{"id":1079,"date":"2022-04-14T12:01:37","date_gmt":"2022-04-14T16:01:37","guid":{"rendered":"http:\/\/wordplaysudburymanitoulin.ca\/formulaire-de-demande-pour-services-dorthophonie-pour-enfants-dage-prescholaire\/"},"modified":"2022-04-14T12:01:37","modified_gmt":"2022-04-14T16:01:37","slug":"formulaire-de-demande-pour-services-dorthophonie-pour-enfants-dage-prescholaire","status":"publish","type":"page","link":"https:\/\/wordplaysudburymanitoulin.ca\/fr\/formulaire-de-demande-pour-services-dorthophonie-pour-enfants-dage-prescholaire\/","title":{"rendered":"Formulaire de demande pour services d&rsquo;orthophonie pour enfants d&rsquo;\u00e2ge pr\u00e9scholaire"},"content":{"rendered":"<p>[et_pb_section fb_built=\u00a0\u00bb1&Prime; _builder_version=\u00a0\u00bb3.22&Prime; global_colors_info=\u00a0\u00bb{}\u00a0\u00bb][et_pb_row _builder_version=\u00a0\u00bb4.14.7&Prime; background_size=\u00a0\u00bbinitial\u00a0\u00bb background_position=\u00a0\u00bbtop_left\u00a0\u00bb background_repeat=\u00a0\u00bbrepeat\u00a0\u00bb hover_enabled=\u00a0\u00bb0&Prime; global_colors_info=\u00a0\u00bb{}\u00a0\u00bb sticky_enabled=\u00a0\u00bb0&Prime;][et_pb_column type=\u00a0\u00bb4_4&Prime; _builder_version=\u00a0\u00bb3.25&Prime; custom_padding=\u00a0\u00bb|||\u00a0\u00bb global_colors_info=\u00a0\u00bb{}\u00a0\u00bb custom_padding__hover=\u00a0\u00bb|||\u00a0\u00bb][et_pb_text _builder_version=\u00a0\u00bb4.14.7&Prime; background_size=\u00a0\u00bbinitial\u00a0\u00bb background_position=\u00a0\u00bbtop_left\u00a0\u00bb background_repeat=\u00a0\u00bbrepeat\u00a0\u00bb hover_enabled=\u00a0\u00bb0&Prime; global_colors_info=\u00a0\u00bb{}\u00a0\u00bb sticky_enabled=\u00a0\u00bb0&Prime;]<\/p>\n<p><!-- divi:tadv\/classic-paragraph -->\n<div class=\"wpcf7 no-js\" id=\"wpcf7-f916-o1\" lang=\"en-US\" dir=\"ltr\" data-wpcf7-id=\"916\">\n<div class=\"screen-reader-response\"><p role=\"status\" aria-live=\"polite\" aria-atomic=\"true\"><\/p> <ul><\/ul><\/div>\n<form action=\"\/fr\/wp-json\/wp\/v2\/pages\/1079#wpcf7-f916-o1\" method=\"post\" class=\"wpcf7-form init\" aria-label=\"Contact form\" novalidate=\"novalidate\" data-status=\"init\">\n<fieldset class=\"hidden-fields-container\"><input type=\"hidden\" name=\"_wpcf7\" value=\"916\" \/><input type=\"hidden\" name=\"_wpcf7_version\" value=\"6.1.5\" \/><input type=\"hidden\" name=\"_wpcf7_locale\" value=\"en_US\" \/><input type=\"hidden\" name=\"_wpcf7_unit_tag\" value=\"wpcf7-f916-o1\" \/><input type=\"hidden\" name=\"_wpcf7_container_post\" value=\"0\" \/><input type=\"hidden\" name=\"_wpcf7_posted_data_hash\" value=\"\" \/>\n<\/fieldset>\n<table>\n\t<tr>\n\t\t<td>\n\t\t\t<p><label>Email: <span class=\"wpcf7-form-control-wrap\" data-name=\"your-email\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-email wpcf7-validates-as-required wpcf7-text wpcf7-validates-as-email\" aria-required=\"true\" aria-invalid=\"false\" value=\"\" type=\"email\" name=\"your-email\" \/><\/span> <\/label>\n\t\t\t<\/p>\n\t\t<\/td>\n\t\t<td>\n\t\t\t<p><label>Consent to Contact By Email: <span class=\"wpcf7-form-control-wrap\" data-name=\"email-contact\"><select class=\"wpcf7-form-control wpcf7-select wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" name=\"email-contact\"><option value=\"\">&#8212;Please choose an option&#8212;<\/option><option value=\"Yes\">Yes<\/option><option value=\"No\">No<\/option><\/select><\/span><\/label>\n\t\t\t<\/p>\n\t\t<\/td>\n\t<\/tr>\n\t<tr>\n\t\t<td>\n\t\t\t<p><label> Child's name (first, middle, last): <span class=\"wpcf7-form-control-wrap\" data-name=\"child-name\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"child-name\" \/><\/span> <\/label>\n\t\t\t<\/p>\n\t\t<\/td>\n\t\t<td>\n\t\t\t<p><label>Gender: <span class=\"wpcf7-form-control-wrap\" data-name=\"gender\"><select class=\"wpcf7-form-control wpcf7-select wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" name=\"gender\"><option