{"id":2376,"date":"2026-10-05T07:24:07","date_gmt":"2026-10-05T11:24:07","guid":{"rendered":"https:\/\/freiheit.ca\/?post_type=sureforms_form&#038;p=2376"},"modified":"2026-10-05T07:54:09","modified_gmt":"2026-10-05T11:54:09","slug":"preliminary-client-intake-assessment-evaluation-preliminaire-dadmission-client","status":"publish","type":"sureforms_form","link":"https:\/\/freiheit.ca\/fr\/form\/preliminary-client-intake-assessment-evaluation-preliminaire-dadmission-client\/","title":{"rendered":"Preliminary Client Intake Assessment \/ \u00c9valuation Pr\u00e9liminaire d\u2019Admission Client"},"content":{"rendered":"<div data-block-id=\"5018b6a5\" class=\"srfm-block-single srfm-block srfm-input-block srf-input-5018b6a5-block  srfm-block-width-50 srfm-slug-client-name-nom-du-client\" >\n\t\t\t\t\t\t\t\t<label id=\"srfm-label-5018b6a5-lbl-MS4gQ2xpZW50IE5hbWUgLyBOb20gZHUgY2xpZW50\" for=\"srfm-input-5018b6a5-lbl-MS4gQ2xpZW50IE5hbWUgLyBOb20gZHUgY2xpZW50\" class=\"srfm-block-label\">\n\t\t\t\t\t\t1. Client Name \/ Nom du client\t\t\t\t\t\t\t\t\t\t\t\t\t<span class=\"srfm-required\" aria-hidden=\"true\"> *<\/span>\n\t\t\t\t\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"srfm-description\" id=\"srfm-description-5018b6a5\">\n\t\t\t\t\t\tPlease enter the client&#039;s full name \/ Veuillez entrer le nom complet du client.\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t<div class=\"srfm-block-wrap\">\n\t\t\t\t<input class=\"srfm-input-common srfm-input-input\" type=\"text\" name=\"srfm-input-5018b6a5-lbl-MS4gQ2xpZW50IE5hbWUgLyBOb20gZHUgY2xpZW50-client-name-nom-du-client\" id=\"srfm-input-5018b6a5-lbl-MS4gQ2xpZW50IE5hbWUgLyBOb20gZHUgY2xpZW50\"\n\t\t\t\t\taria-describedby='srfm-error-5018b6a5 srfm-description-5018b6a5'\t\t\t\t\tdata-required=\"true\" aria-required=\"true\" data-unique=\"false\" maxlength=\"100\" value=\"\"  data-srfm-mask=\"none\"   \/>\n\t\t\t\t<\/div>\n\t\t\t\t<div class=\"srfm-error-wrap\">\n\t\t\t\t\t\t\t\t\t\t<div class=\"srfm-error-message\" data-srfm-id=\"srfm-error-5018b6a5\" data-error-msg=\"This field is required.\" data-unique-msg=\"Value needs to be unique.\">\n\t\t\t\t\t\tThis field is required.\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t<\/div>\n\t\t\n\n\t\t\t<div data-block-id=\"76cb9985\" class=\"srfm-block-single srfm-block srfm-input-block srf-input-76cb9985-block  srfm-block-width-50 srfm-slug-preferred-name-nom-prefere\" >\n\t\t\t\t\t\t\t\t<label id=\"srfm-label-76cb9985-lbl-Mi4gUHJlZmVycmVkIE5hbWUgLyBOb20gcHLDqWbDqXLDqQ\" for=\"srfm-input-76cb9985-lbl-Mi4gUHJlZmVycmVkIE5hbWUgLyBOb20gcHLDqWbDqXLDqQ\" class=\"srfm-block-label\">\n\t\t\t\t\t\t2. Preferred Name \/ Nom pr\u00e9f\u00e9r\u00e9\t\t\t\t\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"srfm-description\" id=\"srfm-description-76cb9985\">\n\t\t\t\t\t\tIf applicable, please enter the preferred name of the client \/ Si applicable, veuillez entrer le nom pr\u00e9f\u00e9r\u00e9 du client.\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t<div class=\"srfm-block-wrap\">\n\t\t\t\t<input class=\"srfm-input-common srfm-input-input\" type=\"text\" name=\"srfm-input-76cb9985-lbl-Mi4gUHJlZmVycmVkIE5hbWUgLyBOb20gcHLDqWbDqXLDqQ-preferred-name-nom-prefere\" id=\"srfm-input-76cb9985-lbl-Mi4gUHJlZmVycmVkIE5hbWUgLyBOb20gcHLDqWbDqXLDqQ\"\n\t\t\t\t\taria-describedby='srfm-error-76cb9985 srfm-description-76cb9985'\t\t\t\t\tdata-required=\"false\" aria-required=\"false\" data-unique=\"false\" maxlength=\"100\" value=\"\"  data-srfm-mask=\"none\"   \/>\n\t\t\t\t<\/div>\n\t\t\t\t<div class=\"srfm-error-wrap\">\n\t\t\t\t\t\t\t\t\t\t<div class=\"srfm-error-message\" data-srfm-id=\"srfm-error-76cb9985\" data-error-msg=\"This field is required.\" data-unique-msg=\"Value needs to be unique.\">\n\t\t\t\t\t\tThis field is required.\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t<\/div>\n\t\t\n\n\t\t\t<div data-block-id=\"b1f2befa\" class=\"srfm-block-single srfm-block srfm-datepicker-block srfm-block-width-50\">\n\t\t\t\t\t\t\t\t\t<label id=\"srfm-label-b1f2befa-lbl-My4gRGF0ZSBvZiBCaXJ0aCAvIERhdGUgZGUgbmFpc3NhbmNl\" for=\"srfm-datepicker-b1f2befa-lbl-My4gRGF0ZSBvZiBCaXJ0aCAvIERhdGUgZGUgbmFpc3NhbmNl\" class=\"srfm-block-label\">\n\t\t\t\t\t\t3. Date of Birth \/ Date de naissance\t\t\t\t\t\t\t\t\t\t\t\t\t<span class=\"srfm-required\" aria-hidden=\"true\"> *<\/span>\n\t\t\t\t\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"srfm-description\" id=\"srfm-description-b1f2befa\">\n\t\t\t\t\t\tPlease select the client&#039;s date of birth \/ Veuillez s\u00e9lectionner la date de naissance du client.\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t<div class=\"srfm-block-wrap srfm-with-icon\">\n\t\t\t\t\t<label class=\"srfm-icon srfm-datepicker-icon srfm-input-icon\" for=\"srfm-datepicker-b1f2befa-lbl-My4gRGF0ZSBvZiBCaXJ0aCAvIERhdGUgZGUgbmFpc3NhbmNl\" aria-hidden=\"true\"><svg width='16' height='16' viewbox='0 0 16 16' fill='none' xmlns='http:\/\/www.w3.org\/2000\/svg'><path d='M12.6667 2.66699H3.33333C2.59695 2.66699 2 3.26395 2 4.00033V13.3337C2 14.07 2.59695 14.667 3.33333 14.667H12.6667C13.403 14.667 14 14.07 14 13.3337V4.00033C14 3.26395 13.403 2.66699 12.6667 2.66699Z' stroke='#1E1E1E' stroke-opacity='0.65' stroke-width='1.25' stroke-linecap='round' stroke-linejoin='round'\/><path d='M10.667 1.33301V3.99967' stroke='#1E1E1E' stroke-opacity='0.65' stroke-linecap='round' stroke-linejoin='round'\/><path d='M5.33301 1.33301V3.99967' stroke='#1E1E1E' stroke-opacity='0.65' stroke-linecap='round' stroke-linejoin='round'\/><path d='M2 6.66699H14' stroke='#1E1E1E' stroke-opacity='0.65' stroke-linecap='round' stroke-linejoin='round'\/><\/svg><\/label>\t\t\t\t\t<input\n\t\t\t\t\t\ttype=\"text\"\n\t\t\t\t\t\tclass=\"srfm-input-common srfm-input-datepicker\"\n\t\t\t\t\t\tname=\"srfm-datepicker-b1f2befa-lbl-My4gRGF0ZSBvZiBCaXJ0aCAvIERhdGUgZGUgbmFpc3NhbmNl-date-of-birth-date-de-naissance\"\n\t\t\t\t\t\tid=\"srfm-datepicker-b1f2befa-lbl-My4gRGF0ZSBvZiBCaXJ0aCAvIERhdGUgZGUgbmFpc3NhbmNl\"\n\t\t\t\t\t\taria-describedby=\"srfm-error-b1f2befa srfm-description-b1f2befa srfm-date-format-b1f2befa\"\n\t\t\t\t\t\taria-required=\"true\" data-required=\"true\"  placeholder=\"mm\/dd\/yyyy\"  value=\"\" min=\"12-31-1899\" max=\"\" data-date-format=\"mm\/dd\/yyyy\" autocomplete=\"off\"\n\t\t\t\t\t\tdata-days-enabled=\"[]\"\n\t\t\t\t\t\tdata-disable-past=\"false\"\n\t\t\t\t\t\tdata-disabled-dates=\"[]\"\n\t\t\t\t\t\tdata-disabled-dates-error=\"This date is not available. Please select a different date.\"\n\t\t\t\t\t>\n\t\t\t\t\t<span class=\"screen-reader-text\" id=\"srfm-date-format-b1f2befa\">mm\/dd\/yyyy<\/span>\n\t\t\t\t<\/div>\n\t\t\t\t<div class=\"srfm-error-wrap\">\n\t\t\t\t\t\t\t\t\t\t<div class=\"srfm-error-message\" data-srfm-id=\"srfm-error-b1f2befa\" data-error-msg=\"This field is required.\">\n\t\t\t\t\t\tThis field is required.\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t<\/div>\n\t\t\n\n\t\t<div data-block-id=\"deda90d3\" class=\"srfm-block-single srfm-block srfm-phone-block srf-phone-deda90d3-block srfm-block-width-50\">\n\t\t\t\t\t\t\t\t<label id=\"srfm-label-deda90d3-lbl-NC4gUGhvbmUgTnVtYmVyIC8gTnVtw6lybyBkZSB0w6lsw6lwaG9uZQ\" for=\"srfm-phone-deda90d3-lbl-NC4gUGhvbmUgTnVtYmVyIC8gTnVtw6lybyBkZSB0w6lsw6lwaG9uZQ\" class=\"srfm-block-label\">\n\t\t\t\t\t\t4. Phone Number \/ Num\u00e9ro de t\u00e9l\u00e9phone\t\t\t\t\t\t\t\t\t\t\t\t\t<span class=\"srfm-required\" aria-hidden=\"true\"> *<\/span>\n\t\t\t\t\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"srfm-description\" id=\"srfm-description-deda90d3\">\n\t\t\t\t\t\tPlease enter the client&#039;s primary phone number \/ Veuillez entrer le num\u00e9ro de t\u00e9l\u00e9phone principal du client.\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"srfm-block-wrap\">\n\t\t\t\t<input type=\"tel\"\n\t\t\t\t\tclass=\"srfm-input-common srfm-input-phone\"\n\t\t\t\t\tname=\"srfm-phone-deda90d3-lbl-NC4gUGhvbmUgTnVtYmVyIC8gTnVtw6lybyBkZSB0w6lsw6lwaG9uZQ-phone-number-numero-de-telephone\"\n\t\t\t\t\tid=\"srfm-phone-deda90d3-lbl-NC4gUGhvbmUgTnVtYmVyIC8gTnVtw6lybyBkZSB0w6lsw6lwaG9uZQ\"\n\t\t\t\t\taria-describedby='srfm-error-deda90d3 srfm-description-deda90d3'\t\t\t\t\tdata-required=\"true\"\n\t\t\t\t\taria-required=\"true\"\n\t\t\t\t\tdefault-country=\"us\"\n\t\t\t\t\t\t\t\t\t\t\tdata-auto-country=\"true\"\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\tvalue=\"\"\n\t\t\t\t\t\t\t\t\t\tdata-unique=\"false\">\n\t\t\t<\/div>\n\t\t\t<div class=\"srfm-error-wrap\">\n\t\t\t\t\t\t\t\t\t<div class=\"srfm-error-message\" data-srfm-id=\"srfm-error-deda90d3\" data-error-msg=\"This field is required.\" data-unique-msg=\"Value needs to be unique.\">\n\t\t\t\t\t\tThis field is required.\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<\/div>\n\t\t<\/div>\n\t\t\n\n\t\t\t<div data-block-id=\"44feea76\" class=\"srfm-block-single srfm-block srfm-address-block srf-address-44feea76-block  srfm-block-width-50 srfm-slug-address-adresse\" data-slug=\"address-adresse\"\n\t\t\t\t\t\t>\n\t\t\t\t<fieldset>\n\t\t\t\t\t<legend class=\"srfm-block-legend\">\n\t\t\t\t\t\t\t\t\t\t\t5. Address \/ Adresse\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<\/legend>\n\t\t\t\t\t\t\t\t\t\t<div class=\"srfm-description\" id=\"srfm-description-44feea76\">\n\t\t\t\t\t\tPlease enter the client&#039;s complete address \/ Veuillez entrer l&#039;adresse compl&egrave;te du client.&lt;br&gt;\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"srfm-block-wrap\">\n\t\t\t\t\t\n\t\t\t<div data-address-component=\"line1\" data-block-id=\"1fbad6fd\" class=\"srfm-block-single srfm-block srfm-input-block srf-input-1fbad6fd-block  srfm-block-width-50 srfm-slug-address-line-1\" >\n\t\t\t\t\t\t\t\t<label id=\"srfm-label-1fbad6fd-lbl-QWRkcmVzcyBMaW5lIDE\" for=\"srfm-input-1fbad6fd-lbl-QWRkcmVzcyBMaW5lIDE\" class=\"srfm-block-label\">\n\t\t\t\t\t\tAddress Line 1\t\t\t\t\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"srfm-block-wrap\">\n\t\t\t\t<input class=\"srfm-input-common srfm-input-input\" type=\"text\" name=\"srfm-input-1fbad6fd-lbl-QWRkcmVzcyBMaW5lIDE-address-line-1\" id=\"srfm-input-1fbad6fd-lbl-QWRkcmVzcyBMaW5lIDE\"\n\t\t\t\t\taria-describedby='srfm-error-1fbad6fd'\t\t\t\t\tdata-required=\"false\" aria-required=\"false\" data-unique=\"false\" maxlength=\"100\" value=\"\"  data-srfm-mask=\"none\"   \/>\n\t\t\t\t<\/div>\n\t\t\t\t<div class=\"srfm-error-wrap\">\n\t\t\t\t\t\t\t\t\t\t<div class=\"srfm-error-message\" data-srfm-id=\"srfm-error-1fbad6fd\" data-error-msg=\"This field is required.\" data-unique-msg=\"Value needs to be unique.\">\n\t\t\t\t\t\tThis field is required.\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t<\/div>\n\t\t\n\n\t\t\t<div data-address-component=\"line2\" data-block-id=\"16ead3a6\" class=\"srfm-block-single srfm-block srfm-input-block srf-input-16ead3a6-block  srfm-block-width-50 srfm-slug-address-line-2\" >\n\t\t\t\t\t\t\t\t<label id=\"srfm-label-16ead3a6-lbl-QWRkcmVzcyBMaW5lIDI\" for=\"srfm-input-16ead3a6-lbl-QWRkcmVzcyBMaW5lIDI\" class=\"srfm-block-label\">\n\t\t\t\t\t\tAddress Line 2\t\t\t\t\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"srfm-block-wrap\">\n\t\t\t\t<input class=\"srfm-input-common srfm-input-input\" type=\"text\" name=\"srfm-input-16ead3a6-lbl-QWRkcmVzcyBMaW5lIDI-address-line-2\" id=\"srfm-input-16ead3a6-lbl-QWRkcmVzcyBMaW5lIDI\"\n\t\t\t\t\taria-describedby='srfm-error-16ead3a6'\t\t\t\t\tdata-required=\"false\" aria-required=\"false\" data-unique=\"false\" maxlength=\"100\" value=\"\"  data-srfm-mask=\"none\"   \/>\n\t\t\t\t<\/div>\n\t\t\t\t<div class=\"srfm-error-wrap\">\n\t\t\t\t\t\t\t\t\t\t<div class=\"srfm-error-message\" data-srfm-id=\"srfm-error-16ead3a6\" data-error-msg=\"This field is required.\" data-unique-msg=\"Value needs to be unique.\">\n\t\t\t\t\t\tThis field is required.\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t<\/div>\n\t\t\n\n\t\t\t<div data-address-component=\"city\" data-block-id=\"6b32d341\" class=\"srfm-block-single srfm-block srfm-input-block srf-input-6b32d341-block  srfm-block-width-50 srfm-slug-city\" >\n\t\t\t\t\t\t\t\t<label id=\"srfm-label-6b32d341-lbl-Q2l0eQ\" for=\"srfm-input-6b32d341-lbl-Q2l0eQ\" class=\"srfm-block-label\">\n\t\t\t\t\t\tCity\t\t\t\t\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"srfm-block-wrap\">\n\t\t\t\t<input class=\"srfm-input-common srfm-input-input\" type=\"text\" name=\"srfm-input-6b32d341-lbl-Q2l0eQ-city\" id=\"srfm-input-6b32d341-lbl-Q2l0eQ\"\n\t\t\t\t\taria-describedby='srfm-error-6b32d341'\t\t\t\t\tdata-required=\"false\" aria-required=\"false\" data-unique=\"false\" maxlength=\"100\" value=\"\"  data-srfm-mask=\"none\"   \/>\n\t\t\t\t<\/div>\n\t\t\t\t<div class=\"srfm-error-wrap\">\n\t\t\t\t\t\t\t\t\t\t<div class=\"srfm-error-message\" data-srfm-id=\"srfm-error-6b32d341\" data-error-msg=\"This field is required.\" data-unique-msg=\"Value needs to be unique.\">\n\t\t\t\t\t\tThis field is required.\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t<\/div>\n\t\t\n\n\t\t\t<div data-address-component=\"state\" data-block-id=\"b8f8ba96\" class=\"srfm-block-single srfm-block srfm-input-block srf-input-b8f8ba96-block  srfm-block-width-50 srfm-slug-state\" >\n\t\t\t\t\t\t\t\t<label id=\"srfm-label-b8f8ba96-lbl-U3RhdGU\" for=\"srfm-input-b8f8ba96-lbl-U3RhdGU\" class=\"srfm-block-label\">\n\t\t\t\t\t\tState\t\t\t\t\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"srfm-block-wrap\">\n\t\t\t\t<input class=\"srfm-input-common srfm-input-input\" type=\"text\" name=\"srfm-input-b8f8ba96-lbl-U3RhdGU-state\" id=\"srfm-input-b8f8ba96-lbl-U3RhdGU\"\n\t\t\t\t\taria-describedby='srfm-error-b8f8ba96'\t\t\t\t\tdata-required=\"false\" aria-required=\"false\" data-unique=\"false\" maxlength=\"100\" value=\"\"  data-srfm-mask=\"none\"   \/>\n\t\t\t\t<\/div>\n\t\t\t\t<div class=\"srfm-error-wrap\">\n\t\t\t\t\t\t\t\t\t\t<div class=\"srfm-error-message\" data-srfm-id=\"srfm-error-b8f8ba96\" data-error-msg=\"This field is required.\" data-unique-msg=\"Value needs to be unique.\">\n\t\t\t\t\t\tThis field is required.\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t<\/div>\n\t\t\n\n\t\t\t<div data-address-component=\"postal_code\" data-block-id=\"a50dd42d\" class=\"srfm-block-single srfm-block srfm-input-block srf-input-a50dd42d-block  srfm-block-width-50 srfm-slug-postal-code\" >\n\t\t\t\t\t\t\t\t<label id=\"srfm-label-a50dd42d-lbl-UG9zdGFsIENvZGU\" for=\"srfm-input-a50dd42d-lbl-UG9zdGFsIENvZGU\" class=\"srfm-block-label\">\n\t\t\t\t\t\tPostal Code\t\t\t\t\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"srfm-block-wrap\">\n\t\t\t\t<input class=\"srfm-input-common srfm-input-input\" type=\"text\" name=\"srfm-input-a50dd42d-lbl-UG9zdGFsIENvZGU-postal-code\" id=\"srfm-input-a50dd42d-lbl-UG9zdGFsIENvZGU\"\n\t\t\t\t\taria-describedby='srfm-error-a50dd42d'\t\t\t\t\tdata-required=\"false\" aria-required=\"false\" data-unique=\"false\" maxlength=\"100\" value=\"\"  data-srfm-mask=\"none\"   \/>\n\t\t\t\t<\/div>\n\t\t\t\t<div class=\"srfm-error-wrap\">\n\t\t\t\t\t\t\t\t\t\t<div class=\"srfm-error-message\" data-srfm-id=\"srfm-error-a50dd42d\" data-error-msg=\"This field is required.