\"checkbox-1[]\" value=\"Overwhelmed\" id=\"forminator-field-checkbox-1-11-69e2eb0684503\" aria-labelledby=\"forminator-field-checkbox-1-11-69e2eb0684503-label\" data-calculation=\"0\"   data-hidden-behavior=\"zero\"\/><span class=\"forminator-checkbox-box\" aria-hidden=\"true\"><\/span><span class=\"forminator-checkbox-label\">Overwhelmed<\/span><\/label><label id=\"forminator-field-checkbox-1-12-69e2eb0684503-label\" for=\"forminator-field-checkbox-1-12-69e2eb0684503\" class=\"forminator-checkbox forminator-checkbox-inline\" title=\"Muddled\"><input type=\"checkbox\" name=\"checkbox-1[]\" value=\"Muddled\" id=\"forminator-field-checkbox-1-12-69e2eb0684503\" aria-labelledby=\"forminator-field-checkbox-1-12-69e2eb0684503-label\" data-calculation=\"0\"   data-hidden-behavior=\"zero\"\/><span class=\"forminator-checkbox-box\" aria-hidden=\"true\"><\/span><span class=\"forminator-checkbox-label\">Muddled<\/span><\/label><label id=\"forminator-field-checkbox-1-13-69e2eb0684503-label\" for=\"forminator-field-checkbox-1-13-69e2eb0684503\" class=\"forminator-checkbox forminator-checkbox-inline\" title=\"Persecuted\"><input type=\"checkbox\" name=\"checkbox-1[]\" value=\"Persecuted\" id=\"forminator-field-checkbox-1-13-69e2eb0684503\" aria-labelledby=\"forminator-field-checkbox-1-13-69e2eb0684503-label\" data-calculation=\"0\"   data-hidden-behavior=\"zero\"\/><span class=\"forminator-checkbox-box\" aria-hidden=\"true\"><\/span><span class=\"forminator-checkbox-label\">Persecuted<\/span><\/label><label id=\"forminator-field-checkbox-1-14-69e2eb0684503-label\" for=\"forminator-field-checkbox-1-14-69e2eb0684503\" class=\"forminator-checkbox forminator-checkbox-inline\" title=\"Guilty\"><input type=\"checkbox\" name=\"checkbox-1[]\" value=\"Guilty\" id=\"forminator-field-checkbox-1-14-69e2eb0684503\" aria-labelledby=\"forminator-field-checkbox-1-14-69e2eb0684503-label\" data-calculation=\"0\"   data-hidden-behavior=\"zero\"\/><span class=\"forminator-checkbox-box\" aria-hidden=\"true\"><\/span><span class=\"forminator-checkbox-label\">Guilty<\/span><\/label><label id=\"forminator-field-checkbox-1-15-69e2eb0684503-label\" for=\"forminator-field-checkbox-1-15-69e2eb0684503\" class=\"forminator-checkbox forminator-checkbox-inline\" title=\"Easily irritated\"><input type=\"checkbox\" name=\"checkbox-1[]\" value=\"Easily-irritated\" id=\"forminator-field-checkbox-1-15-69e2eb0684503\" aria-labelledby=\"forminator-field-checkbox-1-15-69e2eb0684503-label\" data-calculation=\"0\"   data-hidden-behavior=\"zero\"\/><span class=\"forminator-checkbox-box\" aria-hidden=\"true\"><\/span><span class=\"forminator-checkbox-label\">Easily irritated<\/span><\/label><label id=\"forminator-field-checkbox-1-16-69e2eb0684503-label\" for=\"forminator-field-checkbox-1-16-69e2eb0684503\" class=\"forminator-checkbox forminator-checkbox-inline\" title=\"Anxious\"><input type=\"checkbox\" name=\"checkbox-1[]\" value=\"Anxious\" id=\"forminator-field-checkbox-1-16-69e2eb0684503\" aria-labelledby=\"forminator-field-checkbox-1-16-69e2eb0684503-label\" data-calculation=\"0\"   data-hidden-behavior=\"zero\"\/><span class=\"forminator-checkbox-box\" aria-hidden=\"true\"><\/span><span class=\"forminator-checkbox-label\">Anxious<\/span><\/label><label id=\"forminator-field-checkbox-1-17-69e2eb0684503-label\" for=\"forminator-field-checkbox-1-17-69e2eb0684503\" class=\"forminator-checkbox forminator-checkbox-inline\" title=\"Sad\"><input type=\"checkbox\" name=\"checkbox-1[]\" value=\"Sad\" id=\"forminator-field-checkbox-1-17-69e2eb0684503\" aria-labelledby=\"forminator-field-checkbox-1-17-69e2eb0684503-label\" data-calculation=\"0\"   data-hidden-behavior=\"zero\"\/><span class=\"forminator-checkbox-box\" aria-hidden=\"true\"><\/span><span class=\"forminator-checkbox-label\">Sad<\/span><\/label><label id=\"forminator-field-checkbox-1-18-69e2eb0684503-label\" for=\"forminator-field-checkbox-1-18-69e2eb0684503\" class=\"forminator-checkbox forminator-checkbox-inline\" title=\"Grieving\"><input type=\"checkbox\" name=\"checkbox-1[]\" value=\"Grieving\" id=\"forminator-field-checkbox-1-18-69e2eb0684503\" aria-labelledby=\"forminator-field-checkbox-1-18-69e2eb0684503-label\" data-calculation=\"0\"   