value=\"\">&#8212;Please choose an option&#8212;<\/option><option value=\"Male\">Male<\/option><option value=\"Female\">Female<\/option><option value=\"Other\">Other<\/option><\/select><\/span><\/label>\n\t\t\t<\/p>\n\t\t<\/td>\n\t<\/tr>\n\t<tr>\n\t\t<td>\n\t\t\t<p><label>Date of birth: <span class=\"wpcf7-form-control-wrap\" data-name=\"date-birth\"><input class=\"wpcf7-form-control wpcf7-date wpcf7-validates-as-required wpcf7-validates-as-date\" aria-required=\"true\" aria-invalid=\"false\" value=\"\" type=\"date\" name=\"date-birth\" \/><\/span><\/label>\n\t\t\t<\/p>\n\t\t<\/td>\n\t\t<td>\n\t\t\t<p><label>Health Card #: <span class=\"wpcf7-form-control-wrap\" data-name=\"health-card\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"health-card\" \/><\/span><\/label>\n\t\t\t<\/p>\n\t\t<\/td>\n\t<\/tr>\n\t<tr>\n\t\t<td>\n\t\t\t<p><label>Primary Language of child: <span class=\"wpcf7-form-control-wrap\" data-name=\"primary-language\"><select class=\"wpcf7-form-control wpcf7-select wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" name=\"primary-language\"><option value=\"\">&#8212;Please choose an option&#8212;<\/option><option value=\"French\">French<\/option><option value=\"English\">English<\/option><option value=\"Other (please specify)\">Other (please specify)<\/option><\/select><\/span><\/label>\n\t\t\t<\/p>\n\t\t<\/td>\n\t\t<td>\n\t\t\t<p><label>Other Language (please specify): <span class=\"wpcf7-form-control-wrap\" data-name=\"other-language\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"other-language\" \/><\/span><\/label>\n\t\t\t<\/p>\n\t\t<\/td>\n\t<\/tr>\n\t<tr>\n\t\t<td>\n\t\t\t<p><label>Address: <span class=\"wpcf7-form-control-wrap\" data-name=\"address\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" value=\"house\/unit #, street name &amp; direction\" type=\"text\" name=\"address\" \/><\/span><\/label>\n\t\t\t<\/p>\n\t\t<\/td>\n\t\t<td>\n\t\t\t<p><label>Postal Code: <span class=\"wpcf7-form-control-wrap\" data-name=\"postal-code\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"postal-code\" \/><\/span><\/label>\n\t\t\t<\/p>\n\t\t<\/td>\n\t<\/tr>\n\t<tr>\n\t\t<td>\n\t\t\t<p><label>Home\/Cell #: <span class=\"wpcf7-form-control-wrap\" data-name=\"home-cell\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-tel wpcf7-validates-as-required wpcf7-text wpcf7-validates-as-tel\" aria-required=\"true\" aria-invalid=\"false\" value=\"\" type=\"tel\" name=\"home-cell\" \/><\/span><\/label>\n\t\t\t<\/p>\n\t\t<\/td>\n\t\t<td>\n\t\t\t<p><label>Work # (include extension): <span class=\"wpcf7-form-control-wrap\" data-name=\"work\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"work\" \/><\/span><\/label>\n\t\t\t<\/p>\n\t\t<\/td>\n\t<\/tr>\n\t<tr>\n\t\t<td colspan=\"2\">\n\t\t\t<p><label>Legal Guardian: <span class=\"wpcf7-form-control-wrap\" data-name=\"legal-guardian\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"legal-guardian\" \/><\/span><\/label>\n\t\t\t<\/p>\n\t\t<\/td>\n\t<\/tr>\n\t<tr>\n\t\t<td>\n\t\t\t<p><label>Primary Contact: <span class=\"wpcf7-form-control-wrap\" data-name=\"primary-contact\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"primary-contact\" \/><\/span><\/label>\n\t\t\t<\/p>\n\t\t<\/td>\n\t\t<td>\n\t\t\t<p><label>Primary Contact Relationship: <span class=\"wpcf7-form-control-wrap\" data-name=\"primary-contact-relationship\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"primary-contact-relationship\" \/><\/span><\/label>\n\t\t\t<\/p>\n\t\t<\/td>\n\t<\/tr>\n\t<tr>\n\t\t<td>\n\t\t\t<p><label>Secondary Contact: <span class=\"wpcf7-form-control-wrap\" data-name=\"secondary-contact\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"secondary-contact\" \/><\/span><\/label>\n\t\t\t<\/p>\n\t\t<\/td>\n\t\t<td>\n\t\t\t<p><label>Secondary Contact Relationship: <span