\" data-unique-msg=\"Value needs to be unique.\">\n\t\t\t\t\t\tThis field is required.\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t<\/div>\n\t\t\n\n\t\t\t<div data-address-component=\"country\" data-block-id=\"b830ea81\" class=\"srfm-block-single srfm-block srfm-dropdown-block srf-dropdown-b830ea81-block  srfm-block-width-50 srfm-slug-country\">\n\t\t\t\t<fieldset>\n\t\t\t\t\t<input class=\"srfm-input-dropdown-hidden\" data-required=\"false\" aria-required=\"false\"  name=\"srfm-dropdown-1-b830ea81-lbl-Q291bnRyeQ-country\" type=\"hidden\" value=\"\"\/>\n\t\t\t\t\t<legend class=\"srfm-block-legend\">\n\t\t\t\t\t\t\t\t\t\t\tCountry\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<\/legend>\n\t\t\t\t\t\t\t\t\t\t<div class=\"srfm-block-wrap srfm-dropdown-common-wrap\">\n\t\t\t\t\t\t\t\t\t\t<select\n\t\t\t\t\t\tclass=\"srfm-dropdown-common srfm-dropdown-input\"\n\t\t\t\t\t\taria-describedby='srfm-error-b830ea81'\t\t\t\tdata-required=\"false\" aria-required=\"false\"  name=\"srfm-dropdown-1-b830ea81-lbl-Q291bnRyeQ-country\" data-multiple=\"false\" data-searchable=\"true\"\n\t\t\t\t\t\t\t\t\t\t\t\ttabindex=\"0\" aria-hidden=\"true\">\n\t\t\t\t\t<option class=\"srfm-dropdown-placeholder\" value=\"\" disabled selected>Select an option<\/option>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<option value=\"Afghanistan\" data-icon=\"\"  >Afghanistan<\/option>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<option value=\"Aland Islands\" data-icon=\"\"  >Aland Islands<\/option>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<option value=\"Albania\" data-icon=\"\"  >Albania<\/option>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<option value=\"Algeria\" data-icon=\"\"  >Algeria<\/option>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<option value=\"American Samoa\" data-icon=\"\"  >American Samoa<\/option>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<option value=\"Andorra\" data-icon=\"\"  >Andorra<\/option>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<option value=\"Angola\" data-icon=\"\"  >Angola<\/option>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<option value=\"Anguilla\" data-icon=\"\"  >Anguilla<\/option>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<option value=\"Antarctica\" data-icon=\"\"  >Antarctica<\/option>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<option value=\"Antigua and Barbuda\" data-icon=\"\"  >Antigua and Barbuda<\/option>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<option value=\"Argentina\" data-icon=\"\"  >Argentina<\/option>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<option value=\"Armenia\" data-icon=\"\"  >Armenia<\/option>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<option value=\"Aruba\" data-icon=\"\"  >Aruba<\/option>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<option value=\"Australia\" data-icon=\"\"  >Australia<\/option>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<option value=\"Austria\" data-icon=\"\"  >Austria<\/option>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<option value=\"Azerbaijan\" data-icon=\"\"  >Azerbaijan<\/option>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<option value=\"Bahamas\" data-icon=\"\"  >Bahamas<\/option>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<option value=\"Bahrain\" data-icon=\"\"  >Bahrain<\/option>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<option value=\"Bangladesh\" data-icon=\"\"  >Bangladesh<\/option>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<option value=\"Barbados\" data-icon=\"\"  >Barbados<\/option>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<option value=\"Belarus\" data-icon=\"\"  >Belarus<\/option>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<option value=\"Belgium\" data-icon=\"\"  >Belgium<\/option>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<option value=\"Belize\" data-icon=\"\"  >Belize<\/option>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<option value=\"Benin\" data-icon=\"\"  >Benin<\/option>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<option value=\"Bermuda\" data-icon=\"\"  >Bermuda<\/option>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<option value=\"Bhutan\" data-icon=\"\"  >Bhutan<\/option>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<option value=\"Bolivia, Plurinational State of\" data-icon=\"\"  >Bolivia, Plurinational State of<\/option>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<option value=\"Bosnia and Herzegovina\" data-icon=\"\"  >Bosnia and Herzegovina<\/option>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<option value=\"Botswana\" data-icon=\"\"  >Botswana<\/option>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<option value=\"Brazil\" data-icon=\"\"  >Brazil<\/option>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<option value=\"British Indian Ocean Territory\" data-icon=\"\"  >British Indian Ocean Territory<\/option>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<option value=\"Brunei Darussalam\" data-icon=\"\"  >Brunei Darussalam<\/option>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<option value=\"Bulgaria\" data-icon=\"\"  >Bulgaria<\/option>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<option value=\"Burkina Faso\" data-icon=\"\"  >Burkina Faso<\/option>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<option value=\"Burundi\" data-icon=\"\"  >Burundi<\/option>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<option value=\"Cambodia\" data-icon=\"\"  >Cambodia<\/option>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<option value=\"Cameroon\" data-icon=\"\"  >Cameroon<\/option>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<option value=\"Canada\" data-icon=\"\"  >Canada<\/option>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<option value=\"Cape Verde\" data-icon=\"\"  >Cape Verde<\/option>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<option value=\"Cayman Islands\" data-icon=\"\"  >Cayman Islands<\/option>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<option value=\"Central African Republic\" data-icon=\"\"  >Central African Republic<\/option>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<option value=\"Chad\" data-icon=\"\"  >Chad<\/option>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<option value=\"Chile\" data-icon=\"\"  >Chile<\/option>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<option value=\"China\" data-icon=\"\"  >China<\/option>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<option value=\"Christmas Island\" data-icon=\"\"  >Christmas Island<\/option>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<option value=\"Cocos (Keeling) Islands\" data-icon=\"\"  >Cocos (Keeling) Islands<\/option>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<option value=\"Colombia\" data-icon=\"\"  >Colombia<\/option>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<option value=\"Comoros\" data-icon=\"\"  >Comoros<\/option>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<option value=\"Congo\" data-icon=\"\"  >Congo<\/option>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<option value=\"Congo, The Democratic Republic of the Congo\" data-icon=\"\"  >Congo, The Democratic Republic of the Congo<\/option>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<option value=\"Cook Islands\" data-icon=\"\"  >Cook Islands<\/option>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<option value=\"Costa Rica\" data-icon=\"\"  >Costa Rica<\/option>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<option value=\"Cote d&#039;Ivoire\" data-icon=\"\"  >Cote d&#039;Ivoire<\/option>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<option value=\"Croatia\" data-icon=\"\"  >Croatia<\/option>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<option value=\"Cuba\" data-icon=\"\"  >Cuba<\/option>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<option value=\"Cyprus\" data-icon=\"\"  >Cyprus<\/option>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<option value=\"Czech Republic\" data-icon=\"\"  >Czech Republic<\/option>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<option value=\"Denmark\" data-icon=\"\"  >Denmark<\/option>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<option value=\"Djibouti\" data-icon=\"\"  >Djibouti<\/option>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<option value=\"Dominica\" data-icon=\"\"  >Dominica<\/option>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<option value=\"Dominican Republic\" data-icon=\"\"  >Dominican Republic<\/option>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<option value=\"Ecuador\" data-icon=\"\"  >Ecuador<\/option>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<option value=\"Egypt\" data-icon=\"\"  >Egypt<\/option>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<option value=\"El Salvador\" data-icon=\"\"  >El Salvador<\/option>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<option value=\"Equatorial Guinea\" data-icon=\"\"  >Equatorial Guinea<\/option>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<option value=\"Eritrea\" data-icon=\"\"  >Eritrea<\/option>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<option value=\"Estonia\" data-icon=\"\"  >Estonia<\/option>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<option value=\"Ethiopia\" data-icon=\"\"  >Ethiopia<\/option>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<option value=\"Falkland Islands (Malvinas)\" data-icon=\"\"  >Falkland Islands (Malvinas)<\/option>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<option value=\"Faroe Islands\" data-icon=\"\"  >Faroe Islands<\/option>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<option value=\"Fiji\" data-icon=\"\"  >Fiji<\/option>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<option value=\"Finland\" data-icon=\"\"  >Finland<\/option>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<option value=\"France\" data-icon=\"\"  >France<\/option>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<option value=\"French Guiana\" data-icon=\"\"  >French Guiana<\/option>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<option value=\"French Polynesia\" data-icon=\"\"  >French Polynesia<\/option>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<option value=\"Gabon\" data-icon=\"\"  >Gabon<\/option>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<option value=\"Gambia\" data-icon=\"\"  >Gambia<\/option>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<option value=\"Georgia\" data-icon=\"\"  >Georgia<\/option>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<option value=\"Germany\" data-icon=\"\"  >Germany<\/option>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<option value=\"Ghana\" data-icon=\"\"  >Ghana<\/option>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<option value=\"Gibraltar\" data-icon=\"\"  >Gibraltar<\/option>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<option value=\"Greece\" data-icon=\"\"  >Greece<\/option>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<option value=\"Greenland\" data-icon=\"\"  >Greenland<\/option>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<option value=\"Grenada\" data-icon=\"\"  >Grenada<\/option>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<option value=\"Guadeloupe\" data-icon=\"\"  >Guadeloupe<\/option>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<option value=\"Guam\" data-icon=\"\"  >Guam<\/option>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<option value=\"Guatemala\" data-icon=\"\"  >Guatemala<\/option>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<option value=\"Guernsey\" data-icon=\"\"  >Guernsey<\/option>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<option value=\"Guinea\" data-icon=\"\"  >Guinea<\/option>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<option value=\"Guinea-Bissau\" data-icon=\"\"  >Guinea-Bissau<\/option>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<option value=\"Guyana\" data-icon=\"\"  >Guyana<\/option>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<option value=\"Haiti\" data-icon=\"\"  >Haiti<\/option>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<option value=\"Holy See (Vatican City State)\" data-icon=\"\"  >Holy See (Vatican City State)<\/option>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<option value=\"Honduras\" data-icon=\"\"  >Honduras<\/option>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<option value=\"Hong Kong\" data-icon=\"\"  >Hong Kong<\/option>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<option value=\"Hungary\" data-icon=\"\"  >Hungary<\/option>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<option value=\"Iceland\" data-icon=\"\"  >Iceland<\/option>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<option value=\"India\" data-icon=\"\"  >India<\/option>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<option value=\"Indonesia\" data-icon=\"\"  >Indonesia<\/option>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<option value=\"Iran, Islamic Republic of Persian Gulf\" data-icon=\"\"  >Iran, Islamic Republic of Persian Gulf<\/option>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<option value=\"Iraq\" data-icon=\"\"  >Iraq<\/option>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<option value=\"Ireland\" data-icon=\"\"  >Ireland<\/option>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<option value=\"Isle of Man\" data-icon=\"\"  >Isle of Man<\/option>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<option value=\"Israel\" data-icon=\"\"  >Israel<\/option>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<option value=\"Italy\" data-icon=\"\"  >Italy<\/option>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<option value=\"Jamaica\" data-icon=\"\"  >Jamaica<\/option>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<option value=\"Japan\" data-icon=\"\"  >Japan<\/option>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<option value=\"Jersey\" data-icon=\"\"  >Jersey<\/option>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<option value=\"Jordan\" data-icon=\"\"  >Jordan<\/option>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<option value=\"Kazakhstan\" data-icon=\"\"  >Kazakhstan<\/option>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<option value=\"Kenya\" data-icon=\"\"  >Kenya<\/option>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<option value=\"Kiribati\" data-icon=\"\"  >Kiribati<\/option>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<option value=\"Korea, Democratic People&#039;s Republic of Korea\" data-icon=\"\"  >Korea, Democratic People&#039;s Republic of