{"id":1873,"date":"2018-10-17T22:20:32","date_gmt":"2018-10-18T02:20:32","guid":{"rendered":"https:\/\/cliniquespectrum.com\/registration-form\/"},"modified":"2019-02-10T14:16:32","modified_gmt":"2019-02-10T19:16:32","slug":"formulaire-inscription","status":"publish","type":"page","link":"https:\/\/cliniquespectrum.com\/fr\/formulaire-inscription\/","title":{"rendered":"Formulaire d\u2019inscription"},"content":{"rendered":"<p>[et_pb_section fb_built=\u00a0\u00bb1&Prime; _builder_version=\u00a0\u00bb3.0.47&Prime;][et_pb_row _builder_version=\u00a0\u00bb3.0.48&Prime; background_size=\u00a0\u00bbinitial\u00a0\u00bb background_position=\u00a0\u00bbtop_left\u00a0\u00bb background_repeat=\u00a0\u00bbrepeat\u00a0\u00bb][et_pb_column type=\u00a0\u00bb4_4&Prime; _builder_version=\u00a0\u00bb3.0.47&Prime;][et_pb_text _builder_version=\u00a0\u00bb3.19.13&Prime;]<\/p>\n<h1>Formulaire d\u2019inscription<\/h1>\n<p>\u0161&rsquo;il vous pla\u00eet compl\u00e9ter et soumettrer afin d\u2019assurer votre place sur notre liste d\u2019attente<br \/>\n\n<div class=\"wpcf7 no-js\" id=\"wpcf7-f1877-o1\" lang=\"fr-FR\" dir=\"ltr\" data-wpcf7-id=\"1877\">\n<div class=\"screen-reader-response\"><p role=\"status\" aria-live=\"polite\" aria-atomic=\"true\"><\/p> <ul><\/ul><\/div>\n<form action=\"\/fr\/wp-json\/wp\/v2\/pages\/1873#wpcf7-f1877-o1\" method=\"post\" class=\"wpcf7-form init\" aria-label=\"Formulaire de contact\" enctype=\"multipart\/form-data\" novalidate=\"novalidate\" data-status=\"init\">\n<fieldset class=\"hidden-fields-container\"><input type=\"hidden\" name=\"_wpcf7\" value=\"1877\" \/><input type=\"hidden\" name=\"_wpcf7_version\" value=\"6.1.5\" \/><input type=\"hidden\" name=\"_wpcf7_locale\" value=\"fr_FR\" \/><input type=\"hidden\" name=\"_wpcf7_unit_tag\" value=\"wpcf7-f1877-o1\" \/><input type=\"hidden\" name=\"_wpcf7_container_post\" value=\"0\" \/><input type=\"hidden\" name=\"_wpcf7_posted_data_hash\" value=\"\" \/>\n<\/fieldset>\n<div class=\"et_pb_contact reg\">\n\t<p class=\"et_pb_contact_field_half\"><br \/>\n<label>Personne compl\u00e9tant ce formulaire : (requis)<\/label><br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"contacter\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"contacter\" \/><\/span>\n\t<\/p>\n\t<p class=\"et_pb_contact_field_half second\"><br \/>\n<label>Date : (required) (YYYY-MM-DD)<\/label><br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"date\"><input class=\"wpcf7-form-control wpcf7-date wpcf7-validates-as-required wpcf7-validates-as-date\" aria-required=\"true\" aria-invalid=\"false\" value=\"\" type=\"date\" name=\"date\" \/><\/span>\n\t<\/p>\n\t<p class=\"et_pb_contact_field_last\">\n\t<\/p>\n\t<section class=\"subHeading\">\n\t\t<p>Information concernant le \/ la client(e)\n\t\t<\/p>\n\t<\/section>\n\t<p class=\"et_pb_contact_field_half\"><br \/>\n<label>Nom de famille : (requis)<\/label><br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"last-name\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"last-name\" \/><\/span>\n\t<\/p>\n\t<p class=\"et_pb_contact_field_half second\"><br \/>\n<label>Pr\u00e9nom : (requis)<\/label><br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"first-name\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"first-name\" \/><\/span>\n\t<\/p>\n\t<p class=\"et_pb_contact_field_half\"><br \/>\n<label>\u00c2ge :<\/label><br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"age\"><input class=\"wpcf7-form-control wpcf7-number wpcf7-validates-as-number\" aria-invalid=\"false\" value=\"\" type=\"number\" name=\"age\" \/><\/span>\n\t<\/p>\n\t<p class=\"et_pb_contact_field_half second\"><br \/>\n<label>Date de naissance : (YYYY-MM-DD)<\/label><br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"dob\"><input class=\"wpcf7-form-control wpcf7-date