{"id":4497,"date":"2019-12-09T13:34:20","date_gmt":"2019-12-09T10:34:20","guid":{"rendered":"https:\/\/reachabatherapy.com\/reach-client-intake-form-2\/"},"modified":"2025-10-11T09:52:01","modified_gmt":"2025-10-11T06:52:01","slug":"%d8%a5%d8%b3%d8%aa%d9%85%d8%a7%d8%b1%d8%a9-%d8%aa%d8%b3%d8%ac%d9%8a%d9%84-%d8%a7%d9%84%d8%b9%d9%85%d9%84%d8%a7%d8%a1","status":"publish","type":"page","link":"https:\/\/reachabatherapy.com\/ar\/%d8%a5%d8%b3%d8%aa%d9%85%d8%a7%d8%b1%d8%a9-%d8%aa%d8%b3%d8%ac%d9%8a%d9%84-%d8%a7%d9%84%d8%b9%d9%85%d9%84%d8%a7%d8%a1\/","title":{"rendered":"\u0646\u0645\u0648\u0630\u062c \u0627\u0633\u062a\u0642\u0628\u0627\u0644 \u0627\u0644\u0639\u0645\u0644\u0627\u0621"},"content":{"rendered":"<div class=\"wpb-content-wrapper\"><div class=\"vc_row wpb_row vc_row-fluid vc_custom_1619361934881 vc_row-has-fill\"><div class=\"wpb_column vc_column_container vc_col-sm-12\"><div class=\"vc_column-inner vc_custom_1575897730228\"><div class=\"wpb_wrapper\"><div class=\"qodef-content-grid\"><div class=\"vc_row wpb_row vc_inner vc_row-fluid\"><div class=\"wpb_column vc_column_container vc_col-sm-2\"><div class=\"vc_column-inner vc_custom_1575901184522\"><div class=\"wpb_wrapper\"><\/div><\/div><\/div><div class=\"wpb_column vc_column_container vc_col-sm-8\"><div class=\"vc_column-inner\"><div class=\"wpb_wrapper\"><div class=\"qodef-shortcode qodef-m  qodef-section-title qodef-alignment--center \">\n\t\t\t\t<h1 class=\"qodef-m-title\" >\n\t\t\t\t\tIntake Case History &amp; Family Needs Profile\t\t\t<\/h1>\n\t\t<div class=\"qodef-m-text\" >At Reach Behavior and Development Center, we are committed to safeguarding the privacy and confidentiality of the information provided by our clients. As a BHCOE (Behavioral Health Center of Excellence) facility, we adhere to stringent standards to ensure the protection of sensitive data. Upon completing this form, our team will contact you to schedule your consultation at a convenient time.<\/div>\n<\/div><div class=\"vc_empty_space\"   style=\"height: 59px\"><span class=\"vc_empty_space_inner\"><\/span><\/div><script type=\"text\/javascript\">var gform;gform||(document.addEventListener(\"gform_main_scripts_loaded\",function(){gform.scriptsLoaded=!0}),window.addEventListener(\"DOMContentLoaded\",function(){gform.domLoaded=!0}),gform={domLoaded:!1,scriptsLoaded:!1,initializeOnLoaded:function(o){gform.domLoaded&&gform.scriptsLoaded?o():!gform.domLoaded&&gform.scriptsLoaded?window.addEventListener(\"DOMContentLoaded\",o):document.addEventListener(\"gform_main_scripts_loaded\",o)},hooks:{action:{},filter:{}},addAction:function(o,n,r,t){gform.addHook(\"action\",o,n,r,t)},addFilter:function(o,n,r,t){gform.addHook(\"filter\",o,n,r,t)},doAction:function(o){gform.doHook(\"action\",o,arguments)},applyFilters:function(o){return gform.doHook(\"filter\",o,arguments)},removeAction:function(o,n){gform.removeHook(\"action\",o,n)},removeFilter:function(o,n,r){gform.removeHook(\"filter\",o,n,r)},addHook:function(o,n,r,t,i){null==gform.hooks[o][n]&&(gform.hooks[o][n]=[]);var e=gform.hooks[o][n];null==i&&(i=n+\"_\"+e.length),gform.hooks[o][n].push({tag:i,callable:r,priority:t=null==t?10:t})},doHook:function(n,o,r){var t;if(r=Array.prototype.slice.call(r,1),null!=gform.hooks[n][o]&&((o=gform.hooks[n][o]).sort(function(o,n){return o.priority-n.priority}),o.forEach(function(o){\"function\"!=typeof(t=o.callable)&&(t=window[t]),\"action\"==n?t.apply(null,r):r[0]=t.apply(null,r)})),\"filter\"==n)return r[0]},removeHook:function(o,n,t,i){var r;null!=gform.hooks[o][n]&&(r=(r=gform.hooks[o][n]).filter(function(o,n,r){return!!(null!=i&&i!=o.tag||null!=t&&t!=o.priority)}),gform.hooks[o][n]=r)}});<\/script>\n                <div class='gf_browser_gecko gform_wrapper gravity-theme gform-theme--no-framework' data-form-theme='gravity-theme' data-form-index='0' id='gform_wrapper_8' ><form method='post' enctype='multipart\/form-data'  id='gform_8'  action='\/ar\/wp-json\/wp\/v2\/pages\/4497' data-formid='8' >\n                        <div class='gform-body gform_body'><div id='gform_fields_8' class='gform_fields top_label form_sublabel_above description_below'><div id=\"field_8_15\"  class=\"gfield gfield--type-section gsection field_sublabel_above gfield--has-description field_description_below gfield_visibility_hidden\"  data-js-reload=\"field_8_15\"><div class='admin-hidden-markup'><i class='gform-icon gform-icon--hidden'><\/i><span>Hidden<\/span><\/div><h3 class=\"gsection_title\">Next Steps: Sync an Email Add-On<\/h3><div class='gsection_description' id='gfield_description_8_15'>To get the most out of your form, we suggest that you sync this form with an email add-on. To learn more about your email add-on options, visit the following page (https:\/\/www.gravityforms.com\/the-8-best-email-plugins-for-wordpress-in-2020\/). Important: Delete this tip before you publish the form.<\/div><\/div><fieldset id=\"field_8_74\"  class=\"gfield gfield--type-checkbox gfield--type-choice gfield--width-full gfield_contains_required field_sublabel_above gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_8_74\"><legend class='gfield_label gform-field-label gfield_label_before_complex'  >How did you hear about us?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(\u0645\u0637\u0644\u0648\u0628)<\/span><\/span><\/legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox' id='input_8_74'><div class='gchoice gchoice_8_74_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_74.1' type='checkbox'  value='Social Media'  id='choice_8_74_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_8_74_1' id='label_8_74_1' class='gform-field-label gform-field-label--type-inline'>Social Media<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_8_74_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_74.2' type='checkbox'  value='Online Ads'  id='choice_8_74_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_8_74_2' id='label_8_74_2' class='gform-field-label gform-field-label--type-inline'>Online Ads<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_8_74_3'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_74.3' type='checkbox'  value='Google'  id='choice_8_74_3'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_8_74_3' id='label_8_74_3' class='gform-field-label