class=\"wpcf7-form-control-wrap\" data-name=\"secondary-contact-relationship\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"secondary-contact-relationship\" \/><\/span><\/label>\n\t\t\t<\/p>\n\t\t<\/td>\n\t<\/tr>\n\t<tr>\n\t\t<td>\n\t\t\t<p><label>Contacts Address, if different from above: <span class=\"wpcf7-form-control-wrap\" data-name=\"contact-address\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" value=\"house\/unit #, street name &amp; direction\" type=\"text\" name=\"contact-address\" \/><\/span><\/label>\n\t\t\t<\/p>\n\t\t<\/td>\n\t\t<td>\n\t\t\t<p><label>Name of ChildCare: <span class=\"wpcf7-form-control-wrap\" data-name=\"child-care\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"child-care\" \/><\/span><\/label>\n\t\t\t<\/p>\n\t\t<\/td>\n\t<\/tr>\n\t<tr>\n\t\t<td>\n\t\t\t<p><label>Starting School in September? <span class=\"wpcf7-form-control-wrap\" data-name=\"start-school\"><select class=\"wpcf7-form-control wpcf7-select wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" name=\"start-school\"><option value=\"\">&#8212;Please choose an option&#8212;<\/option><option value=\"Yes\">Yes<\/option><option value=\"No\">No<\/option><option value=\"Not sure\">Not sure<\/option><\/select><\/span><\/label>\n\t\t\t<\/p>\n\t\t<\/td>\n\t\t<td>\n\t\t\t<p><label>School Name:<br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"school-name\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"school-name\" \/><\/span><\/label>\n\t\t\t<\/p>\n\t\t<\/td>\n\t<\/tr>\n\t<tr>\n\t\t<td>\n\t\t\t<p><label>Physician: <span class=\"wpcf7-form-control-wrap\" data-name=\"physician\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"physician\" \/><\/span><\/label>\n\t\t\t<\/p>\n\t\t<\/td>\n\t\t<td>\n\t\t\t<p><label>Other Specialists: <span class=\"wpcf7-form-control-wrap\" data-name=\"other-specialists\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"other-specialists\" \/><\/span><\/label>\n\t\t\t<\/p>\n\t\t<\/td>\n\t<\/tr>\n\t<tr>\n\t\t<td>\n\t\t\t<p><label>Has the child previously received speech services? <span class=\"wpcf7-form-control-wrap\" data-name=\"previous-services\"><select class=\"wpcf7-form-control wpcf7-select wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" name=\"previous-services\"><option value=\"\">&#8212;Please choose an option&#8212;<\/option><option value=\"Yes\">Yes<\/option><option value=\"No\">No<\/option><\/select><\/span><\/label>\n\t\t\t<\/p>\n\t\t<\/td>\n\t\t<td>\n\t\t\t<p><label>If yes, name of SLP: <span class=\"wpcf7-form-control-wrap\" data-name=\"name-SLP\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"name-SLP\" \/><\/span><\/label>\n\t\t\t<\/p>\n\t\t<\/td>\n\t<\/tr>\n\t<tr>\n\t\t<td>\n\t\t\t<p><label>Referral Initiated by: <span class=\"wpcf7-form-control-wrap\" data-name=\"referral-initiated\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"referral-initiated\" \/><\/span><\/label>\n\t\t\t<\/p>\n\t\t<\/td>\n\t\t<td>\n\t\t\t<p><label>How did you hear about the service? <span class=\"wpcf7-form-control-wrap\" data-name=\"hear-service\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"hear-service\" \/><\/span><\/label>\n\t\t\t<\/p>\n\t\t<\/td>\n\t<\/tr>\n\t<tr>\n\t\t<td colspan=\"2\">\n\t\t\t<p><label>Presenting Difficulties: <span class=\"wpcf7-form-control-wrap\" data-name=\"presenting-difficulties\"><textarea cols=\"40\" rows=\"10\" maxlength=\"2000\" class=\"wpcf7-form-control wpcf7-textarea wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" name=\"presenting-difficulties\"><\/textarea><\/span><\/label>\n\t\t\t<\/p>\n\t\t<\/td>\n\t<\/tr>\n\t<tr>\n\t\t<td colspan=\"2\">\n\t\t\t<p><label>Does your child have any severe allergies\/health issues that we need to be aware of? <span class=\"wpcf7-form-control-wrap\" data-name=\"allergies-health\"><textarea cols=\"40\" rows=\"10\" maxlength=\"2000\" class=\"wpcf7-form-control wpcf7-textarea\" aria-invalid=\"false\" name=\"allergies-health\"><\/textarea><\/span><\/label>\n\t\t\t<\/p>\n\t\t<\/td>\n\t<\/tr>\n\t<tr>\n\t\t<td colspan=\"2\">\n\t\t\t<p><label>Will anyone attending this appointment require assistance to access our services?