{"id":55229,"date":"2025-07-21T18:33:33","date_gmt":"2025-07-21T18:33:33","guid":{"rendered":"https:\/\/woundedwarriors.ca\/?page_id=55229"},"modified":"2025-07-21T18:33:37","modified_gmt":"2025-07-21T18:33:37","slug":"referral-assessment","status":"publish","type":"page","link":"https:\/\/woundedwarriors.ca\/fr\/referral-assessment\/","title":{"rendered":"Referral Assessment"},"content":{"rendered":"<p>[et_pb_section fb_built=\u00a0\u00bb1&Prime; disabled_on=\u00a0\u00bboff|off|off\u00a0\u00bb admin_label=\u00a0\u00bbRegistration\u00a0\u00bb module_id=\u00a0\u00bbregistration\u00a0\u00bb _builder_version=\u00a0\u00bb4.27.4&Prime; background_color=\u00a0\u00bb#003E5B\u00a0\u00bb custom_padding=\u00a0\u00bb25px||61px||false|false\u00a0\u00bb da_disable_devices=\u00a0\u00bboff|off|off\u00a0\u00bb collapsed=\u00a0\u00bboff\u00a0\u00bb global_colors_info=\u00a0\u00bb{}\u00a0\u00bb theme_builder_area=\u00a0\u00bbpost_content\u00a0\u00bb da_is_popup=\u00a0\u00bboff\u00a0\u00bb 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_module_preset=\u00a0\u00bbdefault\u00a0\u00bb theme_builder_area=\u00a0\u00bbpost_content\u00a0\u00bb hover_enabled=\u00a0\u00bb0&Prime; sticky_enabled=\u00a0\u00bb0&Prime;]<\/p>\n<script type=\"text\/javascript\">\n\/* <![CDATA[ *\/\nvar gform;gform||(document.addEventListener(\"gform_main_scripts_loaded\",function(){gform.scriptsLoaded=!0}),document.addEventListener(\"gform\/theme\/scripts_loaded\",function(){gform.themeScriptsLoaded=!0}),window.addEventListener(\"DOMContentLoaded\",function(){gform.domLoaded=!0}),gform={domLoaded:!1,scriptsLoaded:!1,themeScriptsLoaded:!1,isFormEditor:()=>\"function\"==typeof InitializeEditor,callIfLoaded:function(o){return!(!gform.domLoaded||!gform.scriptsLoaded||!gform.themeScriptsLoaded&&!gform.isFormEditor()||(gform.isFormEditor()&&console.warn(\"The use of gform.initializeOnLoaded() is deprecated in the form editor context and will be removed in Gravity Forms 3.1.\"),o(),0))},initializeOnLoaded:function(o){gform.callIfLoaded(o)||(document.addEventListener(\"gform_main_scripts_loaded\",()=>{gform.scriptsLoaded=!0,gform.callIfLoaded(o)}),document.addEventListener(\"gform\/theme\/scripts_loaded\",()=>{gform.themeScriptsLoaded=!0,gform.callIfLoaded(o)}),window.addEventListener(\"DOMContentLoaded\",()=>{gform.domLoaded=!0,gform.callIfLoaded(o)}))},hooks:{action:{},filter:{}},addAction:function(o,r,e,t){gform.addHook(\"action\",o,r,e,t)},addFilter:function(o,r,e,t){gform.addHook(\"filter\",o,r,e,t)},doAction:function(o){gform.doHook(\"action\",o,arguments)},applyFilters:function(o){return gform.doHook(\"filter\",o,arguments)},removeAction:function(o,r){gform.removeHook(\"action\",o,r)},removeFilter:function(o,r,e){gform.removeHook(\"filter\",o,r,e)},addHook:function(o,r,e,t,n){null==gform.hooks[o][r]&&(gform.hooks[o][r]=[]);var d=gform.hooks[o][r];null==n&&(n=r+\"_\"+d.length),gform.hooks[o][r].push({tag:n,callable:e,priority:t=null==t?10:t})},doHook:function(r,o,e){var t;if(e=Array.prototype.slice.call(e,1),null!=gform.hooks[r][o]&&((o=gform.hooks[r][o]).sort(function(o,r){return o.priority-r.priority}),o.forEach(function(o){\"function\"!=typeof(t=o.callable)&&(t=window[t]),\"action\"==r?t.apply(null,e):e[0]=t.apply(null,e)})),\"filter\"==r)return e[0]},removeHook:function(o,r,t,n){var e;null!=gform.hooks[o][r]&&(e=(e=gform.hooks[o][r]).filter(function(o,r,e){return!!(null!=n&&n!=o.tag||null!=t&&t!=o.priority)}),gform.hooks[o][r]=e)}});\n\/* ]]> *\/\n<\/script>\n\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_3' style='display:none'>\n                        <div class='gform_heading'>\n                            <h2 class=\"gform_title\">WWC Psychological Assessment Referral Form For First Responders & Military Members<\/h2>\n                            <p class='gform_description'>Confidential \u2013 For Professional Use Only<\/p>\n                        <\/div><form method='post' enctype='multipart\/form-data'  id='gform_3'  action='\/fr\/wp-json\/wp\/v2\/pages\/55229' data-formid='3' novalidate>\n                        <div class='gform-body gform_body'><div id='gform_fields_3' class='gform_fields top_label form_sublabel_above description_below validation_below'><div id=\"field_3_64\" class=\"gfield gfield--type-section gfield--input-type-section gsection field_sublabel_above gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><h3 class=\"gsection_title\"><\/h3><\/div><div id=\"field_3_7\" class=\"gfield gfield--type-section gfield--input-type-section gsection field_sublabel_above gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><h3 class=\"gsection_title\">SECTION A: REFERRING PARTY INFORMATION<\/h3><\/div><div id=\"field_3_13\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-full field_sublabel_above gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_3_13'>Referring Provider \/ Agency Name:<\/label><div class='ginput_container ginput_container_text'><input name='input_13' id='input_3_13' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_3_14\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-half field_sublabel_above gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_3_14'>Professional Title \/ Credentials:<\/label><div class='ginput_container ginput_container_text'><input name='input_14' id='input_3_14' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_3_15\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-half field_sublabel_above gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_3_15'>Organization \/ Unit:<\/label><div class='ginput_container ginput_container_text'><input name='input_15' id='input_3_15' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_3_20\" class=\"gfield gfield--type-phone gfield--input-type-phone gfield--width-half field_sublabel_above gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_3_20'>Phone<\/label><div class='ginput_container ginput_container_phone'><input name='input_20' id='input_3_20' type='tel' value='' class='large'    aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_3_19\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-half field_sublabel_above gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_3_19'>Fax:<\/label><div class='ginput_container ginput_container_text'><input name='input_19' id='input_3_19' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_3_22\" class=\"gfield gfield--type-email gfield--input-type-email gfield--width-half field_sublabel_above gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_3_22'>Email<\/label><div class='ginput_container ginput_container_email'>\n                            <input name='input_22' id='input_3_22' type='email' value='' class='large'     aria-invalid=\"false\"  \/>\n                        <\/div><\/div><div id=\"field_3_23\" class=\"gfield gfield--type-date gfield--input-type-date gfield--input-type-datepicker gfield--datepicker-no-icon gfield--width-half field_sublabel_above gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_3_23'>Date of referral:<\/label><div class='ginput_container ginput_container_date'>\n                            <input name='input_23' id='input_3_23' type='text' value='' class='datepicker gform-datepicker mdy datepicker_no_icon gdatepicker-no-icon'   placeholder='mm\/jj\/aaaa' aria-describedby=\"input_3_23_date_format\" aria-invalid=\"false\" \/>\n                            <span id='input_3_23_date_format' class='screen-reader-text'>MM slash JJ slash AAAA<\/span>\n                        <\/div>\n                        <input type='hidden' id='gforms_calendar_icon_input_3_23' class='gform_hidden' value='https:\/\/woundedwarriors.ca\/wp-content\/plugins\/gravityforms\/images\/datepicker\/datepicker.svg'\/><\/div><fieldset id=\"field_3_26\" class=\"gfield gfield--type-list gfield--input-type-list gfield--width-full field_sublabel_above gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Payment Source:<\/legend><div class='ginput_container ginput_container_list ginput_list ginput_container_list--columns'><div class='gfield_list gfield_list_container'><div class=\"gfield_list_header gform-grid-row\"><div class=\"gform-field-label gfield_header_item gform-grid-col\">Pre-approved<\/div><div class=\"gform-field-label gfield_header_item gform-grid-col\">File number\/ID:<\/div><div class=\"gform-field-label gfield_header_item gform-grid-col\">Invoice to:<\/div><div class=\"gform-field-label gfield_header_item gform-grid-col\">Assessment Fee Limits<\/div><div class=\"gfield_header_item gfield_header_item--icons gform-grid-col\">&nbsp;<\/div><\/div><div class=\"gfield_list_groups\"><div class='gfield_list_row_odd gfield_list_group gform-grid-row'><div class='gfield_list_group_item gfield_list_cell gfield_list_26_cell1 gform-grid-col' data-label='Pre-approved'><input aria-invalid='false'   aria-label='Pre-approved, Ligne 1' data-aria-label-template='Pre-approved, Ligne {0}' type='text' name='input_26[]' value=''   \/><\/div><div class='gfield_list_group_item gfield_list_cell gfield_list_26_cell2 gform-grid-col' data-label='File number\/ID:'><input aria-invalid='false'   aria-label='File number\/ID:, Ligne 1' data-aria-label-template='File number\/ID:, Ligne {0}' type='text' name='input_26[]' value=''   \/><\/div><div class='gfield_list_group_item gfield_list_cell gfield_list_26_cell3 gform-grid-col' data-label='Invoice to:'><input aria-invalid='false'   aria-label='Invoice to:, Ligne 1' data-aria-label-template='Invoice to:, Ligne {0}' type='text' name='input_26[]' value=''   \/><\/div><div class='gfield_list_group_item gfield_list_cell gfield_list_26_cell4 gform-grid-col' data-label='Assessment Fee Limits'><input aria-invalid='false'   aria-label='Assessment Fee Limits, Ligne 1' data-aria-label-template='Assessment Fee Limits, Ligne {0}' type='text' name='input_26[]' value=''   \/><\/div><div class='gfield_list_icons gform-grid-col'>   <button type='button'  class='add_list_item ' aria-label='Ajouter une autre ligne' onclick='gformAddListItem(this, 2)'>Ajouter<\/button>   <button type='button'  class='delete_list_item' aria-label='Supprimer la ligne 1' data-aria-label-template='Supprimer la ligne {0}' onclick='gformDeleteListItem(this, 2)' style=\"visibility:hidden;\">Retirer<\/button><\/div><\/div><\/div><\/div><\/div><\/fieldset><div id=\"field_3_65\" class=\"gfield gfield--type-section gfield--input-type-section gsection field_sublabel_above gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><h3 class=\"gsection_title\"><\/h3><\/div><div id=\"field_3_27\" class=\"gfield gfield--type-section gfield--input-type-section gsection field_sublabel_above gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><h3 class=\"gsection_title\">SECTION B: CLIENT \/ MEMBER INFORMATION<\/h3><\/div><fieldset id=\"field_3_28\" class=\"gfield gfield--type-name gfield--input-type-name gfield--width-full field_sublabel_above gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Full Name<\/legend><div class='ginput_complex ginput_container ginput_container--name no_prefix has_first_name no_middle_name has_last_name no_suffix gf_name_has_2 ginput_container_name gform-grid-row' id='input_3_28'>\n                            \n                            <span id='input_3_28_3_container' class='name_first gform-grid-col gform-grid-col--size-auto' >\n                                                    <label for='input_3_28_3' class='gform-field-label gform-field-label--type-sub '>Pr\u00e9nom<\/label>\n                                                    <input type='text' name='input_28.3' id='input_3_28_3' value=''   aria-required='false'     \/>\n                                                <\/span>\n                            \n                            <span id='input_3_28_6_container' class='name_last gform-grid-col gform-grid-col--size-auto' >\n                                                            <label for='input_3_28_6' class='gform-field-label gform-field-label--type-sub '>Nom<\/label>\n                                                            <input type='text' name='input_28.6' id='input_3_28_6' value=''   aria-required='false'     \/>\n                                                        <\/span>\n                            \n                        <\/div><\/fieldset><fieldset id=\"field_3_29\" class=\"gfield gfield--type-date gfield--input-type-date gfield--input-type-datefield gfield--width-full gfield_contains_required field_sublabel_above gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Date of Birth:<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(N\u00e9cessaire)<\/span><\/span><\/legend><div id='input_3_29' class='ginput_container ginput_complex gform-grid-row'><div class='gfield_date_month ginput_container ginput_container_date gform-grid-col' id='input_3_29_1_container'>\n                                            <label for='input_3_29_1' class='gform-field-label gform-field-label--type-sub screen-reader-text'>Mois<\/label>\n                                            <input type='number' maxlength='2' name='input_29[]' id='input_3_29_1' value=''   aria-required='true'   placeholder='MM' min='1' max='12' step='1'\/>\n                                        <\/div><div class='gfield_date_day ginput_container ginput_container_date gform-grid-col' id='input_3_29_2_container'>\n                                            <label for='input_3_29_2' class='gform-field-label gform-field-label--type-sub screen-reader-text'>Jour<\/label>\n                                            <input type='number' maxlength='2' name='input_29[]' id='input_3_29_2' value=''   aria-required='true'   placeholder='JJ' min='1' max='31' step='1'\/>\n                                        <\/div><div class='gfield_date_year ginput_container ginput_container_date gform-grid-col' id='input_3_29_3_container'>\n                                            <label for='input_3_29_3' class='gform-field-label gform-field-label--type-sub screen-reader-text'>Ann\u00e9e<\/label>\n                                            <input type='number' maxlength='4' name='input_29[]' id='input_3_29_3' value=''   aria-required='true'   placeholder='AAAA' min='1920' max='2027' step='1'\/>\n                                       <\/div>\n                                   <\/div><\/fieldset><fieldset id=\"field_3_30\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield--input-type-checkbox gfield--width-full gfield_contains_required field_sublabel_above gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Sex\/Gender:<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(N\u00e9cessaire)<\/span><\/span><\/legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox ' id='input_3_30'><div class='gchoice gchoice_3_30_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_30.1' type='checkbox'  value='Male'  id='choice_3_30_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_3_30_1' id='label_3_30_1' class='gform-field-label gform-field-label--type-inline'>Male<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_3_30_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_30.2' type='checkbox'  value='Female'  id='choice_3_30_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_3_30_2' id='label_3_30_2' class='gform-field-label gform-field-label--type-inline'>Female<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_3_30_3'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_30.3' type='checkbox'  value='Other'  id='choice_3_30_3'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_3_30_3' id='label_3_30_3' class='gform-field-label gform-field-label--type-inline'>Other<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_3_30_4'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_30.4' type='checkbox'  value='Prefer not to say'  id='choice_3_30_4'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_3_30_4' id='label_3_30_4' class='gform-field-label gform-field-label--type-inline'>Prefer not to say<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_3_31\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield--input-type-checkbox gfield--width-full gfield_contains_required field_sublabel_above gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Service Category:<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(N\u00e9cessaire)<\/span><\/span><\/legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox gfield_choice--select_all_enabled' id='input_3_31'><div class='gchoice gchoice_3_31_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_31.1' type='checkbox'  value='Military'  id='choice_3_31_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_3_31_1' id='label_3_31_1' class='gform-field-label gform-field-label--type-inline'>Military<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_3_31_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_31.2' type='checkbox'  value='Veteran'  id='choice_3_31_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_3_31_2' id='label_3_31_2' class='gform-field-label gform-field-label--type-inline'>Veteran<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_3_31_3'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_31.3' type='checkbox'  value='Police'  id='choice_3_31_3'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_3_31_3' id='label_3_31_3' class='gform-field-label gform-field-label--type-inline'>Police<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_3_31_4'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_31.4' type='checkbox'  value='Firefighter'  id='choice_3_31_4'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_3_31_4' id='label_3_31_4' class='gform-field-label gform-field-label--type-inline'>Firefighter<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_3_31_5'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_31.5' type='checkbox'  value='Paramedic'  id='choice_3_31_5'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_3_31_5' id='label_3_31_5' class='gform-field-label gform-field-label--type-inline'>Paramedic<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_3_31_6'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_31.6' type='checkbox'  value='Other'  id='choice_3_31_6'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_3_31_6' id='label_3_31_6' class='gform-field-label gform-field-label--type-inline'>Other<\/label>\n\t\t\t\t\t\t\t<\/div><div class=\"gfield-choice-toggle-all\"><button type=\"button\" id=\"button_31_select_all\" class=\"gfield_choice_all_toggle gform-theme-button--size-sm\" onclick=\"gformToggleCheckboxes( this )\" data-checked=\"0\" data-label-select=\"Tout s\u00e9lectionner\" data-label-deselect=\"Tout d\u00e9s\u00e9lectionner\">Tout s\u00e9lectionner<\/button><\/div><\/div><\/div><\/fieldset><div id=\"field_3_33\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-full field_sublabel_above gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_3_33'>Service Branch \/ Department:<\/label><div class='ginput_container ginput_container_text'><input name='input_33' id='input_3_33' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_3_32\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-half field_sublabel_above gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_3_32'>Rank \/ Role (if applicable):<\/label><div class='ginput_container ginput_container_text'><input name='input_32' id='input_3_32' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_3_36\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-half field_sublabel_above gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_3_36'>Years of Service:<\/label><div class='ginput_container ginput_container_text'><input name='input_36' id='input_3_36' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/div><fieldset id=\"field_3_38\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-full gfield_contains_required field_sublabel_above gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >Is the client aware of and consenting to this referral?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(N\u00e9cessaire)<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_3_38'>\n\t\t\t<div class='gchoice gchoice_3_38_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_38' type='radio' value='Yes'  id='choice_3_38_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_3_38_0' id='label_3_38_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_3_38_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_38' type='radio' value='No'  id='choice_3_38_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_3_38_1' id='label_3_38_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_3_66\" class=\"gfield gfield--type-section gfield--input-type-section gsection field_sublabel_above gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><h3 class=\"gsection_title\"><\/h3><\/div><div id=\"field_3_39\" class=\"gfield gfield--type-section gfield--input-type-section gsection field_sublabel_above gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><h3 class=\"gsection_title\">SECTION C: REASON FOR REFERRAL<\/h3><\/div><fieldset id=\"field_3_41\" class=\"gfield gfield--type-multi_choice gfield--type-choice gfield--input-type-checkbox gfield--width-full field_sublabel_above gfield--no-description field_description_below field_validation_below gfield_visibility_visible gfield--choice-align-vertical\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Primary Assessment Purpose: (check all that apply)<\/legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox ' id='input_3_41'><div class='gchoice gchoice_3_41_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_41.1' type='checkbox'  value='Diagnostic clarification'  id='choice_3_41_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_3_41_1' id='label_3_41_1' class='gform-field-label gform-field-label--type-inline'>Diagnostic clarification<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_3_41_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_41.2' type='checkbox'  value='PTSD \/ trauma-related concerns'  id='choice_3_41_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_3_41_2' id='label_3_41_2' class='gform-field-label gform-field-label--type-inline'>PTSD \/ trauma-related concerns<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_3_41_3'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_41.3' type='checkbox'  value='Return to work readiness'  id='choice_3_41_3'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_3_41_3' id='label_3_41_3' class='gform-field-label gform-field-label--type-inline'>Return to work readiness<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_3_41_4'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_41.4' type='checkbox'  value='Occupational stress injury (OSI)'  id='choice_3_41_4'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_3_41_4' id='label_3_41_4' class='gform-field-label gform-field-label--type-inline'>Occupational stress injury (OSI)<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_3_41_5'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_41.5' type='checkbox'  value='Other (please specify):'  id='choice_3_41_5'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_3_41_5' id='label_3_41_5' class='gform-field-label gform-field-label--type-inline'>Other (please specify):<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_3_42\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-full field_sublabel_above gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_3_42'>Brief Description of Presenting Concerns \/ Context<\/label><div class='ginput_container ginput_container_text'><input name='input_42' id='input_3_42' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_3_67\" class=\"gfield gfield--type-section gfield--input-type-section gsection field_sublabel_above gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><h3 class=\"gsection_title\"><\/h3><\/div><div id=\"field_3_43\" class=\"gfield gfield--type-section gfield--input-type-section gsection field_sublabel_above gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><h3 class=\"gsection_title\">SECTION D: RELEVANT BACKGROUND<\/h3><\/div><div id=\"field_3_44\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-full field_sublabel_above gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_3_44'>Current Diagnoses (if applicable):<\/label><div class='ginput_container ginput_container_text'><input name='input_44' id='input_3_44' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/div><fieldset id=\"field_3_45\" class=\"gfield gfield--type-multi_choice gfield--type-choice gfield--input-type-checkbox gfield--width-full field_sublabel_above gfield--no-description field_description_below field_validation_below gfield_visibility_visible gfield--choice-align-vertical\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Known Psychiatric History:<\/legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox ' id='input_3_45'><div class='gchoice gchoice_3_45_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_45.1' type='checkbox'  value='None Known'  id='choice_3_45_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_3_45_1' id='label_3_45_1' class='gform-field-label gform-field-label--type-inline'>None Known<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_3_45_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_45.2' type='checkbox'  value='Depression'  id='choice_3_45_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_3_45_2' id='label_3_45_2' class='gform-field-label gform-field-label--type-inline'>Depression<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_3_45_3'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_45.3' type='checkbox'  value='Anxiety'  id='choice_3_45_3'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_3_45_3' id='label_3_45_3' class='gform-field-label gform-field-label--type-inline'>Anxiety<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_3_45_4'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_45.6' type='checkbox'  value='PTSD'  id='choice_3_45_4'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_3_45_4' id='label_3_45_4' class='gform-field-label gform-field-label--type-inline'>PTSD<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_3_45_5'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_45.5' type='checkbox'  value='Substance Use'  id='choice_3_45_5'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_3_45_5' id='label_3_45_5' class='gform-field-label gform-field-label--type-inline'>Substance Use<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_3_45_6'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_45.4' type='checkbox'  value='Personality Disorder'  id='choice_3_45_6'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_3_45_6' id='label_3_45_6' class='gform-field-label gform-field-label--type-inline'>Personality Disorder<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_3_45_7'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_45.7' type='checkbox'  value='Psychotic Disorders'  id='choice_3_45_7'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_3_45_7' id='label_3_45_7' class='gform-field-label gform-field-label--type-inline'>Psychotic Disorders<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_3_45_8'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_45.8' type='checkbox'  value='Other'  id='choice_3_45_8'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_3_45_8' id='label_3_45_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_3_46\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-full field_sublabel_above gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_3_46'>Other<\/label><div class='ginput_container ginput_container_text'><input name='input_46' id='input_3_46' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/div><fieldset id=\"field_3_47\" class=\"gfield gfield--type-multi_choice gfield--type-choice gfield--input-type-checkbox gfield--width-full field_sublabel_above gfield--no-description field_description_below field_validation_below gfield_visibility_visible gfield--choice-align-vertical\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Medical Conditions Impacting Assessment:<\/legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox ' id='input_3_47'><div class='gchoice gchoice_3_47_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_47.1' type='checkbox'  value='None Known'  id='choice_3_47_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_3_47_1' id='label_3_47_1' class='gform-field-label gform-field-label--type-inline'>None Known<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_3_47_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_47.2' type='checkbox'  value='TBI'  id='choice_3_47_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_3_47_2' id='label_3_47_2' class='gform-field-label gform-field-label--type-inline'>TBI<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_3_47_3'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_47.3' type='checkbox'  value='Head Injury'  id='choice_3_47_3'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_3_47_3' id='label_3_47_3' class='gform-field-label gform-field-label--type-inline'>Head Injury<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_3_47_4'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_47.4' type='checkbox'  value='Chronic Pain'  id='choice_3_47_4'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_3_47_4' id='label_3_47_4' class='gform-field-label gform-field-label--type-inline'>Chronic Pain<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_3_47_5'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_47.5' type='checkbox'  value='Sleep Disorder'  id='choice_3_47_5'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_3_47_5' id='label_3_47_5' class='gform-field-label gform-field-label--type-inline'>Sleep Disorder<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_3_47_6'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_47.6' type='checkbox'  value='Other'  id='choice_3_47_6'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_3_47_6' id='label_3_47_6' 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_3_48\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-full field_sublabel_above gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_3_48'>Other<\/label><div class='ginput_container ginput_container_text'><input name='input_48' id='input_3_48' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_3_49\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-full field_sublabel_above gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_3_49'>Current Medications:<\/label><div class='ginput_container ginput_container_text'><input name='input_49' id='input_3_49' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_3_68\" class=\"gfield gfield--type-section gfield--input-type-section gsection field_sublabel_above gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><h3 class=\"gsection_title\"><\/h3><\/div><div id=\"field_3_50\" class=\"gfield gfield--type-section gfield--input-type-section gsection field_sublabel_above gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><h3 class=\"gsection_title\">SECTION E: ASSESSMENT LOGISTICS<\/h3><\/div><fieldset id=\"field_3_52\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-full field_sublabel_above gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >Preferred Assessment Location:<\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_3_52'>\n\t\t\t<div class='gchoice gchoice_3_52_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_52' type='radio' value='In person (if appropriate)'  id='choice_3_52_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_3_52_0' id='label_3_52_0' class='gform-field-label gform-field-label--type-inline'>In person (if appropriate)<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_3_52_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_52' type='radio' value='Virtual (if appropriate)'  id='choice_3_52_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_3_52_1' id='label_3_52_1' class='gform-field-label gform-field-label--type-inline'>Virtual (if appropriate)<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_3_52_2'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_52' type='radio' value='No Preference'  id='choice_3_52_2' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_3_52_2' id='label_3_52_2' class='gform-field-label gform-field-label--type-inline'>No Preference<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_3_53\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-full field_sublabel_above gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >Is the client currently on medical leave or restricted duty?<\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_3_53'>\n\t\t\t<div class='gchoice gchoice_3_53_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_53' type='radio' value='Yes'  id='choice_3_53_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_3_53_0' id='label_3_53_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_3_53_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_53' type='radio' value='No'  id='choice_3_53_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_3_53_1' id='label_3_53_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_3_53_2'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_53' type='radio' value='Unknown'  id='choice_3_53_2' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_3_53_2' id='label_3_53_2' class='gform-field-label gform-field-label--type-inline'>Unknown<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_3_69\" class=\"gfield gfield--type-section gfield--input-type-section gsection field_sublabel_above gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><h3 class=\"gsection_title\"><\/h3><\/div><div id=\"field_3_54\" class=\"gfield gfield--type-section gfield--input-type-section gsection field_sublabel_above gfield--has-description field_description_below field_validation_below gfield_visibility_visible\"  ><h3 class=\"gsection_title\">SECTION F: SUPPORTING DOCUMENTS<\/h3><div class='gsection_description' id='gfield_description_3_54'>\u2610 Consent to release information\n\u2610 Previous psychological \/ psychiatric reports\n\u2610 Incident or critical event reports\n\u2610 Work status letters\n\u2610 Physician referrals\n\u2610 Insurance correspondence\n<\/div><\/div><div id=\"field_3_55\" class=\"gfield gfield--type-fileupload gfield--input-type-fileupload gfield--width-full field_sublabel_above gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='gform_browse_button_3_55'>(Attach\/submit all that are applicable)<\/label><div class='ginput_container ginput_container_fileupload'><div id='gform_multifile_upload_3_55' data-settings='{&quot;runtimes&quot;:&quot;html5,flash,html4&quot;,&quot;browse_button&quot;:&quot;gform_browse_button_3_55&quot;,&quot;container&quot;:&quot;gform_multifile_upload_3_55&quot;,&quot;drop_element&quot;:&quot;gform_drag_drop_area_3_55&quot;,&quot;filelist&quot;:&quot;gform_preview_3_55&quot;,&quot;unique_names&quot;:true,&quot;file_data_name&quot;:&quot;file&quot;,&quot;url&quot;:&quot;https:\\\/\\\/woundedwarriors.ca\\\/fr\\\/?gf_page=32852bf95c04454&quot;,&quot;flash_swf_url&quot;:&quot;https:\\\/\\\/woundedwarriors.ca\\\/wp-includes\\\/js\\\/plupload\\\/plupload.flash.swf&quot;,&quot;silverlight_xap_url&quot;:&quot;https:\\\/\\\/woundedwarriors.ca\\\/wp-includes\\\/js\\\/plupload\\\/plupload.silverlight.xap&quot;,&quot;filters&quot;:{&quot;mime_types&quot;:[{&quot;title&quot;:&quot;Fichiers