{"id":22015,"date":"2017-07-18T15:36:55","date_gmt":"2017-07-18T15:36:55","guid":{"rendered":"http:\/\/dev.scsottawa.on.ca\/?page_id=22015"},"modified":"2022-11-11T11:17:23","modified_gmt":"2022-11-11T16:17:23","slug":"registration-form","status":"publish","type":"page","link":"https:\/\/dev.scsonline.ca\/fr\/registration-form\/","title":{"rendered":"Inscription en ligne"},"content":{"rendered":"<div class='gf_browser_gecko gform_wrapper gravity-theme gform-theme--no-framework' data-form-theme='gravity-theme' data-form-index='0' id='gform_wrapper_4' style='display:none'>\n                        <div class='gform_heading'>\n                            <h2 class=\"gform_title\">GESTION DE CAS POUR ENFANTS \u2014 FORMULAIRE DE RENVOI<\/h2>\n                            <p class='gform_description'>Afin de vous inscrire aupr\u00e8s de Service Coordination Support (SCS) pour les personnes ayant une d\u00e9ficience intellectuelle, le travailleur charg\u00e9 de l\u2019accueil devra examiner les documents pertinents afin de confirmer votre admissibilit\u00e9 (ou celle du demandeur). En tant que point d\u2019acc\u00e8s central, nous offrons des renseignements et facilitons l\u2019acc\u00e8s aux services et aux soutiens pour les enfants et les jeunes (0 \u00e0 18 ans) de la r\u00e9gion d\u2019Ottawa ayant une d\u00e9ficience intellectuelle ou un trouble du spectre de l\u2019autisme (TSA). Afin de proc\u00e9der \u00e0 l\u2019inscription, nous avons besoin d\u2019une \u00e9valuation psychologique (ou tout autre document) confirmant le diagnostic d\u2019une d\u00e9ficience intellectuelle et\/ou d\u2019un TSA. De plus, nous aurons besoin de votre consentement pour recueillir, utiliser ou divulguer des renseignements dans le but de cr\u00e9er et tenir votre dossier.\r\n<\/br><\/br>\r\nSi vous avez de la difficult\u00e9 \u00e0 remplir le pr\u00e9sent formulaire, veuillez nous envoyer un courriel \u00e0 l\u2019adresse <a href=\"mailto:childrensintake@scsonline.ca\">childrensintake@scsonline.ca<\/a><\/p>\n\t\t\t\t\t\t\t<p class='gform_required_legend'><\/p>\n                        <\/div><form method='post' enctype='multipart\/form-data'  id='gform_4'  action=\"\/fr\/wp-json\/wp\/v2\/pages\/22015\" data-formid='4' novalidate>\n                        <div class='gform-body gform_body'><div id='gform_fields_4' class='gform_fields top_label form_sublabel_below description_below validation_below'><div id=\"field_4_129\" class=\"gfield gfield--type-honeypot gform_validation_container field_sublabel_below gfield--has-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_4_129'>Company<\/label><div class='ginput_container'><input name='input_129' id='input_4_129' type='text' value='' autocomplete='new-password'\/><\/div><div class='gfield_description' id='gfield_description_4_129'>Ce champ n\u2019est utilis\u00e9 qu\u2019\u00e0 des fins de validation et devrait rester inchang\u00e9.<\/div><\/div><div id=\"field_4_12\" class=\"gfield gfield--type-section gfield--input-type-section gsection field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><h3 class=\"gsection_title\">SECTION 1 \u2014 RENSEIGNEMENTS SUR LA SOURCE DU RENVOI<\/h3><\/div><div id=\"field_4_123\" class=\"gfield gfield--type-date gfield--input-type-date gfield--input-type-datepicker gfield--datepicker-no-icon gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_4_123'>1.1 - Date de r\u00e9f\u00e9rence<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_custom\">(Requis)<\/span><\/span><\/label><div class='ginput_container ginput_container_date'>\n                            <input name='input_123' id='input_4_123' type='text' value='' class='datepicker gform-datepicker dmy datepicker_no_icon gdatepicker-no-icon'   placeholder='jj\/mm\/aaaa' aria-describedby=\"input_4_123_date_format\" aria-invalid=\"false\" aria-required=\"true\"\/>\n                            <span id='input_4_123_date_format' class='screen-reader-text'>JJ slash MM slash AAAA<\/span>\n                        <\/div>\n                        <input type='hidden' id='gforms_calendar_icon_input_4_123' class='gform_hidden' value='https:\/\/dev.scsonline.ca\/wp-content\/plugins\/gravityforms\/images\/datepicker\/datepicker.svg'\/><\/div><div id=\"field_4_1\" class=\"gfield gfield--type-select gfield--input-type-select gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_4_1'>1.2 - Qui effectue le renvoi?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_custom\">(Requis)<\/span><\/span><\/label><div class='ginput_container ginput_container_select'><select name='input_1' id='input_4_1' class='large gfield_select'    aria-required=\"true\" aria-invalid=\"false\" ><option value='Famille' >Famille<\/option><option value='Ami' >Ami<\/option><option value='Acces direct (personne ayant un diagnostic)' >Acces direct (personne ayant un diagnostic)<\/option><option value='Organisme tiers' >Organisme tiers<\/option><\/select><\/div><\/div><div id=\"field_4_2\" class=\"gfield gfield--type-section gfield--input-type-section gsection field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><h3 class=\"gsection_title\"><\/h3><\/div><div id=\"field_4_3\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-half gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_4_3'>Nom:<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_custom\">(Requis)<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_3' id='input_4_3' type='text' value='' class='large'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_4_4\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-half field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_4_4'>Nom de l\u2019organisme:<\/label><div class='ginput_container ginput_container_text'><input name='input_4' id='input_4_4' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_4_5\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-half gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_4_5'>Num\u00e9ro de t\u00e9l\u00e9phone:<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_custom\">(Requis)<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_5' id='input_4_5' type='text' value='' class='large'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_4_6\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-half field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_4_6'>Courriel<\/label><div class='ginput_container ginput_container_text'><input name='input_6' id='input_4_6' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/div><fieldset id=\"field_4_7\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-half field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >Rempli avec les parents:<\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_4_7'>\n\t\t\t<div class='gchoice gchoice_4_7_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_7' type='radio' value='Oui'  id='choice_4_7_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_4_7_0' id='label_4_7_0' class='gform-field-label gform-field-label--type-inline'>Oui<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_4_7_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_7' type='radio' value='Non'  id='choice_4_7_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_4_7_1' id='label_4_7_1' class='gform-field-label gform-field-label--type-inline'>Non<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_4_8\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-half field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >Avez-vous le consentement de la personne pour la r\u00e9f\u00e9rence ?<\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_4_8'>\n\t\t\t<div class='gchoice gchoice_4_8_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_8' type='radio' value='Oui'  id='choice_4_8_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_4_8_0' id='label_4_8_0' class='gform-field-label gform-field-label--type-inline'>Oui<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_4_8_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_8' type='radio' value='Non'  id='choice_4_8_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_4_8_1' id='label_4_8_1' class='gform-field-label gform-field-label--type-inline'>Non<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_4_9\" class=\"gfield gfield--type-section gfield--input-type-section gsection field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><h3 class=\"gsection_title\"><\/h3><\/div><fieldset id=\"field_4_128\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield--input-type-checkbox gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' >1.3 Aide d&#039;un gestionnaire de cas<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_custom\">(Requis)<\/span><\/span><\/legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox ' id='input_4_128'><div class='gchoice gchoice_4_128_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_128.1' type='checkbox'  value='Je confirme que j&#039;aimerais m&#039;inscrire aupr\u00e8s de SCS et recevoir l&#039;aide d&#039;un gestionnaire de cas pour m&#039;aider \u00e0 identifier des buts et \u00e0 \u00e9laborer un plan.'  id='choice_4_128_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_4_128_1' id='label_4_128_1' class='gform-field-label gform-field-label--type-inline'>Je confirme que j'aimerais m'inscrire aupr\u00e8s de SCS et recevoir l'aide d'un gestionnaire de cas pour m'aider \u00e0 identifier des buts et \u00e0 \u00e9laborer un plan.<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_4_13\" class=\"gfield gfield--type-section gfield--input-type-section gsection field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><h3 class=\"gsection_title\">SECTION 2 \u2014 RENSEIGNEMENTS AU SUJET DE L\u2019ENFANT\/LE JEUNE:<\/h3><\/div><div id=\"field_4_24\" class=\"gfield gfield--type-section gfield--input-type-section gsection field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><h3 class=\"gsection_title\">2.1. RENSEIGNEMENTS DE BASE<\/h3><\/div><div id=\"field_4_14\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-half gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_4_14'>Pr\u00e9nom de l\u2019enfant:<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_custom\">(Requis)<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_14' id='input_4_14' type='text' value='' class='large'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_4_15\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-half gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_4_15'>Nom de famille:<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_custom\">(Requis)<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_15' id='input_4_15' type='text' value='' class='large'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_4_16\" class=\"gfield gfield--type-date gfield--input-type-date gfield--input-type-datepicker gfield--datepicker-no-icon gfield--width-half field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_4_16'>Date de naissance:<\/label><div class='ginput_container ginput_container_date'>\n                            <input name='input_16' id='input_4_16' type='text' value='' class='datepicker gform-datepicker mdy datepicker_no_icon gdatepicker-no-icon'   placeholder='mm\/jj\/aaaa' aria-describedby=\"input_4_16_date_format\" aria-invalid=\"false\" \/>\n                            <span id='input_4_16_date_format' class='screen-reader-text'>MM slash JJ slash AAAA<\/span>\n                        <\/div>\n                        <input type='hidden' id='gforms_calendar_icon_input_4_16' class='gform_hidden' value='https:\/\/dev.scsonline.ca\/wp-content\/plugins\/gravityforms\/images\/datepicker\/datepicker.svg'\/><\/div><div id=\"field_4_17\" class=\"gfield gfield--type-select gfield--input-type-select gfield--width-half field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_4_17'>Sexe:<\/label><div class='ginput_container ginput_container_select'><select name='input_17' id='input_4_17' class='large gfield_select'     aria-invalid=\"false\" ><option value='Gar\u00e7on' >Gar\u00e7on<\/option><option value='Fille' >Fille<\/option><\/select><\/div><\/div><div id=\"field_4_18\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-half field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_4_18'>Adresse:<\/label><div class='ginput_container ginput_container_text'><input name='input_18' id='input_4_18' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_4_19\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-half gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_4_19'>Num\u00e9ro de t\u00e9l\u00e9phone au domicile:<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_custom\">(Requis)<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_19' id='input_4_19' type='text' value='' class='large'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_4_124\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_4_124'>Code