(wheelchair\/bus tickets) <span class=\"wpcf7-form-control-wrap\" data-name=\"require-assistance\"><textarea cols=\"40\" rows=\"10\" maxlength=\"2000\" class=\"wpcf7-form-control wpcf7-textarea\" aria-invalid=\"false\" name=\"require-assistance\"><\/textarea><\/span><\/label>\n\t\t\t<\/p>\n\t\t<\/td>\n\t<\/tr>\n\t<tr>\n\t\t<td colspan=\"2\">\n\t\t\t<p><label>When is the best time to contact you? <span class=\"wpcf7-form-control-wrap\" data-name=\"best-contact\"><textarea cols=\"40\" rows=\"10\" maxlength=\"2000\" class=\"wpcf7-form-control wpcf7-textarea wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" name=\"best-contact\"><\/textarea><\/span><\/label>\n\t\t\t<\/p>\n\t\t<\/td>\n\t<\/tr>\n\t<tr>\n\t\t<td>\n\t\t\t<p><label>Family Structure: <span class=\"wpcf7-form-control-wrap\" data-name=\"family-structure\"><select class=\"wpcf7-form-control wpcf7-select wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" name=\"family-structure\"><option value=\"\">&#8212;Please choose an option&#8212;<\/option><option value=\"Both Biological Parents\">Both Biological Parents<\/option><option value=\"Single Parents\">Single Parents<\/option><option value=\"Blended Family\">Blended Family<\/option><option value=\"Foster Parent\">Foster Parent<\/option><option value=\"Adoptive\">Adoptive<\/option><\/select><\/span><\/label>\n\t\t\t<\/p>\n\t\t<\/td>\n\t\t<td>\n\t\t\t<p><label> Marital Status: <span class=\"wpcf7-form-control-wrap\" data-name=\"marital-status\"><select class=\"wpcf7-form-control wpcf7-select wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" name=\"marital-status\"><option value=\"\">&#8212;Please choose an option&#8212;<\/option><option value=\"Married\">Married<\/option><option value=\"Single\">Single<\/option><option value=\"Common Law\">Common Law<\/option><option value=\"Divorced\">Divorced<\/option><option value=\"Separated\">Separated<\/option><\/select><\/span><\/label>\n\t\t\t<\/p>\n\t\t<\/td>\n\t<\/tr>\n\t<tr>\n\t\t<td>\n\t\t\t<p><label>Language Spoken in home:<br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"language-home\"><select class=\"wpcf7-form-control wpcf7-select wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" multiple=\"multiple\" name=\"language-home[]\"><option value=\"French\">French<\/option><option value=\"English\">English<\/option><option value=\"Other (please specify)\">Other (please specify)<\/option><\/select><\/span><\/label>\n\t\t\t<\/p>\n\t\t<\/td>\n\t\t<td>\n\t\t\t<p><label>Other Language:<br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"other-language-home\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"other-language-home\" \/><\/span><\/label>\n\t\t\t<\/p>\n\t\t<\/td>\n\t<\/tr>\n<\/table>\n<p>Per cent Language is spoken in home\n<\/p>\n<table>\n\t<tr>\n\t\t<td>\n\t\t\t<p><label>French: <span class=\"wpcf7-form-control-wrap\" data-name=\"percent-french\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" placeholder=\"%\" value=\"\" type=\"text\" name=\"percent-french\" \/><\/span><\/label>\n\t\t\t<\/p>\n\t\t<\/td>\n\t\t<td>\n\t\t\t<p><label>English: <span class=\"wpcf7-form-control-wrap\" data-name=\"percent-english\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" placeholder=\"%\" value=\"\" type=\"text\" name=\"percent-english\" \/><\/span><\/label>\n\t\t\t<\/p>\n\t\t<\/td>\n\t\t<td>\n\t\t\t<p><label>Other: <span class=\"wpcf7-form-control-wrap\" data-name=\"percent-other\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" placeholder=\"%\" value=\"\" type=\"text\" name=\"percent-other\" \/><\/span><\/label>\n\t\t\t<\/p>\n\t\t<\/td>\n\t<\/tr>\n<\/table>\n<p><input class=\"wpcf7-form-control wpcf7-submit has-spinner btn-send\" type=\"submit\" value=\"Submit\" \/>\n<\/p><div class=\"wpcf7-response-output\" aria-hidden=\"true\"><\/div>\n<\/form>\n<\/div>\n<\/p>\n<p><!