autoris\\u00e9s&quot;,&quot;extensions&quot;:&quot;*&quot;}],&quot;max_file_size&quot;:&quot;209715200b&quot;},&quot;multipart&quot;:true,&quot;urlstream_upload&quot;:false,&quot;multipart_params&quot;:{&quot;form_id&quot;:3,&quot;field_id&quot;:55,&quot;_gform_file_upload_nonce_3_55&quot;:&quot;76adc32f7d&quot;},&quot;gf_vars&quot;:{&quot;max_files&quot;:0,&quot;message_id&quot;:&quot;gform_multifile_messages_3_55&quot;,&quot;disallowed_extensions&quot;:[&quot;php&quot;,&quot;asp&quot;,&quot;aspx&quot;,&quot;cmd&quot;,&quot;csh&quot;,&quot;bat&quot;,&quot;html&quot;,&quot;htm&quot;,&quot;hta&quot;,&quot;jar&quot;,&quot;exe&quot;,&quot;com&quot;,&quot;js&quot;,&quot;lnk&quot;,&quot;htaccess&quot;,&quot;phar&quot;,&quot;phtml&quot;,&quot;ps1&quot;,&quot;ps2&quot;,&quot;php3&quot;,&quot;php4&quot;,&quot;php5&quot;,&quot;php6&quot;,&quot;py&quot;,&quot;rb&quot;,&quot;tmp&quot;]}}' class='gform_fileupload_multifile'>\n\t\t\t\t\t\t\t\t\t\t<div id='gform_drag_drop_area_3_55' class='gform_drop_area gform-theme-field-control'>\n\t\t\t\t\t\t\t\t\t\t\t<span class='gform_drop_instructions'>D\u00e9posez les fichiers ici ou <\/span>\n\t\t\t\t\t\t\t\t\t\t\t<button type='button' id='gform_browse_button_3_55' class='button gform_button_select_files gform-theme-button gform-theme-button--control' aria-describedby=\"gfield_upload_rules_3_55\"  >S\u00e9lectionnez des fichiers<\/button>\n\t\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t<\/div><span class='gfield_description gform_fileupload_rules' id='gfield_upload_rules_3_55'>Taille max. des fichiers\u00a0: 200 MB.<\/span><ul class='validation_message--hidden-on-empty gform-ul-reset' id='gform_multifile_messages_3_55'><\/ul> <div id='gform_preview_3_55' class='ginput_preview_list'><\/div><\/div><\/div><div id=\"field_3_70\" class=\"gfield gfield--type-section gfield--input-type-section gsection field_sublabel_above gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><h3 class=\"gsection_title\"><\/h3><\/div><div id=\"field_3_56\" class=\"gfield gfield--type-section gfield--input-type-section gsection field_sublabel_above gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><h3 class=\"gsection_title\">SECTION G: REFERRAL OUTCOME REQUEST<\/h3><\/div><fieldset id=\"field_3_57\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield--input-type-checkbox gfield--width-full field_sublabel_above gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' >What type of report or feedback is being requested?<\/legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox gfield_choice--select_all_enabled' id='input_3_57'><div class='gchoice gchoice_3_57_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_57.1' type='checkbox'  value='Full psychological assessment report'  id='choice_3_57_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_3_57_1' id='label_3_57_1' class='gform-field-label gform-field-label--type-inline'>Full psychological assessment report<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_3_57_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_57.2' type='checkbox'  value='Summary letter with findings'  id='choice_3_57_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_3_57_2' id='label_3_57_2' class='gform-field-label gform-field-label--type-inline'>Summary letter with findings<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_3_57_3'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_57.3' type='checkbox'  value='Recommendations for treatment'  id='choice_3_57_3'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_3_57_3' id='label_3_57_3' class='gform-field-label gform-field-label--type-inline'>Recommendations for treatment<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_3_57_4'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_57.4' type='checkbox'  value='Return-to-work recommendations'  id='choice_3_57_4'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_3_57_4' id='label_3_57_4' class='gform-field-label gform-field-label--type-inline'>Return-to-work recommendations<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_3_57_5'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_57.5' type='checkbox'  value='Other'  id='choice_3_57_5'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_3_57_5' id='label_3_57_5' class='gform-field-label gform-field-label--type-inline'>Other<\/label>\n\t\t\t\t\t\t\t<\/div><div class=\"gfield-choice-toggle-all\"><button type=\"button\" id=\"button_57_select_all\" class=\"gfield_choice_all_toggle gform-theme-button--size-sm\" onclick=\"gformToggleCheckboxes( this )\" data-checked=\"0\" data-label-select=\"Tout s\u00e9lectionner\" data-label-deselect=\"Tout d\u00e9s\u00e9lectionner\">Tout s\u00e9lectionner<\/button><\/div><\/div><\/div><\/fieldset><div id=\"field_3_58\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-full field_sublabel_above gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_3_58'>Other<\/label><div class='ginput_container ginput_container_text'><input name='input_58' id='input_3_58' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/div><fieldset id=\"field_3_59\" class=\"gfield gfield--type-multi_choice gfield--type-choice gfield--input-type-checkbox gfield--width-full field_sublabel_above gfield--no-description field_description_below field_validation_below gfield_visibility_visible gfield--choice-align-vertical\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Who should receive the report\/results?<\/legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox ' id='input_3_59'><div class='gchoice gchoice_3_59_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_59.1' type='checkbox'  value='Referring provider only'  id='choice_3_59_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_3_59_1' id='label_3_59_1' class='gform-field-label gform-field-label--type-inline'>Referring provider only<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_3_59_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_59.2' type='checkbox'  value='Client'  id='choice_3_59_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_3_59_2' id='label_3_59_2' class='gform-field-label gform-field-label--type-inline'>Client<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_3_59_3'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_59.3' type='checkbox'  value='Employer \/ Agency (specify):'  id='choice_3_59_3'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_3_59_3' id='label_3_59_3' class='gform-field-label gform-field-label--type-inline'>Employer \/ Agency (specify):<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_3_59_4'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_59.4' type='checkbox'  value='Insurer (specify):'  id='choice_3_59_4'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_3_59_4' id='label_3_59_4' class='gform-field-label gform-field-label--type-inline'>Insurer (specify):<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_3_61\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-full field_sublabel_above gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_3_61'>Employer \/ Agency (specify):<\/label><div class='ginput_container ginput_container_text'><input name='input_61' id='input_3_61' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_3_60\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-full field_sublabel_above gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_3_60'>Insurer (specify):<\/label><div class='ginput_container ginput_container_text'><input name='input_60' id='input_3_60' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_3_63\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-full field_sublabel_above gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_3_63'>Signature<\/label><div class='ginput_container ginput_container_text'><input name='input_63' id='input_3_63' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_3_62\" class=\"gfield gfield--type-date gfield--input-type-date gfield--input-type-datepicker gfield--datepicker-no-icon gfield--width-full field_sublabel_above gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_3_62'>Date<\/label><div class='ginput_container ginput_container_date'>\n                            <input name='input_62' id='input_3_62' type='text' value='04\/29\/2026' class='datepicker gform-datepicker mdy datepicker_no_icon gdatepicker-no-icon'   placeholder='mm\/jj\/aaaa' aria-describedby=\"input_3_62_date_format\" aria-invalid=\"false\" \/>\n                            <span id='input_3_62_date_format' class='screen-reader-text'>MM slash JJ slash AAAA<\/span>\n                        <\/div>\n                        <input type='hidden' id='gforms_calendar_icon_input_3_62' class='gform_hidden' value='https:\/\/woundedwarriors.ca\/wp-content\/plugins\/gravityforms\/images\/datepicker\/datepicker.svg'\/><\/div><\/div><\/div>\n        <div class='gform-footer gform_footer top_label'> <input type='submit' id='gform_submit_button_3' class='gform_button button' onclick='gform.submission.handleButtonClick(this);' data-submission-type='submit' value='Submit'  \/> \n            <input type='hidden' class='gform_hidden' name='gform_submission_method' data-js='gform_submission_method_3' value='postback' \/>\n            <input type='hidden' class='gform_hidden' name='gform_theme' data-js='gform_theme_3' id='gform_theme_3' value='gravity-theme' \/>\n            <input type='hidden' class='gform_hidden' name='gform_style_settings' data-js='gform_style_settings_3' id='gform_style_settings_3' value='[]' \/>\n            <input type='hidden' class='gform_hidden' name='is_submit_3' value='1' \/>\n            <input type='hidden' class='gform_hidden' name='gform_submit' value='3' \/>\n            \n            <input type='hidden' class='gform_hidden' name='gform_currency' data-currency='CAD' value='nRqN8Vp2sxwDyID80tt1lAgQVcL2GntDLpKVklGvrHeyO7DMsKtogPR8i1acmGDzdA47pS\/bE4LIv9kqkFQ8i5JZi7CyLJZD5BWh67MMlTBy8HI=' \/>\n            <input type='hidden' class='gform_hidden' name='gform_unique_id' value='' \/>\n            <input