Postal<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_custom\">(Requis)<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_124' id='input_4_124' type='text' value='' class='large'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><fieldset id=\"field_4_20\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-half field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >Interpr\u00e8te requis:<\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_4_20'>\n\t\t\t<div class='gchoice gchoice_4_20_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_20' type='radio' value='Oui'  id='choice_4_20_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_4_20_0' id='label_4_20_0' class='gform-field-label gform-field-label--type-inline'>Oui<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_4_20_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_20' type='radio' value='Non'  id='choice_4_20_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_4_20_1' id='label_4_20_1' class='gform-field-label gform-field-label--type-inline'>Non<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_4_21\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-half field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_4_21'>Langue parl\u00e9e \u00e0 la maison:<\/label><div class='ginput_container ginput_container_text'><input name='input_21' id='input_4_21' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_4_22\" class=\"gfield gfield--type-select gfield--input-type-select gfield--width-half field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_4_22'>Langue pr\u00e9f\u00e9r\u00e9 pour les communications :<\/label><div class='ginput_container ginput_container_select'><select name='input_22' id='input_4_22' class='large gfield_select'     aria-invalid=\"false\" ><option value='Anglais' >Anglais<\/option><option value='Fran\u00e7ais' >Fran\u00e7ais<\/option><\/select><\/div><\/div><fieldset id=\"field_4_23\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield--input-type-checkbox gfield--width-half field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' >L\u2019enfant ou le jeune va accepter les services dans la langue suivante :<\/legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox ' id='input_4_23'><div class='gchoice gchoice_4_23_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_23.1' type='checkbox'  value='Anglais'  id='choice_4_23_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_4_23_1' id='label_4_23_1' class='gform-field-label gform-field-label--type-inline'>Anglais<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_4_23_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_23.2' type='checkbox'  value='Fran\u00e7ais'  id='choice_4_23_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_4_23_2' id='label_4_23_2' class='gform-field-label gform-field-label--type-inline'>Fran\u00e7ais<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_4_26\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield--input-type-checkbox gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' >2.2 - CET ENFANT\/CE JEUNE A UN DIAGNOSTIC CONFIRM\u00c9:<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_custom\">(Requis)<\/span><\/span><\/legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox ' id='input_4_26'><div class='gchoice gchoice_4_26_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_26.1' type='checkbox'  value='Autisme'  id='choice_4_26_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_4_26_1' id='label_4_26_1' class='gform-field-label gform-field-label--type-inline'>Autisme<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_4_26_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_26.2' type='checkbox'  value='D\u00e9ficience intellectuelle'  id='choice_4_26_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_4_26_2' id='label_4_26_2' class='gform-field-label gform-field-label--type-inline'>D\u00e9ficience intellectuelle<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_4_26_3'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_26.3' type='checkbox'  value='Autre diagnostic'  id='choice_4_26_3'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_4_26_3' id='label_4_26_3' class='gform-field-label gform-field-label--type-inline'>Autre diagnostic<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_4_26_4'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_26.4' type='checkbox'  value='Nouveau diagnostic'  id='choice_4_26_4'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_4_26_4' id='label_4_26_4' class='gform-field-label gform-field-label--type-inline'>Nouveau diagnostic<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_4_28\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-full field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_4_28'>D\u00e9tails, s\u2019il y a lieu (Autisme):<\/label><div class='ginput_container ginput_container_text'><input name='input_28' id='input_4_28' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/div><fieldset id=\"field_4_29\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield--input-type-checkbox gfield--width-full field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' >D\u00e9tails, s\u2019il y a lieu (D\u00e9ficience intellectuelle):<\/legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox ' id='input_4_29'><div class='gchoice gchoice_4_29_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_29.1' type='checkbox'  value='Syndrome d&#039;Angelman'  id='choice_4_29_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_4_29_1' id='label_4_29_1' class='gform-field-label gform-field-label--type-inline'>Syndrome d'Angelman<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_4_29_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_29.2' type='checkbox'  value='DD (L\u00e9ger 317)'  id='choice_4_29_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_4_29_2' id='label_4_29_2' class='gform-field-label gform-field-label--type-inline'>DD (L\u00e9ger 317)<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_4_29_3'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_29.3' type='checkbox'  value='DD (Mod\u00e9r\u00e9 318.0)'  id='choice_4_29_3'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_4_29_3' id='label_4_29_3' class='gform-field-label gform-field-label--type-inline'>DD (Mod\u00e9r\u00e9 318.0)<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_4_29_4'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_29.4' type='checkbox'  value='DD (S\u00e9v\u00e8re 318.1)'  id='choice_4_29_4'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_4_29_4' id='label_4_29_4' class='gform-field-label gform-field-label--type-inline'>DD (S\u00e9v\u00e8re 318.1)<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_4_29_5'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_29.5' type='checkbox'  value='DD (Profonde 318.2)'  id='choice_4_29_5'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_4_29_5' id='label_4_29_5' class='gform-field-label gform-field-label--type-inline'>DD (Profonde 318.2)<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_4_29_6'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_29.6' type='checkbox'  value='DD (Gravit\u00e9 non sp\u00e9cifi\u00e9e 319)'  id='choice_4_29_6'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_4_29_6' id='label_4_29_6' class='gform-field-label gform-field-label--type-inline'>DD (Gravit\u00e9 non sp\u00e9cifi\u00e9e 319)<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_4_29_7'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_29.7' type='checkbox'  value='DD (Gravit\u00e9 non sp\u00e9cifi\u00e9e)'  id='choice_4_29_7'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_4_29_7' id='label_4_29_7' class='gform-field-label gform-field-label--type-inline'>DD (Gravit\u00e9 non sp\u00e9cifi\u00e9e)<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_4_29_8'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_29.8' type='checkbox'  value='Syndrome de Down'  id='choice_4_29_8'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_4_29_8' id='label_4_29_8' class='gform-field-label gform-field-label--type-inline'>Syndrome de Down<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_4_29_9'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_29.9' type='checkbox'  value='Syndrome de l&#039;X fragile'  id='choice_4_29_9'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_4_29_9' id='label_4_29_9' class='gform-field-label gform-field-label--type-inline'>Syndrome de l'X fragile<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_4_29_11'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_29.11' type='checkbox'  value='Retard global de d\u00e9veloppement (RGD)'  id='choice_4_29_11'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_4_29_11' id='label_4_29_11' class='gform-field-label gform-field-label--type-inline'>Retard global de d\u00e9veloppement (RGD)<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_4_29_12'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_29.12' type='checkbox'  value='Syndrome de Prader-Willi (SPW)'  id='choice_4_29_12'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_4_29_12' id='label_4_29_12' class='gform-field-label gform-field-label--type-inline'>Syndrome de Prader-Willi (SPW)<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_4_29_13'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_29.13' type='checkbox'  value='Trisomie 21'  id='choice_4_29_13'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_4_29_13' id='label_4_29_13' class='gform-field-label gform-field-label--type-inline'>Trisomie 21<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_4_29_14'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_29.14' type='checkbox'  value='Syndrome de Williams'  id='choice_4_29_14'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_4_29_14' id='label_4_29_14' class='gform-field-label gform-field-label--type-inline'>Syndrome de Williams<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_4_30\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-full field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_4_30'>D\u00e9tails, s\u2019il y a lieu (Autre diagnostic):<\/label><div class='ginput_container ginput_container_text'><input name='input_30' id='input_4_30' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/div><fieldset id=\"field_4_31\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield--input-type-checkbox gfield--width-full field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' >D\u00e9tails, s\u2019il y a lieu (Nouveau diagnostic):<\/legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox ' id='input_4_31'><div class='gchoice gchoice_4_31_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_31.1' type='checkbox'  value='D\u00e9ficience intellectuelle'  id='choice_4_31_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_4_31_1' id='label_4_31_1' class='gform-field-label gform-field-label--type-inline'>D\u00e9ficience intellectuelle<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_4_31_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_31.2' type='checkbox'  value='Trouble du Spectre de l\u2019autisme'  id='choice_4_31_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_4_31_2' id='label_4_31_2' class='gform-field-label gform-field-label--type-inline'>Trouble du Spectre de l\u2019autisme<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_4_33\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield--input-type-checkbox gfield--width-full field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' >2.3 - DE QUELLE FA\u00c7ON L\u2019ENFANT\/LE JEUNE COMMUNIQUE-T-IL (cocher toutes les r\u00e9ponses qui s\u2019appliquent):<\/legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox ' id='input_4_33'><div class='gchoice gchoice_4_33_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_33.1' type='checkbox'  value='Phrases compl\u00e8tes'  id='choice_4_33_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_4_33_1' id='label_4_33_1' class='gform-field-label gform-field-label--type-inline'>Phrases compl\u00e8tes<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_4_33_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_33.2' type='checkbox'  value='Certains mots'  id='choice_4_33_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_4_33_2' id='label_4_33_2' class='gform-field-label gform-field-label--type-inline'>Certains mots<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_4_33_3'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_33.3' type='checkbox'  value='Gestes'  id='choice_4_33_3'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_4_33_3' id='label_4_33_3' class='gform-field-label gform-field-label--type-inline'>Gestes<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_4_33_4'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_33.4' type='checkbox'  value='Communication augment\u00e9e'  id='choice_4_33_4'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_4_33_4' id='label_4_33_4' class='gform-field-label gform-field-label--type-inline'>Communication