-- \/divi:tadv\/classic-paragraph --><\/p>\n<p>[\/et_pb_text][\/et_pb_column][\/et_pb_row][\/et_pb_section]<\/p>\n","protected":false},"excerpt":{"rendered":"\n<div class=\"wpcf7 no-js\" id=\"wpcf7-f916-o2\" lang=\"en-US\" dir=\"ltr\" data-wpcf7-id=\"916\">\n<div class=\"screen-reader-response\"><p role=\"status\" aria-live=\"polite\" aria-atomic=\"true\"><\/p> <ul><\/ul><\/div>\n<form action=\"\/fr\/wp-json\/wp\/v2\/pages\/1079#wpcf7-f916-o2\" method=\"post\" class=\"wpcf7-form init\" aria-label=\"Contact form\" novalidate=\"novalidate\" data-status=\"init\">\n<fieldset class=\"hidden-fields-container\"><input type=\"hidden\" name=\"_wpcf7\" value=\"916\" \/><input type=\"hidden\" name=\"_wpcf7_version\" value=\"6.1.5\" \/><input type=\"hidden\" name=\"_wpcf7_locale\" value=\"en_US\" \/><input type=\"hidden\" name=\"_wpcf7_unit_tag\" value=\"wpcf7-f916-o2\" \/><input type=\"hidden\" name=\"_wpcf7_container_post\" value=\"0\" \/><input type=\"hidden\" name=\"_wpcf7_posted_data_hash\" value=\"\" \/>\n<\/fieldset>\n<table>\n\t<tr>\n\t\t<td>\n\t\t\t<p><label>Email: <span class=\"wpcf7-form-control-wrap\" data-name=\"your-email\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-email wpcf7-validates-as-required wpcf7-text wpcf7-validates-as-email\" aria-required=\"true\" aria-invalid=\"false\" value=\"\" type=\"email\" name=\"your-email\" \/><\/span> <\/label>\n\t\t\t<\/p>\n\t\t<\/td>\n\t\t<td>\n\t\t\t<p><label>Consent to Contact By Email: <span class=\"wpcf7-form-control-wrap\" data-name=\"email-contact\"><select class=\"wpcf7-form-control wpcf7-select wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" name=\"email-contact\"><option value=\"\">&#8212;Please choose an option&#8212;<\/option><option value=\"Yes\">Yes<\/option><option value=\"No\">No<\/option><\/select><\/span><\/label>\n\t\t\t<\/p>\n\t\t<\/td>\n\t<\/tr>\n\t<tr>\n\t\t<td>\n\t\t\t<p><label> Child's name (first, middle, last): <span class=\"wpcf7-form-control-wrap\" data-name=\"child-name\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"child-name\" \/><\/span> <\/label>\n\t\t\t<\/p>\n\t\t<\/td>\n\t\t<td>\n\t\t\t<p><label>Gender: <span class=\"wpcf7-form-control-wrap\" data-name=\"gender\"><select class=\"wpcf7-form-control wpcf7-select wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" name=\"gender\"><option value=\"\">&#8212;Please choose an option&#8212;<\/option><option value=\"Male\">Male<\/option><option value=\"Female\">Female<\/option><option value=\"Other\">Other<\/option><\/select><\/span><\/label>\n\t\t\t<\/p>\n\t\t<\/td>\n\t<\/tr>\n\t<tr>\n\t\t<td>\n\t\t\t<p><label>Date of birth: <span class=\"wpcf7-form-control-wrap\" data-name=\"date-birth\"><input class=\"wpcf7-form-control wpcf7-date wpcf7-validates-as-required wpcf7-validates-as-date\" aria-required=\"true\" aria-invalid=\"false\" value=\"\" type=\"date\" name=\"date-birth\" \/><\/span><\/label>\n\t\t\t<\/p>\n\t\t<\/td>\n\t\t<td>\n\t\t\t<p><label>Health Card #: <span class=\"wpcf7-form-control-wrap\" data-name=\"health-card\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"health-card\" \/><\/span><\/label>\n\t\t\t<\/p>\n\t\t<\/td>\n\t<\/tr>\n\t<tr>\n\t\t<td>\n\t\t\t<p><label>Primary Language of child: <span class=\"wpcf7-form-control-wrap\" data-name=\"primary-language\"><select class=\"wpcf7-form-control wpcf7-select wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" name=\"primary-language\"><option value=\"\">&#8212;Please choose an option&#8212;<\/option><option value=\"French\">French<\/option><option value=\"English\">English<\/option><option value=\"Other (please specify)\">Other (please specify)<\/option><\/select><\/span><\/label>\n\t\t\t<\/p>\n\t\t<\/td>\n\t\t<td>\n\t\t\t<p><label>Other Language (please specify): <span