gform-field-label--type-inline'>Google<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_8_74_4'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_74.4' type='checkbox'  value='Friend'  id='choice_8_74_4'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_8_74_4' id='label_8_74_4' class='gform-field-label gform-field-label--type-inline'>Friend<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_8_74_5'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_74.5' type='checkbox'  value='Family'  id='choice_8_74_5'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_8_74_5' id='label_8_74_5' class='gform-field-label gform-field-label--type-inline'>Family<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_8_74_6'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_74.6' type='checkbox'  value='Doctor'  id='choice_8_74_6'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_8_74_6' id='label_8_74_6' class='gform-field-label gform-field-label--type-inline'>Doctor<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_8_74_7'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_74.7' type='checkbox'  value='School \/ Teacher'  id='choice_8_74_7'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_8_74_7' id='label_8_74_7' class='gform-field-label gform-field-label--type-inline'>School \/ Teacher<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_8_74_8'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_74.8' type='checkbox'  value='Other'  id='choice_8_74_8'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_8_74_8' id='label_8_74_8' class='gform-field-label gform-field-label--type-inline'>Other<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_8_84\"  class=\"gfield gfield--type-text gfield--width-full field_sublabel_above gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_8_84\"><label class='gfield_label gform-field-label' for='input_8_84' >Reffered by:<\/label><div class='ginput_container ginput_container_text'><input name='input_84' id='input_8_84' type='text' value='' class='large'      aria-invalid=\"false\"   \/> <\/div><\/div><div id=\"field_8_16\"  class=\"gfield gfield--type-text gfield--width-half gfield_contains_required field_sublabel_above gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_8_16\"><label class='gfield_label gform-field-label' for='input_8_16' >Child&#039;s Full Name<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(\u0645\u0637\u0644\u0648\u0628)<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_16' id='input_8_16' type='text' value='' class='large'     aria-required=\"true\" aria-invalid=\"false\"   \/> <\/div><\/div><div id=\"field_8_17\"  class=\"gfield gfield--type-date gfield--input-type-datepicker gfield--datepicker-no-icon gfield--width-half gfield_contains_required field_sublabel_above gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_8_17\"><label class='gfield_label gform-field-label' for='input_8_17' >Date of Birth<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(\u0645\u0637\u0644\u0648\u0628)<\/span><\/span><\/label><div class='ginput_container ginput_container_date'>\n                            <input name='input_17' id='input_8_17' type='text' value='' class='datepicker gform-datepicker dmy datepicker_no_icon gdatepicker-no-icon'   placeholder='\u064a\u0648\u0645\/\u0634\u0647\u0631\/\u0633\u0646\u0629' aria-describedby=\"input_8_17_date_format\" aria-invalid=\"false\" aria-required=\"true\"\/>\n                            <span id='input_8_17_date_format' class='screen-reader-text'>\u064a\u0648\u0645 \u0634\u0631\u0637\u0629 \u0645\u0627\u0626\u0644\u0629 \u0634\u0647\u0631 \u0634\u0631\u0637\u0629 \u0645\u0627\u0626\u0644\u0629 \u0633\u0646\u0629<\/span>\n                        <\/div>\n                        <input type='hidden' id='gforms_calendar_icon_input_8_17' class='gform_hidden' value='https:\/\/reachabatherapy.com\/wp-content\/plugins\/gravityforms\/images\/datepicker\/datepicker.svg'\/><\/div><div id=\"field_8_89\"  class=\"gfield gfield--type-select gfield--width-half gfield_contains_required field_sublabel_above gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_8_89\"><label class='gfield_label gform-field-label' for='input_8_89' >Gender<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(\u0645\u0637\u0644\u0648\u0628)<\/span><\/span><\/label><div class='ginput_container ginput_container_select'><select name='input_89' id='input_8_89' class='large gfield_select'    aria-required=\"true\" aria-invalid=\"false\" ><option value='Male' >Male<\/option><option value='Female' >Female<\/option><\/select><\/div><\/div><div id=\"field_8_90\"  class=\"gfield gfield--type-text gfield--width-half gfield_contains_required field_sublabel_above gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_8_90\"><label class='gfield_label gform-field-label' for='input_8_90' >Nationality<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(\u0645\u0637\u0644\u0648\u0628)<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_90' id='input_8_90' type='text' value='' class='large'     aria-required=\"true\" aria-invalid=\"false\"   \/> <\/div><\/div><div id=\"field_8_75\"  class=\"gfield gfield--type-text gfield--width-full gfield_contains_required field_sublabel_above gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_8_75\"><label class='gfield_label gform-field-label' for='input_8_75' >Home Address<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(\u0645\u0637\u0644\u0648\u0628)<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_75' id='input_8_75' type='text' value='' class='large'     aria-required=\"true\" aria-invalid=\"false\"   \/> <\/div><\/div><div id=\"field_8_76\"  class=\"gfield gfield--type-text gfield--width-half gfield_contains_required field_sublabel_above gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_8_76\"><label class='gfield_label gform-field-label' for='input_8_76' >City<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(\u0645\u0637\u0644\u0648\u0628)<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_76' id='input_8_76' type='text' value='' class='large'     aria-required=\"true\" aria-invalid=\"false\"   \/> <\/div><\/div><div id=\"field_8_77\"  class=\"gfield gfield--type-text gfield--width-half gfield_contains_required field_sublabel_above gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_8_77\"><label class='gfield_label gform-field-label' for='input_8_77' >Country<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(\u0645\u0637\u0644\u0648\u0628)<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_77' id='input_8_77' type='text' value='' class='large'     aria-required=\"true\" aria-invalid=\"false\"   \/> <\/div><\/div><div id=\"field_8_19\"  class=\"gfield gfield--type-textarea gfield--width-full gfield_contains_required field_sublabel_above gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_8_19\"><label class='gfield_label gform-field-label' for='input_8_19' >What languages are spoken at home?