augment\u00e9e<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_4_33_5'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_33.5' type='checkbox'  value='Langage gestuel'  id='choice_4_33_5'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_4_33_5' id='label_4_33_5' class='gform-field-label gform-field-label--type-inline'>Langage gestuel<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_4_33_6'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_33.6' type='checkbox'  value='Non verbal'  id='choice_4_33_6'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_4_33_6' id='label_4_33_6' class='gform-field-label gform-field-label--type-inline'>Non verbal<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_4_33_7'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_33.7' type='checkbox'  value='Syst\u00e8me de communication par \u00e9changes d\u2019images (PECS)'  id='choice_4_33_7'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_4_33_7' id='label_4_33_7' class='gform-field-label gform-field-label--type-inline'>Syst\u00e8me de communication par \u00e9changes d\u2019images (PECS)<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_4_33_8'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_33.8' type='checkbox'  value='Vocalise'  id='choice_4_33_8'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_4_33_8' id='label_4_33_8' class='gform-field-label gform-field-label--type-inline'>Vocalise<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_4_33_9'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_33.9' type='checkbox'  value='Autre'  id='choice_4_33_9'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_4_33_9' id='label_4_33_9' class='gform-field-label gform-field-label--type-inline'>Autre<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_4_34\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-full field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_4_34'>Autre<\/label><div class='ginput_container ginput_container_text'><input name='input_34' id='input_4_34' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_4_35\" class=\"gfield gfield--type-section gfield--input-type-section gsection field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><h3 class=\"gsection_title\">2.4 - ENSEIGNEMENTS AU SUJET DE LA SANT\u00c9, DU BIEN-\u00caTRE ET DE LA S\u00c9CURIT\u00c9 DE L\u2019ENFANT\/DU JEUNE<\/h3><\/div><fieldset id=\"field_4_36\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield--input-type-checkbox gfield--width-full field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Cochez toutes les cases qui s&#039;appliquent<\/legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox ' id='input_4_36'><div class='gchoice gchoice_4_36_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_36.1' type='checkbox'  value='Inqui\u00e9tudes au sujet du comportement'  id='choice_4_36_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_4_36_1' id='label_4_36_1' class='gform-field-label gform-field-label--type-inline'>Inqui\u00e9tudes au sujet du comportement<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_4_36_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_36.2' type='checkbox'  value='Sant\u00e9 m\u00e9dicale'  id='choice_4_36_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_4_36_2' id='label_4_36_2' class='gform-field-label gform-field-label--type-inline'>Sant\u00e9 m\u00e9dicale<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_4_36_3'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_36.3' type='checkbox'  value='Sant\u00e9 mentale'  id='choice_4_36_3'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_4_36_3' id='label_4_36_3' class='gform-field-label gform-field-label--type-inline'>Sant\u00e9 mentale<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_4_36_4'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_36.4' type='checkbox'  value='Sant\u00e9 physique'  id='choice_4_36_4'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_4_36_4' id='label_4_36_4' class='gform-field-label gform-field-label--type-inline'>Sant\u00e9 physique<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_4_37\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield--input-type-checkbox gfield--width-half field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Risque de blessures<\/legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox ' id='input_4_37'><div class='gchoice gchoice_4_37_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_37.1' type='checkbox'  value='\u00c0 soi-m\u00eame'  id='choice_4_37_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_4_37_1' id='label_4_37_1' class='gform-field-label gform-field-label--type-inline'>\u00c0 soi-m\u00eame<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_4_37_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_37.2' type='checkbox'  value='Aux autres'  id='choice_4_37_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_4_37_2' id='label_4_37_2' class='gform-field-label gform-field-label--type-inline'>Aux autres<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_4_38\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-half field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_4_38'>Commentaires sur les probl\u00e8mes de comportement<\/label><div class='ginput_container ginput_container_text'><input name='input_38' id='input_4_38' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/div><fieldset id=\"field_4_39\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield--input-type-checkbox gfield--width-half field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Sp\u00e9cifiez les troubles m\u00e9dicaux<\/legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox ' id='input_4_39'><div class='gchoice gchoice_4_39_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_39.1' type='checkbox'  value='SIDA\/VIH'  id='choice_4_39_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_4_39_1' id='label_4_39_1' class='gform-field-label gform-field-label--type-inline'>SIDA\/VIH<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_4_39_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_39.2' type='checkbox'  value='Allergies'  id='choice_4_39_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_4_39_2' id='label_4_39_2' class='gform-field-label gform-field-label--type-inline'>Allergies<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_4_39_3'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_39.3' type='checkbox'  value='Cancer'  id='choice_4_39_3'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_4_39_3' id='label_4_39_3' class='gform-field-label gform-field-label--type-inline'>Cancer<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_4_39_4'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_39.4' type='checkbox'  value='Cardiaque'  id='choice_4_39_4'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_4_39_4' id='label_4_39_4' class='gform-field-label gform-field-label--type-inline'>Cardiaque<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_4_39_5'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_39.5' type='checkbox'  value='Diab\u00e8te'  id='choice_4_39_5'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_4_39_5' id='label_4_39_5' class='gform-field-label gform-field-label--type-inline'>Diab\u00e8te<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_4_39_6'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_39.6' type='checkbox'  value='\u00c9pilepsie'  id='choice_4_39_6'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_4_39_6' id='label_4_39_6' class='gform-field-label gform-field-label--type-inline'>\u00c9pilepsie<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_4_39_7'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_39.7' type='checkbox'  value='Respiratoire'  id='choice_4_39_7'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_4_39_7' id='label_4_39_7' class='gform-field-label gform-field-label--type-inline'>Respiratoire<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_4_39_8'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_39.8' type='checkbox'  value='Trouble \u00e9pileptique'  id='choice_4_39_8'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_4_39_8' id='label_4_39_8' class='gform-field-label gform-field-label--type-inline'>Trouble \u00e9pileptique<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_4_39_9'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_39.9' type='checkbox'  value='Hospitalisations fr\u00e9quentes'  id='choice_4_39_9'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_4_39_9' id='label_4_39_9' class='gform-field-label gform-field-label--type-inline'>Hospitalisations fr\u00e9quentes<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_4_39_11'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_39.11' type='checkbox'  value='Autre'  id='choice_4_39_11'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_4_39_11' id='label_4_39_11' class='gform-field-label gform-field-label--type-inline'>Autre<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_4_40\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-half field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_4_40'>Commentaires sur la sant\u00e9 m\u00e9dicale<\/label><div class='ginput_container ginput_container_text'><input name='input_40' id='input_4_40' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/div><fieldset id=\"field_4_41\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield--input-type-checkbox gfield--width-half field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Sp\u00e9cifiez les troubles de sant\u00e9 mentale:<\/legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox ' id='input_4_41'><div class='gchoice gchoice_4_41_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_41.1' type='checkbox'  value='TDA (Trouble du d\u00e9ficit de l&#039;attention)'  id='choice_4_41_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_4_41_1' id='label_4_41_1' class='gform-field-label gform-field-label--type-inline'>TDA (Trouble du d\u00e9ficit de l'attention)<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_4_41_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_41.2' type='checkbox'  value='TDAH (Trouble de d\u00e9ficit de l&#039;attention avec hyperactivit\u00e9)'  id='choice_4_41_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_4_41_2' id='label_4_41_2' class='gform-field-label gform-field-label--type-inline'>TDAH (Trouble de d\u00e9ficit de l'attention avec hyperactivit\u00e9)<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_4_41_3'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_41.3' type='checkbox'  value='Anxi\u00e9t\u00e9'  id='choice_4_41_3'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_4_41_3' id='label_4_41_3' class='gform-field-label gform-field-label--type-inline'>Anxi\u00e9t\u00e9<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_4_41_4'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_41.4' type='checkbox'  value='Trouble bipolaire'  id='choice_4_41_4'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_4_41_4' id='label_4_41_4' class='gform-field-label gform-field-label--type-inline'>Trouble bipolaire<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_4_41_5'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_41.5' type='checkbox'  value='Trouble d&#039;anxi\u00e9t\u00e9 g\u00e9n\u00e9ralis\u00e9e (TAG)'  id='choice_4_41_5'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_4_41_5' id='label_4_41_5' class='gform-field-label gform-field-label--type-inline'>Trouble d'anxi\u00e9t\u00e9 g\u00e9n\u00e9ralis\u00e9e (TAG)<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_4_41_6'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_41.6' type='checkbox'  value='Trouble d\u00e9pressif majeur'  id='choice_4_41_6'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_4_41_6' id='label_4_41_6' class='gform-field-label gform-field-label--type-inline'>Trouble d\u00e9pressif majeur<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_4_41_7'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_41.7' type='checkbox'  value='Troubles de l&#039;humeur'  id='choice_4_41_7'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_4_41_7' id='label_4_41_7' class='gform-field-label gform-field-label--type-inline'>Troubles de l'humeur<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_4_41_8'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_41.8' type='checkbox'  value='Trouble oppositionnel avec provocation'  id='choice_4_41_8'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_4_41_8' id='label_4_41_8' class='gform-field-label gform-field-label--type-inline'>Trouble oppositionnel avec provocation<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_4_41_9'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_41.9' type='checkbox'  value='Trouble obsessionnel-compulsif (OCD)'  id='choice_4_41_9'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_4_41_9' id='label_4_41_9' class='gform-field-label