data-hidden-behavior=\"zero\"\/><span class=\"forminator-checkbox-box\" aria-hidden=\"true\"><\/span><span class=\"forminator-checkbox-label\">Grieving<\/span><\/label><label id=\"forminator-field-checkbox-1-19-69e2eb0684503-label\" for=\"forminator-field-checkbox-1-19-69e2eb0684503\" class=\"forminator-checkbox forminator-checkbox-inline\" title=\"Unable to grieve\"><input type=\"checkbox\" name=\"checkbox-1[]\" value=\"Unable-to-grieve\" id=\"forminator-field-checkbox-1-19-69e2eb0684503\" aria-labelledby=\"forminator-field-checkbox-1-19-69e2eb0684503-label\" data-calculation=\"0\"   data-hidden-behavior=\"zero\"\/><span class=\"forminator-checkbox-box\" aria-hidden=\"true\"><\/span><span class=\"forminator-checkbox-label\">Unable to grieve<\/span><\/label><label id=\"forminator-field-checkbox-1-20-69e2eb0684503-label\" for=\"forminator-field-checkbox-1-20-69e2eb0684503\" class=\"forminator-checkbox forminator-checkbox-inline\" title=\"Apprehensive\"><input type=\"checkbox\" name=\"checkbox-1[]\" value=\"Apprehensive\" id=\"forminator-field-checkbox-1-20-69e2eb0684503\" aria-labelledby=\"forminator-field-checkbox-1-20-69e2eb0684503-label\" data-calculation=\"0\"   data-hidden-behavior=\"zero\"\/><span class=\"forminator-checkbox-box\" aria-hidden=\"true\"><\/span><span class=\"forminator-checkbox-label\">Apprehensive<\/span><\/label><label id=\"forminator-field-checkbox-1-21-69e2eb0684503-label\" for=\"forminator-field-checkbox-1-21-69e2eb0684503\" class=\"forminator-checkbox forminator-checkbox-inline\" title=\"Agitated\"><input type=\"checkbox\" name=\"checkbox-1[]\" value=\"Agitated\" id=\"forminator-field-checkbox-1-21-69e2eb0684503\" aria-labelledby=\"forminator-field-checkbox-1-21-69e2eb0684503-label\" data-calculation=\"0\"   data-hidden-behavior=\"zero\"\/><span class=\"forminator-checkbox-box\" aria-hidden=\"true\"><\/span><span class=\"forminator-checkbox-label\">Agitated<\/span><\/label><label id=\"forminator-field-checkbox-1-22-69e2eb0684503-label\" for=\"forminator-field-checkbox-1-22-69e2eb0684503\" class=\"forminator-checkbox forminator-checkbox-inline\" title=\"Uneasy\"><input type=\"checkbox\" name=\"checkbox-1[]\" value=\"Uneasy\" id=\"forminator-field-checkbox-1-22-69e2eb0684503\" aria-labelledby=\"forminator-field-checkbox-1-22-69e2eb0684503-label\" data-calculation=\"0\"   data-hidden-behavior=\"zero\"\/><span class=\"forminator-checkbox-box\" aria-hidden=\"true\"><\/span><span class=\"forminator-checkbox-label\">Uneasy<\/span><\/label><label id=\"forminator-field-checkbox-1-23-69e2eb0684503-label\" for=\"forminator-field-checkbox-1-23-69e2eb0684503\" class=\"forminator-checkbox forminator-checkbox-inline\" title=\"Distress\"><input type=\"checkbox\" name=\"checkbox-1[]\" value=\"Distress\" id=\"forminator-field-checkbox-1-23-69e2eb0684503\" aria-labelledby=\"forminator-field-checkbox-1-23-69e2eb0684503-label\" data-calculation=\"0\"   data-hidden-behavior=\"zero\"\/><span class=\"forminator-checkbox-box\" aria-hidden=\"true\"><\/span><span class=\"forminator-checkbox-label\">Distress<\/span><\/label><label id=\"forminator-field-checkbox-1-24-69e2eb0684503-label\" for=\"forminator-field-checkbox-1-24-69e2eb0684503\" class=\"forminator-checkbox forminator-checkbox-inline\" title=\"Fearful\"><input type=\"checkbox\" name=\"checkbox-1[]\" value=\"Fearful\" id=\"forminator-field-checkbox-1-24-69e2eb0684503\" aria-labelledby=\"forminator-field-checkbox-1-24-69e2eb0684503-label\" data-calculation=\"0\"   data-hidden-behavior=\"zero\"\/><span class=\"forminator-checkbox-box\" aria-hidden=\"true\"><\/span><span class=\"forminator-checkbox-label\">Fearful<\/span><\/label><label id=\"forminator-field-checkbox-1-25-69e2eb0684503-label\" for=\"forminator-field-checkbox-1-25-69e2eb0684503\" class=\"forminator-checkbox forminator-checkbox-inline\" title=\"Impatient\"><input type=\"checkbox\" name=\"checkbox-1[]\" value=\"Impatient\" id=\"forminator-field-checkbox-1-25-69e2eb0684503\" aria-labelledby=\"forminator-field-checkbox-1-25-69e2eb0684503-label\" data-calculation=\"0\"   data-hidden-behavior=\"zero\"\/><span class=\"forminator-checkbox-box\" aria-hidden=\"true\"><\/span><span