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(\u0645\u0637\u0644\u0648\u0628)<\/span><\/span><\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_19' id='input_8_19' class='textarea small'     aria-required=\"true\" aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/div><div id=\"field_8_20\"  class=\"gfield gfield--type-text gfield--width-full gfield_contains_required field_sublabel_above gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_8_20\"><label class='gfield_label gform-field-label' for='input_8_20' >Child&#039;s Strongest Language<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(\u0645\u0637\u0644\u0648\u0628)<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_20' id='input_8_20' type='text' value='' class='large'     aria-required=\"true\" aria-invalid=\"false\"   \/> <\/div><\/div><div id=\"field_8_38\"  class=\"gfield gfield--type-text gfield--width-half field_sublabel_above gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_8_38\"><label class='gfield_label gform-field-label' for='input_8_38' >School\/Nursery Name<\/label><div class='ginput_container ginput_container_text'><input name='input_38' id='input_8_38' type='text' value='' class='large'      aria-invalid=\"false\"   \/> <\/div><\/div><div id=\"field_8_39\"  class=\"gfield gfield--type-text gfield--width-half field_sublabel_above gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_8_39\"><label class='gfield_label gform-field-label' for='input_8_39' >Grade Level<\/label><div class='ginput_container ginput_container_text'><input name='input_39' id='input_8_39' type='text' value='' class='large'      aria-invalid=\"false\"   \/> <\/div><\/div><div id=\"field_8_26\"  class=\"gfield gfield--type-section gsection field_sublabel_above gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_8_26\"><h3 class=\"gsection_title\"><\/h3><\/div><div id=\"field_8_21\"  class=\"gfield gfield--type-text gfield--width-third gfield_contains_required field_sublabel_above gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_8_21\"><label class='gfield_label gform-field-label' for='input_8_21' >Parent\/Guardian #1<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(\u0645\u0637\u0644\u0648\u0628)<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_21' id='input_8_21' type='text' value='' class='large'     aria-required=\"true\" aria-invalid=\"false\"   \/> <\/div><\/div><div id=\"field_8_22\"  class=\"gfield gfield--type-phone gfield--width-third gfield_contains_required field_sublabel_above gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_8_22\"><label class='gfield_label gform-field-label' for='input_8_22' >Phone Number<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(\u0645\u0637\u0644\u0648\u0628)<\/span><\/span><\/label><div class='ginput_container ginput_container_phone'><input name='input_22' id='input_8_22' type='text' value='' class='large'   aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_8_25\"  class=\"gfield gfield--type-email gfield--width-third gfield_contains_required field_sublabel_above gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_8_25\"><label class='gfield_label gform-field-label' for='input_8_25' >Email Address<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(\u0645\u0637\u0644\u0648\u0628)<\/span><\/span><\/label><div class='ginput_container ginput_container_email'>\n                            <input name='input_25' id='input_8_25' type='text' value='' class='large'    aria-required=\"true\" aria-invalid=\"false\"  \/>\n                        <\/div><\/div><div id=\"field_8_80\"  class=\"gfield gfield--type-text gfield--width-half field_sublabel_above gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_8_80\"><label class='gfield_label gform-field-label' for='input_8_80' >Occupation<\/label><div class='ginput_container ginput_container_text'><input name='input_80' id='input_8_80' type='text' value='' class='large'      aria-invalid=\"false\"   \/> <\/div><\/div><div id=\"field_8_81\"  class=\"gfield gfield--type-text gfield--width-half field_sublabel_above gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_8_81\"><label class='gfield_label gform-field-label' for='input_8_81' >Employer<\/label><div class='ginput_container ginput_container_text'><input name='input_81' id='input_8_81' type='text' value='' class='large'      aria-invalid=\"false\"   \/> <\/div><\/div><div id=\"field_8_28\"  class=\"gfield gfield--type-text gfield--width-third field_sublabel_above gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_8_28\"><label class='gfield_label gform-field-label' for='input_8_28' >Parent Guardian #2<\/label><div class='ginput_container ginput_container_text'><input name='input_28' id='input_8_28' type='text' value='' class='large'      aria-invalid=\"false\"   \/> <\/div><\/div><div id=\"field_8_29\"  class=\"gfield gfield--type-phone gfield--width-third field_sublabel_above gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_8_29\"><label class='gfield_label gform-field-label' for='input_8_29' >Phone Number<\/label><div class='ginput_container ginput_container_phone'><input name='input_29' id='input_8_29' type='text' value='' class='large'    aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_8_30\"  class=\"gfield gfield--type-email gfield--width-third field_sublabel_above gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_8_30\"><label class='gfield_label gform-field-label' for='input_8_30' >Email Address<\/label><div class='ginput_container ginput_container_email'>\n                            <input name='input_30' id='input_8_30' type='text' value='' class='large'     aria-invalid=\"false\"  \/>\n                        <\/div><\/div><div id=\"field_8_82\"  class=\"gfield gfield--type-text gfield--width-half field_sublabel_above gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_8_82\"><label class='gfield_label gform-field-label' for='input_8_82' >Occupation<\/label><div class='ginput_container ginput_container_text'><input name='input_82' id='input_8_82' type='text' value='' class='large'      aria-invalid=\"false\"   \/> <\/div><\/div><div id=\"field_8_83\"  class=\"gfield gfield--type-text gfield--width-half field_sublabel_above gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_8_83\"><label class='gfield_label gform-field-label' for='input_8_83' >Employer<\/label><div class='ginput_container ginput_container_text'><input name='input_83' id='input_8_83' type='text' value='' class='large'      aria-invalid=\"false\"   \/> <\/div><\/div><fieldset id=\"field_8_78\"  class=\"gfield gfield--type-checkbox gfield--type-choice gfield--width-full gfield_contains_required field_sublabel_above gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_8_78\"><legend class='gfield_label gform-field-label gfield_label_before_complex'  >Preferred Mode of Contact<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(\u0645\u0637\u0644\u0648\u0628)<\/span><\/span><\/legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox' id='input_8_78'><div class='gchoice gchoice_8_78_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_78.1' type='checkbox'  value='Phone'  id='choice_8_78_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_8_78_1' id='label_8_78_1' class='gform-field-label gform-field-label--type-inline'>Phone<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_8_78_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_78.2' type='checkbox'  value='Email'  id='choice_8_78_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_8_78_2' id='label_8_78_2' class='gform-field-label gform-field-label--type-inline'>Email<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_8_78_3'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_78.3' type='checkbox'  value='Text Message'  id='choice_8_78_3'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_8_78_3' id='label_8_78_3' class='gform-field-label gform-field-label--type-inline'>Text Message<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_8_78_4'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_78.4' type='checkbox'  value='Other'  id='choice_8_78_4'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_8_78_4' id='label_8_78_4' class='gform-field-label gform-field-label--type-inline'>Other<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_8_79\"  class=\"gfield gfield--type-text gfield--width-full field_sublabel_above gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_8_79\"><label class='gfield_label gform-field-label' for='input_8_79' >Please specify any other preferred methods of contact below:<\/label><div class='ginput_container ginput_container_text'><input name='input_79' id='input_8_79' type='text' value='' class='large'      aria-invalid=\"false\"   \/> <\/div><\/div><div id=\"field_8_32\"  class=\"gfield gfield--type-section gsection field_sublabel_above gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_8_32\"><h3 class=\"gsection_title\"><\/h3><\/div><div id=\"field_8_34\"  class=\"gfield gfield--type-textarea gfield--width-full field_sublabel_above gfield--has-description field_description_above gfield_visibility_visible\"  data-js-reload=\"field_8_34\"><label class='gfield_label gform-field-label' for='input_8_34' >Siblings Information<\/label><div class='gfield_description' id='gfield_description_8_34'>Number of siblings, names, and ages:<\/div><div class='ginput_container ginput_container_textarea'><textarea name='input_34' id='input_8_34' class='textarea small'  aria-describedby=\"gfield_description_8_34\"    aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/div><div id=\"field_8_35\"  class=\"gfield gfield--type-text gfield--width-half field_sublabel_above gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_8_35\"><label class='gfield_label gform-field-label' for='input_8_35' >Emergency Contact Name<\/label><div class='ginput_container ginput_container_text'><input name='input_35' id='input_8_35' type='text' value='' class='large'      aria-invalid=\"false\"   \/> <\/div><\/div><div id=\"field_8_36\"  class=\"gfield gfield--type-phone gfield--width-half field_sublabel_above gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_8_36\"><label class='gfield_label gform-field-label' for='input_8_36' >Emergency Contact Number<\/label><div class='ginput_container ginput_container_phone'><input name='input_36' id='input_8_36' type='text' value='' class='large'    aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_8_41\"  class=\"gfield gfield--type-section gsection field_sublabel_above gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_8_41\"><h3 class=\"gsection_title\"><\/h3><\/div><div id=\"field_8_42\"  class=\"gfield gfield--type-text gfield--width-half field_sublabel_above gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_8_42\"><label class='gfield_label gform-field-label' for='input_8_42' >Medical History<\/label><div class='ginput_container ginput_container_text'><input name='input_42' id='input_8_42' type='text' value='' class='large'      aria-invalid=\"false\"   \/> <\/div><\/div><div id=\"field_8_43\"  class=\"gfield gfield--type-text gfield--width-half field_sublabel_above gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_8_43\"><label class='gfield_label gform-field-label' for='input_8_43' >Diagnosis<\/label><div class='ginput_container ginput_container_text'><input name='input_43' id='input_8_43' type='text' value='' class='large'      aria-invalid=\"false\"   \/> <\/div><\/div><fieldset id=\"field_8_44\"  class=\"gfield gfield--type-checkbox gfield--type-choice gfield--width-full field_sublabel_above gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_8_44\"><legend class='gfield_label gform-field-label gfield_label_before_complex'  >Please indicate which of the following services your child