gform-field-label--type-inline'>Trouble obsessionnel-compulsif (OCD)<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_4_41_11'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_41.11' type='checkbox'  value='Trouble de la personnalit\u00e9 obsessionnelle compulsive'  id='choice_4_41_11'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_4_41_11' id='label_4_41_11' class='gform-field-label gform-field-label--type-inline'>Trouble de la personnalit\u00e9 obsessionnelle compulsive<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_4_41_12'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_41.12' type='checkbox'  value='Comportements sexualis\u00e9s'  id='choice_4_41_12'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_4_41_12' id='label_4_41_12' class='gform-field-label gform-field-label--type-inline'>Comportements sexualis\u00e9s<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_4_41_13'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_41.13' type='checkbox'  value='Trouble de la personnalit\u00e9 (NSA)'  id='choice_4_41_13'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_4_41_13' id='label_4_41_13' class='gform-field-label gform-field-label--type-inline'>Trouble de la personnalit\u00e9 (NSA)<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_4_41_14'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_41.14' type='checkbox'  value='Pica'  id='choice_4_41_14'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_4_41_14' id='label_4_41_14' class='gform-field-label gform-field-label--type-inline'>Pica<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_4_41_15'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_41.15' type='checkbox'  value='Trouble de stress post-traumatique'  id='choice_4_41_15'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_4_41_15' id='label_4_41_15' class='gform-field-label gform-field-label--type-inline'>Trouble de stress post-traumatique<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_4_41_16'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_41.16' type='checkbox'  value='Trouble psychotique'  id='choice_4_41_16'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_4_41_16' id='label_4_41_16' class='gform-field-label gform-field-label--type-inline'>Trouble psychotique<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_4_41_17'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_41.17' type='checkbox'  value='Trouble schizo-affectif'  id='choice_4_41_17'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_4_41_17' id='label_4_41_17' class='gform-field-label gform-field-label--type-inline'>Trouble schizo-affectif<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_4_41_18'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_41.18' type='checkbox'  value='Schizophr\u00e9nie'  id='choice_4_41_18'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_4_41_18' id='label_4_41_18' class='gform-field-label gform-field-label--type-inline'>Schizophr\u00e9nie<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_4_41_19'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_41.19' type='checkbox'  value='Syndrome de la Tourette'  id='choice_4_41_19'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_4_41_19' id='label_4_41_19' class='gform-field-label gform-field-label--type-inline'>Syndrome de la Tourette<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_4_41_21'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_41.21' type='checkbox'  value='Autre'  id='choice_4_41_21'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_4_41_21' id='label_4_41_21' class='gform-field-label gform-field-label--type-inline'>Autre<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_4_42\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-half field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_4_42'>Commentaires concernant la sant\u00e9 mentale<\/label><div class='ginput_container ginput_container_text'><input name='input_42' id='input_4_42' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/div><fieldset id=\"field_4_43\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield--input-type-checkbox gfield--width-half field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Sp\u00e9cifiez les troubles de sant\u00e9 physique:<\/legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox ' id='input_4_43'><div class='gchoice gchoice_4_43_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_43.1' type='checkbox'  value='Aveugle\/malvoyant'  id='choice_4_43_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_4_43_1' id='label_4_43_1' class='gform-field-label gform-field-label--type-inline'>Aveugle\/malvoyant<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_4_43_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_43.2' type='checkbox'  value='Paralysie c\u00e9r\u00e9brale'  id='choice_4_43_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_4_43_2' id='label_4_43_2' class='gform-field-label gform-field-label--type-inline'>Paralysie c\u00e9r\u00e9brale<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_4_43_3'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_43.3' type='checkbox'  value='Troubles du spectre de l&#039;alcoolisation f\u0153tale'  id='choice_4_43_3'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_4_43_3' id='label_4_43_3' class='gform-field-label gform-field-label--type-inline'>Troubles du spectre de l'alcoolisation f\u0153tale<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_4_43_4'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_43.4' type='checkbox'  value='Traumatisme cr\u00e2nien \/ L\u00e9sions c\u00e9r\u00e9brales acquises (LCA)'  id='choice_4_43_4'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_4_43_4' id='label_4_43_4' class='gform-field-label gform-field-label--type-inline'>Traumatisme cr\u00e2nien \/ L\u00e9sions c\u00e9r\u00e9brales acquises (LCA)<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_4_43_5'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_43.5' type='checkbox'  value='D\u00e9ficience auditive'  id='choice_4_43_5'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_4_43_5' id='label_4_43_5' class='gform-field-label gform-field-label--type-inline'>D\u00e9ficience auditive<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_4_43_6'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_43.6' type='checkbox'  value='Hydroc\u00e9phalie'  id='choice_4_43_6'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_4_43_6' id='label_4_43_6' class='gform-field-label gform-field-label--type-inline'>Hydroc\u00e9phalie<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_4_43_7'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_43.7' type='checkbox'  value='Dystrophie myotonique'  id='choice_4_43_7'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_4_43_7' id='label_4_43_7' class='gform-field-label gform-field-label--type-inline'>Dystrophie myotonique<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_4_43_8'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_43.8' type='checkbox'  value='Parapl\u00e9gique'  id='choice_4_43_8'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_4_43_8' id='label_4_43_8' class='gform-field-label gform-field-label--type-inline'>Parapl\u00e9gique<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_4_43_9'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_43.9' type='checkbox'  value='Quadrapl\u00e9gique'  id='choice_4_43_9'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_4_43_9' id='label_4_43_9' class='gform-field-label gform-field-label--type-inline'>Quadrapl\u00e9gique<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_4_43_11'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_43.11' type='checkbox'  value='Retard dans le d\u00e9veloppement du langage'  id='choice_4_43_11'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_4_43_11' id='label_4_43_11' class='gform-field-label gform-field-label--type-inline'>Retard dans le d\u00e9veloppement du langage<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_4_43_12'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_43.12' type='checkbox'  value='Spina-bifida'  id='choice_4_43_12'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_4_43_12' id='label_4_43_12' class='gform-field-label gform-field-label--type-inline'>Spina-bifida<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_4_43_13'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_43.13' type='checkbox'  value='Scl\u00e9rose tub\u00e9reuse'  id='choice_4_43_13'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_4_43_13' id='label_4_43_13' class='gform-field-label gform-field-label--type-inline'>Scl\u00e9rose tub\u00e9reuse<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_4_43_14'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_43.14' type='checkbox'  value='Autre'  id='choice_4_43_14'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_4_43_14' id='label_4_43_14' class='gform-field-label gform-field-label--type-inline'>Autre<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_4_44\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-half field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_4_44'>Commentaires concernant la sant\u00e9 physique.<\/label><div class='ginput_container ginput_container_text'><input name='input_44' id='input_4_44' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/div><fieldset id=\"field_4_45\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-half field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >Intervention de la police \/ \u00c0 risque avec le syst\u00e8me judiciaire?<\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_4_45'>\n\t\t\t<div class='gchoice gchoice_4_45_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_45' type='radio' value='Oui'  id='choice_4_45_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_4_45_0' id='label_4_45_0' class='gform-field-label gform-field-label--type-inline'>Oui<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_4_45_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_45' type='radio' value='Non'  id='choice_4_45_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_4_45_1' id='label_4_45_1' class='gform-field-label gform-field-label--type-inline'>Non<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_4_46\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-half field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_4_46'>Renseignements additionels:<\/label><div class='ginput_container ginput_container_text'><input name='input_46' id='input_4_46' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_4_47\" class=\"gfield gfield--type-section gfield--input-type-section gsection field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><h3 class=\"gsection_title\">2.5 - RENSEIGNEMENTS AU SUJET DE L\u2019\u00c9DUCATION\/DE L\u2019\u00c9COLE DE L\u2019ENFANT\/DU JEUNE<\/h3><\/div><div id=\"field_4_48\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-half field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_4_48'>Nom de la garderie\/l\u2019\u00e9cole:<\/label><div class='ginput_container ginput_container_text'><input name='input_48' id='input_4_48' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/div><fieldset id=\"field_4_49\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-half field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >Ann\u00e9e (s\u2019il y a lieu):<\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_4_49'>\n\t\t\t<div class='gchoice gchoice_4_49_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_49' type='radio' value='Pr\u00e9scolaire (maternelle et jardin d\u2019enfants)'  id='choice_4_49_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_4_49_0' id='label_4_49_0' class='gform-field-label gform-field-label--type-inline'>Pr\u00e9scolaire (maternelle et jardin d\u2019enfants)<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_4_49_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_49' type='radio' value='Cycle primaire (1\u00e8re \u00e0 la 3i\u00e8me ann\u00e9e)'  id='choice_4_49_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_4_49_1' id='label_4_49_1' class='gform-field-label gform-field-label--type-inline'>Cycle primaire (1\u00e8re \u00e0 la 3i\u00e8me ann\u00e9e)<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_4_49_2'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_49' type='radio' value='Cycle moyen (4\u00e8me \u00e0 la 6\u00e8me ann\u00e9e)'  id='choice_4_49_2' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_4_49_2' id='label_4_49_2' class='gform-field-label gform-field-label--type-inline'>Cycle moyen (4\u00e8me \u00e0 la 6\u00e8me ann\u00e9e)<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_4_49_3'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_49' type='radio' value='Cycle interm\u00e9diaire (7\u00e8me et 8\u00e8me ann\u00e9e)'  