class=\"forminator-checkbox-label\">Impatient<\/span><\/label><label id=\"forminator-field-checkbox-1-26-69e2eb0684503-label\" for=\"forminator-field-checkbox-1-26-69e2eb0684503\" class=\"forminator-checkbox forminator-checkbox-inline\" title=\"Intimidated\"><input type=\"checkbox\" name=\"checkbox-1[]\" value=\"Intimidated\" id=\"forminator-field-checkbox-1-26-69e2eb0684503\" aria-labelledby=\"forminator-field-checkbox-1-26-69e2eb0684503-label\" data-calculation=\"0\"   data-hidden-behavior=\"zero\"\/><span class=\"forminator-checkbox-box\" aria-hidden=\"true\"><\/span><span class=\"forminator-checkbox-label\">Intimidated<\/span><\/label><label id=\"forminator-field-checkbox-1-27-69e2eb0684503-label\" for=\"forminator-field-checkbox-1-27-69e2eb0684503\" class=\"forminator-checkbox forminator-checkbox-inline\" title=\"Restless\"><input type=\"checkbox\" name=\"checkbox-1[]\" value=\"Restless\" id=\"forminator-field-checkbox-1-27-69e2eb0684503\" aria-labelledby=\"forminator-field-checkbox-1-27-69e2eb0684503-label\" data-calculation=\"0\"   data-hidden-behavior=\"zero\"\/><span class=\"forminator-checkbox-box\" aria-hidden=\"true\"><\/span><span class=\"forminator-checkbox-label\">Restless<\/span><\/label><label id=\"forminator-field-checkbox-1-28-69e2eb0684503-label\" for=\"forminator-field-checkbox-1-28-69e2eb0684503\" class=\"forminator-checkbox forminator-checkbox-inline\" title=\"Panic\"><input type=\"checkbox\" name=\"checkbox-1[]\" value=\"Panic\" id=\"forminator-field-checkbox-1-28-69e2eb0684503\" aria-labelledby=\"forminator-field-checkbox-1-28-69e2eb0684503-label\" data-calculation=\"0\"   data-hidden-behavior=\"zero\"\/><span class=\"forminator-checkbox-box\" aria-hidden=\"true\"><\/span><span class=\"forminator-checkbox-label\">Panic<\/span><\/label><label id=\"forminator-field-checkbox-1-29-69e2eb0684503-label\" for=\"forminator-field-checkbox-1-29-69e2eb0684503\" class=\"forminator-checkbox forminator-checkbox-inline\" title=\"Intolerant\"><input type=\"checkbox\" name=\"checkbox-1[]\" value=\"Intolerant\" id=\"forminator-field-checkbox-1-29-69e2eb0684503\" aria-labelledby=\"forminator-field-checkbox-1-29-69e2eb0684503-label\" data-calculation=\"0\"   data-hidden-behavior=\"zero\"\/><span class=\"forminator-checkbox-box\" aria-hidden=\"true\"><\/span><span class=\"forminator-checkbox-label\">Intolerant<\/span><\/label><label id=\"forminator-field-checkbox-1-30-69e2eb0684503-label\" for=\"forminator-field-checkbox-1-30-69e2eb0684503\" class=\"forminator-checkbox forminator-checkbox-inline\" title=\"Uncertainty\"><input type=\"checkbox\" name=\"checkbox-1[]\" value=\"Uncertainty\" id=\"forminator-field-checkbox-1-30-69e2eb0684503\" aria-labelledby=\"forminator-field-checkbox-1-30-69e2eb0684503-label\" data-calculation=\"0\"   data-hidden-behavior=\"zero\"\/><span class=\"forminator-checkbox-box\" aria-hidden=\"true\"><\/span><span class=\"forminator-checkbox-label\">Uncertainty<\/span><\/label><label id=\"forminator-field-checkbox-1-31-69e2eb0684503-label\" for=\"forminator-field-checkbox-1-31-69e2eb0684503\" class=\"forminator-checkbox forminator-checkbox-inline\" title=\"Aggravated\"><input type=\"checkbox\" name=\"checkbox-1[]\" value=\"Aggravated\" id=\"forminator-field-checkbox-1-31-69e2eb0684503\" aria-labelledby=\"forminator-field-checkbox-1-31-69e2eb0684503-label\" data-calculation=\"0\"   data-hidden-behavior=\"zero\"\/><span class=\"forminator-checkbox-box\" aria-hidden=\"true\"><\/span><span class=\"forminator-checkbox-label\">Aggravated<\/span><\/label><label id=\"forminator-field-checkbox-1-32-69e2eb0684503-label\" for=\"forminator-field-checkbox-1-32-69e2eb0684503\" class=\"forminator-checkbox forminator-checkbox-inline\" title=\"Annoyed\"><input type=\"checkbox\" name=\"checkbox-1[]\" value=\"Annoyed\" id=\"forminator-field-checkbox-1-32-69e2eb0684503\" aria-labelledby=\"forminator-field-checkbox-1-32-69e2eb0684503-label\" data-calculation=\"0\"   data-hidden-behavior=\"zero\"\/><span class=\"forminator-checkbox-box\" aria-hidden=\"true\"><\/span><span class=\"forminator-checkbox-label\">Annoyed<\/span><\/label><label