class=\"wpcf7-form-control-wrap\" data-name=\"other-language\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"other-language\" \/><\/span><\/label>\n\t\t\t<\/p>\n\t\t<\/td>\n\t<\/tr>\n\t<tr>\n\t\t<td>\n\t\t\t<p><label>Address: <span class=\"wpcf7-form-control-wrap\" data-name=\"address\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" value=\"house\/unit #, street name &amp; direction\" type=\"text\" name=\"address\" \/><\/span><\/label>\n\t\t\t<\/p>\n\t\t<\/td>\n\t\t<td>\n\t\t\t<p><label>Postal Code: <span class=\"wpcf7-form-control-wrap\" data-name=\"postal-code\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"postal-code\" \/><\/span><\/label>\n\t\t\t<\/p>\n\t\t<\/td>\n\t<\/tr>\n\t<tr>\n\t\t<td>\n\t\t\t<p><label>Home\/Cell #: <span class=\"wpcf7-form-control-wrap\" data-name=\"home-cell\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-tel wpcf7-validates-as-required wpcf7-text wpcf7-validates-as-tel\" aria-required=\"true\" aria-invalid=\"false\" value=\"\" type=\"tel\" name=\"home-cell\" \/><\/span><\/label>\n\t\t\t<\/p>\n\t\t<\/td>\n\t\t<td>\n\t\t\t<p><label>Work # (include extension): <span class=\"wpcf7-form-control-wrap\" data-name=\"work\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"work\" \/><\/span><\/label>\n\t\t\t<\/p>\n\t\t<\/td>\n\t<\/tr>\n\t<tr>\n\t\t<td colspan=\"2\">\n\t\t\t<p><label>Legal Guardian: <span class=\"wpcf7-form-control-wrap\" data-name=\"legal-guardian\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"legal-guardian\" \/><\/span><\/label>\n\t\t\t<\/p>\n\t\t<\/td>\n\t<\/tr>\n\t<tr>\n\t\t<td>\n\t\t\t<p><label>Primary Contact: <span class=\"wpcf7-form-control-wrap\" data-name=\"primary-contact\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"primary-contact\" \/><\/span><\/label>\n\t\t\t<\/p>\n\t\t<\/td>\n\t\t<td>\n\t\t\t<p><label>Primary Contact Relationship: <span class=\"wpcf7-form-control-wrap\" data-name=\"primary-contact-relationship\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"primary-contact-relationship\" \/><\/span><\/label>\n\t\t\t<\/p>\n\t\t<\/td>\n\t<\/tr>\n\t<tr>\n\t\t<td>\n\t\t\t<p><label>Secondary Contact: <span class=\"wpcf7-form-control-wrap\" data-name=\"secondary-contact\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"secondary-contact\" \/><\/span><\/label>\n\t\t\t<\/p>\n\t\t<\/td>\n\t\t<td>\n\t\t\t<p><label>Secondary Contact Relationship: <span class=\"wpcf7-form-control-wrap\" data-name=\"secondary-contact-relationship\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"secondary-contact-relationship\" \/><\/span><\/label>\n\t\t\t<\/p>\n\t\t<\/td>\n\t<\/tr>\n\t<tr>\n\t\t<td>\n\t\t\t<p><label>Contacts Address, if different from above: <span class=\"wpcf7-form-control-wrap\" data-name=\"contact-address\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" value=\"house\/unit #, street name &amp; direction\" type=\"text\" name=\"contact-address\" \/><\/span><\/label>\n\t\t\t<\/p>\n\t\t<\/td>\n\t\t<td>\n\t\t\t<p><label>Name of ChildCare: <span class=\"wpcf7-form-control-wrap\" data-name=\"child-care\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"child-care\" \/><\/span><\/label>\n\t\t\t<\/p>\n\t\t<\/td>\n\t<\/tr>\n\t<tr>\n\t\t<td>\n\t\t\t<p><label>Starting School in September? <span class=\"wpcf7-form-control-wrap\" data-name=\"start-school\"><select class=\"wpcf7-form-control wpcf7-select wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" name=\"start-school\"><option value=\"\">&#8212;Please choose an option&#8212;<\/option><option value=\"Yes\">Yes<\/option><option value=\"No\">No<\/option><option value=\"Not sure\">Not sure<\/option><\/select><\/span><\/label>\n\t\t\t<\/p>\n\t\t<\/td>\n\t\t<td>\n\t\t\t<p><label>School Name:<br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"school-name\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"school-name\" \/><\/span><\/label>\n\t\t\t<\/p>\n\t\t<\/td>\n\t<\/tr>\n\t<tr>\n\t\t<td>\n\t\t\t<p><label>Physician: <span