id='choice_4_49_3' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_4_49_3' id='label_4_49_3' class='gform-field-label gform-field-label--type-inline'>Cycle interm\u00e9diaire (7\u00e8me et 8\u00e8me ann\u00e9e)<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_4_49_4'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_49' type='radio' value='Cycle sup\u00e9rieur\/secondaire (9\u00e8me \u00e0 la 12\u00e8me ann\u00e9e)'  id='choice_4_49_4' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_4_49_4' id='label_4_49_4' class='gform-field-label gform-field-label--type-inline'>Cycle sup\u00e9rieur\/secondaire (9\u00e8me \u00e0 la 12\u00e8me ann\u00e9e)<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_4_50\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-half field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >L\u2019individu est un jeune de 14 \u00e0 18 ans:<\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_4_50'>\n\t\t\t<div class='gchoice gchoice_4_50_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_50' type='radio' value='Oui'  id='choice_4_50_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_4_50_0' id='label_4_50_0' class='gform-field-label gform-field-label--type-inline'>Oui<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_4_50_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_50' type='radio' value='Non'  id='choice_4_50_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_4_50_1' id='label_4_50_1' class='gform-field-label gform-field-label--type-inline'>Non<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_4_50_2'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_50' type='radio' value='Je ne sais pas'  id='choice_4_50_2' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_4_50_2' id='label_4_50_2' class='gform-field-label gform-field-label--type-inline'>Je ne sais pas<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_4_50_3'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_50' type='radio' value='Non applicable'  id='choice_4_50_3' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_4_50_3' id='label_4_50_3' class='gform-field-label gform-field-label--type-inline'>Non applicable<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_4_51\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield--input-type-checkbox gfield--width-half field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Programme scolaire :<\/legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox ' id='input_4_51'><div class='gchoice gchoice_4_51_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_51.1' type='checkbox'  value='\u00e0 temps plein'  id='choice_4_51_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_4_51_1' id='label_4_51_1' class='gform-field-label gform-field-label--type-inline'>\u00e0 temps plein<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_4_51_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_51.2' type='checkbox'  value='\u00e0 temps partiel'  id='choice_4_51_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_4_51_2' id='label_4_51_2' class='gform-field-label gform-field-label--type-inline'>\u00e0 temps partiel<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_4_51_3'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_51.3' type='checkbox'  value='integr\u00e9'  id='choice_4_51_3'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_4_51_3' id='label_4_51_3' class='gform-field-label gform-field-label--type-inline'>integr\u00e9<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_4_51_4'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_51.4' type='checkbox'  value='programme de besoins sp\u00e9ciaux'  id='choice_4_51_4'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_4_51_4' id='label_4_51_4' class='gform-field-label gform-field-label--type-inline'>programme de besoins sp\u00e9ciaux<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_4_51_5'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_51.5' type='checkbox'  value='programmes TSA (Autisme)'  id='choice_4_51_5'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_4_51_5' id='label_4_51_5' class='gform-field-label gform-field-label--type-inline'>programmes TSA (Autisme)<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_4_51_6'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_51.6' type='checkbox'  value='autre:'  id='choice_4_51_6'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_4_51_6' id='label_4_51_6' class='gform-field-label gform-field-label--type-inline'>autre:<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_4_52\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-full field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_4_52'>Autre:<\/label><div class='ginput_container ginput_container_text'><input name='input_52' id='input_4_52' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/div><fieldset id=\"field_4_53\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-full field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >Niveau de soutien:<\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_4_53'>\n\t\t\t<div class='gchoice gchoice_4_53_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_53' type='radio' value='Autonome'  id='choice_4_53_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_4_53_0' id='label_4_53_0' class='gform-field-label gform-field-label--type-inline'>Autonome<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_4_53_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_53' type='radio' value='A besoin de soutien'  id='choice_4_53_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_4_53_1' id='label_4_53_1' class='gform-field-label gform-field-label--type-inline'>A besoin de soutien<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_4_53_2'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_53' type='radio' value='Programme modifi\u00e9'  id='choice_4_53_2' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_4_53_2' id='label_4_53_2' class='gform-field-label gform-field-label--type-inline'>Programme modifi\u00e9<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_4_53_3'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_53' type='radio' value='Classe-ressource'  id='choice_4_53_3' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_4_53_3' id='label_4_53_3' class='gform-field-label gform-field-label--type-inline'>Classe-ressource<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_4_53_4'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_53' type='radio' value='Autre'  id='choice_4_53_4' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_4_53_4' id='label_4_53_4' class='gform-field-label gform-field-label--type-inline'>Autre<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_4_54\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-full field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_4_54'>Autre<\/label><div class='ginput_container ginput_container_text'><input name='input_54' id='input_4_54' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/div><fieldset id=\"field_4_55\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield--input-type-checkbox gfield--width-half field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' >L\u2019enfant\/le jeune fait-il face \u00e0 des d\u00e9fis \u00e0 l\u2019\u00e9cole?<\/legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox ' id='input_4_55'><div class='gchoice gchoice_4_55_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_55.1' type='checkbox'  value='Suspensions'  id='choice_4_55_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_4_55_1' id='label_4_55_1' class='gform-field-label gform-field-label--type-inline'>Suspensions<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_4_55_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_55.2' type='checkbox'  value='Expulsions'  id='choice_4_55_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_4_55_2' id='label_4_55_2' class='gform-field-label gform-field-label--type-inline'>Expulsions<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_4_55_3'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_55.3' type='checkbox'  value='Registre des absences de l\u2019enfant\/du jeune'  id='choice_4_55_3'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_4_55_3' id='label_4_55_3' class='gform-field-label gform-field-label--type-inline'>Registre des absences de l\u2019enfant\/du jeune<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_4_56\" class=\"gfield gfield--type-textarea gfield--input-type-textarea gfield--width-half field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_4_56'>Commentaires concernant l\u2019\u00e9ducation (veuillez expliquer):<\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_56' id='input_4_56' class='textarea large'      aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/div><div id=\"field_4_57\" class=\"gfield gfield--type-section gfield--input-type-section gsection field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><h3 class=\"gsection_title\">SECTION 3 \u2014 RENSEIGNEMENTS AU SUJET DU PARENT\/FOURNISSEUR DE SOINS DE L\u2019ENFANT<\/h3><\/div><div id=\"field_4_58\" class=\"gfield gfield--type-section gfield--input-type-section gsection field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><h3 class=\"gsection_title\">3.1 - Personne-ressource primaire<\/h3><\/div><div id=\"field_4_59\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-full field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_4_59'>Lien avec l\u2019enfant:<\/label><div class='ginput_container ginput_container_text'><input name='input_59' id='input_4_59' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_4_60\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-half gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_4_60'>Pr\u00e9nom:<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_custom\">(Requis)<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_60' id='input_4_60' type='text' value='' class='large'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_4_61\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-half gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_4_61'>Nom de famille:<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_custom\">(Requis)<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_61' id='input_4_61' type='text' value='' class='large'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_4_62\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-half gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_4_62'>Adresse : (si elle est diff\u00e9rente de l\u2019adresse indiqu\u00e9e ci-dessus)<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_custom\">(Requis)<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_62' id='input_4_62' type='text' value='identique \u00e0 ci-dessus' class='large'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_4_63\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-half gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_4_63'>Code postal:<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_custom\">(Requis)<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_63' id='input_4_63' type='text' value='' class='large'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><fieldset id=\"field_4_64\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >S\u00e9lectionnez le moyen de communication pr\u00e9f\u00e9r\u00e9:<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_custom\">(Requis)<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_4_64'>\n\t\t\t<div class='gchoice gchoice_4_64_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_64' type='radio' value='T\u00e9l\u00e9phone \u00e0 domicile'  id='choice_4_64_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_4_64_0' id='label_4_64_0' class='gform-field-label gform-field-label--type-inline'>T\u00e9l\u00e9phone \u00e0 domicile<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_4_64_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_64' type='radio' value='Courriel'  id='choice_4_64_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_4_64_1' id='label_4_64_1' class='gform-field-label gform-field-label--type-inline'>Courriel<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_4_64_2'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_64' type='radio' value='T\u00e9l\u00e9phone au travail'  id='choice_4_64_2' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_4_64_2' id='label_4_64_2' class='gform-field-label gform-field-label--type-inline'>T\u00e9l\u00e9phone au travail<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_4_64_3'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_64' type='radio' value='Cellulaire'  id='choice_4_64_3' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_4_64_3' id='label_4_64_3' class='gform-field-label gform-field-label--type-inline'>Cellulaire<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_4_64_4'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_64' type='radio' value='Autre'  