Korea<\/option>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<option value=\"Korea, Republic of South Korea\" data-icon=\"\"  >Korea, Republic of South Korea<\/option>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<option value=\"Kuwait\" data-icon=\"\"  >Kuwait<\/option>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<option value=\"Kyrgyzstan\" data-icon=\"\"  >Kyrgyzstan<\/option>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<option value=\"Laos\" data-icon=\"\"  >Laos<\/option>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<option value=\"Latvia\" data-icon=\"\"  >Latvia<\/option>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<option value=\"Lebanon\" data-icon=\"\"  >Lebanon<\/option>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<option value=\"Lesotho\" data-icon=\"\"  >Lesotho<\/option>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<option value=\"Liberia\" data-icon=\"\"  >Liberia<\/option>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<option value=\"Libyan Arab Jamahiriya\" data-icon=\"\"  >Libyan Arab Jamahiriya<\/option>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<option value=\"Liechtenstein\" data-icon=\"\"  >Liechtenstein<\/option>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<option value=\"Lithuania\" data-icon=\"\"  >Lithuania<\/option>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<option value=\"Luxembourg\" data-icon=\"\"  >Luxembourg<\/option>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<option value=\"Macao\" data-icon=\"\"  >Macao<\/option>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<option value=\"Macedonia\" data-icon=\"\"  >Macedonia<\/option>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<option value=\"Madagascar\" data-icon=\"\"  >Madagascar<\/option>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<option value=\"Malawi\" data-icon=\"\"  >Malawi<\/option>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<option value=\"Malaysia\" data-icon=\"\"  >Malaysia<\/option>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<option value=\"Maldives\" data-icon=\"\"  >Maldives<\/option>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<option value=\"Mali\" data-icon=\"\"  >Mali<\/option>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<option value=\"Malta\" data-icon=\"\"  >Malta<\/option>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<option value=\"Marshall Islands\" data-icon=\"\"  >Marshall Islands<\/option>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<option value=\"Martinique\" data-icon=\"\"  >Martinique<\/option>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<option value=\"Mauritania\" data-icon=\"\"  >Mauritania<\/option>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<option value=\"Mauritius\" data-icon=\"\"  >Mauritius<\/option>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<option value=\"Mayotte\" data-icon=\"\"  >Mayotte<\/option>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<option value=\"Mexico\" data-icon=\"\"  >Mexico<\/option>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<option value=\"Micronesia, Federated States of Micronesia\" data-icon=\"\"  >Micronesia, Federated States of Micronesia<\/option>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<option value=\"Moldova\" data-icon=\"\"  >Moldova<\/option>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<option value=\"Monaco\" data-icon=\"\"  >Monaco<\/option>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<option value=\"Mongolia\" data-icon=\"\"  >Mongolia<\/option>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<option value=\"Montenegro\" data-icon=\"\"  >Montenegro<\/option>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<option value=\"Montserrat\" data-icon=\"\"  >Montserrat<\/option>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<option value=\"Morocco\" data-icon=\"\"  >Morocco<\/option>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<option value=\"Mozambique\" data-icon=\"\"  >Mozambique<\/option>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<option value=\"Myanmar\" data-icon=\"\"  >Myanmar<\/option>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<option value=\"Namibia\" data-icon=\"\"  >Namibia<\/option>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<option value=\"Nauru\" data-icon=\"\"  >Nauru<\/option>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<option value=\"Nepal\" data-icon=\"\"  >Nepal<\/option>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<option value=\"Netherlands\" data-icon=\"\"  >Netherlands<\/option>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<option value=\"Netherlands Antilles\" data-icon=\"\"  >Netherlands Antilles<\/option>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<option value=\"New Caledonia\" data-icon=\"\"  >New Caledonia<\/option>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<option value=\"New Zealand\" data-icon=\"\"  >New Zealand<\/option>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<option value=\"Nicaragua\" data-icon=\"\"  >Nicaragua<\/option>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<option value=\"Niger\" data-icon=\"\"  >Niger<\/option>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<option value=\"Nigeria\" data-icon=\"\"  >Nigeria<\/option>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<option value=\"Niue\" data-icon=\"\"  >Niue<\/option>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<option value=\"Norfolk Island\" data-icon=\"\"  >Norfolk Island<\/option>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<option value=\"Northern Mariana Islands\" data-icon=\"\"  >Northern Mariana Islands<\/option>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<option value=\"Norway\" data-icon=\"\"  >Norway<\/option>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<option value=\"Oman\" data-icon=\"\"  >Oman<\/option>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<option value=\"Pakistan\" data-icon=\"\"  >Pakistan<\/option>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<option value=\"Palau\" data-icon=\"\"  >Palau<\/option>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<option value=\"Palestinian Territory, Occupied\" data-icon=\"\"  >Palestinian Territory, Occupied<\/option>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<option value=\"Panama\" data-icon=\"\"  >Panama<\/option>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<option value=\"Papua New Guinea\" data-icon=\"\"  >Papua New Guinea<\/option>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<option value=\"Paraguay\" data-icon=\"\"  >Paraguay<\/option>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<option value=\"Peru\" data-icon=\"\"  >Peru<\/option>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<option value=\"Philippines\" data-icon=\"\"  >Philippines<\/option>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<option value=\"Pitcairn\" data-icon=\"\"  >Pitcairn<\/option>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<option value=\"Poland\" data-icon=\"\"  >Poland<\/option>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<option value=\"Portugal\" data-icon=\"\"  >Portugal<\/option>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<option value=\"Puerto Rico\" data-icon=\"\"  >Puerto Rico<\/option>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<option value=\"Qatar\" data-icon=\"\"  >Qatar<\/option>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<option value=\"Romania\" data-icon=\"\"  >Romania<\/option>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<option value=\"Russia\" data-icon=\"\"  >Russia<\/option>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<option value=\"Rwanda\" data-icon=\"\"  >Rwanda<\/option>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<option value=\"Reunion\" data-icon=\"\"  >Reunion<\/option>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<option value=\"Saint Barthelemy\" data-icon=\"\"  >Saint Barthelemy<\/option>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<option value=\"Saint Helena, Ascension and Tristan Da Cunha\" data-icon=\"\"  >Saint Helena, Ascension and Tristan Da Cunha<\/option>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<option value=\"Saint Kitts and Nevis\" data-icon=\"\"  >Saint Kitts and Nevis<\/option>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<option value=\"Saint Lucia\" data-icon=\"\"  >Saint Lucia<\/option>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<option value=\"Saint Martin\" data-icon=\"\"  >Saint Martin<\/option>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<option value=\"Saint Pierre and Miquelon\" data-icon=\"\"  >Saint Pierre and Miquelon<\/option>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<option value=\"Saint Vincent and the Grenadines\" data-icon=\"\"  >Saint Vincent and the Grenadines<\/option>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<option value=\"Samoa\" data-icon=\"\"  >Samoa<\/option>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<option value=\"San Marino\" data-icon=\"\"  >San Marino<\/option>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<option value=\"Sao Tome and Principe\" data-icon=\"\"  >Sao Tome and Principe<\/option>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<option value=\"Saudi Arabia\" data-icon=\"\"  >Saudi Arabia<\/option>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<option value=\"Senegal\" data-icon=\"\"  >Senegal<\/option>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<option value=\"Serbia\" data-icon=\"\"  >Serbia<\/option>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<option value=\"Seychelles\" data-icon=\"\"  >Seychelles<\/option>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<option value=\"Sierra Leone\" data-icon=\"\"  >Sierra Leone<\/option>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<option value=\"Singapore\" data-icon=\"\"  >Singapore<\/option>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<option value=\"Slovakia\" data-icon=\"\"  >Slovakia<\/option>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<option value=\"Slovenia\" data-icon=\"\"  >Slovenia<\/option>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<option value=\"Solomon Islands\" data-icon=\"\"  >Solomon Islands<\/option>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<option value=\"Somalia\" data-icon=\"\"  >Somalia<\/option>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<option value=\"South Africa\" data-icon=\"\"  >South Africa<\/option>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<option value=\"South Sudan\" data-icon=\"\"  >South Sudan<\/option>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<option value=\"South Georgia and the South Sandwich Islands\" data-icon=\"\"  >South Georgia and the South Sandwich Islands<\/option>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<option value=\"Spain\" data-icon=\"\"  >Spain<\/option>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<option value=\"Sri Lanka\" data-icon=\"\"  >Sri Lanka<\/option>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<option value=\"Sudan\" data-icon=\"\"  >Sudan<\/option>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<option value=\"Suriname\" data-icon=\"\"  >Suriname<\/option>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<option value=\"Svalbard and Jan Mayen\" data-icon=\"\"  >Svalbard and Jan Mayen<\/option>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<option value=\"Swaziland\" data-icon=\"\"  >Swaziland<\/option>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<option value=\"Sweden\" data-icon=\"\"  >Sweden<\/option>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<option value=\"Switzerland\" data-icon=\"\"  >Switzerland<\/option>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<option value=\"Syrian Arab Republic\" data-icon=\"\"  >Syrian Arab Republic<\/option>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<option value=\"Taiwan\" data-icon=\"\"  >Taiwan<\/option>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<option value=\"Tajikistan\" data-icon=\"\"  >Tajikistan<\/option>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<option value=\"Tanzania, United Republic of Tanzania\" data-icon=\"\"  >Tanzania, United Republic of Tanzania<\/option>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<option value=\"Thailand\" data-icon=\"\"  >Thailand<\/option>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<option value=\"Timor-Leste\" data-icon=\"\"  >Timor-Leste<\/option>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<option value=\"Togo\" data-icon=\"\"  >Togo<\/option>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<option value=\"Tokelau\" data-icon=\"\"  >Tokelau<\/option>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<option value=\"Tonga\" data-icon=\"\"  >Tonga<\/option>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<option value=\"Trinidad and Tobago\" data-icon=\"\"  >Trinidad and Tobago<\/option>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<option value=\"Tunisia\" data-icon=\"\"  >Tunisia<\/option>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<option value=\"Turkey\" data-icon=\"\"  >Turkey<\/option>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<option value=\"Turkmenistan\" data-icon=\"\"  >Turkmenistan<\/option>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<option value=\"Turks and Caicos Islands\" data-icon=\"\"  >Turks and Caicos Islands<\/option>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<option value=\"Tuvalu\" data-icon=\"\"  >Tuvalu<\/option>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<option value=\"Uganda\" data-icon=\"\"  >Uganda<\/option>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<option value=\"Ukraine\" data-icon=\"\"  >Ukraine<\/option>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<option value=\"United Arab Emirates\" data-icon=\"\"  >United Arab Emirates<\/option>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<option value=\"United Kingdom\" data-icon=\"\"  >United Kingdom<\/option>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<option value=\"United States\" data-icon=\"\"  >United States<\/option>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<option value=\"Uruguay\" data-icon=\"\"  >Uruguay<\/option>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<option value=\"Uzbekistan\" data-icon=\"\"  >Uzbekistan<\/option>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<option value=\"Vanuatu\" data-icon=\"\"  >Vanuatu<\/option>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<option value=\"Venezuela, Bolivarian Republic of Venezuela\" data-icon=\"\"  >Venezuela, Bolivarian Republic of Venezuela<\/option>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<option value=\"Vietnam\" data-icon=\"\"  >Vietnam<\/option>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<option value=\"Virgin Islands, British\" data-icon=\"\"  >Virgin Islands, British<\/option>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<option value=\"Virgin Islands, U.S.