{"id":3554,"date":"2021-10-12T15:51:30","date_gmt":"2021-10-12T19:51:30","guid":{"rendered":"https:\/\/eps-sdg.ca\/?page_id=3554"},"modified":"2021-10-12T15:51:30","modified_gmt":"2021-10-12T19:51:30","slug":"faire-une-demande","status":"publish","type":"page","link":"https:\/\/eps-sdg.ca\/en\/programmes\/violence-familiale\/faire-une-demande\/","title":{"rendered":"Apply for Services"},"content":{"rendered":"<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 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data-form-theme='gravity-theme' data-form-index='0' id='gform_wrapper_2' >\n                        <div class='gform_heading'>\n                            <h2 class=\"gform_title\">Formulaire de r\u00e9f\u00e9rence &#8211; Violence familiale<\/h2>\n                            <p class='gform_description'><\/p>\n                        <\/div><form method='post' enctype='multipart\/form-data'  id='gform_2'  action='\/en\/wp-json\/wp\/v2\/pages\/3554' data-formid='2' novalidate>\n                        <div class='gform-body gform_body'><div id='gform_fields_2' class='gform_fields top_label form_sublabel_below description_below validation_below'><div id=\"field_2_20\" class=\"gfield gfield--type-honeypot gform_validation_container field_sublabel_below gfield--has-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_2_20'>Phone<\/label><div class='ginput_container'><input name='input_20' id='input_2_20' type='text' value='' autocomplete='new-password'\/><\/div><div class='gfield_description' id='gfield_description_2_20'>This field is for validation purposes and should be left unchanged.<\/div><\/div><div id=\"field_2_1\" class=\"gfield gfield--type-date gfield--input-type-datepicker gfield--datepicker-default-icon gfield--width-half field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_2_1'>Date de la demande<\/label><div class='ginput_container ginput_container_date'>\n                            <input name='input_1' id='input_2_1' type='text' value='' class='datepicker gform-datepicker mdy datepicker_with_icon gdatepicker_with_icon'   placeholder='mm\/dd\/yyyy' aria-describedby=\"input_2_1_date_format\" aria-invalid=\"false\" \/>\n                            <span id='input_2_1_date_format' class='screen-reader-text'>MM slash DD slash YYYY<\/span>\n                        <\/div>\n                        <input type='hidden' id='gforms_calendar_icon_input_2_1' class='gform_hidden' value='https:\/\/eps-sdg.ca\/wp-content\/plugins\/gravityforms\/images\/datepicker\/datepicker.svg'\/><\/div><fieldset id=\"field_2_2\" class=\"gfield gfield--type-radio gfield--type-choice gfield--width-half field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >Source de r\u00e9f\u00e9rence<\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_2_2'>\n\t\t\t<div class='gchoice gchoice_2_2_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_2' type='radio' value='Soi-M\u00eame'  id='choice_2_2_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_2_2_0' id='label_2_2_0' class='gform-field-label gform-field-label--type-inline'>Soi-M\u00eame<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_2_2_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_2' type='radio' value='Agence'  id='choice_2_2_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_2_2_1' id='label_2_2_1' class='gform-field-label gform-field-label--type-inline'>Agence<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_2_2_2'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_2' type='radio' value='gf_other_choice'  id='choice_2_2_2' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_2_2_2' id='label_2_2_2' class='gform-field-label gform-field-label--type-inline'>Other<\/label><br \/><input id='input_2_2_other' class='gchoice_other_control' name='input_2_other' type='text' value='Other' aria-label='Other Choice, please specify'  disabled='disabled' \/>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_2_3\" 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\">INFORMATION DE LA CLIENTE<\/h3><\/div><fieldset id=\"field_2_4\" class=\"gfield gfield--type-name gfield--width-half field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Nom du r\u00e9f\u00e9rent<\/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_2_4'>\n                            \n                            <span id='input_2_4_3_container' class='name_first gform-grid-col gform-grid-col--size-auto' >\n                                                    <input type='text' name='input_4.3' id='input_2_4_3' value=''   aria-required='false'     \/>\n                                                    <label for='input_2_4_3' class='gform-field-label gform-field-label--type-sub '>First<\/label>\n                                                <\/span>\n                            \n                            <span id='input_2_4_6_container' class='name_last gform-grid-col gform-grid-col--size-auto' >\n                                                    <input type='text' name='input_4.6' id='input_2_4_6' value=''   aria-required='false'     \/>\n                                                    <label for='input_2_4_6' class='gform-field-label gform-field-label--type-sub '>Last<\/label>\n                                                <\/span>\n                            \n                        <\/div><\/fieldset><div id=\"field_2_5\" class=\"gfield gfield--type-text gfield--width-half field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_2_5'>DDN<\/label><div class='ginput_container ginput_container_text'><input name='input_5' id='input_2_5' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_2_6\" class=\"gfield gfield--type-phone gfield--width-half field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_2_6'>N\u00b0 de t\u00e9l\u00e9phone maison<\/label><div class='ginput_container ginput_container_phone'><input name='input_6' id='input_2_6' type='tel' value='' class='large'    aria-invalid=\"false\"   \/><\/div><\/div><fieldset id=\"field_2_8\" class=\"gfield gfield--type-radio gfield--type-choice gfield--width-half gf_list_inline field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >Peut-on t\u00e9l\u00e9phoner\/laisser un message sans danger ?