id=\"forminator-field-checkbox-1-33-69e2eb0684503-label\" for=\"forminator-field-checkbox-1-33-69e2eb0684503\" class=\"forminator-checkbox forminator-checkbox-inline\" title=\"Angry\"><input type=\"checkbox\" name=\"checkbox-1[]\" value=\"Angry\" id=\"forminator-field-checkbox-1-33-69e2eb0684503\" aria-labelledby=\"forminator-field-checkbox-1-33-69e2eb0684503-label\" data-calculation=\"0\"   data-hidden-behavior=\"zero\"\/><span class=\"forminator-checkbox-box\" aria-hidden=\"true\"><\/span><span class=\"forminator-checkbox-label\">Angry<\/span><\/label><label id=\"forminator-field-checkbox-1-34-69e2eb0684503-label\" for=\"forminator-field-checkbox-1-34-69e2eb0684503\" class=\"forminator-checkbox forminator-checkbox-inline\" title=\"Outraged\"><input type=\"checkbox\" name=\"checkbox-1[]\" value=\"Outraged\" id=\"forminator-field-checkbox-1-34-69e2eb0684503\" aria-labelledby=\"forminator-field-checkbox-1-34-69e2eb0684503-label\" data-calculation=\"0\"   data-hidden-behavior=\"zero\"\/><span class=\"forminator-checkbox-box\" aria-hidden=\"true\"><\/span><span class=\"forminator-checkbox-label\">Outraged<\/span><\/label><label id=\"forminator-field-checkbox-1-35-69e2eb0684503-label\" for=\"forminator-field-checkbox-1-35-69e2eb0684503\" class=\"forminator-checkbox forminator-checkbox-inline\" title=\"Nervous\"><input type=\"checkbox\" name=\"checkbox-1[]\" value=\"Nervous\" id=\"forminator-field-checkbox-1-35-69e2eb0684503\" aria-labelledby=\"forminator-field-checkbox-1-35-69e2eb0684503-label\" data-calculation=\"0\"   data-hidden-behavior=\"zero\"\/><span class=\"forminator-checkbox-box\" aria-hidden=\"true\"><\/span><span class=\"forminator-checkbox-label\">Nervous<\/span><\/label><label id=\"forminator-field-checkbox-1-36-69e2eb0684503-label\" for=\"forminator-field-checkbox-1-36-69e2eb0684503\" class=\"forminator-checkbox forminator-checkbox-inline\" title=\"Worried\"><input type=\"checkbox\" name=\"checkbox-1[]\" value=\"Worried\" id=\"forminator-field-checkbox-1-36-69e2eb0684503\" aria-labelledby=\"forminator-field-checkbox-1-36-69e2eb0684503-label\" data-calculation=\"0\"   data-hidden-behavior=\"zero\"\/><span class=\"forminator-checkbox-box\" aria-hidden=\"true\"><\/span><span class=\"forminator-checkbox-label\">Worried<\/span><\/label><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"radio-2\" class=\"forminator-field-radio forminator-col forminator-col-12 \"><div role=\"radiogroup\" class=\"forminator-field\" aria-labelledby=\"forminator-radiogroup-69e2eb0684503-label\"><span id=\"forminator-radiogroup-69e2eb0684503-label\" class=\"forminator-label\">My family stress is:<\/span><label id=\"forminator-field-radio-2-label-1\" for=\"forminator-field-radio-2-1-69e2eb0684503\" class=\"forminator-radio forminator-radio-inline\" title=\"None\"><input type=\"radio\" name=\"radio-2\" value=\"none\" id=\"forminator-field-radio-2-1-69e2eb0684503\" aria-labelledby=\"forminator-field-radio-2-label-1\" data-calculation=\"0\"   data-hidden-behavior=\"zero\"\/><span class=\"forminator-radio-bullet\" aria-hidden=\"true\"><\/span><span class=\"forminator-radio-label\">None<\/span><\/label><label id=\"forminator-field-radio-2-label-2\" for=\"forminator-field-radio-2-2-69e2eb0684503\" class=\"forminator-radio forminator-radio-inline\" title=\"Minimal\"><input type=\"radio\" name=\"radio-2\" value=\"minimal\" id=\"forminator-field-radio-2-2-69e2eb0684503\" aria-labelledby=\"forminator-field-radio-2-label-2\" data-calculation=\"0\"   data-hidden-behavior=\"zero\"\/><span class=\"forminator-radio-bullet\" aria-hidden=\"true\"><\/span><span class=\"forminator-radio-label\">Minimal<\/span><\/label><label id=\"forminator-field-radio-2-label-3\" for=\"forminator-field-radio-2-3-69e2eb0684503\" class=\"forminator-radio forminator-radio-inline\" title=\"Moderate\"><input type=\"radio\" name=\"radio-2\" value=\"moderate\" id=\"forminator-field-radio-2-3-69e2eb0684503\" aria-labelledby=\"forminator-field-radio-2-label-3\" data-calculation=\"0\"   data-hidden-behavior=\"zero\"\/><span class=\"forminator-radio-bullet\" aria-hidden=\"true\"><\/span><span class=\"forminator-radio-label\">Moderate<\/span><\/label><label