\" data-icon=\"\"  >Virgin Islands, U.S.<\/option>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<option value=\"Wallis and Futuna\" data-icon=\"\"  >Wallis and Futuna<\/option>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<option value=\"Yemen\" data-icon=\"\"  >Yemen<\/option>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<option value=\"Zambia\" data-icon=\"\"  >Zambia<\/option>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<option value=\"Zimbabwe\" data-icon=\"\"  >Zimbabwe<\/option>\n\t\t\t\t\t\t\t\t\t\t\t\t\t<\/select>\n\t\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t<div class=\"srfm-error-wrap\">\n\t\t\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t<\/fieldset>\n\t\t\t<\/div>\n\t\t\n\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t<\/fieldset>\n\t\t\t<\/div>\n\t\t\n\n\t\t\t<div data-block-id=\"8d28a7b9\" class=\"srfm-block-single srfm-block srfm-email-block srf-email-8d28a7b9-block  srfm-block-width-50 srfm-slug-email-courriel srfm-email-block-wrap\">\n\t\t\t\t<div class=\"srfm-email-block srf-email-8d28a7b9-block\">\n\t\t\t\t\t\t\t\t\t\t<label id=\"srfm-label-8d28a7b9-lbl-Ni4gRW1haWwgLyBDb3VycmllbA\" for=\"srfm-email-8d28a7b9-lbl-Ni4gRW1haWwgLyBDb3VycmllbA\" class=\"srfm-block-label\">\n\t\t\t\t\t\t6. Email \/ Courriel\t\t\t\t\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"srfm-description\" id=\"srfm-description-8d28a7b9\">\n\t\t\t\t\t\tIf applicable, please enter the client&#039;s email address \/ Si applicable, veuillez entrer l&#039;adresse courriel du client.\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t<div class=\"srfm-block-wrap\">\n\t\t\t\t\t\t<input class=\"srfm-input-common srfm-input-email\" type=\"email\" name=\"srfm-email-8d28a7b9-lbl-Ni4gRW1haWwgLyBDb3VycmllbA-email-courriel\" id=\"srfm-email-8d28a7b9-lbl-Ni4gRW1haWwgLyBDb3VycmllbA\"\n\t\t\t\t\t\taria-describedby='srfm-error-8d28a7b9 srfm-description-8d28a7b9'\t\t\t\t\t\tdata-required=\"false\" aria-required=\"false\" data-unique=\"false\" value=\"\"   \/>\n\t\t\t\t\t<\/div>\n\t\t\t\t\t<div class=\"srfm-error-wrap\">\n\t\t\t\t\t\t\t\t\t\t\t<div class=\"srfm-error-message\" data-srfm-id=\"srfm-error-8d28a7b9\" data-error-msg=\"This field is required.\" data-unique-msg=\"Value needs to be unique.\">\n\t\t\t\t\t\tThis field is required.\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t\t\t\t<\/div>\n\t\t\n\n\t\t\t<div data-block-id=\"5428a747\" class=\"srfm-block-single srfm-block srfm-input-block srf-input-5428a747-block  srfm-block-width-50 srfm-slug-primary-contact-poa-contact-principal-mandataire\" >\n\t\t\t\t\t\t\t\t<label id=\"srfm-label-5428a747-lbl-Ny4gUHJpbWFyeSBDb250YWN0IC8gUE9BIC8gQ29udGFjdCBwcmluY2lwYWwgLyBNYW5kYXRhaXJl\" for=\"srfm-input-5428a747-lbl-Ny4gUHJpbWFyeSBDb250YWN0IC8gUE9BIC8gQ29udGFjdCBwcmluY2lwYWwgLyBNYW5kYXRhaXJl\" class=\"srfm-block-label\">\n\t\t\t\t\t\t7. Primary Contact \/ POA \/ Contact principal \/ Mandataire\t\t\t\t\t\t\t\t\t\t\t\t\t<span class=\"srfm-required\" aria-hidden=\"true\"> *<\/span>\n\t\t\t\t\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"srfm-description\" id=\"srfm-description-5428a747\">\n\t\t\t\t\t\tPlease enter the primary contact person&#039;s name \/ Veuillez entrer le nom de la personne de contact principal.\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t<div class=\"srfm-block-wrap\">\n\t\t\t\t<input class=\"srfm-input-common srfm-input-input\" type=\"text\" name=\"srfm-input-5428a747-lbl-Ny4gUHJpbWFyeSBDb250YWN0IC8gUE9BIC8gQ29udGFjdCBwcmluY2lwYWwgLyBNYW5kYXRhaXJl-primary-contact-poa-contact-principal-mandataire\" id=\"srfm-input-5428a747-lbl-Ny4gUHJpbWFyeSBDb250YWN0IC8gUE9BIC8gQ29udGFjdCBwcmluY2lwYWwgLyBNYW5kYXRhaXJl\"\n\t\t\t\t\taria-describedby='srfm-error-5428a747 srfm-description-5428a747'\t\t\t\t\tdata-required=\"true\" aria-required=\"true\" data-unique=\"false\" maxlength=\"100\" value=\"\"  data-srfm-mask=\"none\"   \/>\n\t\t\t\t<\/div>\n\t\t\t\t<div class=\"srfm-error-wrap\">\n\t\t\t\t\t\t\t\t\t\t<div class=\"srfm-error-message\" data-srfm-id=\"srfm-error-5428a747\" data-error-msg=\"This field is required.\" data-unique-msg=\"Value needs to be unique.\">\n\t\t\t\t\t\tThis field is required.\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t<\/div>\n\t\t\n\n\t\t\t<div data-block-id=\"8da6c392\" class=\"srfm-block-single srfm-block srfm-input-block srf-input-8da6c392-block  srfm-block-width-50 srfm-slug-relationship-to-client-lien-avec-le-client\" >\n\t\t\t\t\t\t\t\t<label id=\"srfm-label-8da6c392-lbl-OC4gUmVsYXRpb25zaGlwIHRvIENsaWVudCAvIExpZW4gYXZlYyBsZSBjbGllbnQ\" for=\"srfm-input-8da6c392-lbl-OC4gUmVsYXRpb25zaGlwIHRvIENsaWVudCAvIExpZW4gYXZlYyBsZSBjbGllbnQ\" class=\"srfm-block-label\">\n\t\t\t\t\t\t8. Relationship to Client \/ Lien avec le client\t\t\t\t\t\t\t\t\t\t\t\t\t<span class=\"srfm-required\" aria-hidden=\"true\"> *<\/span>\n\t\t\t\t\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"srfm-description\" id=\"srfm-description-8da6c392\">\n\t\t\t\t\t\tPlease describe the relationship of the primary contact to the client \/ Veuillez d\u00e9crire la relation de la personne de contact principal avec le client.\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t<div class=\"srfm-block-wrap\">\n\t\t\t\t<input class=\"srfm-input-common srfm-input-input\" type=\"text\" name=\"srfm-input-8da6c392-lbl-OC4gUmVsYXRpb25zaGlwIHRvIENsaWVudCAvIExpZW4gYXZlYyBsZSBjbGllbnQ-relationship-to-client-lien-avec-le-client\" id=\"srfm-input-8da6c392-lbl-OC4gUmVsYXRpb25zaGlwIHRvIENsaWVudCAvIExpZW4gYXZlYyBsZSBjbGllbnQ\"\n\t\t\t\t\taria-describedby='srfm-error-8da6c392 srfm-description-8da6c392'\t\t\t\t\tdata-required=\"true\" aria-required=\"true\" data-unique=\"false\" maxlength=\"100\" value=\"\"  data-srfm-mask=\"none\"   \/>\n\t\t\t\t<\/div>\n\t\t\t\t<div class=\"srfm-error-wrap\">\n\t\t\t\t\t\t\t\t\t\t<div class=\"srfm-error-message\" data-srfm-id=\"srfm-error-8da6c392\" data-error-msg=\"This field is required.\" data-unique-msg=\"Value needs to be unique.\">\n\t\t\t\t\t\tThis field is required.\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t<\/div>\n\t\t\n\n\t\t<div data-block-id=\"d53e16c1\" class=\"srfm-block-single srfm-block srfm-multi-choice-block srf-multi-choice-d53e16c1-block  srfm-block-width-100 srfm-slug-preferred-method-of-communication-methode-de-communication-preferee srfm-checkbox-mode\">\n\t\t\t<fieldset>\n\t\t\t\t<input class=\"srfm-input-multi-choice-hidden\" data-required=\"true\" aria-required=\"true\"  name=\"srfm-input-multi-choice-d53e16c1-lbl-OS4gUHJlZmVycmVkIE1ldGhvZCBvZiBDb21tdW5pY2F0aW9uIC8gTcOpdGhvZGUgZGUgY29tbXVuaWNhdGlvbiBwcsOpZsOpcsOpZQ-preferred-method-of-communication-methode-de-communication-preferee\" type=\"hidden\" value=\"\"\/>\n\t\t\t\t<legend class=\"srfm-block-legend\">\n\t\t\t\t\t\t\t\t\t\t9. Preferred Method of Communication \/ M\u00e9thode de communication pr\u00e9f\u00e9r\u00e9e\t\t\t\t\t\t\t\t\t\t\t<span class=\"srfm-required\" aria-hidden=\"true\"> *<\/span>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t<\/legend>\n\t\t\t\t\t\t\t\t\t<div class=\"srfm-description\" id=\"srfm-description-d53e16c1\">\n\t\t\t\t\t\tPlease select the preferred method(s) of communication \/ Veuillez s\u00e9lectionner la ou les pr\u00e9f\u00e9rences de communication.\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"srfm-block-wrap srfm-choice-width-33-33\">\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"srfm-multi-choice-single\">\n\t\t\t\t\t\t\t\t\t<input type=\"checkbox\"\n\t\t\t\t\t\t\t\t\t\tid=\"srfm-multi-choice-d53e16c1-0\"\n\t\t\t\t\t\t\t\t\t\tclass=\"srfm-input-multi-choice-single\" \t\t\t\t\t\t\t\t\t\taria-describedby=\"srfm-error-d53e16c1 srfm-description-d53e16c1\"\t\t\t\t\t\t\t\t\t\taria-required=\"true\"\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\/>\n\t\t\t\t\t\t\t\t\t<div class=\"srfm-block-content-wrap\">\n\t\t\t\t\t\t\t\t\t\t<div class=\"srfm-option-container\">\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<!-- This label content is used in conditional logic and for storing values in a hidden input field as comma-separated values.\n\t\t\t\t\t\t\t\t\t\t\tThe markup should remain unchanged.\n\t\t\t\t\t\t\t\t\t\t\tIf you make any changes here, ensure the corresponding JavaScript value functionality and conditional logic are also updated. -->\n\t\t\t\t\t\t\t\t\t\t\t<label for=\"srfm-multi-choice-d53e16c1-0\" data-option-text=\"Phone \/ T\u00e9l\u00e9phone\">Phone \/ T\u00e9l\u00e9phone<\/label>\n\t\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t<div class=\"srfm-icon-container\">\t\t<span class=\"srfm-icon srfm-multi-choice-icon\" aria-hidden=\"true\">\n\t\t\t<svg width=\"17\" height=\"16\" fill=\"none\" xmlns=\"http:\/\/www.w3.org\/2000\/svg\"><path d=\"M6.5 7.33366L8.5 9.33366L15.1667 2.66699\" stroke=\"#111C44\" stroke-width=\"1.25\" stroke-linecap=\"round\" stroke-linejoin=\"round\" \/><path d=\"M14.5 8V12.6667C14.5 13.0203 14.3595 13.3594 14.1095 13.6095C13.8594 13.8595 13.5203 14 13.1667 14H3.83333C3.47971 14 3.14057 13.8595 2.89052 13.6095C2.64048 13.3594 2.5 13.0203 2.5 12.6667V3.33333C2.5 2.97971 2.64048 2.64057 2.89052 2.39052C3.14057 2.14048 3.47971 2 3.83333 2H11.1667\" stroke=\"#111C44\" stroke-width=\"1.25\" stroke-linecap=\"round\" stroke-linejoin=\"round\" \/><\/svg>\t\t<\/span>\n\t\t\t\t<span class=\"srfm-icon srfm-multi-choice-icon-unchecked\" aria-hidden=\"true\">\n\t\t\t<svg width=\"16\" height=\"16\" fill=\"none\" xmlns=\"http:\/\/www.w3.org\/2000\/svg\"><path d=\"M12.6667 2H3.33333C2.59695 2 2 2.59695 2 3.33333V12.6667C2 13.403 2.59695 14 3.33333 14H12.6667C13.403 14 14 13.403 14 12.6667V3.33333C14 2.59695 13.403 2 12.6667 2Z\" stroke=\"#1E1E1E\" stroke-opacity=\"0.7\" stroke-width=\"1.25\" stroke-linecap=\"round\" stroke-linejoin=\"round\" \/><\/svg>\t\t<\/span>\n\t\t<\/div>\n\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"srfm-multi-choice-single\">\n\t\t\t\t\t\t\t\t\t<input type=\"checkbox\"\n\t\t\t\t\t\t\t\t\t\tid=\"srfm-multi-choice-d53e16c1-1\"\n\t\t\t\t\t\t\t\t\t\tclass=\"srfm-input-multi-choice-single\" \t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\/>\n\t\t\t\t\t\t\t\t\t<div class=\"srfm-block-content-wrap\">\n\t\t\t\t\t\t\t\t\t\t<div class=\"srfm-option-container\">\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<!-- This label content is used in conditional logic and for storing values in a hidden input field as comma-separated values.\n\t\t\t\t\t\t\t\t\t\t\tThe markup should remain unchanged.\n\t\t\t\t\t\t\t\t\t\t\tIf you make any changes here, ensure the corresponding JavaScript value functionality and conditional logic are also updated. -->\n\t\t\t\t\t\t\t\t\t\t\t<label for=\"srfm-multi-choice-d53e16c1-1\" data-option-text=\"Email \/ Courriel\">Email \/ Courriel<\/label>\n\t\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t<div class=\"srfm-icon-container\">\t\t<span class=\"srfm-icon srfm-multi-choice-icon\" aria-hidden=\"true\">\n\t\t\t<svg width=\"17\" height=\"16\" fill=\"none\" xmlns=\"http:\/\/www.w3.org\/2000\/svg\"><path d=\"M6.5 7.33366L8.5 9.33366L15.1667 2.66699\" stroke=\"#111C44\" stroke-width=\"1.25\" stroke-linecap=\"round\" stroke-linejoin=\"round\" \/><path d=\"M14.5 8V12.6667C14.5 13.0203 14.3595 13.3594 14.1095 13.6095C13.8594 13.8595 13.5203 14 13.1667 14H3.83333C3.47971 14 3.14057 13.8595 2.89052 13.6095C2.64048 13.3594 2.5 13.0203 2.5 12.6667V3.33333C2.5 2.97971 2.64048 2.64057 2.89052 2.39052C3.14057 2.14048 3.47971 2 3.83333 2H11.1667\" stroke=\"#111C44\" stroke-width=\"1.25\" stroke-linecap=\"round\" stroke-linejoin=\"round\" \/><\/svg>\t\t<\/span>\n\t\t\t\t<span class=\"srfm-icon srfm-multi-choice-icon-unchecked\" aria-hidden=\"true\">\n\t\t\t<svg width=\"16\" height=\"16\" fill=\"none\" xmlns=\"http:\/\/www.w3.org\/2000\/svg\"><path d=\"M12.6667 2H3.33333C2.59695 2 2 2.59695 2 3.33333V12.6667C2 13.403 2.59695 14 3.33333 14H12.6667C13.403 14 14 13.403 14 12.6667V3.33333C14 2.59695 13.403 2 12.6667 2Z\" stroke=\"#1E1E1E\" stroke-opacity=\"0.7\" stroke-width=\"1.25\" stroke-linecap=\"round\" stroke-linejoin=\"round\" \/><\/svg>\t\t<\/span>\n\t\t<\/div>\n\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"srfm-multi-choice-single\">\n\t\t\t\t\t\t\t\t\t<input type=\"checkbox\"\n\t\t\t\t\t\t\t\t\t\tid=\"srfm-multi-choice-d53e16c1-2\"\n\t\t\t\t\t\t\t\t\t\tclass=\"srfm-input-multi-choice-single\" \t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\/>\n\t\t\t\t\t\t\t\t\t<div class=\"srfm-block-content-wrap\">\n\t\t\t\t\t\t\t\t\t\t<div class=\"srfm-option-container\">\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<!-- This label content is used in conditional logic and for storing values in a hidden input field as comma-separated values.\n\t\t\t\t\t\t\t\t\t\t\tThe markup should remain unchanged.\n\t\t\t\t\t\t\t\t\t\t\tIf you make any changes here, ensure the corresponding JavaScript value functionality and conditional logic are also updated. -->\n\t\t\t\t\t\t\t\t\t\t\t<label for=\"srfm-multi-choice-d53e16c1-2\" data-option-text=\"Text \/ Message texte\">Text \/ Message texte<\/label>\n\t\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t<div class=\"srfm-icon-container\">\t\t<span class=\"srfm-icon srfm-multi-choice-icon\" aria-hidden=\"true\">\n\t\t\t<svg width=\"17\" height=\"16\" fill=\"none\" xmlns=\"http:\/\/www.w3.org\/2000\/svg\"><path d=\"M6.5 7.33366L8.5 9.33366L15.1667 2.66699\" stroke=\"#111C44\" stroke-width=\"1.25\" stroke-linecap=\"round\" stroke-linejoin=\"round\" \/><path d=\"M14.5 8V12.6667C14.5 13.0203 14.3595 13.3594 14.1095 13.6095C13.8594 13.8595 13.5203 14 13.1667 14H3.83333C3.47971 14 3.14057 13.8595 2.89052 13.6095C2.64048 13.3594 2.5 13.0203 2.5 12.6667V3.33333C2.5 2.97971 2.64048 2.64057 2.89052 2.39052C3.14057 2.14048 3.47971 2 3.83333 2H11.1667\" stroke=\"#111C44\" stroke-width=\"1.25\" stroke-linecap=\"round\" stroke-linejoin=\"round\" \/><\/svg>\t\t<\/span>\n\t\t\t\t<span class=\"srfm-icon srfm-multi-choice-icon-unchecked\" aria-hidden=\"true\">\n\t\t\t<svg width=\"16\" height=\"16\" fill=\"none\" xmlns=\"http:\/\/www.w3.org\/2000\/svg\"><path d=\"M12.6667 2H3.33333C2.59695 2 2 2.59695 2 3.33333V12.6667C2 13.403 2.59695 14 3.33333 14H12.6667C13.403 14 14 13.403 14 12.6667V3.33333C14 2.59695 13.403 2 12.6667 2Z\" stroke=\"#1E1E1E\" stroke-opacity=\"0.7\" stroke-width=\"1.25\" stroke-linecap=\"round\" stroke-linejoin=\"round\" \/><\/svg>\t\t<\/span>\n\t\t<\/div>\n\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t<div class=\"srfm-error-wrap\">\t\t\t\t\t<div class=\"srfm-error-message\" data-srfm-id=\"srfm-error-d53e16c1\" data-error-msg=\"This field is required.\">\n\t\t\t\t\t\tThis field is required.