type='hidden' class='gform_hidden' name='state_3' value='WyJ7XCIzMC4xXCI6XCIxZTY5Y2VlNjBlYzBkMmU5Yjg3NGU4YjdmZGNlYjIxMlwiLFwiMzAuMlwiOlwiNzkwMzM2YzZiYmQ2ZDAxNjExNzIyNDQ0M2VlZWM4ZTJcIixcIjMwLjNcIjpcIjY2Njg2NGU3OWQzYmU2MzIwNTI4Y2VmZGM2MGIxM2FhXCIsXCIzMC40XCI6XCI1MjFiOWJiNWE0OTBiOWY1NGI4OTQzZGQ4ZTY2MmNmMVwiLFwiMzEuMVwiOlwiNmU2ZGI1NGZkNGI1NTAxYzY3NDBmMzZjMzk3ZWJlYmVcIixcIjMxLjJcIjpcImNmZTdhNmM4MjM2MWY5YTgzNjZmZGU3OGU1MGNjMjU1XCIsXCIzMS4zXCI6XCJhMjVlOWEwYWZiMGVhYmJlNjQ0MjYxYWE4YjE4OTI3MFwiLFwiMzEuNFwiOlwiMzE1Yjg0ODZlYWE1ZjVmNjZiMTMzOWY1NDgzZjFlMDlcIixcIjMxLjVcIjpcImMxZDIxNjcyNDIxMTgzYWVkYmM3ZWYyOTYzM2Y4YWRjXCIsXCIzMS42XCI6XCI2NjY4NjRlNzlkM2JlNjMyMDUyOGNlZmRjNjBiMTNhYVwiLFwiMzhcIjpbXCI4MzdmNzY3YjJjN2MzZWNiMWM3NjU0MDI0Mzk5M2QxZFwiLFwiMDE2YzIwNDg5ZjFhOTE5NmVhYzIyMzFlYmY2NjE3NDVcIl0sXCI0MS4xXCI6XCJlNDY0OTlhNjRhNTkyNDM4YmU5MTk1ZmIyNzFlMDY3ZVwiLFwiNDEuMlwiOlwiYTc5Njc2N2Y1OWIwZWEyODVlMzVhMWU3MDU2ZjIzOWFcIixcIjQxLjNcIjpcImJmODMwN2ViMzQ4YTAxNjJmNzY1MzIwNjcwMGU3YTRmXCIsXCI0MS40XCI6XCIxYTQ0ZGE4ZTEzMDM4NGM3MDI3MDdkMDU3MzBmYWQ1YVwiLFwiNDEuNVwiOlwiODUwMjYwYWMxMTAzYmQyMGRjOWZkNTU0YjhjZjgxOTJcIixcIjQ1LjFcIjpcIjFkNTNkZjQxZDg1Y2I3Zjg0YjEwZjcxYjE2NDZjNWJlXCIsXCI0NS4yXCI6XCIzYWIwOWZlNzZiZmY0MmYyMTc1NDRhYmY5MTkxMjE4NlwiLFwiNDUuM1wiOlwiYzg3OTA5MWQwZDk5MTAyYjVmNTFiNTNhMWVmOTA4MjZcIixcIjQ1LjZcIjpcImRiMjJmNmJjOTg5NDRkM2RiZjBjZTZiZWZlNjZlNjllXCIsXCI0NS41XCI6XCIzNTg0MzNhZDEzYTJmYTk5NTc3ODBjMzRmZjk2ZTkzY1wiLFwiNDUuNFwiOlwiYTEwYTU2Yzc5NmQ1Y2JkYTliMmMxYTVlYmFiNzg5NDBcIixcIjQ1LjdcIjpcIjA1YTZmMzlhMTQwODM3ZDc3ZjIyNzYwZmEwNzE2NDUwXCIsXCI0NS44XCI6XCI2NjY4NjRlNzlkM2JlNjMyMDUyOGNlZmRjNjBiMTNhYVwiLFwiNDcuMVwiOlwiMWQ1M2RmNDFkODVjYjdmODRiMTBmNzFiMTY0NmM1YmVcIixcIjQ3LjJcIjpcImQ0ZmJmNDliZjc1YTI2M2MxZDk4N2E5NDViOTc3ZTg0XCIsXCI0Ny4zXCI6XCI3MDEyOWE2MDZhZjAxOTYxMDAzNzdlN2ZhMzcwOGNjOVwiLFwiNDcuNFwiOlwiZmQ2MmUyODcwMjA3NjQzNzcxNDczNTkxNmRjOWJmNDdcIixcIjQ3LjVcIjpcIjU2ZmY2MGQ4ZWI3YTY1ODEwOTc0Y2YzNjU2MmMzM2EwXCIsXCI0Ny42XCI6XCI2NjY4NjRlNzlkM2JlNjMyMDUyOGNlZmRjNjBiMTNhYVwiLFwiNTJcIjpbXCI4ZDZjYWM5ZTA0MDI0MzA2YmI1Mjk5NWYwZGExZjBmZlwiLFwiY2FlNjRlZjQwN2E3ZWVkY2UxYjczMTkyOWM5MmFkYTlcIixcIjcwYmUxYjgzODk1ZjUwNmFlNGRiYTY0YzEzMjY0ODBlXCJdLFwiNTNcIjpbXCI4MzdmNzY3YjJjN2MzZWNiMWM3NjU0MDI0Mzk5M2QxZFwiLFwiMDE2YzIwNDg5ZjFhOTE5NmVhYzIyMzFlYmY2NjE3NDVcIixcIjYwZmRjMzgzNzljMTNlODBiODQxNjJjNThkYTFiNGE1XCJdLFwiNTcuMVwiOlwiMmE4NTRlMDYyYjYwMTlkOGVhN2U5NDI4Njc3NzhiOTVcIixcIjU3LjJcIjpcIjdjMzRjNWMzYzQzYmVhNzAwNWE2YzUyZDc5NWIxNTBjXCIsXCI1Ny4zXCI6XCI3NWM0MzIyMjNkNWQ4MjEyMTliZDZhOGIzNjYzYmRlYVwiLFwiNTcuNFwiOlwiNDNjMmIzOTExNTMzMDQ1MTBkNzU5OGJhOWEzNjA1NzJcIixcIjU3LjVcIjpcIjY2Njg2NGU3OWQzYmU2MzIwNTI4Y2VmZGM2MGIxM2FhXCIsXCI1OS4xXCI6XCI2MThmYzRmNGZlMzk0OWFiNWRlZDc2ZmViMDllMTJhN1wiLFwiNTkuMlwiOlwiM2NhNjlmMThmYzYyZTI4NzBlZWI0ZjhmNGNmMTBiMGFcIixcIjU5LjNcIjpcIjhlMDgwZGU1ZDJiMzk2YzkzNTllYTI4Mzk3ODc3NTA1XCIsXCI1OS40XCI6XCI3YWI3ZTNmYzM1OGY3ZDZhN2VhNzY2MTFhOGQ2MTc0NlwifSIsImMwMWIxYTE0NmQzNWZlMGVkMGE2ZmVjOGY4Nzg0MDBkIl0=' \/>\n            <input type='hidden' autocomplete='off' class='gform_hidden' name='gform_target_page_number_3' id='gform_target_page_number_3' value='0' \/>\n            <input type='hidden' autocomplete='off' class='gform_hidden' name='gform_source_page_number_3' id='gform_source_page_number_3' value='1' \/>\n            <input type='hidden' name='gform_field_values' value='' \/>\n            <input type='hidden' name='gform_uploaded_files' id='gform_uploaded_files_3' value='' \/>\n        <\/div>\n                        <\/form>\n                        <\/div><script type=\"text\/javascript\">\n\/* <![CDATA[ *\/\n gform.initializeOnLoaded( function() {gformInitSpinner( 3, 'https:\/\/woundedwarriors.ca\/wp-content\/plugins\/gravityforms\/images\/spinner.svg', true );jQuery('#gform_ajax_frame_3').on('load',function(){var contents = jQuery(this).contents().find('*').html();var is_postback = contents.indexOf('GF_AJAX_POSTBACK') >= 0;if(!is_postback){return;}var form_content = jQuery(this).contents().find('#gform_wrapper_3');var is_confirmation = jQuery(this).contents().find('#gform_confirmation_wrapper_3').length > 0;var is_redirect = contents.indexOf('gformRedirect(){') >= 0;var is_form = form_content.length > 0 && ! is_redirect && ! is_confirmation;var mt = parseInt(jQuery('html').css('margin-top'), 10) + parseInt(jQuery('body').css('margin-top'), 10) + 100;if(is_form){form_content.find('form').css('opacity', 0);jQuery('#gform_wrapper_3').html(form_content.html());if(form_content.hasClass('gform_validation_error')){jQuery('#gform_wrapper_3').addClass('gform_validation_error');} else {jQuery('#gform_wrapper_3').removeClass('gform_validation_error');}setTimeout( function() { \/* delay the scroll by 50 milliseconds to fix a bug in chrome *\/  }, 50 );if(window['gformInitDatepicker']) {gformInitDatepicker();}if(window['gformInitPriceFields']) {gformInitPriceFields();}var current_page = jQuery('#gform_source_page_number_3').val();gformInitSpinner( 3, 'https:\/\/woundedwarriors.ca\/wp-content\/plugins\/gravityforms\/images\/spinner.svg', true );jQuery(document).trigger('gform_page_loaded', [3, current_page]);window['gf_submitting_3'] = false;}else if(!is_redirect){var confirmation_content = jQuery(this).contents().find('.GF_AJAX_POSTBACK').html();if(!confirmation_content){confirmation_content = contents;}jQuery('#gform_wrapper_3').replaceWith(confirmation_content);jQuery(document).trigger('gform_confirmation_loaded', [3]);window['gf_submitting_3'] = false;wp.a11y.speak(jQuery('#gform_confirmation_message_3').text());}else{jQuery('#gform_3').append(contents);if(window['gformRedirect']) {gformRedirect();}}jQuery(document).trigger(\"gform_pre_post_render\", [{ formId: \"3\", currentPage: \"current_page\", abort: function() { this.preventDefault(); } }]);        if (event && event.defaultPrevented) {                return;        }        const gformWrapperDiv = document.getElementById( \"gform_wrapper_3\" );        if ( gformWrapperDiv ) {            const visibilitySpan = document.createElement( \"span\" );            visibilitySpan.id = \"gform_visibility_test_3\";            gformWrapperDiv.insertAdjacentElement( \"afterend\", visibilitySpan );        }        const visibilityTestDiv = document.getElementById( \"gform_visibility_test_3\" );        let postRenderFired = false;        function triggerPostRender() {            if ( postRenderFired ) {                return;            }            postRenderFired = true;            gform.core.triggerPostRenderEvents( 3, current_page );            if ( visibilityTestDiv ) {                visibilityTestDiv.parentNode.removeChild( visibilityTestDiv );            }        }        function debounce( func, wait, immediate ) {            var timeout;            return function() {                var context = this, args = arguments;                var later = function() {                    timeout = null;                    if ( !immediate ) func.apply( context, args );                };                var callNow = immediate && !timeout;                clearTimeout( timeout );                timeout = setTimeout( later, wait );                if ( callNow ) func.apply( context, args );            };        }        const debouncedTriggerPostRender = debounce( function() {            triggerPostRender();        }, 200 );        if ( visibilityTestDiv && visibilityTestDiv.offsetParent === null ) {            const observer = new MutationObserver( ( mutations ) => {                mutations.forEach( ( mutation ) => {                    if ( mutation.type === 'attributes' && visibilityTestDiv.offsetParent !== null ) {                        debouncedTriggerPostRender();                        observer.disconnect();                    }                });            });            observer.observe( document.body, {                attributes: true,                childList: false,                subtree: true,                attributeFilter: [ 'style', 'class' ],            });        } else {            triggerPostRender();        }    } );} ); \n\/* ]]> *\/\n<\/script>\n\n<p>[\/et_pb_text][\/et_pb_column][\/et_pb_row][\/et_pb_section]<\/p>\n","protected":false},"excerpt":{"rendered":"\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_3' style='display:none'>\n                        <div class='gform_heading'>\n                            <h2 class=\"gform_title\">WWC Psychological Assessment Referral Form For First Responders & Military Members<\/h2>\n                            <p class='gform_description'>Confidential \u2013 For Professional Use Only<\/p>\n                        <\/div><form method='post' enctype='multipart\/form-data'  id='gform_3'  action='\/fr\/wp-json\/wp\/v2\/pages\/55229' data-formid='3' novalidate>\n                        <div class='gform-body gform_body'><div id='gform_fields_3' class='gform_fields top_label form_sublabel_above description_below validation_below'><div id=\"field_3_64\" class=\"gfield gfield--type-section gfield--input-type-section gsection field_sublabel_above gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><h3 class=\"gsection_title\"><\/h3><\/div><div id=\"field_3_7\" class=\"gfield gfield--type-section gfield--input-type-section gsection field_sublabel_above gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><h3 class=\"gsection_title\">SECTION A: REFERRING PARTY INFORMATION<\/h3><\/div><div id=\"field_3_13\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-full field_sublabel_above gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_3_13'>Referring Provider \/ Agency Name:<\/label><div class='ginput_container ginput_container_text'><input name='input_13' id='input_3_13' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_3_14\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-half field_sublabel_above gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_3_14'>Professional Title \/ Credentials:<\/label><div class='ginput_container ginput_container_text'><input name='input_14' id='input_3_14' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_3_15\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-half field_sublabel_above gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_3_15'>Organization \/ Unit:<\/label><div class='ginput_container ginput_container_text'><input name='input_15' id='input_3_15' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_3_20\" class=\"gfield gfield--type-phone gfield--input-type-phone gfield--width-half field_sublabel_above gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_3_20'>Phone<\/label><div class='ginput_container ginput_container_phone'><input name='input_20' id='input_3_20' type='tel' value='' class='large'    aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_3_19\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-half field_sublabel_above gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_3_19'>Fax:<\/label><div class='ginput_container ginput_container_text'><input name='input_19' id='input_3_19' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_3_22\" class=\"gfield gfield--type-email gfield--input-type-email gfield--width-half field_sublabel_above gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_3_22'>Email<\/label><div class='ginput_container ginput_container_email'>\n                            <input name='input_22' id='input_3_22' type='email' value='' class='large'     aria-invalid=\"false\"  \/>\n                        <\/div><\/div><div id=\"field_3_23\" class=\"gfield gfield--type-date gfield--input-type-date gfield--input-type-datepicker gfield--datepicker-no-icon gfield--width-half field_sublabel_above gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_3_23'>Date of referral:<\/label><div class='ginput_container ginput_container_date'>\n                            <input name='input_23' id='input_3_23' type='text' value='' class='datepicker gform-datepicker mdy datepicker_no_icon gdatepicker-no-icon'   placeholder='mm\/jj\/aaaa' aria-describedby=\"input_3_23_date_format\" aria-invalid=\"false\" \/>\n                            <span id='input_3_23_date_format' class='screen-reader-text'>MM slash JJ slash AAAA<\/span>\n                        <\/div>\n                        <input type='hidden' id='gforms_calendar_icon_input_3_23' class='gform_hidden' value='https:\/\/woundedwarriors.ca\/wp-content\/plugins\/gravityforms\/images\/datepicker\/datepicker.svg'\/><\/div><fieldset id=\"field_3_26\" class=\"gfield gfield--type-list gfield--input-type-list gfield--width-full field_sublabel_above gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Payment Source:<\/legend><div class='ginput_container ginput_container_list ginput_list ginput_container_list--columns'><div class='gfield_list gfield_list_container'><div class=\"gfield_list_header gform-grid-row\"><div class=\"gform-field-label gfield_header_item gform-grid-col\">Pre-approved<\/div><div class=\"gform-field-label gfield_header_item gform-grid-col\">File number\/ID:<\/div><div class=\"gform-field-label gfield_header_item gform-grid-col\">Invoice