id=\"forminator-field-radio-2-label-4\" for=\"forminator-field-radio-2-4-69e2eb0684503\" class=\"forminator-radio forminator-radio-inline\" title=\"Severe\"><input type=\"radio\" name=\"radio-2\" value=\"severe\" id=\"forminator-field-radio-2-4-69e2eb0684503\" aria-labelledby=\"forminator-field-radio-2-label-4\" data-calculation=\"0\"   data-hidden-behavior=\"zero\"\/><span class=\"forminator-radio-bullet\" aria-hidden=\"true\"><\/span><span class=\"forminator-radio-label\">Severe<\/span><\/label><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"radio-3\" class=\"forminator-field-radio forminator-col forminator-col-12 \"><div role=\"radiogroup\" class=\"forminator-field\" aria-labelledby=\"forminator-radiogroup-69e2eb0684503-label\"><span id=\"forminator-radiogroup-69e2eb0684503-label\" class=\"forminator-label\">My relationship stress is:<\/span><label id=\"forminator-field-radio-3-label-1\" for=\"forminator-field-radio-3-1-69e2eb0684503\" class=\"forminator-radio forminator-radio-inline\" title=\"None\"><input type=\"radio\" name=\"radio-3\" value=\"none\" id=\"forminator-field-radio-3-1-69e2eb0684503\" aria-labelledby=\"forminator-field-radio-3-label-1\" data-calculation=\"0\"   data-hidden-behavior=\"zero\"\/><span class=\"forminator-radio-bullet\" aria-hidden=\"true\"><\/span><span class=\"forminator-radio-label\">None<\/span><\/label><label id=\"forminator-field-radio-3-label-2\" for=\"forminator-field-radio-3-2-69e2eb0684503\" class=\"forminator-radio forminator-radio-inline\" title=\"Minimal\"><input type=\"radio\" name=\"radio-3\" value=\"minimal\" id=\"forminator-field-radio-3-2-69e2eb0684503\" aria-labelledby=\"forminator-field-radio-3-label-2\" data-calculation=\"0\"   data-hidden-behavior=\"zero\"\/><span class=\"forminator-radio-bullet\" aria-hidden=\"true\"><\/span><span class=\"forminator-radio-label\">Minimal<\/span><\/label><label id=\"forminator-field-radio-3-label-3\" for=\"forminator-field-radio-3-3-69e2eb0684503\" class=\"forminator-radio forminator-radio-inline\" title=\"Moderate\"><input type=\"radio\" name=\"radio-3\" value=\"moderate\" id=\"forminator-field-radio-3-3-69e2eb0684503\" aria-labelledby=\"forminator-field-radio-3-label-3\" data-calculation=\"0\"   data-hidden-behavior=\"zero\"\/><span class=\"forminator-radio-bullet\" aria-hidden=\"true\"><\/span><span class=\"forminator-radio-label\">Moderate<\/span><\/label><label id=\"forminator-field-radio-3-label-4\" for=\"forminator-field-radio-3-4-69e2eb0684503\" class=\"forminator-radio forminator-radio-inline\" title=\"Severe\"><input type=\"radio\" name=\"radio-3\" value=\"severe\" id=\"forminator-field-radio-3-4-69e2eb0684503\" aria-labelledby=\"forminator-field-radio-3-label-4\" data-calculation=\"0\"   data-hidden-behavior=\"zero\"\/><span class=\"forminator-radio-bullet\" aria-hidden=\"true\"><\/span><span class=\"forminator-radio-label\">Severe<\/span><\/label><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"radio-4\" class=\"forminator-field-radio forminator-col forminator-col-12 \"><div role=\"radiogroup\" class=\"forminator-field\" aria-labelledby=\"forminator-radiogroup-69e2eb0684503-label\"><span id=\"forminator-radiogroup-69e2eb0684503-label\" class=\"forminator-label\">My work stress is:<\/span><label id=\"forminator-field-radio-4-label-1\" for=\"forminator-field-radio-4-1-69e2eb0684503\" class=\"forminator-radio forminator-radio-inline\" title=\"None\"><input type=\"radio\" name=\"radio-4\" value=\"none\" id=\"forminator-field-radio-4-1-69e2eb0684503\" aria-labelledby=\"forminator-field-radio-4-label-1\" data-calculation=\"0\"   data-hidden-behavior=\"zero\"\/><span class=\"forminator-radio-bullet\" aria-hidden=\"true\"><\/span><span class=\"forminator-radio-label\">None<\/span><\/label><label id=\"forminator-field-radio-4-label-2\" for=\"forminator-field-radio-4-2-69e2eb0684503\" class=\"forminator-radio forminator-radio-inline\" title=\"Minimal\"><input type=\"radio\" name=\"radio-4\" value=\"minimal\" id=\"forminator-field-radio-4-2-69e2eb0684503\" aria-labelledby=\"forminator-field-radio-4-label-2\" data-calculation=\"0\"   data-hidden-behavior=\"zero\"\/><span class=\"forminator-radio-bullet\" aria-hidden=\"true\"><\/span><span