{"id":207,"date":"2021-05-27T15:43:13","date_gmt":"2021-05-27T19:43:13","guid":{"rendered":"https:\/\/eps-sdg.ca\/?page_id=18"},"modified":"2022-12-21T12:40:27","modified_gmt":"2022-12-21T17:40:27","slug":"services-de-sante-mentale-faire-une-demande-de-service","status":"publish","type":"page","link":"https:\/\/eps-sdg.ca\/en\/programmes\/services-en-sante-mentale\/services-de-sante-mentale-faire-une-demande-de-service\/","title":{"rendered":"Apply for Mental Health Services"},"content":{"rendered":"\n<p>Pour effectuer une demande en sant\u00e9 mentale, veuillez composer le 613-938-7112 au poste #226.<\/p>\n\n\n\n<p>Pour effectuer une demande en ligne, remplir le formulaire de demande ci-dessous.<\/p>\n\n\n\n<h2 class=\"wp-block-heading\">Ligne de crise<\/h2>\n\n\n\n<p>Apr\u00e8s les heures d\u2019ouverture et les fins de semaine:<br><strong>Sans frais:<\/strong>&nbsp;1-877-377-7775<\/p>\n\n\n<script type=\"text\/javascript\">\n\/* <![CDATA[ *\/\nvar gform;gform||(document.addEventListener(\"gform_main_scripts_loaded\",function(){gform.scriptsLoaded=!0}),document.addEventListener(\"gform\/theme\/scripts_loaded\",function(){gform.themeScriptsLoaded=!0}),window.addEventListener(\"DOMContentLoaded\",function(){gform.domLoaded=!0}),gform={domLoaded:!1,scriptsLoaded:!1,themeScriptsLoaded:!1,isFormEditor:()=>\"function\"==typeof InitializeEditor,callIfLoaded:function(o){return!(!gform.domLoaded||!gform.scriptsLoaded||!gform.themeScriptsLoaded&&!gform.isFormEditor()||(gform.isFormEditor()&&console.warn(\"The use of gform.initializeOnLoaded() is deprecated in the form editor context and will be removed in Gravity Forms 3.1.\"),o(),0))},initializeOnLoaded:function(o){gform.callIfLoaded(o)||(document.addEventListener(\"gform_main_scripts_loaded\",()=>{gform.scriptsLoaded=!0,gform.callIfLoaded(o)}),document.addEventListener(\"gform\/theme\/scripts_loaded\",()=>{gform.themeScriptsLoaded=!0,gform.callIfLoaded(o)}),window.addEventListener(\"DOMContentLoaded\",()=>{gform.domLoaded=!0,gform.callIfLoaded(o)}))},hooks:{action:{},filter:{}},addAction:function(o,r,e,t){gform.addHook(\"action\",o,r,e,t)},addFilter:function(o,r,e,t){gform.addHook(\"filter\",o,r,e,t)},doAction:function(o){gform.doHook(\"action\",o,arguments)},applyFilters:function(o){return gform.doHook(\"filter\",o,arguments)},removeAction:function(o,r){gform.removeHook(\"action\",o,r)},removeFilter:function(o,r,e){gform.removeHook(\"filter\",o,r,e)},addHook:function(o,r,e,t,n){null==gform.hooks[o][r]&&(gform.hooks[o][r]=[]);var d=gform.hooks[o][r];null==n&&(n=r+\"_\"+d.length),gform.hooks[o][r].push({tag:n,callable:e,priority:t=null==t?10:t})},doHook:function(r,o,e){var t;if(e=Array.prototype.slice.call(e,1),null!=gform.hooks[r][o]&&((o=gform.hooks[r][o]).sort(function(o,r){return o.priority-r.priority}),o.forEach(function(o){\"function\"!=typeof(t=o.callable)&&(t=window[t]),\"action\"==r?t.apply(null,e):e[0]=t.apply(null,e)})),\"filter\"==r)return e[0]},removeHook:function(o,r,t,n){var e;null!=gform.hooks[o][r]&&(e=(e=gform.hooks[o][r]).filter(function(o,r,e){return!!(null!=n&&n!=o.tag||null!=t&&t!=o.priority)}),gform.hooks[o][r]=e)}});\n\/* ]]> *\/\n<\/script>\n\n                <div class='gf_browser_gecko gform_wrapper gravity-theme gform-theme--no-framework' data-form-theme='gravity-theme' data-form-index='0' id='gform_wrapper_3' >\n                        <div class='gform_heading'>\n                            <h2 class=\"gform_title\">Formulaire de r\u00e9f\u00e9rence &#8211; Sant\u00e9 mentale<\/h2>\n                            <p class='gform_description'><\/p>\n                        <\/div><form method='post' enctype='multipart\/form-data'  id='gform_3'  action='\/en\/wp-json\/wp\/v2\/pages\/207' data-formid='3' novalidate>\n                        <div class='gform-body gform_body'><div id='gform_fields_3' class='gform_fields top_label form_sublabel_below description_below validation_below'><div id=\"field_3_1\" class=\"gfield gfield--type-date gfield--input-type-datepicker gfield--datepicker-default-icon gfield--width-half gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_3_1'>Date de la demande<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/label><div class='ginput_container ginput_container_date'>\n                            <input name='input_1' id='input_3_1' type='text' value='' class='datepicker gform-datepicker mdy datepicker_with_icon gdatepicker_with_icon'   placeholder='04\/16\/2026' aria-describedby=\"input_3_1_date_format\" aria-invalid=\"false\" aria-required=\"true\"\/>\n                            <span id='input_3_1_date_format' class='screen-reader-text'>MM slash