to:<\/div><div class=\"gform-field-label gfield_header_item gform-grid-col\">Assessment Fee Limits<\/div><div class=\"gfield_header_item gfield_header_item--icons gform-grid-col\">&nbsp;<\/div><\/div><div class=\"gfield_list_groups\"><div class='gfield_list_row_odd gfield_list_group gform-grid-row'><div class='gfield_list_group_item gfield_list_cell gfield_list_26_cell1 gform-grid-col' data-label='Pre-approved'><input aria-invalid='false'   aria-label='Pre-approved, Ligne 1' data-aria-label-template='Pre-approved, Ligne {0}' type='text' name='input_26[]' value=''   \/><\/div><div class='gfield_list_group_item gfield_list_cell gfield_list_26_cell2 gform-grid-col' data-label='File number\/ID:'><input aria-invalid='false'   aria-label='File number\/ID:, Ligne 1' data-aria-label-template='File number\/ID:, Ligne {0}' type='text' name='input_26[]' value=''   \/><\/div><div class='gfield_list_group_item gfield_list_cell gfield_list_26_cell3 gform-grid-col' data-label='Invoice to:'><input aria-invalid='false'   aria-label='Invoice to:, Ligne 1' data-aria-label-template='Invoice to:, Ligne {0}' type='text' name='input_26[]' value=''   \/><\/div><div class='gfield_list_group_item gfield_list_cell gfield_list_26_cell4 gform-grid-col' data-label='Assessment Fee Limits'><input aria-invalid='false'   aria-label='Assessment Fee Limits, Ligne 1' data-aria-label-template='Assessment Fee Limits, Ligne {0}' type='text' name='input_26[]' value=''   \/><\/div><div class='gfield_list_icons gform-grid-col'>   <button type='button'  class='add_list_item ' aria-label='Ajouter une autre ligne' onclick='gformAddListItem(this, 2)'>Ajouter<\/button>   <button type='button'  class='delete_list_item' aria-label='Supprimer la ligne 1' data-aria-label-template='Supprimer la ligne {0}' onclick='gformDeleteListItem(this, 2)' style=\"visibility:hidden;\">Retirer<\/button><\/div><\/div><\/div><\/div><\/div><\/fieldset><div id=\"field_3_65\" class=\"gfield gfield--type-section gfield--input-type-section gsection field_sublabel_above gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><h3 class=\"gsection_title\"><\/h3><\/div><div id=\"field_3_27\" class=\"gfield gfield--type-section gfield--input-type-section gsection field_sublabel_above gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><h3 class=\"gsection_title\">SECTION B: CLIENT \/ MEMBER INFORMATION<\/h3><\/div><fieldset id=\"field_3_28\" class=\"gfield gfield--type-name gfield--input-type-name gfield--width-full field_sublabel_above gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Full Name<\/legend><div class='ginput_complex ginput_container ginput_container--name no_prefix has_first_name no_middle_name has_last_name no_suffix gf_name_has_2 ginput_container_name gform-grid-row' id='input_3_28'>\n                            \n                            <span id='input_3_28_3_container' class='name_first gform-grid-col gform-grid-col--size-auto' >\n                                                    <label for='input_3_28_3' class='gform-field-label gform-field-label--type-sub '>Pr\u00e9nom<\/label>\n                                                    <input type='text' name='input_28.3' id='input_3_28_3' value=''   aria-required='false'     \/>\n                                                <\/span>\n                            \n                            <span id='input_3_28_6_container' class='name_last gform-grid-col gform-grid-col--size-auto' >\n                                                            <label for='input_3_28_6' class='gform-field-label gform-field-label--type-sub '>Nom<\/label>\n                                                            <input type='text' name='input_28.6' id='input_3_28_6' value=''   aria-required='false'     \/>\n                                                        <\/span>\n                            \n                        <\/div><\/fieldset><fieldset id=\"field_3_29\" class=\"gfield gfield--type-date gfield--input-type-date gfield--input-type-datefield gfield--width-full gfield_contains_required field_sublabel_above gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Date of Birth:<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(N\u00e9cessaire)<\/span><\/span><\/legend><div id='input_3_29' class='ginput_container ginput_complex gform-grid-row'><div class='gfield_date_month ginput_container ginput_container_date gform-grid-col' id='input_3_29_1_container'>\n                                            <label for='input_3_29_1' class='gform-field-label gform-field-label--type-sub screen-reader-text'>Mois<\/label>\n                                            <input type='number' maxlength='2' name='input_29[]' id='input_3_29_1' value=''   aria-required='true'   placeholder='MM' min='1' max='12' step='1'\/>\n                                        <\/div><div class='gfield_date_day ginput_container ginput_container_date gform-grid-col' id='input_3_29_2_container'>\n                                            <label for='input_3_29_2' class='gform-field-label gform-field-label--type-sub screen-reader-text'>Jour<\/label>\n                                            <input type='number' maxlength='2' name='input_29[]' id='input_3_29_2' value=''   aria-required='true'   placeholder='JJ' min='1' max='31' step='1'\/>\n                                        <\/div><div class='gfield_date_year ginput_container ginput_container_date gform-grid-col' id='input_3_29_3_container'>\n                                            <label for='input_3_29_3' class='gform-field-label gform-field-label--type-sub screen-reader-text'>Ann\u00e9e<\/label>\n                                            <input type='number' maxlength='4' name='input_29[]' id='input_3_29_3' value=''   aria-required='true'   placeholder='AAAA' min='1920' max='2027' step='1'\/>\n                                       <\/div>\n                                   <\/div><\/fieldset><fieldset id=\"field_3_30\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield--input-type-checkbox gfield--width-full gfield_contains_required field_sublabel_above gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Sex\/Gender:<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(N\u00e9cessaire)<\/span><\/span><\/legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox ' id='input_3_30'><div class='gchoice gchoice_3_30_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_30.1' type='checkbox'  value='Male'  id='choice_3_30_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_3_30_1' id='label_3_30_1' class='gform-field-label gform-field-label--type-inline'>Male<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_3_30_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_30.2' type='checkbox'  value='Female'  id='choice_3_30_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_3_30_2' id='label_3_30_2' class='gform-field-label gform-field-label--type-inline'>Female<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_3_30_3'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_30.3' type='checkbox'  value='Other'  id='choice_3_30_3'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_3_30_3' id='label_3_30_3' class='gform-field-label gform-field-label--type-inline'>Other<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_3_30_4'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_30.4' type='checkbox'  value='Prefer not to say'  id='choice_3_30_4'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_3_30_4' id='label_3_30_4' class='gform-field-label gform-field-label--type-inline'>Prefer not to say<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_3_31\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield--input-type-checkbox gfield--width-full gfield_contains_required field_sublabel_above gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Service Category:<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(N\u00e9cessaire)<\/span><\/span><\/legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox gfield_choice--select_all_enabled' id='input_3_31'><div class='gchoice gchoice_3_31_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_31.1' type='checkbox'  value='Military'  id='choice_3_31_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_3_31_1' id='label_3_31_1' class='gform-field-label gform-field-label--type-inline'>Military<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_3_31_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_31.2' type='checkbox'  value='Veteran'  id='choice_3_31_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_3_31_2' id='label_3_31_2' class='gform-field-label gform-field-label--type-inline'>Veteran<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_3_31_3'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_31.3' type='checkbox'  value='Police'  id='choice_3_31_3'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_3_31_3' id='label_3_31_3' class='gform-field-label gform-field-label--type-inline'>Police<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_3_31_4'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_31.4' type='checkbox'  value='Firefighter'  id='choice_3_31_4'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_3_31_4' id='label_3_31_4' class='gform-field-label gform-field-label--type-inline'>Firefighter<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_3_31_5'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_31.5' type='checkbox'  value='Paramedic'  id='choice_3_31_5'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_3_31_5' id='label_3_31_5' class='gform-field-label gform-field-label--type-inline'>Paramedic<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_3_31_6'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_31.6' type='checkbox'  value='Other'  id='choice_3_31_6'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_3_31_6' id='label_3_31_6' class='gform-field-label gform-field-label--type-inline'>Other<\/label>\n\t\t\t\t\t\t\t<\/div><div class=\"gfield-choice-toggle-all\"><button type=\"button\" id=\"button_31_select_all\" class=\"gfield_choice_all_toggle gform-theme-button--size-sm\" onclick=\"gformToggleCheckboxes( this )\" data-checked=\"0\" data-label-select=\"Tout s\u00e9lectionner\" data-label-deselect=\"Tout d\u00e9s\u00e9lectionner\">Tout s\u00e9lectionner<\/button><\/div><\/div><\/div><\/fieldset><div id=\"field_3_33\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-full field_sublabel_above gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_3_33'>Service Branch \/ Department:<\/label><div class='ginput_container ginput_container_text'><input name='input_33' id='input_3_33' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_3_32\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-half field_sublabel_above gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_3_32'>Rank \/ Role (if applicable):<\/label><div class='ginput_container ginput_container_text'><input name='input_32' id='input_3_32' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_3_36\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-half field_sublabel_above gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_3_36'>Years of Service:<\/label><div class='ginput_container ginput_container_text'><input name='input_36' id='input_3_36' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/div><fieldset id=\"field_3_38\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-full gfield_contains_required field_sublabel_above gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >Is the client aware of and consenting to this referral?