wpcf7-validates-as-required wpcf7-validates-as-date\" aria-required=\"true\" aria-invalid=\"false\" value=\"\" type=\"date\" name=\"dob\" \/><\/span>\n\t<\/p>\n\t<p class=\"et_pb_contact_field_last\"><br \/>\n<label>Gender Identity :<\/label><br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"sex\"><span class=\"wpcf7-form-control wpcf7-radio\"><span class=\"wpcf7-list-item first\"><input type=\"radio\" name=\"sex\" value=\"Male\/Man\" \/><span class=\"wpcf7-list-item-label\">Male\/Man<\/span><\/span><span class=\"wpcf7-list-item\"><input type=\"radio\" name=\"sex\" value=\"Female\/Woman\" \/><span class=\"wpcf7-list-item-label\">Female\/Woman<\/span><\/span><span class=\"wpcf7-list-item\"><input type=\"radio\" name=\"sex\" value=\"TransMale\/TransMan\" \/><span class=\"wpcf7-list-item-label\">TransMale\/TransMan<\/span><\/span><span class=\"wpcf7-list-item\"><input type=\"radio\" name=\"sex\" value=\"TransFemale\/TransWoman\" \/><span class=\"wpcf7-list-item-label\">TransFemale\/TransWoman<\/span><\/span><span class=\"wpcf7-list-item\"><input type=\"radio\" name=\"sex\" value=\"Gender Neutral\/Gender Nonconforming\" \/><span class=\"wpcf7-list-item-label\">Gender Neutral\/Gender Nonconforming<\/span><\/span><span class=\"wpcf7-list-item\"><input type=\"radio\" name=\"sex\" value=\"Something else\" \/><span class=\"wpcf7-list-item-label\">Something else<\/span><\/span><span class=\"wpcf7-list-item last\"><input type=\"radio\" name=\"sex\" value=\"Decline to answer\" \/><span class=\"wpcf7-list-item-label\">Decline to answer<\/span><\/span><\/span><\/span>\n\t<\/p>\n\t<p class=\"et_pb_contact_field_last\"><br \/>\n<label>\u00c9tat civil du client :<\/label><br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"maritalStatus\"><span class=\"wpcf7-form-control wpcf7-radio\"><span class=\"wpcf7-list-item first\"><input type=\"radio\" name=\"maritalStatus\" value=\"Mari\u00e9 (e)\" \/><span class=\"wpcf7-list-item-label\">Mari\u00e9 (e)<\/span><\/span><span class=\"wpcf7-list-item\"><input type=\"radio\" name=\"maritalStatus\" value=\"C\u00e9libataire\" \/><span class=\"wpcf7-list-item-label\">C\u00e9libataire<\/span><\/span><span class=\"wpcf7-list-item\"><input type=\"radio\" name=\"maritalStatus\" value=\"S\u00e9par\u00e9(e)\" \/><span class=\"wpcf7-list-item-label\">S\u00e9par\u00e9(e)<\/span><\/span><span class=\"wpcf7-list-item\"><input type=\"radio\" name=\"maritalStatus\" value=\"Divorc\u00e9(e)\" \/><span class=\"wpcf7-list-item-label\">Divorc\u00e9(e)<\/span><\/span><span class=\"wpcf7-list-item last\"><input type=\"radio\" name=\"maritalStatus\" value=\"N\/A\" \/><span class=\"wpcf7-list-item-label\">N\/A<\/span><\/span><\/span><\/span>\n\t<\/p>\n\t<p class=\"et_pb_contact_field_last\"><br \/>\n<label>Person with limited mobility:<\/label><br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"mobility\"><span class=\"wpcf7-form-control wpcf7-radio\"><span class=\"wpcf7-list-item first\"><input type=\"radio\" name=\"mobility\" value=\"Oui\" \/><span class=\"wpcf7-list-item-label\">Oui<\/span><\/span><span class=\"wpcf7-list-item last\"><input type=\"radio\" name=\"mobility\" value=\"Non\" \/><span class=\"wpcf7-list-item-label\">Non<\/span><\/span><\/span><\/span>\n\t<\/p>\n\t<p class=\"et_pb_contact_field_last\"><br \/>\n<label>Adresse :<\/label><br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"address\"><textarea cols=\"40\" rows=\"10\" maxlength=\"2000\" class=\"wpcf7-form-control wpcf7-textarea\" aria-invalid=\"false\" name=\"address\"><\/textarea><\/span>\n\t<\/p>\n\t<p class=\"et_pb_contact_field_last\"><br \/>\n<label>Si le \/ la client(e) est sous une garde l\u00e9gale, veuillez indiquer qui a la garde l\u00e9gale :<\/label><br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"guardianship\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"guardianship\" \/><\/span>\n\t<\/p>\n\t<p