DD slash YYYY<\/span>\n                        <\/div>\n                        <input type='hidden' id='gforms_calendar_icon_input_3_1' class='gform_hidden' value='https:\/\/eps-sdg.ca\/wp-content\/plugins\/gravityforms\/images\/datepicker\/datepicker.svg'\/><\/div><div id=\"field_3_3\" class=\"gfield gfield--type-select gfield--width-half gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_3_3'>Source de r\u00e9f\u00e9rence<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/label><div class='ginput_container ginput_container_select'><select name='input_3' id='input_3_3' class='large gfield_select'    aria-required=\"true\" aria-invalid=\"false\" ><option value='Auto-r\u00e9f\u00e9rence' >Auto-r\u00e9f\u00e9rence<\/option><option value='Parent\/Tuteur' >Parent\/Tuteur<\/option><option value='Agence' >Agence<\/option><option value='Professionnel' >Professionnel<\/option><option value='\u00c9cole' >\u00c9cole<\/option><option value='Autre' >Autre<\/option><\/select><\/div><\/div><div id=\"field_3_4\" class=\"gfield gfield--type-text gfield--width-full field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_3_4'>Nom du r\u00e9f\u00e9rent<\/label><div class='ginput_container ginput_container_text'><input name='input_4' id='input_3_4' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/div><fieldset id=\"field_3_5\" class=\"gfield gfield--type-name gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Nom de l\u2019enfant\/du jeune<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/legend><div class='ginput_complex ginput_container ginput_container--name no_prefix has_first_name no_middle_name has_last_name no_suffix gf_name_has_2 ginput_container_name gform-grid-row' id='input_3_5'>\n                            \n                            <span id='input_3_5_3_container' class='name_first gform-grid-col gform-grid-col--size-auto' >\n                                                    <input type='text' name='input_5.3' id='input_3_5_3' value=''   aria-required='true'     \/>\n                                                    <label for='input_3_5_3' class='gform-field-label gform-field-label--type-sub '>First<\/label>\n                                                <\/span>\n                            \n                            <span id='input_3_5_6_container' class='name_last gform-grid-col gform-grid-col--size-auto' >\n                                                    <input type='text' name='input_5.6' id='input_3_5_6' value=''   aria-required='true'     \/>\n                                                    <label for='input_3_5_6' class='gform-field-label gform-field-label--type-sub '>Last<\/label>\n                                                <\/span>\n                            \n                        <\/div><\/fieldset><div id=\"field_3_6\" class=\"gfield gfield--type-select gfield--width-half gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_3_6'>Garde l\u00e9gale<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/label><div class='ginput_container ginput_container_select'><select name='input_6' id='input_3_6' class='large gfield_select'    aria-required=\"true\" aria-invalid=\"false\" ><option value='M\u00e8re' >M\u00e8re<\/option><option value='P\u00e8re' >P\u00e8re<\/option><option value='Parents' >Parents<\/option><option value='Autre' >Autre<\/option><\/select><\/div><\/div><div id=\"field_3_8\" class=\"gfield gfield--type-number gfield--width-half gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_3_8'>\u00c2ge du client<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/label><div class='ginput_container ginput_container_number'><input name='input_8' id='input_3_8' type='number' step='any'   value='' class='large'     aria-required=\"true\" aria-invalid=\"false\"  \/><\/div><\/div><div id=\"field_3_9\" class=\"gfield gfield--type-date gfield--input-type-datepicker gfield--datepicker-default-icon gfield--width-half gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_3_9'>Date de naissance<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/label><div class='ginput_container ginput_container_date'>\n                            <input name='input_9' id='input_3_9' type='text' value='' class='datepicker gform-datepicker mdy datepicker_with_icon gdatepicker_with_icon'   placeholder='mm\/dd\/yyyy' aria-describedby=\"input_3_9_date_format\" aria-invalid=\"false\" aria-required=\"true\"\/>\n                            <span id='input_3_9_date_format' class='screen-reader-text'>MM slash DD slash YYYY<\/span>\n                        <\/div>\n                        <input