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(N\u00e9cessaire)<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_3_38'>\n\t\t\t<div class='gchoice gchoice_3_38_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_38' type='radio' value='Yes'  id='choice_3_38_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_3_38_0' id='label_3_38_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_3_38_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_38' type='radio' value='No'  id='choice_3_38_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_3_38_1' id='label_3_38_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_3_66\" class=\"gfield gfield--type-section gfield--input-type-section gsection field_sublabel_above gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><h3 class=\"gsection_title\"><\/h3><\/div><div id=\"field_3_39\" class=\"gfield gfield--type-section gfield--input-type-section gsection field_sublabel_above gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><h3 class=\"gsection_title\">SECTION C: REASON FOR REFERRAL<\/h3><\/div><fieldset id=\"field_3_41\" class=\"gfield gfield--type-multi_choice gfield--type-choice gfield--input-type-checkbox gfield--width-full field_sublabel_above gfield--no-description field_description_below field_validation_below gfield_visibility_visible gfield--choice-align-vertical\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Primary Assessment Purpose: (check all that apply)<\/legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox ' id='input_3_41'><div class='gchoice gchoice_3_41_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_41.1' type='checkbox'  value='Diagnostic clarification'  id='choice_3_41_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_3_41_1' id='label_3_41_1' class='gform-field-label gform-field-label--type-inline'>Diagnostic clarification<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_3_41_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_41.2' type='checkbox'  value='PTSD \/ trauma-related concerns'  id='choice_3_41_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_3_41_2' id='label_3_41_2' class='gform-field-label gform-field-label--type-inline'>PTSD \/ trauma-related concerns<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_3_41_3'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_41.3' type='checkbox'  value='Return to work readiness'  id='choice_3_41_3'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_3_41_3' id='label_3_41_3' class='gform-field-label gform-field-label--type-inline'>Return to work readiness<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_3_41_4'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_41.4' type='checkbox'  value='Occupational stress injury (OSI)'  id='choice_3_41_4'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_3_41_4' id='label_3_41_4' class='gform-field-label gform-field-label--type-inline'>Occupational stress injury (OSI)<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_3_41_5'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_41.5' type='checkbox'  value='Other (please specify):'  id='choice_3_41_5'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_3_41_5' id='label_3_41_5' class='gform-field-label gform-field-label--type-inline'>Other (please specify):<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_3_42\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-full field_sublabel_above gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_3_42'>Brief Description of Presenting Concerns \/ Context<\/label><div class='ginput_container ginput_container_text'><input name='input_42' id='input_3_42' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_3_67\" class=\"gfield gfield--type-section gfield--input-type-section gsection field_sublabel_above gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><h3 class=\"gsection_title\"><\/h3><\/div><div id=\"field_3_43\" class=\"gfield gfield--type-section gfield--input-type-section gsection field_sublabel_above gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><h3 class=\"gsection_title\">SECTION D: RELEVANT BACKGROUND<\/h3><\/div><div id=\"field_3_44\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-full field_sublabel_above gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_3_44'>Current Diagnoses (if applicable):<\/label><div class='ginput_container ginput_container_text'><input name='input_44' id='input_3_44' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/div><fieldset id=\"field_3_45\" class=\"gfield gfield--type-multi_choice gfield--type-choice gfield--input-type-checkbox gfield--width-full field_sublabel_above gfield--no-description field_description_below field_validation_below gfield_visibility_visible gfield--choice-align-vertical\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Known Psychiatric History:<\/legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox ' id='input_3_45'><div class='gchoice gchoice_3_45_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_45.1' type='checkbox'  value='None Known'  id='choice_3_45_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_3_45_1' id='label_3_45_1' class='gform-field-label gform-field-label--type-inline'>None Known<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_3_45_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_45.2' type='checkbox'  value='Depression'  id='choice_3_45_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_3_45_2' id='label_3_45_2' class='gform-field-label gform-field-label--type-inline'>Depression<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_3_45_3'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_45.3' type='checkbox'  value='Anxiety'  id='choice_3_45_3'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_3_45_3' id='label_3_45_3' class='gform-field-label gform-field-label--type-inline'>Anxiety<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_3_45_4'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_45.6' type='checkbox'  value='PTSD'  id='choice_3_45_4'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_3_45_4' id='label_3_45_4' class='gform-field-label gform-field-label--type-inline'>PTSD<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_3_45_5'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_45.5' type='checkbox'  value='Substance Use'  id='choice_3_45_5'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_3_45_5' id='label_3_45_5' class='gform-field-label gform-field-label--type-inline'>Substance Use<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_3_45_6'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_45.4' type='checkbox'  value='Personality Disorder'  id='choice_3_45_6'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_3_45_6' id='label_3_45_6' class='gform-field-label gform-field-label--type-inline'>Personality Disorder<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_3_45_7'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_45.7' type='checkbox'  value='Psychotic Disorders'  id='choice_3_45_7'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_3_45_7' id='label_3_45_7' class='gform-field-label gform-field-label--type-inline'>Psychotic Disorders<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_3_45_8'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_45.8' type='checkbox'  value='Other'  id='choice_3_45_8'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_3_45_8' id='label_3_45_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_3_46\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-full field_sublabel_above gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_3_46'>Other<\/label><div class='ginput_container ginput_container_text'><input name='input_46' id='input_3_46' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/div><fieldset id=\"field_3_47\" class=\"gfield gfield--type-multi_choice gfield--type-choice gfield--input-type-checkbox gfield--width-full field_sublabel_above gfield--no-description field_description_below field_validation_below gfield_visibility_visible gfield--choice-align-vertical\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Medical Conditions Impacting Assessment:<\/legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox ' id='input_3_47'><div class='gchoice gchoice_3_47_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_47.1' type='checkbox'  value='None Known'  id='choice_3_47_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_3_47_1' id='label_3_47_1' class='gform-field-label gform-field-label--type-inline'>None Known<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_3_47_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_47.2' type='checkbox'  value='TBI'  id='choice_3_47_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_3_47_2' id='label_3_47_2' class='gform-field-label gform-field-label--type-inline'>TBI<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_3_47_3'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_47.3' type='checkbox'  value='Head Injury'  id='choice_3_47_3'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_3_47_3' id='label_3_47_3' class='gform-field-label gform-field-label--type-inline'>Head Injury<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_3_47_4'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_47.4' type='checkbox'  value='Chronic Pain'  id='choice_3_47_4'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_3_47_4' id='label_3_47_4' class='gform-field-label gform-field-label--type-inline'>Chronic Pain<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_3_47_5'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_47.5' type='checkbox'  value='Sleep Disorder'  id='choice_3_47_5'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_3_47_5' id='label_3_47_5' class='gform-field-label gform-field-label--type-inline'>Sleep Disorder<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_3_47_6'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_47.6' type='checkbox'  value='Other'  id='choice_3_47_6'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_3_47_6' id='label_3_47_6' 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_3_48\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-full field_sublabel_above gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_3_48'>Other<\/label><div class='ginput_container ginput_container_text'><input name='input_48' id='input_3_48' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_3_49\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-full field_sublabel_above gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_3_49'>Current Medications:<\/label><div class='ginput_container ginput_container_text'><input name='input_49' id='input_3_49' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_3_68\" class=\"gfield gfield--type-section gfield--input-type-section gsection field_sublabel_above gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><h3 class=\"gsection_title\"><\/h3><\/div><div id=\"field_3_50\" class=\"gfield gfield--type-section gfield--input-type-section gsection field_sublabel_above gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><h3 class=\"gsection_title\">SECTION E: ASSESSMENT LOGISTICS<\/h3><\/div><fieldset id=\"field_3_52\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-full field_sublabel_above gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >Preferred Assessment Location:<\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_3_52'>\n\t\t\t<div class='gchoice gchoice_3_52_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_52' type='radio' value='In person (if appropriate)'  id='choice_3_52_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_3_52_0' id='label_3_52_0' class='gform-field-label gform-field-label--type-inline'>In person (if appropriate)<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_3_52_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_52' type='radio' value='Virtual (if appropriate)'  id='choice_3_52_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_3_52_1' id='label_3_52_1' class='gform-field-label gform-field-label--type-inline'>Virtual (if appropriate)<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_3_52_2'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_52' type='radio' value='No Preference'  id='choice_3_52_2' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_3_52_2' id='label_3_52_2' class='gform-field-label gform-field-label--type-inline'>No Preference<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_3_53\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-full field_sublabel_above gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >Is the client currently on medical leave or restricted duty?