class=\"forminator-radio-label\">Minimal<\/span><\/label><label id=\"forminator-field-radio-4-label-3\" for=\"forminator-field-radio-4-3-69e2eb0684503\" class=\"forminator-radio forminator-radio-inline\" title=\"Moderate\"><input type=\"radio\" name=\"radio-4\" value=\"moderate\" id=\"forminator-field-radio-4-3-69e2eb0684503\" aria-labelledby=\"forminator-field-radio-4-label-3\" data-calculation=\"0\"   data-hidden-behavior=\"zero\"\/><span class=\"forminator-radio-bullet\" aria-hidden=\"true\"><\/span><span class=\"forminator-radio-label\">Moderate<\/span><\/label><label id=\"forminator-field-radio-4-label-4\" for=\"forminator-field-radio-4-4-69e2eb0684503\" class=\"forminator-radio forminator-radio-inline\" title=\"Severe\"><input type=\"radio\" name=\"radio-4\" value=\"severe\" id=\"forminator-field-radio-4-4-69e2eb0684503\" aria-labelledby=\"forminator-field-radio-4-label-4\" data-calculation=\"0\"   data-hidden-behavior=\"zero\"\/><span class=\"forminator-radio-bullet\" aria-hidden=\"true\"><\/span><span class=\"forminator-radio-label\">Severe<\/span><\/label><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"radio-5\" class=\"forminator-field-radio forminator-col forminator-col-12 \"><div role=\"radiogroup\" class=\"forminator-field\" aria-labelledby=\"forminator-radiogroup-69e2eb0684503-label\"><span id=\"forminator-radiogroup-69e2eb0684503-label\" class=\"forminator-label\">My financial stress is:<\/span><label id=\"forminator-field-radio-5-label-1\" for=\"forminator-field-radio-5-1-69e2eb0684503\" class=\"forminator-radio forminator-radio-inline\" title=\"None\"><input type=\"radio\" name=\"radio-5\" value=\"none\" id=\"forminator-field-radio-5-1-69e2eb0684503\" aria-labelledby=\"forminator-field-radio-5-label-1\" data-calculation=\"0\"   data-hidden-behavior=\"zero\"\/><span class=\"forminator-radio-bullet\" aria-hidden=\"true\"><\/span><span class=\"forminator-radio-label\">None<\/span><\/label><label id=\"forminator-field-radio-5-label-2\" for=\"forminator-field-radio-5-2-69e2eb0684503\" class=\"forminator-radio forminator-radio-inline\" title=\"Minimal\"><input type=\"radio\" name=\"radio-5\" value=\"minimal\" id=\"forminator-field-radio-5-2-69e2eb0684503\" aria-labelledby=\"forminator-field-radio-5-label-2\" data-calculation=\"0\"   data-hidden-behavior=\"zero\"\/><span class=\"forminator-radio-bullet\" aria-hidden=\"true\"><\/span><span class=\"forminator-radio-label\">Minimal<\/span><\/label><label id=\"forminator-field-radio-5-label-3\" for=\"forminator-field-radio-5-3-69e2eb0684503\" class=\"forminator-radio forminator-radio-inline\" title=\"Moderate\"><input type=\"radio\" name=\"radio-5\" value=\"moderate\" id=\"forminator-field-radio-5-3-69e2eb0684503\" aria-labelledby=\"forminator-field-radio-5-label-3\" data-calculation=\"0\"   data-hidden-behavior=\"zero\"\/><span class=\"forminator-radio-bullet\" aria-hidden=\"true\"><\/span><span class=\"forminator-radio-label\">Moderate<\/span><\/label><label id=\"forminator-field-radio-5-label-4\" for=\"forminator-field-radio-5-4-69e2eb0684503\" class=\"forminator-radio forminator-radio-inline\" title=\"Severe\"><input type=\"radio\" name=\"radio-5\" value=\"severe\" id=\"forminator-field-radio-5-4-69e2eb0684503\" aria-labelledby=\"forminator-field-radio-5-label-4\" data-calculation=\"0\"   data-hidden-behavior=\"zero\"\/><span class=\"forminator-radio-bullet\" aria-hidden=\"true\"><\/span><span class=\"forminator-radio-label\">Severe<\/span><\/label><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"radio-6\" class=\"forminator-field-radio forminator-col forminator-col-12 \"><div role=\"radiogroup\" class=\"forminator-field\" aria-labelledby=\"forminator-radiogroup-69e2eb0684503-label\"><span id=\"forminator-radiogroup-69e2eb0684503-label\" class=\"forminator-label\">My health stress is:<\/span><label id=\"forminator-field-radio-6-label-1\" for=\"forminator-field-radio-6-1-69e2eb0684503\" class=\"forminator-radio forminator-radio-inline\" title=\"None\"><input type=\"radio\" name=\"radio-6\" value=\"none\" id=\"forminator-field-radio-6-1-69e2eb0684503\" aria-labelledby=\"forminator-field-radio-6-label-1\" data-calculation=\"0\"   