class=\"et_pb_contact_field_third\"><br \/>\n<label>T\u00e9l\u00e9phone maison du client :<\/label><br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"homePhone\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-tel wpcf7-text wpcf7-validates-as-tel\" aria-invalid=\"false\" value=\"\" type=\"tel\" name=\"homePhone\" \/><\/span>\n\t<\/p>\n\t<p class=\"et_pb_contact_field_third second\"><br \/>\n<label>T\u00e9l\u00e9phone cellulaire du client :<\/label><br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"cellPhone\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-tel wpcf7-text wpcf7-validates-as-tel\" aria-invalid=\"false\" value=\"\" type=\"tel\" name=\"cellPhone\" \/><\/span>\n\t<\/p>\n\t<p class=\"et_pb_contact_field_third second\"><br \/>\n<label>T\u00e9l\u00e9phone travail\/occupation du client :<\/label><br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"workPhone\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-tel wpcf7-text wpcf7-validates-as-tel\" aria-invalid=\"false\" value=\"\" type=\"tel\" name=\"workPhone\" \/><\/span>\n\t<\/p>\n\t<p class=\"et_pb_contact_field_half\"><br \/>\n<label>Courriel du client :<\/label><br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"email\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-email wpcf7-text wpcf7-validates-as-email\" aria-invalid=\"false\" value=\"\" type=\"email\" name=\"email\" \/><\/span>\n\t<\/p>\n\t<p class=\"et_pb_contact_field_half second\"><br \/>\n<label>Veuillez noter que nous pouvons vous contacter par courriel :<\/label><br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"emailContact\"><span class=\"wpcf7-form-control wpcf7-radio\"><span class=\"wpcf7-list-item first\"><input type=\"radio\" name=\"emailContact\" value=\"Oui\" checked=\"checked\" \/><span class=\"wpcf7-list-item-label\">Oui<\/span><\/span><span class=\"wpcf7-list-item last\"><input type=\"radio\" name=\"emailContact\" value=\"Non\" \/><span class=\"wpcf7-list-item-label\">Non<\/span><\/span><\/span><\/span>\n\t<\/p>\n<hr \/>\n\t<p class=\"et_pb_contact_field_half\"><br \/>\n<label>Nom du parent ou tuteur :<\/label><br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"caregiver1Name\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"caregiver1Name\" \/><\/span>\n\t<\/p>\n\t<p class=\"et_pb_contact_field_half second\"><br \/>\n<label>T\u00e9l\u00e9phone du parent ou tuteur :<\/label><br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"caregiver1Phone\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-tel wpcf7-text wpcf7-validates-as-tel\" aria-invalid=\"false\" value=\"\" type=\"tel\" name=\"caregiver1Phone\" \/><\/span>\n\t<\/p>\n\t<p class=\"et_pb_contact_field_last\"><br \/>\n<label>Courriel du parent ou tuteur :<\/label><br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"caregiver1Email\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-email wpcf7-text wpcf7-validates-as-email\" aria-invalid=\"false\" value=\"\" type=\"email\" name=\"caregiver1Email\" \/><\/span>\n\t<\/p>\n\t<p class=\"et_pb_contact_field_half\"><br \/>\n<label>Relation du parent ou tuteur avec le \/ la client(e) :<\/label><br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"caregiver1Relationship\"><span class=\"wpcf7-form-control wpcf7-radio\"><span class=\"wpcf7-list-item first\"><input type=\"radio\" name=\"caregiver1Relationship\" value=\"M\u00e8re\" \/><span class=\"wpcf7-list-item-label\">M\u00e8re<\/span><\/span><span class=\"wpcf7-list-item\"><input type=\"radio\" name=\"caregiver1Relationship\" value=\"P\u00e8re\" \/><span class=\"wpcf7-list-item-label\">P\u00e8re<\/span><\/span><span class=\"wpcf7-list-item\"><input type=\"radio\" name=\"caregiver1Relationship\" value=\"Tuteur\" \/><span class=\"wpcf7-list-item-label\">Tuteur<\/span><\/span><span class=\"wpcf7-list-item last\"><input type=\"radio\" name=\"caregiver1Relationship\" value=\"Autre\" \/><span class=\"wpcf7-list-item-label\">Autre<\/span><\/span><\/span><\/span>\n\t<\/p>\n\t<p class=\"et_pb_contact_field_half second\"><br \/>\n<label>Parent ou tuteur habite \u00e0 la m\u00eame adresse ?