type='hidden' id='gforms_calendar_icon_input_3_9' class='gform_hidden' value='https:\/\/eps-sdg.ca\/wp-content\/plugins\/gravityforms\/images\/datepicker\/datepicker.svg'\/><\/div><fieldset id=\"field_3_10\" class=\"gfield gfield--type-radio gfield--type-choice gfield--width-half gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >Identification<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_3_10'>\n\t\t\t<div class='gchoice gchoice_3_10_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_10' type='radio' value='F'  id='choice_3_10_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_3_10_0' id='label_3_10_0' class='gform-field-label gform-field-label--type-inline'>F<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_3_10_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_10' type='radio' value='M'  id='choice_3_10_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_3_10_1' id='label_3_10_1' class='gform-field-label gform-field-label--type-inline'>M<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_3_10_2'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_10' type='radio' value='gf_other_choice'  id='choice_3_10_2' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_3_10_2' id='label_3_10_2' class='gform-field-label gform-field-label--type-inline'>Other<\/label><br \/><input id='input_3_10_other' class='gchoice_other_control' name='input_10_other' type='text' value='Other' aria-label='Other Choice, please specify'  disabled='disabled' \/>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_3_11\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Motif(s) de la r\u00e9f\u00e9rence<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox ' id='input_3_11'><div class='gchoice gchoice_3_11_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_11.1' type='checkbox'  value='Comportement ext\u00e9rioris\u00e9 (agressivit\u00e9, opposition\/d\u00e9fiance)'  id='choice_3_11_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_3_11_1' id='label_3_11_1' class='gform-field-label gform-field-label--type-inline'>Comportement ext\u00e9rioris\u00e9 (agressivit\u00e9, opposition\/d\u00e9fiance)<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_3_11_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_11.2' type='checkbox'  value='Automutilation'  id='choice_3_11_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_3_11_2' id='label_3_11_2' class='gform-field-label gform-field-label--type-inline'>Automutilation<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_3_11_3'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_11.3' type='checkbox'  value='Diagnostique en sant\u00e9 mentale (TDA, TDAH, anxi\u00e9t\u00e9)'  id='choice_3_11_3'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_3_11_3' id='label_3_11_3' class='gform-field-label gform-field-label--type-inline'>Diagnostique en sant\u00e9 mentale (TDA, TDAH, anxi\u00e9t\u00e9)<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_3_11_4'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_11.4' type='checkbox'  value='Troubles alimentaires'  id='choice_3_11_4'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_3_11_4' id='label_3_11_4' class='gform-field-label gform-field-label--type-inline'>Troubles alimentaires<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_3_11_5'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_11.5' type='checkbox'  value='Peurs, phobies, anxi\u00e9t\u00e9'  id='choice_3_11_5'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_3_11_5' id='label_3_11_5' class='gform-field-label gform-field-label--type-inline'>Peurs, phobies, anxi\u00e9t\u00e9<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_3_11_6'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_11.6' type='checkbox'  value='Conflits familiaux'  id='choice_3_11_6'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_3_11_6' id='label_3_11_6' class='gform-field-label gform-field-label--type-inline'>Conflits familiaux<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_3_11_7'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_11.7' type='checkbox'  value='Relations malsaines'  id='choice_3_11_7'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_3_11_7' id='label_3_11_7' class='gform-field-label gform-field-label--type-inline'>Relations malsaines<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_3_11_8'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_11.8' type='checkbox'  value='Humeur d\u00e9pressive'  id='choice_3_11_8'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_3_11_8' id='label_3_11_8' class='gform-field-label gform-field-label--type-inline'>Humeur