data-hidden-behavior=\"zero\"\/><span class=\"forminator-radio-bullet\" aria-hidden=\"true\"><\/span><span class=\"forminator-radio-label\">None<\/span><\/label><label id=\"forminator-field-radio-6-label-2\" for=\"forminator-field-radio-6-2-69e2eb0684503\" class=\"forminator-radio forminator-radio-inline\" title=\"Minimal\"><input type=\"radio\" name=\"radio-6\" value=\"minimal\" id=\"forminator-field-radio-6-2-69e2eb0684503\" aria-labelledby=\"forminator-field-radio-6-label-2\" data-calculation=\"0\"   data-hidden-behavior=\"zero\"\/><span class=\"forminator-radio-bullet\" aria-hidden=\"true\"><\/span><span class=\"forminator-radio-label\">Minimal<\/span><\/label><label id=\"forminator-field-radio-6-label-3\" for=\"forminator-field-radio-6-3-69e2eb0684503\" class=\"forminator-radio forminator-radio-inline\" title=\"Moderate\"><input type=\"radio\" name=\"radio-6\" value=\"moderate\" id=\"forminator-field-radio-6-3-69e2eb0684503\" aria-labelledby=\"forminator-field-radio-6-label-3\" data-calculation=\"0\"   data-hidden-behavior=\"zero\"\/><span class=\"forminator-radio-bullet\" aria-hidden=\"true\"><\/span><span class=\"forminator-radio-label\">Moderate<\/span><\/label><label id=\"forminator-field-radio-6-label-4\" for=\"forminator-field-radio-6-4-69e2eb0684503\" class=\"forminator-radio forminator-radio-inline\" title=\"Severe\"><input type=\"radio\" name=\"radio-6\" value=\"severe\" id=\"forminator-field-radio-6-4-69e2eb0684503\" aria-labelledby=\"forminator-field-radio-6-label-4\" data-calculation=\"0\"   data-hidden-behavior=\"zero\"\/><span class=\"forminator-radio-bullet\" aria-hidden=\"true\"><\/span><span class=\"forminator-radio-label\">Severe<\/span><\/label><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"radio-7\" class=\"forminator-field-radio forminator-col forminator-col-12 \"><div role=\"radiogroup\" class=\"forminator-field\" aria-labelledby=\"forminator-radiogroup-69e2eb0684503-label\"><span id=\"forminator-radiogroup-69e2eb0684503-label\" class=\"forminator-label\">Do you have chronic or acute pain\/discomfort in your body?<\/span><label id=\"forminator-field-radio-7-label-1\" for=\"forminator-field-radio-7-1-69e2eb0684503\" class=\"forminator-radio\" title=\"Yes\"><input type=\"radio\" name=\"radio-7\" value=\"one\" id=\"forminator-field-radio-7-1-69e2eb0684503\" aria-labelledby=\"forminator-field-radio-7-label-1\" data-calculation=\"0\"   data-hidden-behavior=\"zero\"\/><span class=\"forminator-radio-bullet\" aria-hidden=\"true\"><\/span><span class=\"forminator-radio-label\">Yes<\/span><\/label><label id=\"forminator-field-radio-7-label-2\" for=\"forminator-field-radio-7-2-69e2eb0684503\" class=\"forminator-radio\" title=\"No\"><input type=\"radio\" name=\"radio-7\" value=\"two\" id=\"forminator-field-radio-7-2-69e2eb0684503\" aria-labelledby=\"forminator-field-radio-7-label-2\" data-calculation=\"0\" checked=\"checked\"  data-hidden-behavior=\"zero\"\/><span class=\"forminator-radio-bullet\" aria-hidden=\"true\"><\/span><span class=\"forminator-radio-label\">No<\/span><\/label><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"textarea-10\" class=\"forminator-field-textarea forminator-col forminator-col-12 \"><div class=\"forminator-field\"><label for=\"forminator-field-textarea-10_69e2eb0684503\" id=\"forminator-field-textarea-10_69e2eb0684503-label\" class=\"forminator-label\">Please describe location, type of pain, and rate the pain from 1-10 with 1 being barely there and 10 being unbearable. List all areas of concern.<\/label><textarea name=\"textarea-10\" placeholder=\"Example: right back of shoulder, chronic tightness and aching, usual pain is 3 topping out at 6 some days\" id=\"forminator-field-textarea-10_69e2eb0684503\" class=\"forminator-textarea\" rows=\"6\" style=\"min-height:140px;\" ><\/textarea><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"textarea-11\" class=\"forminator-field-textarea forminator-col forminator-col-12 \"><div class=\"forminator-field\"><label for=\"forminator-field-textarea-11_69e2eb0684503\" id=\"forminator-field-textarea-11_69e2eb0684503-label\" class=\"forminator-label\">Is there anything else you would like to share?