<\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_2_8'>\n\t\t\t<div class='gchoice gchoice_2_8_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_8' type='radio' value='Oui'  id='choice_2_8_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_2_8_0' id='label_2_8_0' class='gform-field-label gform-field-label--type-inline'>Oui<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_2_8_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_8' type='radio' value='Non'  id='choice_2_8_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_2_8_1' id='label_2_8_1' class='gform-field-label gform-field-label--type-inline'>Non<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_2_7\" class=\"gfield gfield--type-phone gfield--width-half field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_2_7'>N\u00b0 de t\u00e9l\u00e9phone cellulaire<\/label><div class='ginput_container ginput_container_phone'><input name='input_7' id='input_2_7' type='tel' value='' class='large'    aria-invalid=\"false\"   \/><\/div><\/div><fieldset id=\"field_2_9\" class=\"gfield gfield--type-radio gfield--type-choice gfield--width-half gf_list_inline field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >Peut-on t\u00e9l\u00e9phoner\/laisser un message sans danger ?<\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_2_9'>\n\t\t\t<div class='gchoice gchoice_2_9_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_9' type='radio' value='Oui'  id='choice_2_9_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_2_9_0' id='label_2_9_0' class='gform-field-label gform-field-label--type-inline'>Oui<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_2_9_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_9' type='radio' value='Non'  id='choice_2_9_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_2_9_1' id='label_2_9_1' class='gform-field-label gform-field-label--type-inline'>Non<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_2_10\" 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_2_10'>Adresse courriel<\/label><div class='ginput_container ginput_container_email'>\n                            <input name='input_10' id='input_2_10' type='email' value='' class='large'     aria-invalid=\"false\"  \/>\n                        <\/div><\/div><div id=\"field_2_11\" 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\">RAISON POUR LA R\u00c9F\u00c9RENCE<\/h3><\/div><fieldset id=\"field_2_14\" class=\"gfield gfield--type-radio gfield--type-choice gfield--width-half field_sublabel_below gfield--no-description field_description_below hidden_label field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >RAISON POUR LA R\u00c9F\u00c9RENCE<\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_2_14'>\n\t\t\t<div class='gchoice gchoice_2_14_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_14' type='radio' value='Victime de violence'  id='choice_2_14_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_2_14_0' id='label_2_14_0' class='gform-field-label gform-field-label--type-inline'>Victime de violence<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_2_14_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_14' type='radio' value='Relation malsaine'  id='choice_2_14_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_2_14_1' id='label_2_14_1' class='gform-field-label gform-field-label--type-inline'>Relation malsaine<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_2_14_2'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_14' type='radio' value='Gestion des \u00e9motions'  id='choice_2_14_2' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_2_14_2' id='label_2_14_2' class='gform-field-label gform-field-label--type-inline'>Gestion des \u00e9motions<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_2_14_3'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_14' type='radio' value='Estime de soi'  id='choice_2_14_3' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_2_14_3' id='label_2_14_3' class='gform-field-label gform-field-label--type-inline'>Estime de soi<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_2_14_4'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_14' type='radio' value='Conflit \/ Probl\u00e8mes familiaux'  id='choice_2_14_4' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_2_14_4' id='label_2_14_4' class='gform-field-label gform-field-label--type-inline'>Conflit \/ Probl\u00e8mes familiaux<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_2_14_5'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_14' type='radio' value='Propos suicidaire'  id='choice_2_14_5' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_2_14_5' id='label_2_14_5' class='gform-field-label gform-field-label--type-inline'>Propos suicidaire<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_2_14_6'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_14' type='radio' value='Signes de d\u00e9pression'  id='choice_2_14_6' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_2_14_6' id='label_2_14_6' class='gform-field-label gform-field-label--type-inline'>Signes de d\u00e9pression<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_2_14_7'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_14' type='radio' value='S\u00e9paration\/Divorce\/Deuil (Sp\u00e9cifiez dans Autre)'  id='choice_2_14_7' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_2_14_7' id='label_2_14_7' class='gform-field-label gform-field-label--type-inline'>S\u00e9paration\/Divorce\/Deuil (Sp\u00e9cifiez dans Autre)<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_2_14_8'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_14' type='radio' value='gf_other_choice'  id='choice_2_14_8' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_2_14_8' id='label_2_14_8' class='gform-field-label gform-field-label--type-inline'>Other<\/label><br \/><input id='input_2_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_2_15\" class=\"gfield gfield--type-textarea gfield--width-half field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_2_15'>Description de la probl\u00e9matique<\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_15' id='input_2_15' class='textarea large'      aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/div><div id=\"field_2_19\" class=\"gfield gfield--type-text gfield--width-full field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_2_19'>NOM DE L\u2019ORGANISME R\u00c9F\u00c9RANT<\/label><div class='ginput_container ginput_container_text'><input name='input_19' id='input_2_19' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/div><fieldset id=\"field_2_18\" 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 DE LA PERSONNE RESSOURCE<\/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_2_18'>\n                            \n                            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