d\u00e9pressive<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_3_11_9'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_11.9' type='checkbox'  value='Consommation\/d\u00e9pendance'  id='choice_3_11_9'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_3_11_9' id='label_3_11_9' class='gform-field-label gform-field-label--type-inline'>Consommation\/d\u00e9pendance<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_3_11_11'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_11.11' type='checkbox'  value='Pauvres habilet\u00e9s sociales'  id='choice_3_11_11'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_3_11_11' id='label_3_11_11' class='gform-field-label gform-field-label--type-inline'>Pauvres habilet\u00e9s sociales<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_3_11_12'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_11.12' type='checkbox'  value='Probl\u00e8mes d\u2019estime de soi'  id='choice_3_11_12'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_3_11_12' id='label_3_11_12' class='gform-field-label gform-field-label--type-inline'>Probl\u00e8mes d\u2019estime de soi<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_3_11_13'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_11.13' type='checkbox'  value='D\u00e9crochage scolaire'  id='choice_3_11_13'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_3_11_13' id='label_3_11_13' class='gform-field-label gform-field-label--type-inline'>D\u00e9crochage scolaire<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_3_11_14'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_11.14' type='checkbox'  value='Id\u00e9es, propos ou tentatives suicidaires'  id='choice_3_11_14'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_3_11_14' id='label_3_11_14' class='gform-field-label gform-field-label--type-inline'>Id\u00e9es, propos ou tentatives suicidaires<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_3_12\" class=\"gfield gfield--type-textarea gfield--width-full field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_3_12'>Autre<\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_12' id='input_3_12' class='textarea large'      aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/div><fieldset id=\"field_3_14\" class=\"gfield gfield--type-radio gfield--type-choice gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >Parent(s)\/tuteurs(s)<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_3_14'>\n\t\t\t<div class='gchoice gchoice_3_14_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_14' type='radio' value='Mari\u00e9s'  id='choice_3_14_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_3_14_0' id='label_3_14_0' class='gform-field-label gform-field-label--type-inline'>Mari\u00e9s<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_3_14_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_14' type='radio' value='S\u00e9par\u00e9s'  id='choice_3_14_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_3_14_1' id='label_3_14_1' class='gform-field-label gform-field-label--type-inline'>S\u00e9par\u00e9s<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_3_14_2'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_14' type='radio' value='gf_other_choice'  id='choice_3_14_2' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_3_14_2' id='label_3_14_2' class='gform-field-label gform-field-label--type-inline'>Other<\/label><br \/><input id='input_3_14_other' class='gchoice_other_control' name='input_14_other' type='text' value='Other' aria-label='Other Choice, please specify'  disabled='disabled' \/>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_3_13\" class=\"gfield gfield--type-section gsection field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><h3 class=\"gsection_title\">Parent\/tuteur primaire<\/h3><\/div><fieldset id=\"field_3_16\" class=\"gfield gfield--type-name gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Nom<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/legend><div class='ginput_complex ginput_container ginput_container--name no_prefix has_first_name no_middle_name has_last_name no_suffix gf_name_has_2 ginput_container_name gform-grid-row' id='input_3_16'>\n                            \n                            <span id='input_3_16_3_container' class='name_first gform-grid-col gform-grid-col--size-auto' >\n                                                    <input type='text' name='input_16.3' id='input_3_16_3' value=''   aria-required='true'     \/>\n                                                    <label for='input_3_16_3' class='gform-field-label gform-field-label--type-sub '>First<\/label>\n                                                <\/span>\n                            \n                            <span id='input_3_16_6_container' class='name_last gform-grid-col gform-grid-col--size-auto' >\n                                                    <input type='text' name='input_16.6' id='input_3_16_6' value=''   aria-required='true'     \/>\n                                                    <label for='input_3_16_6' class='gform-field-label gform-field-label--type-sub '>Last<\/label>\n                                                <\/span>\n                            \n                        <\/div><\/fieldset><fieldset id=\"field_3_17\" class=\"gfield gfield--type-address gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Adresse<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/legend>    \n                    <div class='ginput_complex ginput_container has_street has_street2 has_city has_state has_zip ginput_container_address gform-grid-row' id='input_3_17' >\n                         <span class='ginput_full address_line_1 ginput_address_line_1 gform-grid-col' id='input_3_17_1_container' >\n                                        <input type='text' name='input_17.1' id='input_3_17_1' value=''    aria-required='true'    \/>\n                                        <label for='input_3_17_1' id='input_3_17_1_label' class='gform-field-label gform-field-label--type-sub '>Street Address<\/label>\n                                    <\/span><span class='ginput_full address_line_2 ginput_address_line_2 gform-grid-col' id='input_3_17_2_container' >\n                                        <input type='text' name='input_17.2' id='input_3_17_2' value=''     aria-required='false'   \/>\n                                        <label for='input_3_17_2' id='input_3_17_2_label' class='gform-field-label gform-field-label--type-sub '>Address Line 2<\/label>\n                                    <\/span><span class='ginput_left address_city ginput_address_city gform-grid-col' id='input_3_17_3_container' >\n                                    <input type='text' name='input_17.3' id='input_3_17_3' value=''    aria-required='true'    \/>\n                                    <label for='input_3_17_3' id='input_3_17_3_label' class='gform-field-label gform-field-label--type-sub '>City<\/label>\n                                 <\/span><span class='ginput_right address_state ginput_address_state gform-grid-col' id='input_3_17_4_container' >\n                                        <select name='input_17.4' id='input_3_17_4'     aria-required='true'    ><option value='' selected='selected'><\/option><option value='Alberta' >Alberta<\/option><option value='British Columbia' >British Columbia<\/option><option value='Manitoba' >Manitoba<\/option><option value='New Brunswick' >New Brunswick<\/option><option value='Newfoundland and Labrador' >Newfoundland and Labrador<\/option><option value='Northwest Territories' >Northwest Territories<\/option><option value='Nova Scotia' >Nova Scotia<\/option><option value='Nunavut' >Nunavut<\/option><option value='Ontario' >Ontario<\/option><option value='Prince Edward Island' >Prince Edward Island<\/option><option value='Quebec' >Quebec<\/option><option value='Saskatchewan' >Saskatchewan<\/option><option value='Yukon' >Yukon<\/option><\/select>\n                                        <label for='input_3_17_4' id='input_3_17_4_label' class='gform-field-label gform-field-label--type-sub '>Province<\/label>\n                                      <\/span><span class='ginput_left address_zip ginput_address_zip gform-grid-col' id='input_3_17_5_container' >\n                                    <input type='text' name='input_17.5' id='input_3_17_5' value=''    aria-required='true'    \/>\n                                    <label for='input_3_17_5' id='input_3_17_5_label' class='gform-field-label gform-field-label--type-sub '>Postal Code<\/label>\n                                <\/span><input type='hidden' class='gform_hidden' name='input_17.6' id='input_3_17_6' value='Canada' \/>\n                    <div class='gf_clear gf_clear_complex'><\/div>\n                <\/div><\/fieldset><div id=\"field_3_18\" class=\"gfield gfield--type-email gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_3_18'>Adresse courriel<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/label><div class='ginput_container ginput_container_email'>\n                            <input name='input_18' id='input_3_18' type='email' value='' class='large'    aria-required=\"true\" aria-invalid=\"false\"  \/>\n                        <\/div><\/div><div