<\/label><textarea name=\"textarea-11\" placeholder=\"\" id=\"forminator-field-textarea-11_69e2eb0684503\" class=\"forminator-textarea\" rows=\"6\" style=\"min-height:140px;\" ><\/textarea><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"html-5\" class=\"forminator-field-html forminator-col forminator-col-12 \"><div class=\"forminator-field forminator-merge-tags\" data-field=\"html-5\"><label class=\"forminator-label\">Consent<\/label><p>I, {name-1-first-name} {name-1-last-name}, understand that the BodyTalk session(s) provided by Suzi Cook, Certified BodyTalk Practitioner is intended to enhance relaxation, increase communication within the areas of the body, and to educate me to possible energetic or emotional blocks that may create pain and disease. BodyTalk is non-invasive, safe, and objective. It utilizes the body\u2019s own innate intelligence to reestablish communication within itself. I understand that BodyTalk is not a substitute for medical treatment or medications. I am aware that the BodyTalk Practitioner does not diagnose illness or disease nor does the Practitioner prescribe medications.<\/p><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"text-1\" class=\"forminator-field-text forminator-col forminator-col-6 \"><div class=\"forminator-field\"><label for=\"forminator-field-text-1_69e2eb0684503\" id=\"forminator-field-text-1_69e2eb0684503-label\" class=\"forminator-label\">Signature <span class=\"forminator-required\">*<\/span><\/label><input type=\"text\" name=\"text-1\" value=\"\" placeholder=\"\" id=\"forminator-field-text-1_69e2eb0684503\" class=\"forminator-input forminator-name--field\" data-required=\"1\" \/><\/div><\/div><div id=\"html-4\" class=\"forminator-field-html forminator-col forminator-col-6 \"><div class=\"forminator-field forminator-merge-tags\" data-field=\"html-4\"><label class=\"forminator-label\">Submission Date<\/label><p>04\/17\/2026<\/p><\/div><\/div><\/div><input type=\"hidden\" name=\"referer_url\" value=\"\" \/><div class=\"forminator-row forminator-row-last\"><div class=\"forminator-col\"><div class=\"forminator-field\"><button class=\"forminator-button forminator-button-submit\">Submit Signed Consent and Client Information Form<\/button><\/div><\/div><\/div><input type=\"hidden\" id=\"forminator_nonce\" name=\"forminator_nonce\" value=\"7b38cdd9b7\" \/><input type=\"hidden\" name=\"_wp_http_referer\" value=\"\/wellness\/wp-json\/wp\/v2\/pages\/220\" \/><input type=\"hidden\" name=\"form_id\" value=\"219\"><input type=\"hidden\" name=\"page_id\" value=\"220\"><input type=\"hidden\" name=\"form_type\" value=\"default\"><input type=\"hidden\" name=\"current_url\" value=\"https:\/\/choicebodytalk.ca\/wellness\/forms\/\"><input type=\"hidden\" name=\"render_id\" value=\"1\"><input type=\"hidden\" name=\"action\" value=\"forminator_submit_form_custom-forms\"><\/form>Don&#8217;t Wait Any Longer. Start Forging Your Own Path Today!<\/p>\n","protected":false},"author":1,"featured_media":0,"parent":0,"menu_order":0,"comment_status":"closed","ping_status":"closed","template":"","meta":{"_et_pb_use_builder":"on","_et_pb_old_content":"","_et_gb_content_width":"","footnotes":""},"class_list":["post-220","page","type-page","status-publish","hentry"],"_links":{"self":[{"href":"https:\/\/choicebodytalk.ca\/wellness\/wp-json\/wp\/v2\/pages\/220","targetHints":{"allow":["GET"]}}],"collection":[{"href":"https:\/\/choicebodytalk.ca\/wellness\/wp-json\/wp\/v2\/pages"}],"about":[{"href":"https:\/\/choicebodytalk.ca\/wellness\/wp-json\/wp\/v2\/types\/page"}],"author":[{"embeddable":true,"href":"https:\/\/choicebodytalk.ca\/wellness\/wp-json\/wp\/v2\/users\/1"}],"replies":[{"embeddable":true,"href":"https:\/\/choicebodytalk.ca\/wellness\/wp-json\/wp\/v2\/comments?post=220"}],"version-history":[{"count":7,"href":"https:\/\/choicebodytalk.ca\/wellness\/wp-json\/wp\/v2\/pages\/220\/revisions"}],"predecessor-version":[{"id":235,"href":"https:\/\/choicebodytalk.ca\/wellness\/wp-json\/wp\/v2\/pages\/220\/revisions\/235"}],"wp:attachment":[{"href":"https:\/\/choicebodytalk.ca\/wellness\/wp-json\/wp\/v2\/media?parent=220"}],"curies":[{"name":"wp","href":"https:\/\/api.w.org\/{rel}","templated":true}]}}