class=\"wpcf7-form-control-wrap\" data-name=\"physician\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"physician\" \/><\/span><\/label>\n\t\t\t<\/p>\n\t\t<\/td>\n\t\t<td>\n\t\t\t<p><label>Other Specialists: <span class=\"wpcf7-form-control-wrap\" data-name=\"other-specialists\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"other-specialists\" \/><\/span><\/label>\n\t\t\t<\/p>\n\t\t<\/td>\n\t<\/tr>\n\t<tr>\n\t\t<td>\n\t\t\t<p><label>Has the child previously received speech services? <span class=\"wpcf7-form-control-wrap\" data-name=\"previous-services\"><select class=\"wpcf7-form-control wpcf7-select wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" name=\"previous-services\"><option value=\"\">&#8212;Please choose an option&#8212;<\/option><option value=\"Yes\">Yes<\/option><option value=\"No\">No<\/option><\/select><\/span><\/label>\n\t\t\t<\/p>\n\t\t<\/td>\n\t\t<td>\n\t\t\t<p><label>If yes, name of SLP: <span class=\"wpcf7-form-control-wrap\" data-name=\"name-SLP\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"name-SLP\" \/><\/span><\/label>\n\t\t\t<\/p>\n\t\t<\/td>\n\t<\/tr>\n\t<tr>\n\t\t<td>\n\t\t\t<p><label>Referral Initiated by: <span class=\"wpcf7-form-control-wrap\" data-name=\"referral-initiated\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"referral-initiated\" \/><\/span><\/label>\n\t\t\t<\/p>\n\t\t<\/td>\n\t\t<td>\n\t\t\t<p><label>How did you hear about the service? <span class=\"wpcf7-form-control-wrap\" data-name=\"hear-service\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"hear-service\" \/><\/span><\/label>\n\t\t\t<\/p>\n\t\t<\/td>\n\t<\/tr>\n\t<tr>\n\t\t<td colspan=\"2\">\n\t\t\t<p><label>Presenting Difficulties: <span class=\"wpcf7-form-control-wrap\" data-name=\"presenting-difficulties\"><textarea cols=\"40\" rows=\"10\" maxlength=\"2000\" class=\"wpcf7-form-control wpcf7-textarea wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" name=\"presenting-difficulties\"><\/textarea><\/span><\/label>\n\t\t\t<\/p>\n\t\t<\/td>\n\t<\/tr>\n\t<tr>\n\t\t<td colspan=\"2\">\n\t\t\t<p><label>Does your child have any severe allergies\/health issues that we need to be aware of? <span class=\"wpcf7-form-control-wrap\" data-name=\"allergies-health\"><textarea cols=\"40\" rows=\"10\" maxlength=\"2000\" class=\"wpcf7-form-control wpcf7-textarea\" aria-invalid=\"false\" name=\"allergies-health\"><\/textarea><\/span><\/label>\n\t\t\t<\/p>\n\t\t<\/td>\n\t<\/tr>\n\t<tr>\n\t\t<td colspan=\"2\">\n\t\t\t<p><label>Will anyone attending this appointment require assistance to access our services?(wheelchair\/bus tickets) <span class=\"wpcf7-form-control-wrap\" data-name=\"require-assistance\"><textarea cols=\"40\" rows=\"10\" maxlength=\"2000\" class=\"wpcf7-form-control wpcf7-textarea\" aria-invalid=\"false\" name=\"require-assistance\"><\/textarea><\/span><\/label>\n\t\t\t<\/p>\n\t\t<\/td>\n\t<\/tr>\n\t<tr>\n\t\t<td colspan=\"2\">\n\t\t\t<p><label>When is the best time to contact you? <span class=\"wpcf7-form-control-wrap\" data-name=\"best-contact\"><textarea cols=\"40\" rows=\"10\" maxlength=\"2000\" class=\"wpcf7-form-control wpcf7-textarea wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" name=\"best-contact\"><\/textarea><\/span><\/label>\n\t\t\t<\/p>\n\t\t<\/td>\n\t<\/tr>\n\t<tr>\n\t\t<td>\n\t\t\t<p><label>Family Structure: <span class=\"wpcf7-form-control-wrap\" data-name=\"family-structure\"><select class=\"wpcf7-form-control wpcf7-select wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" name=\"family-structure\"><option value=\"\">&#8212;Please choose an option&#8212;<\/option><option value=\"Both Biological Parents\">Both Biological Parents<\/option><option value=\"Single Parents\">Single Parents<\/option><option value=\"Blended Family\">Blended Family<\/option><option value=\"Foster Parent\">Foster Parent<\/option><option value=\"Adoptive\">Adoptive<\/option><\/select><\/span><\/label>\n\t\t\t<\/p>\n\t\t<\/td>\n\t\t<td>\n\t\t\t<p><label> Marital Status: <span class=\"wpcf7-form-control-wrap\" data-name=\"marital-status\"><select class=\"wpcf7-form-control wpcf7-select wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" name=\"marital-status\"><option value=\"\">&#8212;Please choose an option&#8212;<\/option><option value=\"Married\">Married<\/option><option value=\"Single\">Single<\/option><option value=\"Common Law\">Common Law<\/option><option value=\"Divorced\">Divorced<\/option><option value=\"Separated\">Separated<\/option><\/select><\/span><\/label>\n\t\t\t<\/p>\n\t\t<\/td>\n\t<\/tr>\n\t<tr>\n\t\t<td>\n\t\t\t<p><label>Language Spoken in home:<br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"language-home\"><select class=\"wpcf7-form-control wpcf7-select wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" multiple=\"multiple\" name=\"language-home[]\"><option value=\"French\">French<\/option><option value=\"English\">English<\/option><option value=\"Other (please specify)\">Other (please specify)<\/option><\/select><\/span><\/label>\n\t\t\t<\/p>\n\t\t<\/td>\n\t\t<td>\n\t\t\t<p><label>Other Language:<br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"other-language-home\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"other-language-home\" \/><\/span><\/label>\n\t\t\t<\/p>\n\t\t<\/td>\n\t<\/tr>\n<\/table>\n<p>Per cent Language is spoken in home\n<\/p>\n<table>\n\t<tr>\n\t\t<td>\n\t\t\t<p><label>French: <span class=\"wpcf7-form-control-wrap\" data-name=\"percent-french\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" placeholder=\"%\" value=\"\" type=\"text\" name=\"percent-french\" \/><\/span><\/label>\n\t\t\t<\/p>\n\t\t<\/td>\n\t\t<td>\n\t\t\t<p><label>English: <span class=\"wpcf7-form-control-wrap\" data-name=\"percent-english\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" placeholder=\"%\" value=\"\" type=\"text\" name=\"percent-english\" \/><\/span><\/label>\n\t\t\t<\/p>\n\t\t<\/td>\n\t\t<td>\n\t\t\t<p><label>Other: <span class=\"wpcf7-form-control-wrap\" data-name=\"percent-other\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" placeholder=\"%\" value=\"\" type=\"text\" name=\"percent-other\" \/><\/span><\/label>\n\t\t\t<\/p>\n\t\t<\/td>\n\t<\/tr>\n<\/table>\n<p><input class=\"wpcf7-form-control wpcf7-submit has-spinner btn-send\" type=\"submit\" value=\"Submit\" \/>\n<\/p><div class=\"wpcf7-response-output\" aria-hidden=\"true\"><\/div>\n<\/form>\n<\/div>\n\n","protected":false},"author":2,"featured_media":0,"parent":0,"menu_order":0,"comment_status":"closed","ping_status":"closed","template":"","meta":{"_et_pb_use_builder":"on","_et_pb_old_content":"","_et_gb_content_width":"","om_disable_all_campaigns":false,"_monsterinsights_skip_tracking":false,"_monsterinsights_sitenote_active":false,"_monsterinsights_sitenote_note":"","_monsterinsights_sitenote_category":0,"footnotes":""},"class_list":["post-1079","page","type-page","status-publish","hentry"],"_links":{"self":[{"href":"https:\/\/wordplaysudburymanitoulin.ca\/fr\/wp-json\/wp\/v2\/pages\/1079","targetHints":{"allow":["GET"]}}],"collection":[{"href":"https:\/\/wordplaysudburymanitoulin.ca\/fr\/wp-json\/wp\/v2\/pages"}],"about":[{"href":"https:\/\/wordplaysudburymanitoulin.ca\/fr\/wp-json\/wp\/v2\/types\/page"}],"author":[{"embeddable":true,"href":"https:\/\/wordplaysudburymanitoulin.ca\/fr\/wp-json\/wp\/v2\/users\/2"}],"replies":[{"embeddable":true,"href":"https:\/\/wordplaysudburymanitoulin.ca\/fr\/wp-json\/wp\/v2\/comments?post=1079"}],"version-history":[{"count":2,"href":"https:\/\/wordplaysudburymanitoulin.ca\/fr\/wp-json\/wp\/v2\/pages\/1079\/revisions"}],"predecessor-version":[{"id":1082,"href":"https:\/\/wordplaysudburymanitoulin.ca\/fr\/wp-json\/wp\/v2\/pages\/1079\/revisions\/1082"}],"wp:attachment":[{"href":"https:\/\/wordplaysudburymanitoulin.ca\/fr\/wp-json\/wp\/v2\/media?parent=1079"}],"curies":[{"name":"wp","href":"https:\/\/api.w.org\/{rel}","templated":true}]}}