id='choice_4_64_4' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_4_64_4' id='label_4_64_4' class='gform-field-label gform-field-label--type-inline'>Autre<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_4_66\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_4_66'>T\u00e9l\u00e9phone \u00e0 domicile:<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_custom\">(Requis)<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_66' id='input_4_66' type='text' value='' class='large'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_4_67\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_4_67'>Courriel<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_custom\">(Requis)<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_67' id='input_4_67' type='text' value='' class='large'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_4_68\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_4_68'>T\u00e9l\u00e9phone au travail<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_custom\">(Requis)<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_68' id='input_4_68' type='text' value='' class='large'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_4_69\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_4_69'>Cellulaire:<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_custom\">(Requis)<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_69' id='input_4_69' type='text' value='' class='large'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_4_70\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_4_70'>Veuillez expliquer:<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_custom\">(Requis)<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_70' id='input_4_70' type='text' value='' class='large'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><fieldset id=\"field_4_71\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-half field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >Est-ce que vous \u00eates la personne avec qui nous devons communiquer?<\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_4_71'>\n\t\t\t<div class='gchoice gchoice_4_71_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_71' type='radio' value='Oui'  id='choice_4_71_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_4_71_0' id='label_4_71_0' class='gform-field-label gform-field-label--type-inline'>Oui<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_4_71_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_71' type='radio' value='Non'  id='choice_4_71_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_4_71_1' id='label_4_71_1' class='gform-field-label gform-field-label--type-inline'>Non<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_4_72\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield--input-type-checkbox gfield--width-half field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Facteurs de risque pour le parent\/personne-ressource<\/legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox ' id='input_4_72'><div class='gchoice gchoice_4_72_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_72.1' type='checkbox'  value='Proche aidant vieillissant'  id='choice_4_72_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_4_72_1' id='label_4_72_1' class='gform-field-label gform-field-label--type-inline'>Proche aidant vieillissant<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_4_72_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_72.2' type='checkbox'  value='\u00c9tat de sant\u00e9'  id='choice_4_72_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_4_72_2' id='label_4_72_2' class='gform-field-label gform-field-label--type-inline'>\u00c9tat de sant\u00e9<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_4_72_3'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_72.3' type='checkbox'  value='Probl\u00e8mes de sant\u00e9 mentale'  id='choice_4_72_3'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_4_72_3' id='label_4_72_3' class='gform-field-label gform-field-label--type-inline'>Probl\u00e8mes de sant\u00e9 mentale<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_4_72_4'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_72.4' type='checkbox'  value='Diagnostic de d\u00e9ficience intellectuelle'  id='choice_4_72_4'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_4_72_4' id='label_4_72_4' class='gform-field-label gform-field-label--type-inline'>Diagnostic de d\u00e9ficience intellectuelle<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_4_72_5'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_72.5' type='checkbox'  value='Barri\u00e8re linguistique'  id='choice_4_72_5'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_4_72_5' id='label_4_72_5' class='gform-field-label gform-field-label--type-inline'>Barri\u00e8re linguistique<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_4_72_6'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_72.6' type='checkbox'  value='Parent seul'  id='choice_4_72_6'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_4_72_6' id='label_4_72_6' class='gform-field-label gform-field-label--type-inline'>Parent seul<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_4_73\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-full field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >Y a-t-il une personne-ressource secondaire:<\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_4_73'>\n\t\t\t<div class='gchoice gchoice_4_73_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_73' type='radio' value='Oui'  id='choice_4_73_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_4_73_0' id='label_4_73_0' class='gform-field-label gform-field-label--type-inline'>Oui<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_4_73_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_73' type='radio' value='Non'  id='choice_4_73_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_4_73_1' id='label_4_73_1' class='gform-field-label gform-field-label--type-inline'>Non<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_4_74\" class=\"gfield gfield--type-section gfield--input-type-section gsection field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><h3 class=\"gsection_title\">3.1 - Personne-ressource secondaire<\/h3><\/div><div id=\"field_4_77\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-full field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_4_77'>Lien avec l\u2019enfant:<\/label><div class='ginput_container ginput_container_text'><input name='input_77' id='input_4_77' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_4_78\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-half gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_4_78'>Pr\u00e9nom:<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_custom\">(Requis)<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_78' id='input_4_78' type='text' value='' class='large'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_4_79\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-half gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_4_79'>Nom de famille:<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_custom\">(Requis)<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_79' id='input_4_79' type='text' value='' class='large'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_4_80\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-half gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_4_80'>Adresse : (si elle est diff\u00e9rente de l\u2019adresse indiqu\u00e9e ci-dessus)<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_custom\">(Requis)<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_80' id='input_4_80' type='text' value='' class='large'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_4_81\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-half gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_4_81'>Code postal:<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_custom\">(Requis)<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_81' id='input_4_81' type='text' value='' class='large'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><fieldset id=\"field_4_83\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >S\u00e9lectionnez le moyen de communication pr\u00e9f\u00e9r\u00e9:<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_custom\">(Requis)<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_4_83'>\n\t\t\t<div class='gchoice gchoice_4_83_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_83' type='radio' value='T\u00e9l\u00e9phone \u00e0 domicile'  id='choice_4_83_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_4_83_0' id='label_4_83_0' class='gform-field-label gform-field-label--type-inline'>T\u00e9l\u00e9phone \u00e0 domicile<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_4_83_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_83' type='radio' value='Courriel'  id='choice_4_83_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_4_83_1' id='label_4_83_1' class='gform-field-label gform-field-label--type-inline'>Courriel<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_4_83_2'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_83' type='radio' value='T\u00e9l\u00e9phone au travail'  id='choice_4_83_2' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_4_83_2' id='label_4_83_2' class='gform-field-label gform-field-label--type-inline'>T\u00e9l\u00e9phone au travail<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_4_83_3'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_83' type='radio' value='Cellulaire'  id='choice_4_83_3' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_4_83_3' id='label_4_83_3' class='gform-field-label gform-field-label--type-inline'>Cellulaire<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_4_83_4'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_83' type='radio' value='Autre'  id='choice_4_83_4' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_4_83_4' id='label_4_83_4' class='gform-field-label gform-field-label--type-inline'>Autre<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_4_84\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_4_84'>T\u00e9l\u00e9phone \u00e0 domicile<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_custom\">(Requis)<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_84' id='input_4_84' type='text' value='' class='large'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_4_85\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_4_85'>Courriel<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_custom\">(Requis)<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_85' id='input_4_85' type='text' value='' class='large'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_4_86\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_4_86'>T\u00e9l\u00e9phone au travail<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_custom\">(Requis)<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_86' id='input_4_86' type='text' value='' class='large'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_4_87\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_4_87'>Cellulaire<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_custom\">(Requis)<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_87' id='input_4_87' type='text' value='' class='large'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_4_88\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_4_88'>Veuillez expliquer:<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_custom\">(Requis)<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_88' id='input_4_88' type='text' value='' class='large'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><fieldset id=\"field_4_89\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-half field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >Est-ce que vous \u00eates la personne avec qui nous devons communiquer?