is currently receiving or has received in the past:<\/legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox' id='input_8_44'><div class='gchoice gchoice_8_44_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_44.1' type='checkbox'  value='Behavior Therapy'  id='choice_8_44_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_8_44_1' id='label_8_44_1' class='gform-field-label gform-field-label--type-inline'>Behavior Therapy<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_8_44_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_44.2' type='checkbox'  value='Speech Language Therapy'  id='choice_8_44_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_8_44_2' id='label_8_44_2' class='gform-field-label gform-field-label--type-inline'>Speech Language Therapy<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_8_44_3'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_44.3' type='checkbox'  value='Occupational Therapy'  id='choice_8_44_3'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_8_44_3' id='label_8_44_3' class='gform-field-label gform-field-label--type-inline'>Occupational Therapy<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_8_44_4'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_44.4' type='checkbox'  value='Physiotherapy'  id='choice_8_44_4'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_8_44_4' id='label_8_44_4' class='gform-field-label gform-field-label--type-inline'>Physiotherapy<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_8_44_5'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_44.5' type='checkbox'  value='Other'  id='choice_8_44_5'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_8_44_5' id='label_8_44_5' class='gform-field-label gform-field-label--type-inline'>Other<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_8_45\"  class=\"gfield gfield--type-select gfield--width-full field_sublabel_above gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_8_45\"><label class='gfield_label gform-field-label' for='input_8_45' >Are your child\u2019s immunizations up to date?<\/label><div class='ginput_container ginput_container_select'><select name='input_45' id='input_8_45' class='large gfield_select'     aria-invalid=\"false\" ><option value='' selected='selected' class='gf_placeholder'>Please select your answer.<\/option><option value='Yes' >Yes<\/option><option value='No' >No<\/option><option value='Unsure' >Unsure<\/option><\/select><\/div><\/div><div id=\"field_8_46\"  class=\"gfield gfield--type-select gfield--width-full field_sublabel_above gfield--has-description field_description_above gfield_visibility_visible\"  data-js-reload=\"field_8_46\"><label class='gfield_label gform-field-label' for='input_8_46' >Does your child have any medical problems for which he\/she sees a doctor or takes medication?<\/label><div class='gfield_description' id='gfield_description_8_46'>(Examples: Asthma, Diabetes, Heart condition, Neurological condition)<\/div><div class='ginput_container ginput_container_select'><select name='input_46' id='input_8_46' class='large gfield_select'  aria-describedby=\"gfield_description_8_46\"   aria-invalid=\"false\" ><option value='' selected='selected' class='gf_placeholder'>Please select your answer.<\/option><option value='Yes' >Yes<\/option><option value='No' >No<\/option><\/select><\/div><\/div><div id=\"field_8_47\"  class=\"gfield gfield--type-text gfield--width-full field_sublabel_above gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_8_47\"><label class='gfield_label gform-field-label' for='input_8_47' >If Yes, what?<\/label><div class='ginput_container ginput_container_text'><input name='input_47' id='input_8_47' type='text' value='' class='large'      aria-invalid=\"false\"   \/> <\/div><\/div><div id=\"field_8_48\"  class=\"gfield gfield--type-select gfield--width-full gfield_contains_required field_sublabel_above gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_8_48\"><label class='gfield_label gform-field-label' for='input_8_48' >Does your child have any allergies?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(\u0645\u0637\u0644\u0648\u0628)<\/span><\/span><\/label><div class='ginput_container ginput_container_select'><select name='input_48' id='input_8_48' class='large gfield_select'    aria-required=\"true\" aria-invalid=\"false\" ><option value='' selected='selected' class='gf_placeholder'>Please select your answer.<\/option><option value='Yes' >Yes<\/option><option value='No' >No<\/option><option value='Unsure' >Unsure<\/option><\/select><\/div><\/div><div id=\"field_8_49\"  class=\"gfield gfield--type-text gfield--width-half field_sublabel_above gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_8_49\"><label class='gfield_label gform-field-label' for='input_8_49' >If Yes, what?<\/label><div class='ginput_container ginput_container_text'><input name='input_49' id='input_8_49' type='text' value='' class='large'      aria-invalid=\"false\"   \/> <\/div><\/div><div id=\"field_8_50\"  class=\"gfield gfield--type-select gfield--width-half field_sublabel_above gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_8_50\"><label class='gfield_label gform-field-label' for='input_8_50' >How serious?<\/label><div class='ginput_container ginput_container_select'><select name='input_50' id='input_8_50' class='large gfield_select'     aria-invalid=\"false\" ><option value='' selected='selected' class='gf_placeholder'>Please select your answer.<\/option><option value='Potentially Life-threatening' >Potentially Life-threatening<\/option><option value='Minor \/ Ongoing' >Minor \/ Ongoing<\/option><option value='Occasional Problem' >Occasional Problem<\/option><\/select><\/div><\/div><div id=\"field_8_51\"  class=\"gfield gfield--type-select gfield--width-full gfield_contains_required field_sublabel_above gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_8_51\"><label class='gfield_label gform-field-label' for='input_8_51' >Does your child have any hearing or vision problems?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(\u0645\u0637\u0644\u0648\u0628)<\/span><\/span><\/label><div class='ginput_container ginput_container_select'><select name='input_51' id='input_8_51' class='large gfield_select'    aria-required=\"true\" aria-invalid=\"false\" ><option value='' selected='selected' class='gf_placeholder'>Please select your answer.