\t\t\t\t\t<\/div>\n\t\t\t\t\t<\/div>\n\t\t\t<\/fieldset>\n\t\t<\/div>\n\t\t\n\n\t\t<div data-block-id=\"9435b229\" class=\"srfm-block-single srfm-block srfm-multi-choice-block srf-multi-choice-9435b229-block  srfm-block-width-100 srfm-slug-reason-for-inquiry-raison-de-la-demande srfm-checkbox-mode\">\n\t\t\t<fieldset>\n\t\t\t\t<input class=\"srfm-input-multi-choice-hidden\" data-required=\"true\" aria-required=\"true\"  name=\"srfm-input-multi-choice-9435b229-lbl-MTAuIFJlYXNvbiBmb3IgSW5xdWlyeSAvIFJhaXNvbiBkZSBsYSBkZW1hbmRl-reason-for-inquiry-raison-de-la-demande\" type=\"hidden\" value=\"\"\/>\n\t\t\t\t<legend class=\"srfm-block-legend\">\n\t\t\t\t\t\t\t\t\t\t10. Reason for Inquiry \/ Raison de la demande\t\t\t\t\t\t\t\t\t\t\t<span class=\"srfm-required\" aria-hidden=\"true\"> *<\/span>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t<\/legend>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"srfm-block-wrap srfm-choice-width-50\">\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"srfm-multi-choice-single\">\n\t\t\t\t\t\t\t\t\t<input type=\"checkbox\"\n\t\t\t\t\t\t\t\t\t\tid=\"srfm-multi-choice-9435b229-0\"\n\t\t\t\t\t\t\t\t\t\tclass=\"srfm-input-multi-choice-single\" \t\t\t\t\t\t\t\t\t\taria-describedby=\"srfm-error-9435b229\"\t\t\t\t\t\t\t\t\t\taria-required=\"true\"\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\/>\n\t\t\t\t\t\t\t\t\t<div class=\"srfm-block-content-wrap\">\n\t\t\t\t\t\t\t\t\t\t<div class=\"srfm-option-container\">\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<!-- This label content is used in conditional logic and for storing values in a hidden input field as comma-separated values.\n\t\t\t\t\t\t\t\t\t\t\tThe markup should remain unchanged.\n\t\t\t\t\t\t\t\t\t\t\tIf you make any changes here, ensure the corresponding JavaScript value functionality and conditional logic are also updated. -->\n\t\t\t\t\t\t\t\t\t\t\t<label for=\"srfm-multi-choice-9435b229-0\" data-option-text=\"Companion Care \/ Soins de compagnie\">Companion Care \/ Soins de compagnie<\/label>\n\t\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t<div class=\"srfm-icon-container\">\t\t<span class=\"srfm-icon srfm-multi-choice-icon\" aria-hidden=\"true\">\n\t\t\t<svg width=\"17\" height=\"16\" fill=\"none\" xmlns=\"http:\/\/www.w3.org\/2000\/svg\"><path d=\"M6.5 7.33366L8.5 9.33366L15.1667 2.66699\" stroke=\"#111C44\" stroke-width=\"1.25\" stroke-linecap=\"round\" stroke-linejoin=\"round\" \/><path d=\"M14.5 8V12.6667C14.5 13.0203 14.3595 13.3594 14.1095 13.6095C13.8594 13.8595 13.5203 14 13.1667 14H3.83333C3.47971 14 3.14057 13.8595 2.89052 13.6095C2.64048 13.3594 2.5 13.0203 2.5 12.6667V3.33333C2.5 2.97971 2.64048 2.64057 2.89052 2.39052C3.14057 2.14048 3.47971 2 3.83333 2H11.1667\" stroke=\"#111C44\" stroke-width=\"1.25\" stroke-linecap=\"round\" stroke-linejoin=\"round\" \/><\/svg>\t\t<\/span>\n\t\t\t\t<span class=\"srfm-icon srfm-multi-choice-icon-unchecked\" aria-hidden=\"true\">\n\t\t\t<svg width=\"16\" height=\"16\" fill=\"none\" xmlns=\"http:\/\/www.w3.org\/2000\/svg\"><path d=\"M12.6667 2H3.33333C2.59695 2 2 2.59695 2 3.33333V12.6667C2 13.403 2.59695 14 3.33333 14H12.6667C13.403 14 14 13.403 14 12.6667V3.33333C14 2.59695 13.403 2 12.6667 2Z\" stroke=\"#1E1E1E\" stroke-opacity=\"0.7\" stroke-width=\"1.25\" stroke-linecap=\"round\" stroke-linejoin=\"round\" \/><\/svg>\t\t<\/span>\n\t\t<\/div>\n\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"srfm-multi-choice-single\">\n\t\t\t\t\t\t\t\t\t<input type=\"checkbox\"\n\t\t\t\t\t\t\t\t\t\tid=\"srfm-multi-choice-9435b229-1\"\n\t\t\t\t\t\t\t\t\t\tclass=\"srfm-input-multi-choice-single\" \t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\/>\n\t\t\t\t\t\t\t\t\t<div class=\"srfm-block-content-wrap\">\n\t\t\t\t\t\t\t\t\t\t<div class=\"srfm-option-container\">\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<!-- This label content is used in conditional logic and for storing values in a hidden input field as comma-separated values.\n\t\t\t\t\t\t\t\t\t\t\tThe markup should remain unchanged.\n\t\t\t\t\t\t\t\t\t\t\tIf you make any changes here, ensure the corresponding JavaScript value functionality and conditional logic are also updated. -->\n\t\t\t\t\t\t\t\t\t\t\t<label for=\"srfm-multi-choice-9435b229-1\" data-option-text=\"Personal Support \/ PSW Care \/ Soins de soutien personnel \/ Soins PAB\">Personal Support \/ PSW Care \/ Soins de soutien personnel \/ Soins PAB<\/label>\n\t\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t<div class=\"srfm-icon-container\">\t\t<span class=\"srfm-icon srfm-multi-choice-icon\" aria-hidden=\"true\">\n\t\t\t<svg width=\"17\" height=\"16\" fill=\"none\" xmlns=\"http:\/\/www.w3.org\/2000\/svg\"><path d=\"M6.5 7.33366L8.5 9.33366L15.1667 2.66699\" stroke=\"#111C44\" stroke-width=\"1.25\" stroke-linecap=\"round\" stroke-linejoin=\"round\" \/><path d=\"M14.5 8V12.6667C14.5 13.0203 14.3595 13.3594 14.1095 13.6095C13.8594 13.8595 13.5203 14 13.1667 14H3.83333C3.47971 14 3.14057 13.8595 2.89052 13.6095C2.64048 13.3594 2.5 13.0203 2.5 12.6667V3.33333C2.5 2.97971 2.64048 2.64057 2.89052 2.39052C3.14057 2.14048 3.47971 2 3.83333 2H11.1667\" stroke=\"#111C44\" stroke-width=\"1.25\" stroke-linecap=\"round\" stroke-linejoin=\"round\" \/><\/svg>\t\t<\/span>\n\t\t\t\t<span class=\"srfm-icon srfm-multi-choice-icon-unchecked\" aria-hidden=\"true\">\n\t\t\t<svg width=\"16\" height=\"16\" fill=\"none\" xmlns=\"http:\/\/www.w3.org\/2000\/svg\"><path d=\"M12.6667 2H3.33333C2.59695 2 2 2.59695 2 3.33333V12.6667C2 13.403 2.59695 14 3.33333 14H12.6667C13.403 14 14 13.403 14 12.6667V3.33333C14 2.59695 13.403 2 12.6667 2Z\" stroke=\"#1E1E1E\" stroke-opacity=\"0.7\" stroke-width=\"1.25\" stroke-linecap=\"round\" stroke-linejoin=\"round\" \/><\/svg>\t\t<\/span>\n\t\t<\/div>\n\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"srfm-multi-choice-single\">\n\t\t\t\t\t\t\t\t\t<input type=\"checkbox\"\n\t\t\t\t\t\t\t\t\t\tid=\"srfm-multi-choice-9435b229-2\"\n\t\t\t\t\t\t\t\t\t\tclass=\"srfm-input-multi-choice-single\" \t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\/>\n\t\t\t\t\t\t\t\t\t<div class=\"srfm-block-content-wrap\">\n\t\t\t\t\t\t\t\t\t\t<div class=\"srfm-option-container\">\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<!-- This label content is used in conditional logic and for storing values in a hidden input field as comma-separated values.\n\t\t\t\t\t\t\t\t\t\t\tThe markup should remain unchanged.\n\t\t\t\t\t\t\t\t\t\t\tIf you make any changes here, ensure the corresponding JavaScript value functionality and conditional logic are also updated. -->\n\t\t\t\t\t\t\t\t\t\t\t<label for=\"srfm-multi-choice-9435b229-2\" data-option-text=\"Nursing Care \/ Soins infirmiers\">Nursing Care \/ Soins infirmiers<\/label>\n\t\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t<div class=\"srfm-icon-container\">\t\t<span class=\"srfm-icon srfm-multi-choice-icon\" aria-hidden=\"true\">\n\t\t\t<svg width=\"17\" height=\"16\" fill=\"none\" xmlns=\"http:\/\/www.w3.org\/2000\/svg\"><path d=\"M6.5 7.33366L8.5 9.33366L15.1667 2.66699\" stroke=\"#111C44\" stroke-width=\"1.25\" stroke-linecap=\"round\" stroke-linejoin=\"round\" \/><path d=\"M14.5 8V12.6667C14.5 13.0203 14.3595 13.3594 14.1095 13.6095C13.8594 13.8595 13.5203 14 13.1667 14H3.83333C3.47971 14 3.14057 13.8595 2.89052 13.6095C2.64048 13.3594 2.5 13.0203 2.5 12.6667V3.33333C2.5 2.97971 2.64048 2.64057 2.89052 2.39052C3.14057 2.14048 3.47971 2 3.83333 2H11.1667\" stroke=\"#111C44\" stroke-width=\"1.25\" stroke-linecap=\"round\" stroke-linejoin=\"round\" \/><\/svg>\t\t<\/span>\n\t\t\t\t<span class=\"srfm-icon srfm-multi-choice-icon-unchecked\" aria-hidden=\"true\">\n\t\t\t<svg width=\"16\" height=\"16\" fill=\"none\" xmlns=\"http:\/\/www.w3.org\/2000\/svg\"><path d=\"M12.6667 2H3.33333C2.59695 2 2 2.59695 2 3.33333V12.6667C2 13.403 2.59695 14 3.33333 14H12.6667C13.403 14 14 13.403 14 12.6667V3.33333C14 2.59695 13.403 2 12.6667 2Z\" stroke=\"#1E1E1E\" stroke-opacity=\"0.7\" stroke-width=\"1.25\" stroke-linecap=\"round\" stroke-linejoin=\"round\" \/><\/svg>\t\t<\/span>\n\t\t<\/div>\n\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"srfm-multi-choice-single\">\n\t\t\t\t\t\t\t\t\t<input type=\"checkbox\"\n\t\t\t\t\t\t\t\t\t\tid=\"srfm-multi-choice-9435b229-3\"\n\t\t\t\t\t\t\t\t\t\tclass=\"srfm-input-multi-choice-single\" \t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\/>\n\t\t\t\t\t\t\t\t\t<div class=\"srfm-block-content-wrap\">\n\t\t\t\t\t\t\t\t\t\t<div class=\"srfm-option-container\">\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<!-- This label content is used in conditional logic and for storing values in a hidden input field as comma-separated values.\n\t\t\t\t\t\t\t\t\t\t\tThe markup should remain unchanged.\n\t\t\t\t\t\t\t\t\t\t\tIf you make any changes here, ensure the corresponding JavaScript value functionality and conditional logic are also updated. -->\n\t\t\t\t\t\t\t\t\t\t\t<label for=\"srfm-multi-choice-9435b229-3\" data-option-text=\"Respite Care \/ Soins de r\u00e9pit\">Respite Care \/ Soins de r\u00e9pit<\/label>\n\t\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t<div class=\"srfm-icon-container\">\t\t<span class=\"srfm-icon srfm-multi-choice-icon\" aria-hidden=\"true\">\n\t\t\t<svg width=\"17\" height=\"16\" fill=\"none\" xmlns=\"http:\/\/www.w3.org\/2000\/svg\"><path d=\"M6.5 7.33366L8.5 9.33366L15.1667 2.66699\" stroke=\"#111C44\" stroke-width=\"1.25\" stroke-linecap=\"round\" stroke-linejoin=\"round\" \/><path d=\"M14.5 8V12.6667C14.5 13.0203 14.3595 13.3594 14.1095 13.6095C13.8594 13.8595 13.5203 14 13.1667 14H3.83333C3.47971 14 3.14057 13.8595 2.89052 13.6095C2.64048 13.3594 2.5 13.0203 2.5 12.6667V3.33333C2.5 2.97971 2.64048 2.64057 2.89052 2.39052C3.14057 2.14048 3.47971 2 3.83333 2H11.1667\" stroke=\"#111C44\" stroke-width=\"1.25\" stroke-linecap=\"round\" stroke-linejoin=\"round\" \/><\/svg>\t\t<\/span>\n\t\t\t\t<span class=\"srfm-icon srfm-multi-choice-icon-unchecked\" aria-hidden=\"true\">\n\t\t\t<svg width=\"16\" height=\"16\" fill=\"none\" xmlns=\"http:\/\/www.w3.org\/2000\/svg\"><path d=\"M12.6667 2H3.33333C2.59695 2 2 2.59695 2 3.33333V12.6667C2 13.403 2.59695 14 3.33333 14H12.6667C13.403 14 14 13.403 14 12.6667V3.33333C14 2.59695 13.403 2 12.6667 2Z\" stroke=\"#1E1E1E\" stroke-opacity=\"0.7\" stroke-width=\"1.25\" stroke-linecap=\"round\" stroke-linejoin=\"round\" \/><\/svg>\t\t<\/span>\n\t\t<\/div>\n\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"srfm-multi-choice-single\">\n\t\t\t\t\t\t\t\t\t<input type=\"checkbox\"\n\t\t\t\t\t\t\t\t\t\tid=\"srfm-multi-choice-9435b229-4\"\n\t\t\t\t\t\t\t\t\t\tclass=\"srfm-input-multi-choice-single\" \t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\/>\n\t\t\t\t\t\t\t\t\t<div class=\"srfm-block-content-wrap\">\n\t\t\t\t\t\t\t\t\t\t<div class=\"srfm-option-container\">\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<!-- This label content is used in conditional logic and for storing values in a hidden input field as comma-separated values.\n\t\t\t\t\t\t\t\t\t\t\tThe markup should remain unchanged.\n\t\t\t\t\t\t\t\t\t\t\tIf you make any changes here, ensure the corresponding JavaScript value functionality and conditional logic are also updated. -->\n\t\t\t\t\t\t\t\t\t\t\t<label for=\"srfm-multi-choice-9435b229-4\" data-option-text=\"Overnight Support \/ Soutien de nuit\">Overnight Support \/ Soutien de nuit<\/label>\n\t\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t<div class=\"srfm-icon-container\">\t\t<span class=\"srfm-icon srfm-multi-choice-icon\" aria-hidden=\"true\">\n\t\t\t<svg width=\"17\" height=\"16\" fill=\"none\" xmlns=\"http:\/\/www.w3.org\/2000\/svg\"><path d=\"M6.5 7.33366L8.5 9.33366L15.1667 2.66699\" stroke=\"#111C44\" stroke-width=\"1.25\" stroke-linecap=\"round\" stroke-linejoin=\"round\" \/><path d=\"M14.5 8V12.6667C14.5 13.0203 14.3595 13.3594 14.1095 13.6095C13.8594 13.8595 13.5203 14 13.1667 14H3.83333C3.47971 14 3.14057 13.8595 2.89052 13.6095C2.64048 13.3594 2.5 13.0203 2.5 12.6667V3.33333C2.5 2.97971 2.64048 2.64057 2.89052 2.39052C3.14057 2.14048 3.47971 2 3.83333 2H11.1667\" stroke=\"#111C44\" stroke-width=\"1.25\" stroke-linecap=\"round\" stroke-linejoin=\"round\" \/><\/svg>\t\t<\/span>\n\t\t\t\t<span class=\"srfm-icon srfm-multi-choice-icon-unchecked\" aria-hidden=\"true\">\n\t\t\t<svg width=\"16\" height=\"16\" fill=\"none\" xmlns=\"http:\/\/www.w3.org\/2000\/svg\"><path d=\"M12.6667 2H3.33333C2.59695 2 2 2.59695 2 3.33333V12.6667C2 13.403 2.59695 14 3.33333 14H12.6667C13.403 14 14 13.403 14 12.6667V3.33333C14 2.59695 13.403 2 12.6667 2Z\" stroke=\"#1E1E1E\" stroke-opacity=\"0.7\" stroke-width=\"1.25\" stroke-linecap=\"round\" stroke-linejoin=\"round\" \/><\/svg>\t\t<\/span>\n\t\t<\/div>\n\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"srfm-multi-choice-single\">\n\t\t\t\t\t\t\t\t\t<input type=\"checkbox\"\n\t\t\t\t\t\t\t\t\t\tid=\"srfm-multi-choice-9435b229-5\"\n\t\t\t\t\t\t\t\t\t\tclass=\"srfm-input-multi-choice-single\" \t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\/>\n\t\t\t\t\t\t\t\t\t<div class=\"srfm-block-content-wrap\">\n\t\t\t\t\t\t\t\t\t\t<div class=\"srfm-option-container\">\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<!-- This label content is used in conditional logic and for storing values in a hidden input field as comma-separated values.\n\t\t\t\t\t\t\t\t\t\t\tThe markup should remain unchanged.\n\t\t\t\t\t\t\t\t\t\t\tIf you make any changes here, ensure the corresponding JavaScript value functionality and conditional logic are also updated. -->\n\t\t\t\t\t\t\t\t\t\t\t<label for=\"srfm-multi-choice-9435b229-5\" data-option-text=\"Post-Operative Care \/ Soins postop\u00e9ratoires\">Post-Operative Care \/ Soins postop\u00e9ratoires<\/label>\n\t\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t<div class=\"srfm-icon-container\">\t\t<span class=\"srfm-icon srfm-multi-choice-icon\" aria-hidden=\"true\">\n\t\t\t<svg width=\"17\" height=\"16\" fill=\"none\" xmlns=\"http:\/\/www.w3.org\/2000\/svg\"><path d=\"M6.5 7.33366L8.5 9.33366L15.1667 2.66699\" stroke=\"#111C44\" stroke-width=\"1.25\" stroke-linecap=\"round\" stroke-linejoin=\"round\" \/><path d=\"M14.5 8V12.6667C14.5 13.0203 14.3595 13.3594 14.1095 13.6095C13.8594 13.8595 13.5203 14 13.1667 14H3.83333C3.47971 14 3.14057 13.8595 2.89052 13.6095C2.64048 13.3594 2.5 13.0203 2.5 12.6667V3.33333C2.5 2.97971 2.64048 2.64057 2.89052 2.39052C3.14057 2.14048 3.47971 2 3.83333 2H11.1667\" stroke=\"#111C44\" stroke-width=\"1.25\" stroke-linecap=\"round\" stroke-linejoin=\"round\" \/><\/svg>\t\t<\/span>\n\t\t\t\t<span class=\"srfm-icon srfm-multi-choice-icon-unchecked\" aria-hidden=\"true\">\n\t\t\t<svg width=\"16\" height=\"16\" fill=\"none\" xmlns=\"http:\/\/www.w3.org\/2000\/svg\"><path d=\"M12.6667 2H3.33333C2.59695 2 2 2.59695 2 3.33333V12.6667C2 13.403 2.59695 14 3.33333 14H12.6667C13.403 14 14 13.403 14 12.6667V3.33333C14 2.59695 13.403 2 12.6667 2Z\" stroke=\"#1E1E1E\" stroke-opacity=\"0.7\" stroke-width=\"1.25\" stroke-linecap=\"round\" stroke-linejoin=\"round\" \/><\/svg>\t\t<\/span>\n\t\t<\/div>\n\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"srfm-multi-choice-single\">\n\t\t\t\t\t\t\t\t\t<input type=\"checkbox\"\n\t\t\t\t\t\t\t\t\t\tid=\"srfm-multi-choice-9435b229-6\"\n\t\t\t\t\t\t\t\t\t\tclass=\"srfm-input-multi-choice-single\" \t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\/>\n\t\t\t\t\t\t\t\t\t<div class=\"srfm-block-content-wrap\">\n\t\t\t\t\t\t\t\t\t\t<div class=\"srfm-option-container\">\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<!