<\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_4_89'>\n\t\t\t<div class='gchoice gchoice_4_89_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_89' type='radio' value='Oui'  id='choice_4_89_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_4_89_0' id='label_4_89_0' class='gform-field-label gform-field-label--type-inline'>Oui<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_4_89_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_89' type='radio' value='Non'  id='choice_4_89_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_4_89_1' id='label_4_89_1' class='gform-field-label gform-field-label--type-inline'>Non<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_4_126\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield--input-type-checkbox gfield--width-half field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Facteurs de risque pour le parent\/personne-ressource<\/legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox ' id='input_4_126'><div class='gchoice gchoice_4_126_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_126.1' type='checkbox'  value='Proche aidant vieillissant'  id='choice_4_126_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_4_126_1' id='label_4_126_1' class='gform-field-label gform-field-label--type-inline'>Proche aidant vieillissant<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_4_126_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_126.2' type='checkbox'  value='\u00c9tat de sant\u00e9'  id='choice_4_126_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_4_126_2' id='label_4_126_2' class='gform-field-label gform-field-label--type-inline'>\u00c9tat de sant\u00e9<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_4_126_3'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_126.3' type='checkbox'  value='Probl\u00e8mes de sant\u00e9 mentale'  id='choice_4_126_3'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_4_126_3' id='label_4_126_3' class='gform-field-label gform-field-label--type-inline'>Probl\u00e8mes de sant\u00e9 mentale<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_4_126_4'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_126.4' type='checkbox'  value='Diagnostic de d\u00e9ficience intellectuelle'  id='choice_4_126_4'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_4_126_4' id='label_4_126_4' class='gform-field-label gform-field-label--type-inline'>Diagnostic de d\u00e9ficience intellectuelle<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_4_126_5'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_126.5' type='checkbox'  value='Barri\u00e8re linguistique'  id='choice_4_126_5'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_4_126_5' id='label_4_126_5' class='gform-field-label gform-field-label--type-inline'>Barri\u00e8re linguistique<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_4_126_6'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_126.6' type='checkbox'  value='Parent seul'  id='choice_4_126_6'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_4_126_6' id='label_4_126_6' class='gform-field-label gform-field-label--type-inline'>Parent seul<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_4_91\" class=\"gfield gfield--type-section gfield--input-type-section gsection field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><h3 class=\"gsection_title\">3.2 - Conditions de vie de la famille<\/h3><\/div><fieldset id=\"field_4_92\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield--input-type-checkbox gfield--width-half field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Famille et conditions de vie:<\/legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox ' id='input_4_92'><div class='gchoice gchoice_4_92_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_92.1' type='checkbox'  value='Changement de la situation de famille'  id='choice_4_92_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_4_92_1' id='label_4_92_1' class='gform-field-label gform-field-label--type-inline'>Changement de la situation de famille<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_4_92_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_92.2' type='checkbox'  value='Faillite financi\u00e8re'  id='choice_4_92_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_4_92_2' id='label_4_92_2' class='gform-field-label gform-field-label--type-inline'>Faillite financi\u00e8re<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_4_92_3'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_92.3' type='checkbox'  value='Sans abri\/refuge'  id='choice_4_92_3'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_4_92_3' id='label_4_92_3' class='gform-field-label gform-field-label--type-inline'>Sans abri\/refuge<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_4_92_4'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_92.4' type='checkbox'  value='Autres fr\u00e8res et s\u0153urs ayant besoin de soutien suppl\u00e9mentaire'  id='choice_4_92_4'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_4_92_4' id='label_4_92_4' class='gform-field-label gform-field-label--type-inline'>Autres fr\u00e8res et s\u0153urs ayant besoin de soutien suppl\u00e9mentaire<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_4_92_5'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_92.5' type='checkbox'  value='Implication de l\u2019aide \u00e0 l\u2019Enfance'  id='choice_4_92_5'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_4_92_5' id='label_4_92_5' class='gform-field-label gform-field-label--type-inline'>Implication de l\u2019aide \u00e0 l\u2019Enfance<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_4_92_6'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_92.6' type='checkbox'  value='Risque de perdre son logement'  id='choice_4_92_6'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_4_92_6' id='label_4_92_6' class='gform-field-label gform-field-label--type-inline'>Risque de perdre son logement<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_4_93\" class=\"gfield gfield--type-textarea gfield--input-type-textarea gfield--width-half field_sublabel_below gfield--has-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_4_93'>Autres d\u00e9tails :<\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_93' id='input_4_93' class='textarea large'  aria-describedby=\"gfield_description_4_93\"    aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><div class='gfield_description' id='gfield_description_4_93'>Qui vit dans la maison? \u00c0 quoi ressemble votre r\u00e9seau de soutien? Situation financi\u00e8re? Quelles exigences suppl\u00e9mentaires ont des r\u00e9percussions sur votre vie familiale?<\/div><\/div><div id=\"field_4_94\" class=\"gfield gfield--type-section gfield--input-type-section gsection field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><h3 class=\"gsection_title\">4 - Soutiens Financiers<\/h3><\/div><div id=\"field_4_95\" class=\"gfield gfield--type-select gfield--input-type-select gfield--width-half field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_4_95'>Cr\u00e9dit d&#039;imp\u00f4t pour personnes handicap\u00e9es\/arr\u00e9rages  (choisir une r\u00e9ponse) :<\/label><div class='ginput_container ginput_container_select'><select name='input_95' id='input_4_95' class='large gfield_select'     aria-invalid=\"false\" ><option value=''  class='gf_placeholder'>(S\u00e9lectionner)<\/option><option value='Appliqu\u00e9' >Appliqu\u00e9<\/option><option value='Re\u00e7u' >Re\u00e7u<\/option><option value='Refus\u00e9' >Refus\u00e9<\/option><option value='En processus' >En processus<\/option><option value='Non applicable' >Non applicable<\/option><\/select><\/div><\/div><div id=\"field_4_96\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-half field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_4_96'>Ann\u00e9e de la demande:<\/label><div class='ginput_container ginput_container_text'><input name='input_96' id='input_4_96' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_4_97\" class=\"gfield gfield--type-select gfield--input-type-select gfield--width-half field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_4_97'>Programme de services particuliers \u00e0 domicile (PSPD)   (choisir une r\u00e9ponse) :<\/label><div class='ginput_container ginput_container_select'><select name='input_97' id='input_4_97' class='large gfield_select'     aria-invalid=\"false\" ><option value=''  class='gf_placeholder'>(S\u00e9lectionner)<\/option><option value='Appliqu\u00e9' >Appliqu\u00e9<\/option><option value='Re\u00e7u' >Re\u00e7u<\/option><option value='Refus\u00e9' >Refus\u00e9<\/option><option value='En processus' >En processus<\/option><option value='Non applicable' >Non applicable<\/option><\/select><\/div><\/div><div id=\"field_4_98\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-half field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_4_98'>Ann\u00e9e de la demande\u202f:<\/label><div class='ginput_container ginput_container_text'><input name='input_98' id='input_4_98' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_4_99\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-half field_sublabel_below gfield--has-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_4_99'>Montant annuel re\u00e7u\u202f:<\/label><div class='ginput_container ginput_container_text'><input name='input_99' id='input_4_99' type='text' value='' class='large'  aria-describedby=\"gfield_description_4_99\"    aria-invalid=\"false\"   \/><\/div><div class='gfield_description' id='gfield_description_4_99'>Sera compl\u00e9t\u00e9 par un gestionnaire de cas, si applicable.<\/div><\/div><div id=\"field_4_100\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-half field_sublabel_below gfield--has-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_4_100'>Nom de l\u2019agent(e) des ententes particuli\u00e8res\u202f:<\/label><div class='ginput_container ginput_container_text'><input name='input_100' id='input_4_100' type='text' value='' class='large'  aria-describedby=\"gfield_description_4_100\"    aria-invalid=\"false\"   \/><\/div><div class='gfield_description' id='gfield_description_4_100'>Sera compl\u00e9t\u00e9 par un gestionnaire de cas, si applicable.<\/div><\/div><div id=\"field_4_101\" class=\"gfield gfield--type-select gfield--input-type-select gfield--width-half field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_4_101'>Programme ontarien des services en mati\u00e8re d\u2019autisme   (choisir une r\u00e9ponse) :<\/label><div class='ginput_container ginput_container_select'><select name='input_101' id='input_4_101' class='large gfield_select'     aria-invalid=\"false\" ><option value=''  class='gf_placeholder'>(S\u00e9lectionner)<\/option><option value='Appliqu\u00e9' >Appliqu\u00e9<\/option><option value='Re\u00e7u' >Re\u00e7u<\/option><option value='Non accept\u00e9' >Non accept\u00e9<\/option><option value='En processus' >En processus<\/option><option value='Non applicable' >Non applicable<\/option><\/select><\/div><\/div><div id=\"field_4_102\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-half field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_4_102'>Ann\u00e9e de la demande:<\/label><div class='ginput_container ginput_container_text'><input name='input_102' id='input_4_102' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_4_103\" class=\"gfield gfield--type-select gfield--input-type-select gfield--width-half field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_4_103'>Initiative de financement pour les troubles du spectre d\u2019autisme (Service Coordination Soutien)  (choisir une r\u00e9ponse) :<\/label><div class='ginput_container ginput_container_select'><select name='input_103' id='input_4_103' class='large gfield_select'     aria-invalid=\"false\" ><option value=''  class='gf_placeholder'>(S\u00e9lectionner)<\/option><option value='Appliqu\u00e9' >Appliqu\u00e9<\/option><option value='Re\u00e7u' >Re\u00e7u<\/option><option value='Non accept\u00e9' >Non accept\u00e9<\/option><option value='En processus' >En processus<\/option><option value='Non applicable' >Non applicable<\/option><\/select><\/div><\/div><div id=\"field_4_104\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-half field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_4_104'>Ann\u00e9e de la demande:<\/label><div class='ginput_container ginput_container_text'><input name='input_104' id='input_4_104' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_4_106\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-full field_sublabel_below gfield--has-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_4_106'>Montant annuel re\u00e7u\u202f:<\/label><div class='ginput_container ginput_container_text'><input name='input_106' id='input_4_106' type='text' value='' class='large'  aria-describedby=\"gfield_description_4_106\"    aria-invalid=\"false\"   \/><\/div><div class='gfield_description' id='gfield_description_4_106'>Sera compl\u00e9t\u00e9 par un gestionnaire de cas, si applicable.<\/div><\/div><div id=\"field_4_107\" class=\"gfield gfield--type-select gfield--input-type-select gfield--width-half field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_4_107'>Centres d\u2019acc\u00e8s aux soins communautaires (CASC) Programme de financement accru des services de rel\u00e8ve<\/label><div class='ginput_container ginput_container_select'><select name='input_107' id='input_4_107' class='large gfield_select'     aria-invalid=\"false\" ><option value=''  class='gf_placeholder'>(S\u00e9lectionner)<\/option><option value='Appliqu\u00e9' >Appliqu\u00e9<\/option><option value='Re\u00e7u' >Re\u00e7u<\/option><option value='Non accept\u00e9' >Non accept\u00e9<\/option><option value='En processus' >En processus<\/option><option value='Non applicable' >Non applicable<\/option><\/select><\/div><\/div><div id=\"field_4_108\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-half field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_4_108'>Ann\u00e9e de la demande:<\/label><div class='ginput_container ginput_container_text'><input name='input_108' id='input_4_108' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_4_109\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-full field_sublabel_below gfield--has-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_4_109'>Montant re\u00e7u:<\/label><div class='ginput_container ginput_container_text'><input name='input_109' id='input_4_109' type='text' value='' class='large'  aria-describedby=\"gfield_description_4_109\"    aria-invalid=\"false\"   \/><\/div><div class='gfield_description' id='gfield_description_4_109'>Sera compl\u00e9t\u00e9 par un gestionnaire de cas, si applicable.