id=\"field_3_19\" class=\"gfield gfield--type-phone gfield--width-full field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_3_19'>N\u00b0 de t\u00e9l\u00e9phone maison<\/label><div class='ginput_container ginput_container_phone'><input name='input_19' id='input_3_19' type='tel' value='' class='large'    aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_3_20\" class=\"gfield gfield--type-phone gfield--width-full field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_3_20'>N\u00b0 de t\u00e9l\u00e9phone travail<\/label><div class='ginput_container ginput_container_phone'><input name='input_20' id='input_3_20' type='tel' value='' class='large'    aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_3_21\" class=\"gfield gfield--type-phone gfield--width-full field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_3_21'>N\u00b0 de t\u00e9l\u00e9phone cellulaire<\/label><div class='ginput_container ginput_container_phone'><input name='input_21' id='input_3_21' type='tel' value='' class='large'    aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_3_22\" class=\"gfield gfield--type-section gsection field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><h3 class=\"gsection_title\">Parent\/tuteur secondaire<\/h3><\/div><fieldset id=\"field_3_34\" class=\"gfield gfield--type-name gfield--width-full field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Nom<\/legend><div class='ginput_complex ginput_container ginput_container--name no_prefix has_first_name no_middle_name has_last_name no_suffix gf_name_has_2 ginput_container_name gform-grid-row' id='input_3_34'>\n                            \n                            <span id='input_3_34_3_container' class='name_first gform-grid-col gform-grid-col--size-auto' >\n                                                    <input type='text' name='input_34.3' id='input_3_34_3' value=''   aria-required='false'     \/>\n                                                    <label for='input_3_34_3' class='gform-field-label gform-field-label--type-sub '>First<\/label>\n                                                <\/span>\n                            \n                            <span id='input_3_34_6_container' class='name_last gform-grid-col gform-grid-col--size-auto' >\n                                                    <input type='text' name='input_34.6' id='input_3_34_6' value=''   aria-required='false'     \/>\n                                                    <label for='input_3_34_6' class='gform-field-label gform-field-label--type-sub '>Last<\/label>\n                                                <\/span>\n                            \n                        <\/div><\/fieldset><fieldset id=\"field_3_33\" class=\"gfield gfield--type-address gfield--width-full field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Adresse<\/legend>    \n                    <div class='ginput_complex ginput_container has_street has_street2 has_city has_state has_zip ginput_container_address gform-grid-row' id='input_3_33' >\n                         <span class='ginput_full address_line_1 ginput_address_line_1 gform-grid-col' id='input_3_33_1_container' >\n                                        <input type='text' name='input_33.1' id='input_3_33_1' value=''    aria-required='false'    \/>\n                                        <label for='input_3_33_1' id='input_3_33_1_label' class='gform-field-label gform-field-label--type-sub '>Street Address<\/label>\n                                    <\/span><span class='ginput_full address_line_2 ginput_address_line_2 gform-grid-col' id='input_3_33_2_container' >\n                                        <input type='text' name='input_33.2' id='input_3_33_2' value=''     aria-required='false'   \/>\n                                        <label for='input_3_33_2' id='input_3_33_2_label' class='gform-field-label gform-field-label--type-sub '>Address Line 2<\/label>\n                                    <\/span><span class='ginput_left address_city ginput_address_city gform-grid-col' id='input_3_33_3_container' >\n                                    <input type='text' name='input_33.3' id='input_3_33_3' value=''    aria-required='false'    \/>\n                                    <label for='input_3_33_3' id='input_3_33_3_label' class='gform-field-label gform-field-label--type-sub '>City<\/label>\n                                 <\/span><span class='ginput_right address_state ginput_address_state gform-grid-col' id='input_3_33_4_container' >\n                                        <select name='input_33.4' id='input_3_33_4'     aria-required='false'    ><option value='' selected='selected'><\/option><option value='Alberta' >Alberta<\/option><option value='British Columbia' >British Columbia<\/option><option value='Manitoba' >Manitoba<\/option><option value='New Brunswick' >New Brunswick<\/option><option value='Newfoundland and Labrador' >Newfoundland and Labrador<\/option><option value='Northwest Territories' >Northwest Territories<\/option><option value='Nova Scotia' >Nova Scotia<\/option><option value='Nunavut' >Nunavut<\/option><option value='Ontario' >Ontario<\/option><option value='Prince Edward Island' >Prince Edward Island<\/option><option value='Quebec' >Quebec<\/option><option value='Saskatchewan' >Saskatchewan<\/option><option value='Yukon' >Yukon<\/option><\/select>\n                                        <label for='input_3_33_4' id='input_3_33_4_label' class='gform-field-label gform-field-label--type-sub '>Province<\/label>\n                                      <\/span><span class='ginput_left address_zip ginput_address_zip gform-grid-col' id='input_3_33_5_container' >\n                                    <input type='text' name='input_33.5' id='input_3_33_5' value=''    aria-required='false'    \/>\n                                    <label for='input_3_33_5' id='input_3_33_5_label' class='gform-field-label gform-field-label--type-sub '>Postal Code<\/label>\n                                <\/span><input type='hidden' class='gform_hidden' name='input_33.6' id='input_3_33_6' value='Canada' \/>\n                    <div class='gf_clear gf_clear_complex'><\/div>\n                <\/div><\/fieldset><div id=\"field_3_25\" class=\"gfield gfield--type-email gfield--width-full field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_3_25'>Adresse courriel<\/label><div class='ginput_container ginput_container_email'>\n                            <input name='input_25' id='input_3_25' type='email' value='' class='large'     aria-invalid=\"false\"  \/>\n                        <\/div><\/div><div id=\"field_3_32\" class=\"gfield gfield--type-phone gfield--width-full field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_3_32'>N\u00b0 de t\u00e9l\u00e9phone maison<\/label><div class='ginput_container ginput_container_phone'><input name='input_32' id='input_3_32' type='tel' value='' class='large'    aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_3_31\" class=\"gfield gfield--type-phone gfield--width-full field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_3_31'>N\u00b0 de t\u00e9l\u00e9phone travail<\/label><div class='ginput_container ginput_container_phone'><input name='input_31' id='input_3_31' type='tel' value='' class='large'    aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_3_30\" class=\"gfield gfield--type-phone gfield--width-full field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_3_30'>N\u00b0 de t\u00e9l\u00e9phone cellulaire<\/label><div class='ginput_container ginput_container_phone'><input name='input_30' id='input_3_30' type='tel' value='' class='large'    aria-invalid=\"false\"   \/><\/div><\/div><fieldset id=\"field_3_29\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below hidden_label field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Untitled<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox ' id='input_3_29'><div class='gchoice gchoice_3_29_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_29.1' type='checkbox'  value='Je consens \u00e0 ce que mon enfant soit r\u00e9f\u00e9r\u00e9 aux services de l\u2019\u00c9quipe psycho-sociale.'  id='choice_3_29_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_3_29_1' id='label_3_29_1' class='gform-field-label gform-field-label--type-inline'>Je consens \u00e0 ce que mon enfant soit r\u00e9f\u00e9r\u00e9 aux services de l\u2019\u00c9quipe psycho-sociale.<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><\/div><\/div>\n        <div class='gform-footer gform_footer top_label'> <input type='submit' id='gform_submit_button_3' class='gform_button button' onclick='gform.submission.handleButtonClick(this);' data-submission-type='submit' value='Soumettre la demande'  \/> \n            <input type='hidden' class='gform_hidden' name='gform_submission_method' data-js='gform_submission_method_3' value='postback' \/>\n            <input type='hidden' class='gform_hidden' name='gform_theme' data-js='gform_theme_3' id='gform_theme_3' value='gravity-theme' \/>\n            <input type='hidden' class='gform_hidden' name='gform_style_settings' data-js='gform_style_settings_3' id='gform_style_settings_3' value='[]' \/>\n            <input type='hidden' class='gform_hidden' name='is_submit_3' value='1' \/>\n            <input type='hidden' class='gform_hidden' name='gform_submit' value='3' \/>\n            \n            <input type='hidden' class='gform_hidden' name='gform_currency' data-currency='USD' value='tW129XXWLWHMdITlWMG1ilj038GXgsRgoLySzn9oZitpwa4nlCSX8vZ98k0NpYlsnhOfohDoM9lpfwU7EkunMDSPZKDkfkDNiEoN6tu4UzCe4eI=' \/>\n            <input type='hidden' class='gform_hidden' name='gform_unique_id' value='' \/>\n            <input type='hidden' class='gform_hidden' name='state_3' value='WyJ7XCIxMFwiOltcImQwNTc3NjQ3YjFjZWExZThjN2Y5YmI2MWMzODRhYWM1XCIsXCJjM2NmNjNhNDdmODg3Nzk1NmM4MDIzMGU2N2JhMTdlOVwiXSxcIjE0XCI6W1wiYWMyZWRkMWZmMmFkYjMyZjcxMzM1OWZkMjljYTUxYzVcIixcIjVhZDA0MjJjOWJmZGIwOWNlMzhmZWFmZTZkMWZhYTdjXCJdfSIsIjIxODRmN2VmNzExM2I1MmNmNDk3NWUyZGE4NWMwNDY2Il0=' \/>\n            <input type='hidden' autocomplete='off' class='gform_hidden' name='gform_target_page_number_3' id='gform_target_page_number_3' value='0' \/>\n            <input type='hidden' autocomplete='off' class='gform_hidden' name='gform_source_page_number_3' id='gform_source_page_number_3' value='1' \/>\n            <input type='hidden' name='gform_field_values' value='' \/>\n            \n        <\/div>\n                        <\/form>\n                        <\/div><script type=\"text\/javascript\">\n\/* <![CDATA[ *\/\n gform.initializeOnLoaded( function() {gformInitSpinner( 3, 'https:\/\/eps-sdg.ca\/wp-content\/plugins\/gravityforms\/images\/spinner.svg', true );jQuery('#gform_ajax_frame_3').on('load',function(){var contents = jQuery(this).contents().find('*').html();var is_postback = contents.indexOf('GF_AJAX_POSTBACK') >= 0;if(!is_postback){return;}var form_content = jQuery(this).contents().find('#gform_wrapper_3');var is_confirmation = jQuery(this).contents().find('#gform_confirmation_wrapper_3').length > 0;var is_redirect = contents.indexOf('gformRedirect(){') >= 0;var is_form = form_content.length > 0 && ! is_redirect && ! is_confirmation;var mt = parseInt(jQuery('html').css('margin-top'), 10) + parseInt(jQuery('body').css('margin-top'), 10) + 100;if(is_form){jQuery('#gform_wrapper_3').html(form_content.html());if(form_content.hasClass('gform_validation_error')){jQuery('#gform_wrapper_3').addClass('gform_validation_error');} else {jQuery('#gform_wrapper_3').removeClass('gform_validation_error');}setTimeout( function() { \/* delay the scroll by 50 milliseconds to fix a bug in chrome *\/  }, 50 );if(window['gformInitDatepicker']) {gformInitDatepicker();}if(window['gformInitPriceFields']) {gformInitPriceFields();}var current_page = jQuery('#gform_source_page_number_3').val();gformInitSpinner( 3, 'https:\/\/eps-sdg.ca\/wp-content\/plugins\/gravityforms\/images\/spinner.svg', true );jQuery(document).trigger('gform_page_loaded', [3, current_page]);window['gf_submitting_3'] = false;}else if(!is_redirect){var confirmation_content = jQuery(this).contents().find('.GF_AJAX_POSTBACK').html();if(!confirmation_content){confirmation_content = contents;}jQuery('#gform_wrapper_3').replaceWith(confirmation_content);jQuery(document).trigger('gform_confirmation_loaded', [3]);window['gf_submitting_3'] = false;wp.a11y.speak(jQuery('#gform_confirmation_message_3').text());}else{jQuery('#gform_3').append(contents);if(window['gformRedirect']) {gformRedirect();}}jQuery(document).trigger(\"gform_pre_post_render\", [{ formId: \"3\", currentPage: \"current_page\", abort: function() { this.preventDefault(); } }]);        if (event && event.defaultPrevented) {                return;        }        const gformWrapperDiv = document.getElementById( \"gform_wrapper_3\" );        if ( gformWrapperDiv ) {            const visibilitySpan = document.createElement( \"span\" );            visibilitySpan.id = \"gform_visibility_test_3\";            gformWrapperDiv.insertAdjacentElement( \"afterend\", visibilitySpan );        }        const visibilityTestDiv = document.getElementById( \"gform_visibility_test_3\" );        let postRenderFired = false;        function triggerPostRender() {            if ( postRenderFired ) {                return;            }            postRenderFired = true;            gform.core.triggerPostRenderEvents( 3, current_page );            if ( visibilityTestDiv ) {                visibilityTestDiv.parentNode.removeChild( visibilityTestDiv );            }        }        function debounce( func, wait, immediate ) {            var timeout;            return function() {                var context = 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Pour effectuer une demande en ligne, remplir le formulaire de demande ci-dessous. 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