-- This label content is used in conditional logic and for storing values in a hidden input field as comma-separated values.\n\t\t\t\t\t\t\t\t\t\t\tThe markup should remain unchanged.\n\t\t\t\t\t\t\t\t\t\t\tIf you make any changes here, ensure the corresponding JavaScript value functionality and conditional logic are also updated. -->\n\t\t\t\t\t\t\t\t\t\t\t<label for=\"srfm-multi-choice-9435b229-6\" data-option-text=\"Dementia \/ Cognitive Support \/ Soutien pour d\u00e9mence \/ troubles cognitifs\">Dementia \/ Cognitive Support \/ Soutien pour d\u00e9mence \/ troubles cognitifs<\/label>\n\t\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t<div class=\"srfm-icon-container\">\t\t<span class=\"srfm-icon srfm-multi-choice-icon\" aria-hidden=\"true\">\n\t\t\t<svg width=\"17\" height=\"16\" fill=\"none\" xmlns=\"http:\/\/www.w3.org\/2000\/svg\"><path d=\"M6.5 7.33366L8.5 9.33366L15.1667 2.66699\" stroke=\"#111C44\" stroke-width=\"1.25\" stroke-linecap=\"round\" stroke-linejoin=\"round\" \/><path d=\"M14.5 8V12.6667C14.5 13.0203 14.3595 13.3594 14.1095 13.6095C13.8594 13.8595 13.5203 14 13.1667 14H3.83333C3.47971 14 3.14057 13.8595 2.89052 13.6095C2.64048 13.3594 2.5 13.0203 2.5 12.6667V3.33333C2.5 2.97971 2.64048 2.64057 2.89052 2.39052C3.14057 2.14048 3.47971 2 3.83333 2H11.1667\" stroke=\"#111C44\" stroke-width=\"1.25\" stroke-linecap=\"round\" stroke-linejoin=\"round\" \/><\/svg>\t\t<\/span>\n\t\t\t\t<span class=\"srfm-icon srfm-multi-choice-icon-unchecked\" aria-hidden=\"true\">\n\t\t\t<svg width=\"16\" height=\"16\" fill=\"none\" xmlns=\"http:\/\/www.w3.org\/2000\/svg\"><path d=\"M12.6667 2H3.33333C2.59695 2 2 2.59695 2 3.33333V12.6667C2 13.403 2.59695 14 3.33333 14H12.6667C13.403 14 14 13.403 14 12.6667V3.33333C14 2.59695 13.403 2 12.6667 2Z\" stroke=\"#1E1E1E\" stroke-opacity=\"0.7\" stroke-width=\"1.25\" stroke-linecap=\"round\" stroke-linejoin=\"round\" \/><\/svg>\t\t<\/span>\n\t\t<\/div>\n\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"srfm-multi-choice-single\">\n\t\t\t\t\t\t\t\t\t<input type=\"checkbox\"\n\t\t\t\t\t\t\t\t\t\tid=\"srfm-multi-choice-9435b229-7\"\n\t\t\t\t\t\t\t\t\t\tclass=\"srfm-input-multi-choice-single\" \t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\/>\n\t\t\t\t\t\t\t\t\t<div class=\"srfm-block-content-wrap\">\n\t\t\t\t\t\t\t\t\t\t<div class=\"srfm-option-container\">\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<!-- This label content is used in conditional logic and for storing values in a hidden input field as comma-separated values.\n\t\t\t\t\t\t\t\t\t\t\tThe markup should remain unchanged.\n\t\t\t\t\t\t\t\t\t\t\tIf you make any changes here, ensure the corresponding JavaScript value functionality and conditional logic are also updated. -->\n\t\t\t\t\t\t\t\t\t\t\t<label for=\"srfm-multi-choice-9435b229-7\" data-option-text=\"Other \/ Autre\">Other \/ Autre<\/label>\n\t\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t<div class=\"srfm-icon-container\">\t\t<span class=\"srfm-icon srfm-multi-choice-icon\" aria-hidden=\"true\">\n\t\t\t<svg width=\"17\" height=\"16\" fill=\"none\" xmlns=\"http:\/\/www.w3.org\/2000\/svg\"><path d=\"M6.5 7.33366L8.5 9.33366L15.1667 2.66699\" stroke=\"#111C44\" stroke-width=\"1.25\" stroke-linecap=\"round\" stroke-linejoin=\"round\" \/><path d=\"M14.5 8V12.6667C14.5 13.0203 14.3595 13.3594 14.1095 13.6095C13.8594 13.8595 13.5203 14 13.1667 14H3.83333C3.47971 14 3.14057 13.8595 2.89052 13.6095C2.64048 13.3594 2.5 13.0203 2.5 12.6667V3.33333C2.5 2.97971 2.64048 2.64057 2.89052 2.39052C3.14057 2.14048 3.47971 2 3.83333 2H11.1667\" stroke=\"#111C44\" stroke-width=\"1.25\" stroke-linecap=\"round\" stroke-linejoin=\"round\" \/><\/svg>\t\t<\/span>\n\t\t\t\t<span class=\"srfm-icon srfm-multi-choice-icon-unchecked\" aria-hidden=\"true\">\n\t\t\t<svg width=\"16\" height=\"16\" fill=\"none\" xmlns=\"http:\/\/www.w3.org\/2000\/svg\"><path d=\"M12.6667 2H3.33333C2.59695 2 2 2.59695 2 3.33333V12.6667C2 13.403 2.59695 14 3.33333 14H12.6667C13.403 14 14 13.403 14 12.6667V3.33333C14 2.59695 13.403 2 12.6667 2Z\" stroke=\"#1E1E1E\" stroke-opacity=\"0.7\" stroke-width=\"1.25\" stroke-linecap=\"round\" stroke-linejoin=\"round\" \/><\/svg>\t\t<\/span>\n\t\t<\/div>\n\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t<div class=\"srfm-error-wrap\">\t\t\t\t\t<div class=\"srfm-error-message\" data-srfm-id=\"srfm-error-9435b229\" data-error-msg=\"This field is required.\">\n\t\t\t\t\t\tThis field is required.\t\t\t\t\t<\/div>\n\t\t\t\t\t<\/div>\n\t\t\t<\/fieldset>\n\t\t<\/div>\n\t\t\n\n\t\t\t<div data-block-id=\"9078881a\" class=\"srfm-block-single srfm-block srfm-input-block srf-input-9078881a-block  srfm-block-width-100 srfm-slug-11-briefly-describe-the-main-concerns-or-support-needs-decrivez-brievement-les-besoins-ou-preoccupations-principales\" >\n\t\t\t\t\t\t\t\t<label id=\"srfm-label-9078881a-lbl-MTEuIEJyaWVmbHkgZGVzY3JpYmUgdGhlIG1haW4gY29uY2VybnMgb3Igc3VwcG9ydCBuZWVkcyAvIETDqWNyaXZleiBicmnDqHZlbWVudCBsZXMgYmVzb2lucyBvdSBwcsOpb2NjdXBhdGlvbnMgcHJpbmNpcGFsZXM6\" for=\"srfm-input-9078881a-lbl-MTEuIEJyaWVmbHkgZGVzY3JpYmUgdGhlIG1haW4gY29uY2VybnMgb3Igc3VwcG9ydCBuZWVkcyAvIETDqWNyaXZleiBicmnDqHZlbWVudCBsZXMgYmVzb2lucyBvdSBwcsOpb2NjdXBhdGlvbnMgcHJpbmNpcGFsZXM6\" class=\"srfm-block-label\">\n\t\t\t\t\t\t11. Briefly describe the main concerns or support needs \/ D\u00e9crivez bri\u00e8vement les besoins ou pr\u00e9occupations principales:\t\t\t\t\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"srfm-block-wrap\">\n\t\t\t\t<input class=\"srfm-input-common srfm-input-input\" type=\"text\" name=\"srfm-input-9078881a-lbl-MTEuIEJyaWVmbHkgZGVzY3JpYmUgdGhlIG1haW4gY29uY2VybnMgb3Igc3VwcG9ydCBuZWVkcyAvIETDqWNyaXZleiBicmnDqHZlbWVudCBsZXMgYmVzb2lucyBvdSBwcsOpb2NjdXBhdGlvbnMgcHJpbmNpcGFsZXM6-11-briefly-describe-the-main-concerns-or-support-needs-decrivez-brievement-les-besoins-ou-preoccupations-principales\" id=\"srfm-input-9078881a-lbl-MTEuIEJyaWVmbHkgZGVzY3JpYmUgdGhlIG1haW4gY29uY2VybnMgb3Igc3VwcG9ydCBuZWVkcyAvIETDqWNyaXZleiBicmnDqHZlbWVudCBsZXMgYmVzb2lucyBvdSBwcsOpb2NjdXBhdGlvbnMgcHJpbmNpcGFsZXM6\"\n\t\t\t\t\taria-describedby='srfm-error-9078881a'\t\t\t\t\tdata-required=\"false\" aria-required=\"false\" data-unique=\"false\" maxlength=\"1000\" value=\"\"  data-srfm-mask=\"none\"   \/>\n\t\t\t\t<\/div>\n\t\t\t\t<div class=\"srfm-error-wrap\">\n\t\t\t\t\t\t\t\t\t\t<div class=\"srfm-error-message\" data-srfm-id=\"srfm-error-9078881a\" data-error-msg=\"This field is required.\" data-unique-msg=\"Value needs to be unique.\">\n\t\t\t\t\t\tThis field is required.\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t<\/div>\n\t\t\n\n\t\t<div data-block-id=\"780eb565\" class=\"srfm-block-single srfm-block srfm-multi-choice-block srf-multi-choice-780eb565-block  srfm-block-width-100 srfm-slug-12-current-living-situation-situation-de-vie-actuelle srfm-checkbox-mode\">\n\t\t\t<fieldset>\n\t\t\t\t<input class=\"srfm-input-multi-choice-hidden\" data-required=\"false\" aria-required=\"false\"  name=\"srfm-input-multi-choice-780eb565-lbl-MTIuIEN1cnJlbnQgTGl2aW5nIFNpdHVhdGlvbiAvIFNpdHVhdGlvbiBkZSB2aWUgYWN0dWVsbGU-12-current-living-situation-situation-de-vie-actuelle\" type=\"hidden\" value=\"\"\/>\n\t\t\t\t<legend class=\"srfm-block-legend\">\n\t\t\t\t\t\t\t\t\t\t12. Current Living Situation \/ Situation de vie actuelle\t\t\t\t\t\t\t\t\t\t\t\t\t\t<\/legend>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"srfm-block-wrap srfm-choice-width-100\">\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"srfm-multi-choice-single\">\n\t\t\t\t\t\t\t\t\t<input type=\"checkbox\"\n\t\t\t\t\t\t\t\t\t\tid=\"srfm-multi-choice-780eb565-0\"\n\t\t\t\t\t\t\t\t\t\tclass=\"srfm-input-multi-choice-single\" \t\t\t\t\t\t\t\t\t\taria-describedby=\"srfm-error-780eb565\"\t\t\t\t\t\t\t\t\t\taria-required=\"false\"\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\/>\n\t\t\t\t\t\t\t\t\t<div class=\"srfm-block-content-wrap\">\n\t\t\t\t\t\t\t\t\t\t<div class=\"srfm-option-container\">\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<!-- This label content is used in conditional logic and for storing values in a hidden input field as comma-separated values.\n\t\t\t\t\t\t\t\t\t\t\tThe markup should remain unchanged.\n\t\t\t\t\t\t\t\t\t\t\tIf you make any changes here, ensure the corresponding JavaScript value functionality and conditional logic are also updated. -->\n\t\t\t\t\t\t\t\t\t\t\t<label for=\"srfm-multi-choice-780eb565-0\" data-option-text=\"Lives Alone \/ Vit seul(e)\">Lives Alone \/ Vit seul(e)<\/label>\n\t\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t<div class=\"srfm-icon-container\">\t\t<span class=\"srfm-icon srfm-multi-choice-icon\" aria-hidden=\"true\">\n\t\t\t<svg width=\"17\" height=\"16\" fill=\"none\" xmlns=\"http:\/\/www.w3.org\/2000\/svg\"><path d=\"M6.5 7.33366L8.5 9.33366L15.1667 2.66699\" stroke=\"#111C44\" stroke-width=\"1.25\" stroke-linecap=\"round\" stroke-linejoin=\"round\" \/><path d=\"M14.5 8V12.6667C14.5 13.0203 14.3595 13.3594 14.1095 13.6095C13.8594 13.8595 13.5203 14 13.1667 14H3.83333C3.47971 14 3.14057 13.8595 2.89052 13.6095C2.64048 13.3594 2.5 13.0203 2.5 12.6667V3.33333C2.5 2.97971 2.64048 2.64057 2.89052 2.39052C3.14057 2.14048 3.47971 2 3.83333 2H11.1667\" stroke=\"#111C44\" stroke-width=\"1.25\" stroke-linecap=\"round\" stroke-linejoin=\"round\" \/><\/svg>\t\t<\/span>\n\t\t\t\t<span class=\"srfm-icon srfm-multi-choice-icon-unchecked\" aria-hidden=\"true\">\n\t\t\t<svg width=\"16\" height=\"16\" fill=\"none\" xmlns=\"http:\/\/www.w3.org\/2000\/svg\"><path d=\"M12.6667 2H3.33333C2.59695 2 2 2.59695 2 3.33333V12.6667C2 13.403 2.59695 14 3.33333 14H12.6667C13.403 14 14 13.403 14 12.6667V3.33333C14 2.59695 13.403 2 12.6667 2Z\" stroke=\"#1E1E1E\" stroke-opacity=\"0.7\" stroke-width=\"1.25\" stroke-linecap=\"round\" stroke-linejoin=\"round\" \/><\/svg>\t\t<\/span>\n\t\t<\/div>\n\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"srfm-multi-choice-single\">\n\t\t\t\t\t\t\t\t\t<input type=\"checkbox\"\n\t\t\t\t\t\t\t\t\t\tid=\"srfm-multi-choice-780eb565-1\"\n\t\t\t\t\t\t\t\t\t\tclass=\"srfm-input-multi-choice-single\" \t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\/>\n\t\t\t\t\t\t\t\t\t<div class=\"srfm-block-content-wrap\">\n\t\t\t\t\t\t\t\t\t\t<div class=\"srfm-option-container\">\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<!-- This label content is used in conditional logic and for storing values in a hidden input field as comma-separated values.\n\t\t\t\t\t\t\t\t\t\t\tThe markup should remain unchanged.\n\t\t\t\t\t\t\t\t\t\t\tIf you make any changes here, ensure the corresponding JavaScript value functionality and conditional logic are also updated. -->\n\t\t\t\t\t\t\t\t\t\t\t<label for=\"srfm-multi-choice-780eb565-1\" data-option-text=\"Lives with Spouse\/Family \/ Vit avec conjoint\/famille\">Lives with Spouse\/Family \/ Vit avec conjoint\/famille<\/label>\n\t\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t<div class=\"srfm-icon-container\">\t\t<span class=\"srfm-icon srfm-multi-choice-icon\" aria-hidden=\"true\">\n\t\t\t<svg width=\"17\" height=\"16\" fill=\"none\" xmlns=\"http:\/\/www.w3.org\/2000\/svg\"><path d=\"M6.5 7.33366L8.5 9.33366L15.1667 2.66699\" stroke=\"#111C44\" stroke-width=\"1.25\" stroke-linecap=\"round\" stroke-linejoin=\"round\" \/><path d=\"M14.5 8V12.6667C14.5 13.0203 14.3595 13.3594 14.1095 13.6095C13.8594 13.8595 13.5203 14 13.1667 14H3.83333C3.47971 14 3.14057 13.8595 2.89052 13.6095C2.64048 13.3594 2.5 13.0203 2.5 12.6667V3.33333C2.5 2.97971 2.64048 2.64057 2.89052 2.39052C3.14057 2.14048 3.47971 2 3.83333 2H11.1667\" stroke=\"#111C44\" stroke-width=\"1.25\" stroke-linecap=\"round\" stroke-linejoin=\"round\" \/><\/svg>\t\t<\/span>\n\t\t\t\t<span class=\"srfm-icon srfm-multi-choice-icon-unchecked\" aria-hidden=\"true\">\n\t\t\t<svg width=\"16\" height=\"16\" fill=\"none\" xmlns=\"http:\/\/www.w3.org\/2000\/svg\"><path d=\"M12.6667 2H3.33333C2.59695 2 2 2.59695 2 3.33333V12.6667C2 13.403 2.59695 14 3.33333 14H12.6667C13.403 14 14 13.403 14 12.6667V3.33333C14 2.59695 13.403 2 12.6667 2Z\" stroke=\"#1E1E1E\" stroke-opacity=\"0.7\" stroke-width=\"1.25\" stroke-linecap=\"round\" stroke-linejoin=\"round\" \/><\/svg>\t\t<\/span>\n\t\t<\/div>\n\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"srfm-multi-choice-single\">\n\t\t\t\t\t\t\t\t\t<input type=\"checkbox\"\n\t\t\t\t\t\t\t\t\t\tid=\"srfm-multi-choice-780eb565-2\"\n\t\t\t\t\t\t\t\t\t\tclass=\"srfm-input-multi-choice-single\" \t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\/>\n\t\t\t\t\t\t\t\t\t<div class=\"srfm-block-content-wrap\">\n\t\t\t\t\t\t\t\t\t\t<div class=\"srfm-option-container\">\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<!-- This label content is used in conditional logic and for storing values in a hidden input field as comma-separated values.\n\t\t\t\t\t\t\t\t\t\t\tThe markup should remain unchanged.\n\t\t\t\t\t\t\t\t\t\t\tIf you make any changes here, ensure the corresponding JavaScript value functionality and conditional logic are also updated. -->\n\t\t\t\t\t\t\t\t\t\t\t<label for=\"srfm-multi-choice-780eb565-2\" data-option-text=\"Retirement Residence \/ R\u00e9sidence pour retrait\u00e9s\">Retirement Residence \/ R\u00e9sidence pour retrait\u00e9s<\/label>\n\t\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t<div class=\"srfm-icon-container\">\t\t<span class=\"srfm-icon srfm-multi-choice-icon\" aria-hidden=\"true\">\n\t\t\t<svg width=\"17\" height=\"16\" fill=\"none\" xmlns=\"http:\/\/www.w3.org\/2000\/svg\"><path d=\"M6.5 7.33366L8.5 9.33366L15.1667 2.66699\" stroke=\"#111C44\" stroke-width=\"1.25\" stroke-linecap=\"round\" stroke-linejoin=\"round\" \/><path d=\"M14.5 8V12.6667C14.5 13.0203 14.3595 13.3594 14.1095 13.6095C13.8594 13.8595 13.5203 14 13.1667 14H3.83333C3.47971 14 3.14057 13.8595 2.89052 13.6095C2.64048 13.3594 2.5 13.0203 2.5 12.6667V3.33333C2.5 2.97971 2.64048 2.64057 2.89052 2.39052C3.14057 2.14048 3.47971 2 3.83333 2H11.1667\" stroke=\"#111C44\" stroke-width=\"1.25\" stroke-linecap=\"round\" stroke-linejoin=\"round\" \/><\/svg>\t\t<\/span>\n\t\t\t\t<span class=\"srfm-icon srfm-multi-choice-icon-unchecked\" aria-hidden=\"true\">\n\t\t\t<svg width=\"16\" height=\"16\" fill=\"none\" xmlns=\"http:\/\/www.w3.org\/2000\/svg\"><path d=\"M12.6667 2H3.33333C2.59695 2 2 2.59695 2 3.33333V12.6667C2 13.403 2.59695 14 3.33333 14H12.6667C13.403 14 14 13.403 14 12.6667V3.33333C14 2.59695 13.403 2 12.6667 2Z\" stroke=\"#1E1E1E\" stroke-opacity=\"0.7\" stroke-width=\"1.25\" stroke-linecap=\"round\" stroke-linejoin=\"round\" \/><\/svg>\t\t<\/span>\n\t\t<\/div>\n\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"srfm-multi-choice-single\">\n\t\t\t\t\t\t\t\t\t<input type=\"checkbox\"\n\t\t\t\t\t\t\t\t\t\tid=\"srfm-multi-choice-780eb565-3\"\n\t\t\t\t\t\t\t\t\t\tclass=\"srfm-input-multi-choice-single\" \t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\/>\n\t\t\t\t\t\t\t\t\t<div class=\"srfm-block-content-wrap\">\n\t\t\t\t\t\t\t\t\t\t<div class=\"srfm-option-container\">\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<!