<\/option><option value='Yes' >Yes<\/option><option value='No' >No<\/option><\/select><\/div><\/div><div id=\"field_8_53\"  class=\"gfield gfield--type-textarea gfield--width-full field_sublabel_above gfield--no-description field_description_above gfield_visibility_visible\"  data-js-reload=\"field_8_53\"><label class='gfield_label gform-field-label' for='input_8_53' >Please list the date of the last hearing\/vision test and the professional who performed it (e.g., Doctor, Optometrist, Audiologist, School).<\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_53' id='input_8_53' class='textarea small'      aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/div><fieldset id=\"field_8_54\"  class=\"gfield gfield--type-checkbox gfield--type-choice gfield--width-full gfield_contains_required field_sublabel_above gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_8_54\"><legend class='gfield_label gform-field-label gfield_label_before_complex'  >Mode of Communication<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(\u0645\u0637\u0644\u0648\u0628)<\/span><\/span><\/legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox' id='input_8_54'><div class='gchoice gchoice_8_54_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_54.1' type='checkbox'  value='Pointing'  id='choice_8_54_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_8_54_1' id='label_8_54_1' class='gform-field-label gform-field-label--type-inline'>Pointing<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_8_54_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_54.2' type='checkbox'  value='Gestures'  id='choice_8_54_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_8_54_2' id='label_8_54_2' class='gform-field-label gform-field-label--type-inline'>Gestures<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_8_54_3'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_54.3' type='checkbox'  value='Verbal'  id='choice_8_54_3'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_8_54_3' id='label_8_54_3' class='gform-field-label gform-field-label--type-inline'>Verbal<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_8_54_4'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_54.4' type='checkbox'  value='Sign language'  id='choice_8_54_4'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_8_54_4' id='label_8_54_4' class='gform-field-label gform-field-label--type-inline'>Sign language<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_8_54_5'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_54.5' type='checkbox'  value='Pictures'  id='choice_8_54_5'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_8_54_5' id='label_8_54_5' class='gform-field-label gform-field-label--type-inline'>Pictures<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_8_54_6'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_54.6' type='checkbox'  value='High-tech augmentative alternative communication'  id='choice_8_54_6'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_8_54_6' id='label_8_54_6' class='gform-field-label gform-field-label--type-inline'>High-tech augmentative alternative communication<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_8_55\"  class=\"gfield gfield--type-textarea gfield--width-full field_sublabel_above gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_8_55\"><label class='gfield_label gform-field-label' for='input_8_55' >What are your concerns regarding your child\u2019s Social Skills?<\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_55' id='input_8_55' class='textarea small'      aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/div><div id=\"field_8_56\"  class=\"gfield gfield--type-textarea gfield--width-full field_sublabel_above gfield--has-description field_description_above gfield_visibility_visible\"  data-js-reload=\"field_8_56\"><label class='gfield_label gform-field-label' for='input_8_56' >What are your concerns regarding your child\u2019s Fine Motor Skills?<\/label><div class='gfield_description' id='gfield_description_8_56'>(For example: Pencil grip, Scissor skills, Writing name\/writing legibly)<\/div><div class='ginput_container ginput_container_textarea'><textarea name='input_56' id='input_8_56' class='textarea small'  aria-describedby=\"gfield_description_8_56\"    aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/div><div id=\"field_8_57\"  class=\"gfield gfield--type-textarea gfield--width-full field_sublabel_above gfield--has-description field_description_above gfield_visibility_visible\"  data-js-reload=\"field_8_57\"><label class='gfield_label gform-field-label' for='input_8_57' >What are your concerns regarding your child\u2019s Gross Motor Skills?<\/label><div class='gfield_description' id='gfield_description_8_57'>(For example: Ball kicking, Catching, Throwing, Aiming at a given target?)<\/div><div class='ginput_container ginput_container_textarea'><textarea name='input_57' id='input_8_57' class='textarea small'  aria-describedby=\"gfield_description_8_57\"    aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/div><div id=\"field_8_58\"  class=\"gfield gfield--type-textarea gfield--width-full field_sublabel_above gfield--has-description field_description_above gfield_visibility_visible\"  data-js-reload=\"field_8_58\"><label class='gfield_label gform-field-label' for='input_8_58' >What are your concerns regarding sensory-seeking behavior?<\/label><div class='gfield_description' id='gfield_description_8_58'>(For example: Flapping hands, Accepting and\/or avoiding different textures, Covers ears in loud environments)<\/div><div class='ginput_container ginput_container_textarea'><textarea name='input_58' id='input_8_58' class='textarea small'  aria-describedby=\"gfield_description_8_58\"    aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/div><div id=\"field_8_59\"  class=\"gfield gfield--type-textarea gfield--width-full field_sublabel_above gfield--no-description field_description_above gfield_visibility_visible\"  data-js-reload=\"field_8_59\"><label class='gfield_label gform-field-label' for='input_8_59' >What are your concerns regarding your child\u2019s play skills?