<\/div><\/div><div id=\"field_4_110\" class=\"gfield gfield--type-select gfield--input-type-select gfield--width-half field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_4_110'>Programme de subvention \u00e0 l&#039;achat de fournitures d&#039;incontinence de Timbres de P\u00e2ques   (choisir une r\u00e9ponse) :<\/label><div class='ginput_container ginput_container_select'><select name='input_110' id='input_4_110' class='large gfield_select'     aria-invalid=\"false\" ><option value=''  class='gf_placeholder'>(S\u00e9lectionner)<\/option><option value='Appliqu\u00e9' >Appliqu\u00e9<\/option><option value='Re\u00e7u' >Re\u00e7u<\/option><option value='Non accept\u00e9' >Non accept\u00e9<\/option><option value='En processus' >En processus<\/option><option value='Non applicable' >Non applicable<\/option><\/select><\/div><\/div><div id=\"field_4_111\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-half field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_4_111'>Ann\u00e9e de la demande:<\/label><div class='ginput_container ginput_container_text'><input name='input_111' id='input_4_111' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_4_112\" class=\"gfield gfield--type-section gfield--input-type-section gsection field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><h3 class=\"gsection_title\">4.1 - Soutiens Financiers pour un revenu familial annuel en-dessous de $63,000<\/h3><\/div><div id=\"field_4_125\" class=\"gfield gfield--type-select gfield--input-type-select gfield--width-half field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_4_125'>Aide \u00e0 l&#039;\u00e9gard d\u2019enfants qui ont un handicap grave (\u00e0 base de revenue)   (choisir une r\u00e9ponse) :<\/label><div class='ginput_container ginput_container_select'><select name='input_125' id='input_4_125' class='large gfield_select'     aria-invalid=\"false\" ><option value=''  class='gf_placeholder'>(S\u00e9lectionner)<\/option><option value='Appliqu\u00e9' >Appliqu\u00e9<\/option><option value='Re\u00e7u' >Re\u00e7u<\/option><option value='Non accept\u00e9' >Non accept\u00e9<\/option><option value='En processus' >En processus<\/option><option value='Non applicable' >Non applicable<\/option><\/select><\/div><\/div><div id=\"field_4_114\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-half field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_4_114'>Ann\u00e9e de la demande:<\/label><div class='ginput_container ginput_container_text'><input name='input_114' id='input_4_114' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_4_115\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-half field_sublabel_below gfield--has-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_4_115'>Montant re\u00e7u mensuellement:<\/label><div class='ginput_container ginput_container_text'><input name='input_115' id='input_4_115' type='text' value='' class='large'  aria-describedby=\"gfield_description_4_115\"    aria-invalid=\"false\"   \/><\/div><div class='gfield_description' id='gfield_description_4_115'>Sera compl\u00e9t\u00e9 par un gestionnaire de cas, si applicable.<\/div><\/div><div id=\"field_4_116\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-half field_sublabel_below gfield--has-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_4_116'>Nom de l\u2019agent(e) des ententes particuli\u00e8res\u202f:<\/label><div class='ginput_container ginput_container_text'><input name='input_116' id='input_4_116' type='text' value='' class='large'  aria-describedby=\"gfield_description_4_116\"    aria-invalid=\"false\"   \/><\/div><div class='gfield_description' id='gfield_description_4_116'>Sera compl\u00e9t\u00e9 par un gestionnaire de cas, si applicable.<\/div><\/div><fieldset id=\"field_4_117\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-full field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >Autre ressources priv\u00e9 ou publique (choisir une r\u00e9ponse):<\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_4_117'>\n\t\t\t<div class='gchoice gchoice_4_117_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_117' type='radio' value='Oui'  id='choice_4_117_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_4_117_0' id='label_4_117_0' class='gform-field-label gform-field-label--type-inline'>Oui<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_4_117_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_117' type='radio' value='Non'  id='choice_4_117_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_4_117_1' id='label_4_117_1' class='gform-field-label gform-field-label--type-inline'>Non<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_4_118\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-full field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_4_118'>Si oui, veuillez pr\u00e9ciser le nom\u202f:<\/label><div class='ginput_container ginput_container_text'><input name='input_118' id='input_4_118' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_4_120\" class=\"gfield gfield--type-section gfield--input-type-section gsection field_sublabel_below gfield--has-description field_description_below field_validation_below gfield_visibility_visible\"  ><h3 class=\"gsection_title\">Section 5 - Demande de service<\/h3><div class='gsection_description' id='gfield_description_4_120'>De quelle mani\u00e8re esp\u00e9rez-vous qu'un gestionnaire de cas vous aidera ? Quel type de ressources recherchez-vous en ce moment ? <\/div><\/div><fieldset id=\"field_4_121\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield--input-type-checkbox gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' >J&#039;ai besoin d&#039;un gestionnaire de cas pour m&#039;aider \u00e0 d\u00e9velopper un plan pour atteindre mes buts et m&#039;aider \u00e0 explorer et \u00e0 coordonner les ressources communautaires, telles que :<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_custom\">(Requis)<\/span><\/span><\/legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox ' id='input_4_121'><div class='gchoice gchoice_4_121_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_121.1' type='checkbox'  value='Programmes de d\u00e9veloppement des comp\u00e9tences ou d&#039;\u00e9ducation'  id='choice_4_121_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_4_121_1' id='label_4_121_1' class='gform-field-label gform-field-label--type-inline'>Programmes de d\u00e9veloppement des comp\u00e9tences ou d'\u00e9ducation<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_4_121_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_121.2' type='checkbox'  value='Programmes sociaux et r\u00e9cr\u00e9atifs'  id='choice_4_121_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_4_121_2' id='label_4_121_2' class='gform-field-label gform-field-label--type-inline'>Programmes sociaux et r\u00e9cr\u00e9atifs<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_4_121_3'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_121.3' type='checkbox'  value='Programmes de garde d&#039;enfants'  id='choice_4_121_3'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_4_121_3' id='label_4_121_3' class='gform-field-label gform-field-label--type-inline'>Programmes de garde d'enfants<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_4_121_4'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_121.4' type='checkbox'  value='Travailleurs de soutien ou programmes de r\u00e9pit'  id='choice_4_121_4'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_4_121_4' id='label_4_121_4' class='gform-field-label gform-field-label--type-inline'>Travailleurs de soutien ou programmes de r\u00e9pit<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_4_121_5'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_121.5' type='checkbox'  value='Possibilit\u00e9s de b\u00e9n\u00e9volat ou d\u2019emploi'  id='choice_4_121_5'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_4_121_5' id='label_4_121_5' class='gform-field-label gform-field-label--type-inline'>Possibilit\u00e9s de b\u00e9n\u00e9volat ou d\u2019emploi<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_4_121_6'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_121.6' type='checkbox'  value='Groupes de soutien'  id='choice_4_121_6'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_4_121_6' id='label_4_121_6' class='gform-field-label gform-field-label--type-inline'>Groupes de soutien<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_4_121_7'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_121.7' type='checkbox'  value='Programmes financiers'  id='choice_4_121_7'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_4_121_7' id='label_4_121_7' class='gform-field-label gform-field-label--type-inline'>Programmes financiers<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_4_121_8'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_121.8' type='checkbox'  value='Services de logement'  id='choice_4_121_8'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_4_121_8' id='label_4_121_8' class='gform-field-label gform-field-label--type-inline'>Services de logement<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_4_121_9'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_121.9' type='checkbox'  value='Services de transport'  id='choice_4_121_9'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_4_121_9' id='label_4_121_9' class='gform-field-label gform-field-label--type-inline'>Services de transport<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_4_121_11'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_121.11' type='checkbox'  value='Services sp\u00e9cialis\u00e9s, comme le counselling, la gestion du comportement, les soins m\u00e9dicaux, la th\u00e9rapie, l&#039;\u00e9quipement, etc.'  id='choice_4_121_11'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_4_121_11' id='label_4_121_11' class='gform-field-label gform-field-label--type-inline'>Services sp\u00e9cialis\u00e9s, comme le counselling, la gestion du comportement, les soins m\u00e9dicaux, la th\u00e9rapie, l'\u00e9quipement, etc.<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_4_121_12'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_121.12' type='checkbox'  value='Coordonner les r\u00e9unions avec les autres prestataires de services'  id='choice_4_121_12'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_4_121_12' id='label_4_121_12' class='gform-field-label gform-field-label--type-inline'>Coordonner les r\u00e9unions avec les autres prestataires de services<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_4_121_13'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_121.13' type='checkbox'  value='Autre\u202f:'  id='choice_4_121_13'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_4_121_13' id='label_4_121_13' class='gform-field-label gform-field-label--type-inline'>Autre\u202f:<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_4_122\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_4_122'>Autre:<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_custom\">(Requis)<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_122' id='input_4_122' type='text' value='' class='large'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><\/div><\/div>\n        <div class='gform-footer gform_footer top_label'> <input type='submit' id='gform_submit_button_4' class='gform_button button' onclick='gform.submission.handleButtonClick(this);' data-submission-type='submit' value='Envoyer'  \/> \n            <input type='hidden' class='gform_hidden' name='gform_submission_method' data-js='gform_submission_method_4' value='postback' \/>\n            <input type='hidden' class='gform_hidden' name='gform_theme' data-js='gform_theme_4' id='gform_theme_4' value='gravity-theme' \/>\n            <input type='hidden' class='gform_hidden' name='gform_style_settings' data-js='gform_style_settings_4' id='gform_style_settings_4' value='[]' \/>\n            <input type='hidden' class='gform_hidden' name='is_submit_4' value='1' \/>\n            <input type='hidden' class='gform_hidden' name='gform_submit' value='4' \/>\n            \n            <input type='hidden' class='gform_hidden' name='gform_unique_id' value='' \/>\n            <input type='hidden' class='gform_hidden' name='state_4' 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