-- This label content is used in conditional logic and for storing values in a hidden input field as comma-separated values.\n\t\t\t\t\t\t\t\t\t\t\tThe markup should remain unchanged.\n\t\t\t\t\t\t\t\t\t\t\tIf you make any changes here, ensure the corresponding JavaScript value functionality and conditional logic are also updated. -->\n\t\t\t\t\t\t\t\t\t\t\t<label for=\"srfm-multi-choice-780eb565-3\" data-option-text=\"Long-Term Care \/ Soins de longue dur\u00e9e\">Long-Term Care \/ Soins de longue dur\u00e9e<\/label>\n\t\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t<div class=\"srfm-icon-container\">\t\t<span class=\"srfm-icon srfm-multi-choice-icon\" aria-hidden=\"true\">\n\t\t\t<svg width=\"17\" height=\"16\" fill=\"none\" xmlns=\"http:\/\/www.w3.org\/2000\/svg\"><path d=\"M6.5 7.33366L8.5 9.33366L15.1667 2.66699\" stroke=\"#111C44\" stroke-width=\"1.25\" stroke-linecap=\"round\" stroke-linejoin=\"round\" \/><path d=\"M14.5 8V12.6667C14.5 13.0203 14.3595 13.3594 14.1095 13.6095C13.8594 13.8595 13.5203 14 13.1667 14H3.83333C3.47971 14 3.14057 13.8595 2.89052 13.6095C2.64048 13.3594 2.5 13.0203 2.5 12.6667V3.33333C2.5 2.97971 2.64048 2.64057 2.89052 2.39052C3.14057 2.14048 3.47971 2 3.83333 2H11.1667\" stroke=\"#111C44\" stroke-width=\"1.25\" stroke-linecap=\"round\" stroke-linejoin=\"round\" \/><\/svg>\t\t<\/span>\n\t\t\t\t<span class=\"srfm-icon srfm-multi-choice-icon-unchecked\" aria-hidden=\"true\">\n\t\t\t<svg width=\"16\" height=\"16\" fill=\"none\" xmlns=\"http:\/\/www.w3.org\/2000\/svg\"><path d=\"M12.6667 2H3.33333C2.59695 2 2 2.59695 2 3.33333V12.6667C2 13.403 2.59695 14 3.33333 14H12.6667C13.403 14 14 13.403 14 12.6667V3.33333C14 2.59695 13.403 2 12.6667 2Z\" stroke=\"#1E1E1E\" stroke-opacity=\"0.7\" stroke-width=\"1.25\" stroke-linecap=\"round\" stroke-linejoin=\"round\" \/><\/svg>\t\t<\/span>\n\t\t<\/div>\n\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"srfm-multi-choice-single\">\n\t\t\t\t\t\t\t\t\t<input type=\"checkbox\"\n\t\t\t\t\t\t\t\t\t\tid=\"srfm-multi-choice-780eb565-4\"\n\t\t\t\t\t\t\t\t\t\tclass=\"srfm-input-multi-choice-single\" \t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\/>\n\t\t\t\t\t\t\t\t\t<div class=\"srfm-block-content-wrap\">\n\t\t\t\t\t\t\t\t\t\t<div class=\"srfm-option-container\">\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<!-- This label content is used in conditional logic and for storing values in a hidden input field as comma-separated values.\n\t\t\t\t\t\t\t\t\t\t\tThe markup should remain unchanged.\n\t\t\t\t\t\t\t\t\t\t\tIf you make any changes here, ensure the corresponding JavaScript value functionality and conditional logic are also updated. -->\n\t\t\t\t\t\t\t\t\t\t\t<label for=\"srfm-multi-choice-780eb565-4\" data-option-text=\"Other \/ Autre\">Other \/ Autre<\/label>\n\t\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t<div class=\"srfm-icon-container\">\t\t<span class=\"srfm-icon srfm-multi-choice-icon\" aria-hidden=\"true\">\n\t\t\t<svg width=\"17\" height=\"16\" fill=\"none\" xmlns=\"http:\/\/www.w3.org\/2000\/svg\"><path d=\"M6.5 7.33366L8.5 9.33366L15.1667 2.66699\" stroke=\"#111C44\" stroke-width=\"1.25\" stroke-linecap=\"round\" stroke-linejoin=\"round\" \/><path d=\"M14.5 8V12.6667C14.5 13.0203 14.3595 13.3594 14.1095 13.6095C13.8594 13.8595 13.5203 14 13.1667 14H3.83333C3.47971 14 3.14057 13.8595 2.89052 13.6095C2.64048 13.3594 2.5 13.0203 2.5 12.6667V3.33333C2.5 2.97971 2.64048 2.64057 2.89052 2.39052C3.14057 2.14048 3.47971 2 3.83333 2H11.1667\" stroke=\"#111C44\" stroke-width=\"1.25\" stroke-linecap=\"round\" stroke-linejoin=\"round\" \/><\/svg>\t\t<\/span>\n\t\t\t\t<span class=\"srfm-icon srfm-multi-choice-icon-unchecked\" aria-hidden=\"true\">\n\t\t\t<svg width=\"16\" height=\"16\" fill=\"none\" xmlns=\"http:\/\/www.w3.org\/2000\/svg\"><path d=\"M12.6667 2H3.33333C2.59695 2 2 2.59695 2 3.33333V12.6667C2 13.403 2.59695 14 3.33333 14H12.6667C13.403 14 14 13.403 14 12.6667V3.33333C14 2.59695 13.403 2 12.6667 2Z\" stroke=\"#1E1E1E\" stroke-opacity=\"0.7\" stroke-width=\"1.25\" stroke-linecap=\"round\" stroke-linejoin=\"round\" \/><\/svg>\t\t<\/span>\n\t\t<\/div>\n\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t<div class=\"srfm-error-wrap\"><\/div>\n\t\t\t<\/fieldset>\n\t\t<\/div>\n\t\t\n\n\t\t<div data-block-id=\"4302a9a0\" class=\"srfm-block-single srfm-block srfm-multi-choice-block srf-multi-choice-4302a9a0-block  srfm-block-width-50 srfm-slug-13-are-there-pets-in-the-home-y-a-t-il-des-animaux-dans-le-domicile srfm-checkbox-mode\">\n\t\t\t<fieldset>\n\t\t\t\t<input class=\"srfm-input-multi-choice-hidden\" data-required=\"false\" aria-required=\"false\"  name=\"srfm-input-multi-choice-4302a9a0-lbl-MTMuIEFyZSB0aGVyZSBwZXRzIGluIHRoZSBob21lPyAvIFkgYS10LWlsIGRlcyBhbmltYXV4IGRhbnMgbGUgZG9taWNpbGU\/-13-are-there-pets-in-the-home-y-a-t-il-des-animaux-dans-le-domicile\" type=\"hidden\" value=\"\"\/>\n\t\t\t\t<legend class=\"srfm-block-legend\">\n\t\t\t\t\t\t\t\t\t\t13. Are there pets in the home? \/ Y a-t-il des animaux dans le domicile?\t\t\t\t\t\t\t\t\t\t\t\t\t\t<\/legend>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"srfm-block-wrap srfm-choice-width-50\">\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"srfm-multi-choice-single\">\n\t\t\t\t\t\t\t\t\t<input type=\"checkbox\"\n\t\t\t\t\t\t\t\t\t\tid=\"srfm-multi-choice-4302a9a0-0\"\n\t\t\t\t\t\t\t\t\t\tclass=\"srfm-input-multi-choice-single\" \t\t\t\t\t\t\t\t\t\taria-describedby=\"srfm-error-4302a9a0\"\t\t\t\t\t\t\t\t\t\taria-required=\"false\"\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\/>\n\t\t\t\t\t\t\t\t\t<div class=\"srfm-block-content-wrap\">\n\t\t\t\t\t\t\t\t\t\t<div class=\"srfm-option-container\">\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<!-- This label content is used in conditional logic and for storing values in a hidden input field as comma-separated values.\n\t\t\t\t\t\t\t\t\t\t\tThe markup should remain unchanged.\n\t\t\t\t\t\t\t\t\t\t\tIf you make any changes here, ensure the corresponding JavaScript value functionality and conditional logic are also updated. -->\n\t\t\t\t\t\t\t\t\t\t\t<label for=\"srfm-multi-choice-4302a9a0-0\" data-option-text=\"Yes \/ Oui\">Yes \/ Oui<\/label>\n\t\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t<div class=\"srfm-icon-container\">\t\t<span class=\"srfm-icon srfm-multi-choice-icon\" aria-hidden=\"true\">\n\t\t\t<svg width=\"17\" height=\"16\" fill=\"none\" xmlns=\"http:\/\/www.w3.org\/2000\/svg\"><path d=\"M6.5 7.33366L8.5 9.33366L15.1667 2.66699\" stroke=\"#111C44\" stroke-width=\"1.25\" stroke-linecap=\"round\" stroke-linejoin=\"round\" \/><path d=\"M14.5 8V12.6667C14.5 13.0203 14.3595 13.3594 14.1095 13.6095C13.8594 13.8595 13.5203 14 13.1667 14H3.83333C3.47971 14 3.14057 13.8595 2.89052 13.6095C2.64048 13.3594 2.5 13.0203 2.5 12.6667V3.33333C2.5 2.97971 2.64048 2.64057 2.89052 2.39052C3.14057 2.14048 3.47971 2 3.83333 2H11.1667\" stroke=\"#111C44\" stroke-width=\"1.25\" stroke-linecap=\"round\" stroke-linejoin=\"round\" \/><\/svg>\t\t<\/span>\n\t\t\t\t<span class=\"srfm-icon srfm-multi-choice-icon-unchecked\" aria-hidden=\"true\">\n\t\t\t<svg width=\"16\" height=\"16\" fill=\"none\" xmlns=\"http:\/\/www.w3.org\/2000\/svg\"><path d=\"M12.6667 2H3.33333C2.59695 2 2 2.59695 2 3.33333V12.6667C2 13.403 2.59695 14 3.33333 14H12.6667C13.403 14 14 13.403 14 12.6667V3.33333C14 2.59695 13.403 2 12.6667 2Z\" stroke=\"#1E1E1E\" stroke-opacity=\"0.7\" stroke-width=\"1.25\" stroke-linecap=\"round\" stroke-linejoin=\"round\" \/><\/svg>\t\t<\/span>\n\t\t<\/div>\n\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"srfm-multi-choice-single\">\n\t\t\t\t\t\t\t\t\t<input type=\"checkbox\"\n\t\t\t\t\t\t\t\t\t\tid=\"srfm-multi-choice-4302a9a0-1\"\n\t\t\t\t\t\t\t\t\t\tclass=\"srfm-input-multi-choice-single\" \t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\/>\n\t\t\t\t\t\t\t\t\t<div class=\"srfm-block-content-wrap\">\n\t\t\t\t\t\t\t\t\t\t<div class=\"srfm-option-container\">\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<!-- This label content is used in conditional logic and for storing values in a hidden input field as comma-separated values.\n\t\t\t\t\t\t\t\t\t\t\tThe markup should remain unchanged.\n\t\t\t\t\t\t\t\t\t\t\tIf you make any changes here, ensure the corresponding JavaScript value functionality and conditional logic are also updated. -->\n\t\t\t\t\t\t\t\t\t\t\t<label for=\"srfm-multi-choice-4302a9a0-1\" data-option-text=\"No \/ Non\">No \/ Non<\/label>\n\t\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t<div class=\"srfm-icon-container\">\t\t<span class=\"srfm-icon srfm-multi-choice-icon\" aria-hidden=\"true\">\n\t\t\t<svg width=\"17\" height=\"16\" fill=\"none\" xmlns=\"http:\/\/www.w3.org\/2000\/svg\"><path d=\"M6.5 7.33366L8.5 9.33366L15.1667 2.66699\" stroke=\"#111C44\" stroke-width=\"1.25\" stroke-linecap=\"round\" stroke-linejoin=\"round\" \/><path d=\"M14.5 8V12.6667C14.5 13.0203 14.3595 13.3594 14.1095 13.6095C13.8594 13.8595 13.5203 14 13.1667 14H3.83333C3.47971 14 3.14057 13.8595 2.89052 13.6095C2.64048 13.3594 2.5 13.0203 2.5 12.6667V3.33333C2.5 2.97971 2.64048 2.64057 2.89052 2.39052C3.14057 2.14048 3.47971 2 3.83333 2H11.1667\" stroke=\"#111C44\" stroke-width=\"1.25\" stroke-linecap=\"round\" stroke-linejoin=\"round\" \/><\/svg>\t\t<\/span>\n\t\t\t\t<span class=\"srfm-icon srfm-multi-choice-icon-unchecked\" aria-hidden=\"true\">\n\t\t\t<svg width=\"16\" height=\"16\" fill=\"none\" xmlns=\"http:\/\/www.w3.org\/2000\/svg\"><path d=\"M12.6667 2H3.33333C2.59695 2 2 2.59695 2 3.33333V12.6667C2 13.403 2.59695 14 3.33333 14H12.6667C13.403 14 14 13.403 14 12.6667V3.33333C14 2.59695 13.403 2 12.6667 2Z\" stroke=\"#1E1E1E\" stroke-opacity=\"0.7\" stroke-width=\"1.25\" stroke-linecap=\"round\" stroke-linejoin=\"round\" \/><\/svg>\t\t<\/span>\n\t\t<\/div>\n\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t<div class=\"srfm-error-wrap\"><\/div>\n\t\t\t<\/fieldset>\n\t\t<\/div>\n\t\t\n\n\t\t<div data-block-id=\"a9f20877\" class=\"srfm-block-single srfm-block srfm-multi-choice-block srf-multi-choice-a9f20877-block  srfm-block-width-50 srfm-slug-14-are-there-stairs-in-the-home-y-a-t-il-des-escaliers-dans-le-domicile srfm-checkbox-mode\">\n\t\t\t<fieldset>\n\t\t\t\t<input class=\"srfm-input-multi-choice-hidden\" data-required=\"false\" aria-required=\"false\"  name=\"srfm-input-multi-choice-a9f20877-lbl-MTQuIEFyZSB0aGVyZSBzdGFpcnMgaW4gdGhlIGhvbWU\/IC8gWSBhLXQtaWwgZGVzIGVzY2FsaWVycyBkYW5zIGxlIGRvbWljaWxlPw-14-are-there-stairs-in-the-home-y-a-t-il-des-escaliers-dans-le-domicile\" type=\"hidden\" value=\"\"\/>\n\t\t\t\t<legend class=\"srfm-block-legend\">\n\t\t\t\t\t\t\t\t\t\t14. Are there stairs in the home? \/ Y a-t-il des escaliers dans le domicile?\t\t\t\t\t\t\t\t\t\t\t\t\t\t<\/legend>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"srfm-block-wrap srfm-choice-width-50\">\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"srfm-multi-choice-single\">\n\t\t\t\t\t\t\t\t\t<input type=\"checkbox\"\n\t\t\t\t\t\t\t\t\t\tid=\"srfm-multi-choice-a9f20877-0\"\n\t\t\t\t\t\t\t\t\t\tclass=\"srfm-input-multi-choice-single\" \t\t\t\t\t\t\t\t\t\taria-describedby=\"srfm-error-a9f20877\"\t\t\t\t\t\t\t\t\t\taria-required=\"false\"\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\/>\n\t\t\t\t\t\t\t\t\t<div class=\"srfm-block-content-wrap\">\n\t\t\t\t\t\t\t\t\t\t<div class=\"srfm-option-container\">\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<!-- This label content is used in conditional logic and for storing values in a hidden input field as comma-separated values.\n\t\t\t\t\t\t\t\t\t\t\tThe markup should remain unchanged.\n\t\t\t\t\t\t\t\t\t\t\tIf you make any changes here, ensure the corresponding JavaScript value functionality and conditional logic are also updated. -->\n\t\t\t\t\t\t\t\t\t\t\t<label for=\"srfm-multi-choice-a9f20877-0\" data-option-text=\"Yes \/ Oui\">Yes \/ Oui<\/label>\n\t\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t<div class=\"srfm-icon-container\">\t\t<span class=\"srfm-icon srfm-multi-choice-icon\" aria-hidden=\"true\">\n\t\t\t<svg width=\"17\" height=\"16\" fill=\"none\" xmlns=\"http:\/\/www.w3.org\/2000\/svg\"><path d=\"M6.5 7.33366L8.5 9.33366L15.1667 2.66699\" stroke=\"#111C44\" stroke-width=\"1.25\" stroke-linecap=\"round\" stroke-linejoin=\"round\" \/><path d=\"M14.5 8V12.6667C14.5 13.0203 14.3595 13.3594 14.1095 13.6095C13.8594 13.8595 13.5203 14 13.1667 14H3.83333C3.47971 14 3.14057 13.8595 2.89052 13.6095C2.64048 13.3594 2.5 13.0203 2.5 12.6667V3.33333C2.5 2.97971 2.64048 2.64057 2.89052 2.39052C3.14057 2.14048 3.47971 2 3.83333 2H11.1667\" stroke=\"#111C44\" stroke-width=\"1.25\" stroke-linecap=\"round\" stroke-linejoin=\"round\" \/><\/svg>\t\t<\/span>\n\t\t\t\t<span class=\"srfm-icon srfm-multi-choice-icon-unchecked\" aria-hidden=\"true\">\n\t\t\t<svg width=\"16\" height=\"16\" fill=\"none\" xmlns=\"http:\/\/www.w3.org\/2000\/svg\"><path d=\"M12.6667 2H3.33333C2.59695 2 2 2.59695 2 3.33333V12.6667C2 13.403 2.59695 14 3.33333 14H12.6667C13.403 14 14 13.403 14 12.6667V3.33333C14 2.59695 13.403 2 12.6667 2Z\" stroke=\"#1E1E1E\" stroke-opacity=\"0.7\" stroke-width=\"1.25\" stroke-linecap=\"round\" stroke-linejoin=\"round\" \/><\/svg>\t\t<\/span>\n\t\t<\/div>\n\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"srfm-multi-choice-single\">\n\t\t\t\t\t\t\t\t\t<input type=\"checkbox\"\n\t\t\t\t\t\t\t\t\t\tid=\"srfm-multi-choice-a9f20877-1\"\n\t\t\t\t\t\t\t\t\t\tclass=\"srfm-input-multi-choice-single\" \t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\/>\n\t\t\t\t\t\t\t\t\t<div class=\"srfm-block-content-wrap\">\n\t\t\t\t\t\t\t\t\t\t<div class=\"srfm-option-container\">\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<!-- This label content is used in conditional logic and for storing values in a hidden input field as comma-separated values.\n\t\t\t\t\t\t\t\t\t\t\tThe markup should remain unchanged.