<\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_3_53'>\n\t\t\t<div class='gchoice gchoice_3_53_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_53' type='radio' value='Yes'  id='choice_3_53_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_3_53_0' id='label_3_53_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_3_53_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_53' type='radio' value='No'  id='choice_3_53_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_3_53_1' id='label_3_53_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_3_53_2'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_53' type='radio' value='Unknown'  id='choice_3_53_2' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_3_53_2' id='label_3_53_2' class='gform-field-label gform-field-label--type-inline'>Unknown<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_3_69\" class=\"gfield gfield--type-section gfield--input-type-section gsection field_sublabel_above gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><h3 class=\"gsection_title\"><\/h3><\/div><div id=\"field_3_54\" class=\"gfield gfield--type-section gfield--input-type-section gsection field_sublabel_above gfield--has-description field_description_below field_validation_below gfield_visibility_visible\"  ><h3 class=\"gsection_title\">SECTION F: SUPPORTING DOCUMENTS<\/h3><div class='gsection_description' id='gfield_description_3_54'>\u2610 Consent to release information\n\u2610 Previous psychological \/ psychiatric reports\n\u2610 Incident or critical event reports\n\u2610 Work status letters\n\u2610 Physician referrals\n\u2610 Insurance correspondence\n<\/div><\/div><div id=\"field_3_55\" class=\"gfield gfield--type-fileupload gfield--input-type-fileupload gfield--width-full field_sublabel_above gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='gform_browse_button_3_55'>(Attach\/submit all that are applicable)<\/label><div class='ginput_container ginput_container_fileupload'><div id='gform_multifile_upload_3_55' data-settings='{&quot;runtimes&quot;:&quot;html5,flash,html4&quot;,&quot;browse_button&quot;:&quot;gform_browse_button_3_55&quot;,&quot;container&quot;:&quot;gform_multifile_upload_3_55&quot;,&quot;drop_element&quot;:&quot;gform_drag_drop_area_3_55&quot;,&quot;filelist&quot;:&quot;gform_preview_3_55&quot;,&quot;unique_names&quot;:true,&quot;file_data_name&quot;:&quot;file&quot;,&quot;url&quot;:&quot;https:\\\/\\\/woundedwarriors.ca\\\/fr\\\/?gf_page=32852bf95c04454&quot;,&quot;flash_swf_url&quot;:&quot;https:\\\/\\\/woundedwarriors.ca\\\/wp-includes\\\/js\\\/plupload\\\/plupload.flash.swf&quot;,&quot;silverlight_xap_url&quot;:&quot;https:\\\/\\\/woundedwarriors.ca\\\/wp-includes\\\/js\\\/plupload\\\/plupload.silverlight.xap&quot;,&quot;filters&quot;:{&quot;mime_types&quot;:[{&quot;title&quot;:&quot;Fichiers autoris\\u00e9s&quot;,&quot;extensions&quot;:&quot;*&quot;}],&quot;max_file_size&quot;:&quot;209715200b&quot;},&quot;multipart&quot;:true,&quot;urlstream_upload&quot;:false,&quot;multipart_params&quot;:{&quot;form_id&quot;:3,&quot;field_id&quot;:55,&quot;_gform_file_upload_nonce_3_55&quot;:&quot;76adc32f7d&quot;},&quot;gf_vars&quot;:{&quot;max_files&quot;:0,&quot;message_id&quot;:&quot;gform_multifile_messages_3_55&quot;,&quot;disallowed_extensions&quot;:[&quot;php&quot;,&quot;asp&quot;,&quot;aspx&quot;,&quot;cmd&quot;,&quot;csh&quot;,&quot;bat&quot;,&quot;html&quot;,&quot;htm&quot;,&quot;hta&quot;,&quot;jar&quot;,&quot;exe&quot;,&quot;com&quot;,&quot;js&quot;,&quot;lnk&quot;,&quot;htaccess&quot;,&quot;phar&quot;,&quot;phtml&quot;,&quot;ps1&quot;,&quot;ps2&quot;,&quot;php3&quot;,&quot;php4&quot;,&quot;php5&quot;,&quot;php6&quot;,&quot;py&quot;,&quot;rb&quot;,&quot;tmp&quot;]}}' class='gform_fileupload_multifile'>\n\t\t\t\t\t\t\t\t\t\t<div id='gform_drag_drop_area_3_55' class='gform_drop_area gform-theme-field-control'>\n\t\t\t\t\t\t\t\t\t\t\t<span class='gform_drop_instructions'>D\u00e9posez les fichiers ici ou <\/span>\n\t\t\t\t\t\t\t\t\t\t\t<button type='button' id='gform_browse_button_3_55' class='button gform_button_select_files gform-theme-button gform-theme-button--control' aria-describedby=\"gfield_upload_rules_3_55\"  >S\u00e9lectionnez des fichiers<\/button>\n\t\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t<\/div><span class='gfield_description gform_fileupload_rules' id='gfield_upload_rules_3_55'>Taille max. des fichiers\u00a0: 200 MB.<\/span><ul class='validation_message--hidden-on-empty gform-ul-reset' id='gform_multifile_messages_3_55'><\/ul> <div id='gform_preview_3_55' class='ginput_preview_list'><\/div><\/div><\/div><div id=\"field_3_70\" class=\"gfield gfield--type-section gfield--input-type-section gsection field_sublabel_above gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><h3 class=\"gsection_title\"><\/h3><\/div><div id=\"field_3_56\" class=\"gfield gfield--type-section gfield--input-type-section gsection field_sublabel_above gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><h3 class=\"gsection_title\">SECTION G: REFERRAL OUTCOME REQUEST<\/h3><\/div><fieldset id=\"field_3_57\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield--input-type-checkbox gfield--width-full field_sublabel_above gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' >What type of report or feedback is being requested?<\/legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox gfield_choice--select_all_enabled' id='input_3_57'><div class='gchoice gchoice_3_57_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_57.1' type='checkbox'  value='Full psychological assessment report'  id='choice_3_57_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_3_57_1' id='label_3_57_1' class='gform-field-label gform-field-label--type-inline'>Full psychological assessment report<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_3_57_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_57.2' type='checkbox'  value='Summary letter with findings'  id='choice_3_57_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_3_57_2' id='label_3_57_2' class='gform-field-label gform-field-label--type-inline'>Summary letter with findings<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_3_57_3'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_57.3' type='checkbox'  value='Recommendations for treatment'  id='choice_3_57_3'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_3_57_3' id='label_3_57_3' class='gform-field-label gform-field-label--type-inline'>Recommendations for treatment<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_3_57_4'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_57.4' type='checkbox'  value='Return-to-work recommendations'  id='choice_3_57_4'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_3_57_4' id='label_3_57_4' class='gform-field-label gform-field-label--type-inline'>Return-to-work recommendations<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_3_57_5'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_57.5' type='checkbox'  value='Other'  id='choice_3_57_5'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_3_57_5' id='label_3_57_5' class='gform-field-label gform-field-label--type-inline'>Other<\/label>\n\t\t\t\t\t\t\t<\/div><div class=\"gfield-choice-toggle-all\"><button type=\"button\" id=\"button_57_select_all\" class=\"gfield_choice_all_toggle gform-theme-button--size-sm\" onclick=\"gformToggleCheckboxes( this )\" data-checked=\"0\" data-label-select=\"Tout s\u00e9lectionner\" data-label-deselect=\"Tout d\u00e9s\u00e9lectionner\">Tout s\u00e9lectionner<\/button><\/div><\/div><\/div><\/fieldset><div id=\"field_3_58\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-full field_sublabel_above gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_3_58'>Other<\/label><div class='ginput_container ginput_container_text'><input name='input_58' id='input_3_58' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/div><fieldset id=\"field_3_59\" class=\"gfield gfield--type-multi_choice gfield--type-choice gfield--input-type-checkbox gfield--width-full field_sublabel_above gfield--no-description field_description_below field_validation_below gfield_visibility_visible gfield--choice-align-vertical\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Who should receive the report\/results?<\/legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox ' id='input_3_59'><div class='gchoice gchoice_3_59_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_59.1' type='checkbox'  value='Referring provider only'  id='choice_3_59_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_3_59_1' id='label_3_59_1' class='gform-field-label gform-field-label--type-inline'>Referring provider only<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_3_59_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_59.2' type='checkbox'  value='Client'  id='choice_3_59_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_3_59_2' id='label_3_59_2' class='gform-field-label gform-field-label--type-inline'>Client<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_3_59_3'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_59.3' type='checkbox'  value='Employer \/ Agency (specify):'  id='choice_3_59_3'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_3_59_3' id='label_3_59_3' class='gform-field-label gform-field-label--type-inline'>Employer \/ Agency (specify):<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_3_59_4'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_59.4' type='checkbox'  value='Insurer (specify):'  id='choice_3_59_4'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_3_59_4' id='label_3_59_4' class='gform-field-label gform-field-label--type-inline'>Insurer (specify):<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_3_61\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-full field_sublabel_above gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_3_61'>Employer \/ Agency (specify):<\/label><div class='ginput_container ginput_container_text'><input name='input_61' id='input_3_61' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_3_60\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-full field_sublabel_above gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_3_60'>Insurer (specify):<\/label><div class='ginput_container ginput_container_text'><input name='input_60' id='input_3_60' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_3_63\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-full field_sublabel_above gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_3_63'>Signature<\/label><div class='ginput_container ginput_container_text'><input name='input_63' id='input_3_63' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_3_62\" class=\"gfield 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