<\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_59' id='input_8_59' class='textarea small'      aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/div><div id=\"field_8_60\"  class=\"gfield gfield--type-textarea gfield--width-full field_sublabel_above gfield--no-description field_description_above gfield_visibility_visible\"  data-js-reload=\"field_8_60\"><label class='gfield_label gform-field-label' for='input_8_60' >What are your concerns regarding your child\u2019s academics?<\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_60' id='input_8_60' class='textarea small'      aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/div><div id=\"field_8_62\"  class=\"gfield gfield--type-textarea gfield--width-full field_sublabel_above gfield--no-description field_description_above gfield_visibility_visible\"  data-js-reload=\"field_8_62\"><label class='gfield_label gform-field-label' for='input_8_62' >Are there any concerns in school?<\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_62' id='input_8_62' class='textarea small'      aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/div><div id=\"field_8_63\"  class=\"gfield gfield--type-textarea gfield--width-full field_sublabel_above gfield--has-description field_description_above gfield_visibility_visible\"  data-js-reload=\"field_8_63\"><label class='gfield_label gform-field-label' for='input_8_63' >Are there any concerns with your child\u2019s daily living skills?<\/label><div class='gfield_description' id='gfield_description_8_63'>(For example: eating, toileting, dressing, washing\/bathing)<\/div><div class='ginput_container ginput_container_textarea'><textarea name='input_63' id='input_8_63' class='textarea small'  aria-describedby=\"gfield_description_8_63\"    aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/div><fieldset id=\"field_8_65\"  class=\"gfield gfield--type-checkbox gfield--type-choice gfield--width-half field_sublabel_above gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_8_65\"><legend class='gfield_label gform-field-label gfield_label_before_complex'  >Does your child have any of the following?<\/legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox' id='input_8_65'><div class='gchoice gchoice_8_65_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_65.1' type='checkbox'  value='Tantrums'  id='choice_8_65_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_8_65_1' id='label_8_65_1' class='gform-field-label gform-field-label--type-inline'>Tantrums<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_8_65_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_65.2' type='checkbox'  value='Screaming'  id='choice_8_65_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_8_65_2' id='label_8_65_2' class='gform-field-label gform-field-label--type-inline'>Screaming<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_8_65_3'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_65.3' type='checkbox'  value='Biting'  id='choice_8_65_3'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_8_65_3' id='label_8_65_3' class='gform-field-label gform-field-label--type-inline'>Biting<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_8_65_4'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_65.4' type='checkbox'  value='Hitting'  id='choice_8_65_4'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_8_65_4' id='label_8_65_4' class='gform-field-label gform-field-label--type-inline'>Hitting<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_8_65_5'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_65.5' type='checkbox'  value='Spitting'  id='choice_8_65_5'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_8_65_5' id='label_8_65_5' class='gform-field-label gform-field-label--type-inline'>Spitting<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_8_65_6'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_65.6' type='checkbox'  value='Running away'  id='choice_8_65_6'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_8_65_6' id='label_8_65_6' class='gform-field-label gform-field-label--type-inline'>Running away<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_8_66\"  class=\"gfield gfield--type-text gfield--width-half field_sublabel_above gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_8_66\"><label class='gfield_label gform-field-label' for='input_8_66' >Are there any other behaviors that are harmful to him\/herself or others?<\/label><div class='ginput_container ginput_container_text'><input name='input_66' id='input_8_66' type='text' value='' class='large'      aria-invalid=\"false\"   \/> <\/div><\/div><div id=\"field_8_67\"  class=\"gfield gfield--type-textarea gfield--width-full field_sublabel_above gfield--no-description field_description_above gfield_visibility_visible\"  data-js-reload=\"field_8_67\"><label class='gfield_label gform-field-label' for='input_8_67' >Please list any items that scare or frighten your child or anything that your child does not like:<\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_67' id='input_8_67' class='textarea small'      aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/div><div id=\"field_8_68\"  class=\"gfield gfield--type-textarea gfield--width-full gfield_contains_required field_sublabel_above gfield--no-description field_description_above gfield_visibility_visible\"  data-js-reload=\"field_8_68\"><label class='gfield_label gform-field-label' for='input_8_68' >Please list your child\u2019s preferred toys and activities:<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(\u0645\u0637\u0644\u0648\u0628)<\/span><\/span><\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_68' id='input_8_68' class='textarea small'     aria-required=\"true\" aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/div><div id=\"field_8_69\"  class=\"gfield gfield--type-section gsection field_sublabel_above gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_8_69\"><h3 class=\"gsection_title\"><\/h3><\/div><fieldset id=\"field_8_70\"  class=\"gfield gfield--type-checkbox gfield--type-choice gfield--width-full gfield_contains_required field_sublabel_above gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_8_70\"><legend class='gfield_label gform-field-label gfield_label_before_complex'  >Please indicate what service\/s you are seeking:<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(\u0645\u0637\u0644\u0648\u0628)<\/span><\/span><\/legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox' id='input_8_70'><div class='gchoice gchoice_8_70_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_70.1' type='checkbox'  value='Behavior Therapy'  id='choice_8_70_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_8_70_1' id='label_8_70_1' class='gform-field-label gform-field-label--type-inline'>Behavior Therapy<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_8_70_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_70.2' type='checkbox'  value='Speech Language Therapy'  id='choice_8_70_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_8_70_2' id='label_8_70_2' class='gform-field-label gform-field-label--type-inline'>Speech Language Therapy<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_8_70_3'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_70.3' type='checkbox'  value='Occupational Therapy'  id='choice_8_70_3'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_8_70_3' id='label_8_70_3' class='gform-field-label gform-field-label--type-inline'>Occupational Therapy<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_8_70_4'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_70.4' type='checkbox'  value='Feeding Therapy'  id='choice_8_70_4'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_8_70_4' id='label_8_70_4' class='gform-field-label gform-field-label--type-inline'>Feeding Therapy<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_8_70_5'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_70.5' type='checkbox'  value='Social Skills'  id='choice_8_70_5'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_8_70_5' id='label_8_70_5' class='gform-field-label gform-field-label--type-inline'>Social Skills<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_8_70_6'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_70.6' type='checkbox'  value='School Shadow'  id='choice_8_70_6'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_8_70_6' id='label_8_70_6' class='gform-field-label gform-field-label--type-inline'>School Shadow<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_8_70_7'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_70.7' type='checkbox'  value='Toilet Training'  id='choice_8_70_7'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_8_70_7' id='label_8_70_7' class='gform-field-label gform-field-label--type-inline'>Toilet Training<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_8_70_8'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_70.8' type='checkbox'  value='School Readiness Program'  id='choice_8_70_8'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_8_70_8' id='label_8_70_8' class='gform-field-label gform-field-label--type-inline'>School Readiness Program<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_8_70_9'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_70.9' type='checkbox'  value='Academic Support Program'  id='choice_8_70_9'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_8_70_9' id='label_8_70_9' class='gform-field-label gform-field-label--type-inline'>Academic Support Program<\/label>\n\t\t\t\t\t\t\t<\/div><button type=\"button\" id=\"button_70_select_all\" class=\"gfield_choice_all_toggle gform-theme-button--size-sm\" onclick=\"gformToggleCheckboxes( this )\" data-checked=\"0\" data-label-select=\"\u062d\u062f\u064a\u062f \u0627\u0644\u0643\u0644\" data-label-deselect=\"\u0627\u0644\u063a\u0627\u0621 \u062a\u062d\u062f\u064a\u062f \u0627\u0644\u0643\u0644\">\u062d\u062f\u064a\u062f \u0627\u0644\u0643\u0644<\/button><\/div><\/div><\/fieldset><div id=\"field_8_85\"  class=\"gfield gfield--type-text gfield--width-full field_sublabel_above gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_8_85\"><label class='gfield_label gform-field-label' for='input_8_85' >Others Please Specify:<\/label><div class='ginput_container ginput_container_text'><input name='input_85' id='input_8_85' type='text' value='' class='large'      aria-invalid=\"false\"   \/> <\/div><\/div><div id=\"field_8_88\"  class=\"gfield gfield--type-select gfield--width-full field_sublabel_above gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_8_88\"><label class='gfield_label gform-field-label' for='input_8_88' >Please let us know if you would like an Arabic translator to join the session.<\/label><div class='ginput_container ginput_container_select'><select name='input_88' id='input_8_88' class='large gfield_select'     aria-invalid=\"false\" ><option value='' selected='selected' class='gf_placeholder'>Yes or No<\/option><option value='Yes' >Yes<\/option><option value='No' >No<\/option><\/select><\/div><\/div><div id=\"field_8_86\"  class=\"gfield gfield--type-textarea gfield--width-full gfield_contains_required field_sublabel_above gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_8_86\"><label class='gfield_label gform-field-label' for='input_8_86' >What goals do you have for your child\u2019s therapy and development?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(\u0645\u0637\u0644\u0648\u0628)<\/span><\/span><\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_86' id='input_8_86' class='textarea small'     aria-required=\"true\" aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/div><div id=\"field_8_72\"  class=\"gfield gfield--type-textarea gfield--width-full field_sublabel_above gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_8_72\"><label class='gfield_label gform-field-label' for='input_8_72' >Is there anything else you want us to know about your child or family?<\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_72' id='input_8_72' class='textarea small'      aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/div><div id=\"field_8_91\"  class=\"gfield gfield--type-honeypot gform_validation_container field_sublabel_above gfield--has-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_8_91\"><label class='gfield_label gform-field-label' for='input_8_91' >Comments<\/label><div class='ginput_container'><input name='input_91' id='input_8_91' type='text' 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