\n\t\t\t\t\t\t\t\t\t\t\tIf you make any changes here, ensure the corresponding JavaScript value functionality and conditional logic are also updated. -->\n\t\t\t\t\t\t\t\t\t\t\t<label for=\"srfm-multi-choice-a9f20877-1\" data-option-text=\"No \/ Non\">No \/ Non<\/label>\n\t\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t<div class=\"srfm-icon-container\">\t\t<span class=\"srfm-icon srfm-multi-choice-icon\" aria-hidden=\"true\">\n\t\t\t<svg width=\"17\" height=\"16\" fill=\"none\" xmlns=\"http:\/\/www.w3.org\/2000\/svg\"><path d=\"M6.5 7.33366L8.5 9.33366L15.1667 2.66699\" stroke=\"#111C44\" stroke-width=\"1.25\" stroke-linecap=\"round\" stroke-linejoin=\"round\" \/><path d=\"M14.5 8V12.6667C14.5 13.0203 14.3595 13.3594 14.1095 13.6095C13.8594 13.8595 13.5203 14 13.1667 14H3.83333C3.47971 14 3.14057 13.8595 2.89052 13.6095C2.64048 13.3594 2.5 13.0203 2.5 12.6667V3.33333C2.5 2.97971 2.64048 2.64057 2.89052 2.39052C3.14057 2.14048 3.47971 2 3.83333 2H11.1667\" stroke=\"#111C44\" stroke-width=\"1.25\" stroke-linecap=\"round\" stroke-linejoin=\"round\" \/><\/svg>\t\t<\/span>\n\t\t\t\t<span class=\"srfm-icon srfm-multi-choice-icon-unchecked\" aria-hidden=\"true\">\n\t\t\t<svg width=\"16\" height=\"16\" fill=\"none\" xmlns=\"http:\/\/www.w3.org\/2000\/svg\"><path d=\"M12.6667 2H3.33333C2.59695 2 2 2.59695 2 3.33333V12.6667C2 13.403 2.59695 14 3.33333 14H12.6667C13.403 14 14 13.403 14 12.6667V3.33333C14 2.59695 13.403 2 12.6667 2Z\" stroke=\"#1E1E1E\" stroke-opacity=\"0.7\" stroke-width=\"1.25\" stroke-linecap=\"round\" stroke-linejoin=\"round\" \/><\/svg>\t\t<\/span>\n\t\t<\/div>\n\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t<div class=\"srfm-error-wrap\"><\/div>\n\t\t\t<\/fieldset>\n\t\t<\/div>\n\t\t\n\n\t\t\t<div data-block-id=\"458b3214\" class=\"srfm-block-single srfm-block srfm-input-block srf-input-458b3214-block  srfm-block-width-100 srfm-slug-15-mobility-safety-mobilite-et-securite\" >\n\t\t\t\t\t\t\t\t<label id=\"srfm-label-458b3214-lbl-MTUuIE1vYmlsaXR5ICZhbXA7IFNhZmV0eSAvIE1vYmlsaXTDqSBldCBzw6ljdXJpdMOp\" for=\"srfm-input-458b3214-lbl-MTUuIE1vYmlsaXR5ICZhbXA7IFNhZmV0eSAvIE1vYmlsaXTDqSBldCBzw6ljdXJpdMOp\" class=\"srfm-block-label\">\n\t\t\t\t\t\t15. Mobility &amp; Safety \/ Mobilit\u00e9 et s\u00e9curit\u00e9\t\t\t\t\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"srfm-block-wrap\">\n\t\t\t\t<input class=\"srfm-input-common srfm-input-input\" type=\"text\" name=\"srfm-input-458b3214-lbl-MTUuIE1vYmlsaXR5ICZhbXA7IFNhZmV0eSAvIE1vYmlsaXTDqSBldCBzw6ljdXJpdMOp-15-mobility-safety-mobilite-et-securite\" id=\"srfm-input-458b3214-lbl-MTUuIE1vYmlsaXR5ICZhbXA7IFNhZmV0eSAvIE1vYmlsaXTDqSBldCBzw6ljdXJpdMOp\"\n\t\t\t\t\taria-describedby='srfm-error-458b3214'\t\t\t\t\tdata-required=\"false\" aria-required=\"false\" data-unique=\"false\" maxlength=\"1000\" value=\"\"  data-srfm-mask=\"none\"   \/>\n\t\t\t\t<\/div>\n\t\t\t\t<div class=\"srfm-error-wrap\">\n\t\t\t\t\t\t\t\t\t\t<div class=\"srfm-error-message\" data-srfm-id=\"srfm-error-458b3214\" data-error-msg=\"This field is required.\" data-unique-msg=\"Value needs to be unique.\">\n\t\t\t\t\t\tThis field is required.\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t<\/div>\n\t\t\n\n\t\t\t<div data-block-id=\"5816d2cc\" class=\"srfm-block-single srfm-block srfm-input-block srf-input-5816d2cc-block  srfm-block-width-100 srfm-slug-16-personal-care-needs-besoins-de-soins-personnels\" >\n\t\t\t\t\t\t\t\t<label id=\"srfm-label-5816d2cc-lbl-MTYuIFBlcnNvbmFsIENhcmUgTmVlZHMgLyBCZXNvaW5zIGRlIHNvaW5zIHBlcnNvbm5lbHM\" for=\"srfm-input-5816d2cc-lbl-MTYuIFBlcnNvbmFsIENhcmUgTmVlZHMgLyBCZXNvaW5zIGRlIHNvaW5zIHBlcnNvbm5lbHM\" class=\"srfm-block-label\">\n\t\t\t\t\t\t16. Personal Care Needs \/ Besoins de soins personnels\t\t\t\t\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"srfm-block-wrap\">\n\t\t\t\t<input class=\"srfm-input-common srfm-input-input\" type=\"text\" name=\"srfm-input-5816d2cc-lbl-MTYuIFBlcnNvbmFsIENhcmUgTmVlZHMgLyBCZXNvaW5zIGRlIHNvaW5zIHBlcnNvbm5lbHM-16-personal-care-needs-besoins-de-soins-personnels\" id=\"srfm-input-5816d2cc-lbl-MTYuIFBlcnNvbmFsIENhcmUgTmVlZHMgLyBCZXNvaW5zIGRlIHNvaW5zIHBlcnNvbm5lbHM\"\n\t\t\t\t\taria-describedby='srfm-error-5816d2cc'\t\t\t\t\tdata-required=\"false\" aria-required=\"false\" data-unique=\"false\" maxlength=\"1000\" value=\"\"  data-srfm-mask=\"none\"   \/>\n\t\t\t\t<\/div>\n\t\t\t\t<div class=\"srfm-error-wrap\">\n\t\t\t\t\t\t\t\t\t\t<div class=\"srfm-error-message\" data-srfm-id=\"srfm-error-5816d2cc\" data-error-msg=\"This field is required.\" data-unique-msg=\"Value needs to be unique.\">\n\t\t\t\t\t\tThis field is required.\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t<\/div>\n\t\t\n\n\t\t\t<div data-block-id=\"c763c1d7\" class=\"srfm-block-single srfm-block srfm-input-block srf-input-c763c1d7-block  srfm-block-width-100 srfm-slug-17-medical-overview-apercu-medical\" >\n\t\t\t\t\t\t\t\t<label id=\"srfm-label-c763c1d7-lbl-MTcuIE1lZGljYWwgT3ZlcnZpZXcgLyBBcGVyw6d1IG3DqWRpY2Fs\" for=\"srfm-input-c763c1d7-lbl-MTcuIE1lZGljYWwgT3ZlcnZpZXcgLyBBcGVyw6d1IG3DqWRpY2Fs\" class=\"srfm-block-label\">\n\t\t\t\t\t\t17. Medical Overview \/ Aper\u00e7u m\u00e9dical\t\t\t\t\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"srfm-block-wrap\">\n\t\t\t\t<input class=\"srfm-input-common srfm-input-input\" type=\"text\" name=\"srfm-input-c763c1d7-lbl-MTcuIE1lZGljYWwgT3ZlcnZpZXcgLyBBcGVyw6d1IG3DqWRpY2Fs-17-medical-overview-apercu-medical\" id=\"srfm-input-c763c1d7-lbl-MTcuIE1lZGljYWwgT3ZlcnZpZXcgLyBBcGVyw6d1IG3DqWRpY2Fs\"\n\t\t\t\t\taria-describedby='srfm-error-c763c1d7'\t\t\t\t\tdata-required=\"false\" aria-required=\"false\" data-unique=\"false\" maxlength=\"1000\" value=\"\"  data-srfm-mask=\"none\"   \/>\n\t\t\t\t<\/div>\n\t\t\t\t<div class=\"srfm-error-wrap\">\n\t\t\t\t\t\t\t\t\t\t<div class=\"srfm-error-message\" data-srfm-id=\"srfm-error-c763c1d7\" data-error-msg=\"This field is required.\" data-unique-msg=\"Value needs to be unique.\">\n\t\t\t\t\t\tThis field is required.\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t<\/div>\n\t\t\n\n\t\t\t<div data-block-id=\"bca29eec\" class=\"srfm-block-single srfm-block srfm-input-block srf-input-bca29eec-block  srfm-block-width-100 srfm-slug-18-scheduling-needs-besoins-dhoraire\" >\n\t\t\t\t\t\t\t\t<label id=\"srfm-label-bca29eec-lbl-MTguIFNjaGVkdWxpbmcgTmVlZHMgLyBCZXNvaW5zIGTigJlob3JhaXJl\" for=\"srfm-input-bca29eec-lbl-MTguIFNjaGVkdWxpbmcgTmVlZHMgLyBCZXNvaW5zIGTigJlob3JhaXJl\" class=\"srfm-block-label\">\n\t\t\t\t\t\t18. Scheduling Needs \/ Besoins d\u2019horaire\t\t\t\t\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"srfm-block-wrap\">\n\t\t\t\t<input class=\"srfm-input-common srfm-input-input\" type=\"text\" name=\"srfm-input-bca29eec-lbl-MTguIFNjaGVkdWxpbmcgTmVlZHMgLyBCZXNvaW5zIGTigJlob3JhaXJl-18-scheduling-needs-besoins-dhoraire\" id=\"srfm-input-bca29eec-lbl-MTguIFNjaGVkdWxpbmcgTmVlZHMgLyBCZXNvaW5zIGTigJlob3JhaXJl\"\n\t\t\t\t\taria-describedby='srfm-error-bca29eec'\t\t\t\t\tdata-required=\"false\" aria-required=\"false\" data-unique=\"false\" maxlength=\"1000\" value=\"\"  data-srfm-mask=\"none\"   \/>\n\t\t\t\t<\/div>\n\t\t\t\t<div class=\"srfm-error-wrap\">\n\t\t\t\t\t\t\t\t\t\t<div class=\"srfm-error-message\" data-srfm-id=\"srfm-error-bca29eec\" data-error-msg=\"This field is required.\" data-unique-msg=\"Value needs to be unique.\">\n\t\t\t\t\t\tThis field is required.\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t<\/div>\n\t\t\n\n\t\t\t<div data-block-id=\"1c35b044\" class=\"srfm-block-single srfm-block srfm-input-block srf-input-1c35b044-block  srfm-block-width-100 srfm-slug-19-is-there-parking-available-if-so-please-provide-details-y-a-t-il-des-places-de-stationnement-disponibles-si-oui-veuillez-fournir-des-details\" >\n\t\t\t\t\t\t\t\t<label id=\"srfm-label-1c35b044-lbl-MTkuIElzIHRoZXJlIHBhcmtpbmcgYXZhaWxhYmxlPyBJZiBzbywgcGxlYXNlIHByb3ZpZGUgZGV0YWlscyAvIFkgYS10LWlsIGRlcyBwbGFjZXMgZGUgc3RhdGlvbm5lbWVudCBkaXNwb25pYmxlcz8gU2kgb3VpLCB2ZXVpbGxleiBmb3VybmlyIGRlcyBkw6l0YWlscy4\" for=\"srfm-input-1c35b044-lbl-MTkuIElzIHRoZXJlIHBhcmtpbmcgYXZhaWxhYmxlPyBJZiBzbywgcGxlYXNlIHByb3ZpZGUgZGV0YWlscyAvIFkgYS10LWlsIGRlcyBwbGFjZXMgZGUgc3RhdGlvbm5lbWVudCBkaXNwb25pYmxlcz8gU2kgb3VpLCB2ZXVpbGxleiBmb3VybmlyIGRlcyBkw6l0YWlscy4\" class=\"srfm-block-label\">\n\t\t\t\t\t\t19. Is there parking available? If so, please provide details \/ Y a-t-il des places de stationnement disponibles? Si oui, veuillez fournir des d\u00e9tails.\t\t\t\t\t\t\t\t\t\t\t\t\t<span class=\"srfm-required\" aria-hidden=\"true\"> *<\/span>\n\t\t\t\t\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"srfm-block-wrap\">\n\t\t\t\t<input class=\"srfm-input-common srfm-input-input\" type=\"text\" name=\"srfm-input-1c35b044-lbl-MTkuIElzIHRoZXJlIHBhcmtpbmcgYXZhaWxhYmxlPyBJZiBzbywgcGxlYXNlIHByb3ZpZGUgZGV0YWlscyAvIFkgYS10LWlsIGRlcyBwbGFjZXMgZGUgc3RhdGlvbm5lbWVudCBkaXNwb25pYmxlcz8gU2kgb3VpLCB2ZXVpbGxleiBmb3VybmlyIGRlcyBkw6l0YWlscy4-19-is-there-parking-available-if-so-please-provide-details-y-a-t-il-des-places-de-stationnement-disponibles-si-oui-veuillez-fournir-des-details\" id=\"srfm-input-1c35b044-lbl-MTkuIElzIHRoZXJlIHBhcmtpbmcgYXZhaWxhYmxlPyBJZiBzbywgcGxlYXNlIHByb3ZpZGUgZGV0YWlscyAvIFkgYS10LWlsIGRlcyBwbGFjZXMgZGUgc3RhdGlvbm5lbWVudCBkaXNwb25pYmxlcz8gU2kgb3VpLCB2ZXVpbGxleiBmb3VybmlyIGRlcyBkw6l0YWlscy4\"\n\t\t\t\t\taria-describedby='srfm-error-1c35b044'\t\t\t\t\tdata-required=\"true\" aria-required=\"true\" data-unique=\"false\" maxlength=\"1000\" value=\"\"  data-srfm-mask=\"none\"   \/>\n\t\t\t\t<\/div>\n\t\t\t\t<div class=\"srfm-error-wrap\">\n\t\t\t\t\t\t\t\t\t\t<div class=\"srfm-error-message\" data-srfm-id=\"srfm-error-1c35b044\" data-error-msg=\"This field is required.\" data-unique-msg=\"Value needs to be unique.\">\n\t\t\t\t\t\tThis field is required.\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t<\/div>\n\t\t\n\n\t\t\t<div data-block-id=\"b006064b\" class=\"srfm-block-single srfm-block srfm-input-block srf-input-b006064b-block  srfm-block-width-100 srfm-slug-19-additional-information-informations-supplementaires\" >\n\t\t\t\t\t\t\t\t<label id=\"srfm-label-b006064b-lbl-MjAuIEFkZGl0aW9uYWwgSW5mb3JtYXRpb24gLyBJbmZvcm1hdGlvbnMgc3VwcGzDqW1lbnRhaXJlcw\" for=\"srfm-input-b006064b-lbl-MjAuIEFkZGl0aW9uYWwgSW5mb3JtYXRpb24gLyBJbmZvcm1hdGlvbnMgc3VwcGzDqW1lbnRhaXJlcw\" class=\"srfm-block-label\">\n\t\t\t\t\t\t20. Additional Information \/ Informations suppl\u00e9mentaires\t\t\t\t\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"srfm-block-wrap\">\n\t\t\t\t<input class=\"srfm-input-common srfm-input-input\" type=\"text\" name=\"srfm-input-b006064b-lbl-MjAuIEFkZGl0aW9uYWwgSW5mb3JtYXRpb24gLyBJbmZvcm1hdGlvbnMgc3VwcGzDqW1lbnRhaXJlcw-19-additional-information-informations-supplementaires\" id=\"srfm-input-b006064b-lbl-MjAuIEFkZGl0aW9uYWwgSW5mb3JtYXRpb24gLyBJbmZvcm1hdGlvbnMgc3VwcGzDqW1lbnRhaXJlcw\"\n\t\t\t\t\taria-describedby='srfm-error-b006064b'\t\t\t\t\tdata-required=\"false\" aria-required=\"false\" data-unique=\"false\" maxlength=\"1000\" value=\"\"  data-srfm-mask=\"none\"   \/>\n\t\t\t\t<\/div>\n\t\t\t\t<div class=\"srfm-error-wrap\">\n\t\t\t\t\t\t\t\t\t\t<div class=\"srfm-error-message\" data-srfm-id=\"srfm-error-b006064b\" data-error-msg=\"This field is required.\" data-unique-msg=\"Value needs to be unique.\">\n\t\t\t\t\t\tThis field is required.\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t<\/div>","protected":false},"author":6,"template":"","meta":{"site-sidebar-layout":"default","site-content-layout":"","ast-site-content-layout":"default","site-content-style":"default","site-sidebar-style":"default","ast-global-header-display":"","ast-banner-title-visibility":"","ast-main-header-display":"","ast-hfb-above-header-display":"","ast-hfb-below-header-display":"","ast-hfb-mobile-header-display":"","site-post-title":"","ast-breadcrumbs-content":"","ast-featured-img":"","footer-sml-layout":"","ast-disable-related-posts":"","theme-transparent-header-meta":"","adv-header-id-meta":"","stick-header-meta":"","header-above-stick-meta":"","header-main-stick-meta":"","header-below-stick-meta":"","astra-migrate-meta-layouts":"default","ast-page-background-enabled":"default","ast-page-background-meta":{"desktop":{"background-color":"var(--ast-global-color-5)","background-image":"","background-repeat":"repeat","background-position":"center center","background-size":"auto","background-attachment":"scroll","background-type":"","background-media":"","overlay-type":"","overlay-color":"","overlay-opacity":"","overlay-gradient":""},"tablet":{"background-color":"","background-image":"","background-repeat":"repeat","background-position":"center center","background-size":"auto","background-attachment":"scroll","background-type":"","background-media":"","overlay-type":"","overlay-color":"","overlay-opacity":"","overlay-gradient":""},"mobile":{"background-color":"","background-image":"","background-repeat":"repeat","background-position":"center center","background-size":"auto","background-attachment":"scroll","background-type":"","background-media":"","overlay-type":"","overlay-color":"","overlay-opacity":"","overlay-gradient":""}},"ast-content-background-meta":{"desktop":{"background-color":"var(--ast-global-color-4)","background-image":"","background-repeat":"repeat","background-position":"center center","background-size":"auto","background-attachment":"scroll","background-type":"","background-media":"","overlay-type":"","overlay-color":"","overlay-opacity":"","overlay-gradient":""},"tablet":{"background-color":"var(--ast-global-color-4)","background-image":"","background-repeat":"repeat","background-position":"center center","background-size":"auto","background-attachment":"scroll","background-type":"","background-media":"","overlay-type":"","overlay-color":"","overlay-opacity":"","overlay-gradient":""},"mobile":{"background-color":"var(--ast-global-color-4)","background-image":"","background-repeat":"repeat","background-position":"center center","background-size":"auto","background-attachment":"scroll","background-type":"","background-media":"","overlay-type":"","overlay-color":"","overlay-opacity":"","overlay-gradient":""}},"_srfm_form_confirmation":[{"id":1,"confirmation_type":"same page","page_url":"","custom_url":"","message":"<p style=\"text-align: center\"><br><\/p><p style=\"text-align: center\"><br><\/p><p style=\"text-align: center\"><img src=\"data:image\/svg+xml;base64,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\" alt=\"\" aria-hidden=\"true\"><\/p><h2 style=\"text-align: center\">Thank you<\/h2><p style=\"text-align: center\">Your intake assessment form has been submitted successfully. We'll review your details and get back to you soon.<\/p>","submission_action":"hide form","enable_query_params":false,"query_params":[]}]},"class_list":["post-2376","sureforms_form","type-sureforms_form","status-publish","hentry"],"_links":{"self":[{"href":"https:\/\/freiheit.ca\/fr\/wp-json\/wp\/v2\/sureforms_form\/2376","targetHints":{"allow":["GET"]}}],"collection":[{"href":"https:\/\/freiheit.ca\/fr\/wp-json\/wp\/v2\/sureforms_form"}],"about":[{"href":"https:\/\/freiheit.ca\/fr\/wp-json\/wp\/v2\/types\/sureforms_form"}],"author":[{"embeddable":true,"href":"https:\/\/freiheit.ca\/fr\/wp-json\/wp\/v2\/users\/6"}],"wp:attachment":[{"href":"https:\/\/freiheit.ca\/fr\/wp-json\/wp\/v2\/media?parent=2376"}],"curies":[{"name":"wp","href":"https:\/\/api.w.org\/{rel}","templated":true}]}}