<\/label><br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"caregiver1Address\"><span class=\"wpcf7-form-control wpcf7-radio\"><span class=\"wpcf7-list-item first\"><input type=\"radio\" name=\"caregiver1Address\" value=\"Oui\" \/><span class=\"wpcf7-list-item-label\">Oui<\/span><\/span><span class=\"wpcf7-list-item last\"><input type=\"radio\" name=\"caregiver1Address\" value=\"Non\" \/><span class=\"wpcf7-list-item-label\">Non<\/span><\/span><\/span><\/span>\n\t<\/p>\n<hr \/>\n\t<p class=\"et_pb_contact_field_half\"><br \/>\n<label>Nom du deuxieme parent ou tuteur:<\/label><br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"caregiver2Name\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"caregiver2Name\" \/><\/span>\n\t<\/p>\n\t<p class=\"et_pb_contact_field_half second\"><br \/>\n<label>T\u00e9l\u00e9phone du deuxieme parent ou tuteur :<\/label><br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"caregiver2Phone\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-tel wpcf7-text wpcf7-validates-as-tel\" aria-invalid=\"false\" value=\"\" type=\"tel\" name=\"caregiver2Phone\" \/><\/span>\n\t<\/p>\n\t<p class=\"et_pb_contact_field_last\"><br \/>\n<label>Courriel du deuxieme parent ou tuteur :<\/label><br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"caregiver2Email\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-email wpcf7-text wpcf7-validates-as-email\" aria-invalid=\"false\" value=\"\" type=\"email\" name=\"caregiver2Email\" \/><\/span>\n\t<\/p>\n\t<p class=\"et_pb_contact_field_half\"><br \/>\n<label>Relation du deuxieme parent ou tuteur avec le \/ la client(e) :<\/label><br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"caregiver2Relationship\"><span class=\"wpcf7-form-control wpcf7-radio\"><span class=\"wpcf7-list-item first\"><input type=\"radio\" name=\"caregiver2Relationship\" value=\"M\u00e8re\" \/><span class=\"wpcf7-list-item-label\">M\u00e8re<\/span><\/span><span class=\"wpcf7-list-item\"><input type=\"radio\" name=\"caregiver2Relationship\" value=\"P\u00e8re\" \/><span class=\"wpcf7-list-item-label\">P\u00e8re<\/span><\/span><span class=\"wpcf7-list-item\"><input type=\"radio\" name=\"caregiver2Relationship\" value=\"Tuteur\" \/><span class=\"wpcf7-list-item-label\">Tuteur<\/span><\/span><span class=\"wpcf7-list-item last\"><input type=\"radio\" name=\"caregiver2Relationship\" value=\"Autre\" \/><span class=\"wpcf7-list-item-label\">Autre<\/span><\/span><\/span><\/span>\n\t<\/p>\n\t<p class=\"et_pb_contact_field_half second\"><br \/>\n<label>Deuxieme parent ou tuteur habite \u00e0 la m\u00eame adresse ?<\/label><br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"caregiver2Address\"><span class=\"wpcf7-form-control wpcf7-radio\"><span class=\"wpcf7-list-item first\"><input type=\"radio\" name=\"caregiver2Address\" value=\"Oui\" \/><span class=\"wpcf7-list-item-label\">Oui<\/span><\/span><span class=\"wpcf7-list-item last\"><input type=\"radio\" name=\"caregiver2Address\" value=\"Non\" \/><span class=\"wpcf7-list-item-label\">Non<\/span><\/span><\/span><\/span>\n\t<\/p>\n<hr \/>\n\t<p class=\"et_pb_contact_field_half\"><br \/>\n<label>Num\u00e9ro de la RAMQ du client :<\/label><br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"ramqNo\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"ramqNo\" \/><\/span>\n\t<\/p>\n\t<p class=\"et_pb_contact_field_half second\"><br \/>\n<label>Date d\u2019expiration : (YYYY-MM-DD)<\/label><br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"exp\"><input class=\"wpcf7-form-control wpcf7-date wpcf7-validates-as-date\" aria-invalid=\"false\" value=\"\" type=\"date\" name=\"exp\" \/><\/span>\n\t<\/p>\n\t<p class=\"et_pb_contact_field_last\"><br \/>\n<label>Nom sur la carte :<\/label><br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"ramqName\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"ramqName\" \/><\/span>\n\t<\/p>\n\t<p class=\"et_pb_contact_field_last\"><br \/>\n<label>Comment avez-vous entendu parler de Clinique Spectrum ?<\/label><br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"hearAbout\"><span class=\"wpcf7-form-control wpcf7-radio\"><span class=\"wpcf7-list-item first\"><input type=\"radio\" name=\"hearAbout\" value=\"Famille \/ Amis\" \/><span class=\"wpcf7-list-item-label\">Famille \/ Amis<\/span><\/span><span class=\"wpcf7-list-item\"><input type=\"radio\" name=\"hearAbout\" value=\"M\u00e9dias sociaux\" \/><span class=\"wpcf7-list-item-label\">M\u00e9dias sociaux<\/span><\/span><span class=\"wpcf7-list-item\"><input type=\"radio\" name=\"hearAbout\" value=\"M\u00e9decin Dr\" \/><span class=\"wpcf7-list-item-label\">M\u00e9decin Dr<\/span><\/span><span class=\"wpcf7-list-item last\"><input type=\"radio\" name=\"hearAbout\" value=\"Autre\" \/><span class=\"wpcf7-list-item-label\">Autre<\/span><\/span><\/span><\/span>\n\t<\/p>\n\t<section class=\"subHeading\">\n\t\t<p>Type de service recherch\u00e9\n\t\t<\/p>\n\t<\/section>\n\n<!-- <p class=\"et_pb_contact_field_half\">\n    <label>Pour une demande de consultation en <b>Psychiatrie<\/b>, qui est votre m\u00e9decin r\u00e9f\u00e9rant ?<\/label>\n    <span class=\"wpcf7-form-control-wrap\" data-name=\"service-referrer\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"service-referrer\" \/><\/span>\n<\/p>\n<p class=\"et_pb_contact_field_half second\">\n    <label>\u0161'il vous pla\u00eet joindre la r\u00e9f\u00e9rence du m\u00e9decin \u00e0 ce formulaire :<\/label>\n    <span class=\"wpcf7-form-control-wrap\" data-name=\"file-upload\"><input size=\"40\" class=\"wpcf7-form-control wpcf7-file wpcf7-validates-as-required\" accept=\".doc,.docx,.pdf,.txt,.odt\" aria-required=\"true\" aria-invalid=\"false\" type=\"file\" name=\"file-upload\" \/><\/span>\n<\/p> -->\n\t<p class=\"et_pb_contact_field_last listBlock\"><br \/>\n<label>Quel type de service recherchez-vous ?<\/label><br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"service-services\"><span class=\"wpcf7-form-control wpcf7-checkbox\"><span class=\"wpcf7-list-item first\"><input type=\"checkbox\" name=\"service-services[]\" value=\"\u00c9valuation diagnostique\" \/><span class=\"wpcf7-list-item-label\">\u00c9valuation diagnostique<\/span><\/span><span class=\"wpcf7-list-item\"><input type=\"checkbox\" name=\"service-services[]\" value=\"\u00c9valuation diagnostique de l&#039;autisme + \u00e9valuation psychiatrique compl\u00e8te\" \/><span class=\"wpcf7-list-item-label\">\u00c9valuation diagnostique de l&#039;autisme + \u00e9valuation psychiatrique compl\u00e8te<\/span><\/span><span class=\"wpcf7-list-item\"><input type=\"checkbox\" name=\"service-services[]\" value=\"\u00c9valuation psychiatrique (pour patients d\u00e9j\u00e0 ayant obtenus un diagnostic d\u2019autisme)\" \/><span class=\"wpcf7-list-item-label\">\u00c9valuation psychiatrique (pour patients d\u00e9j\u00e0 ayant obtenus un diagnostic d\u2019autisme)<\/span><\/span><span class=\"wpcf7-list-item last\"><input type=\"checkbox\" name=\"service-services[]\" value=\"Psychoth\u00e9rapie\" \/><span class=\"wpcf7-list-item-label\">Psychoth\u00e9rapie<\/span><\/span><\/span><\/span>\n\t<\/p>\n\n<!-- <p class=\"et_pb_contact_field_last\">\n    <label>Quel type de service recherchez-vous ?<\/label>\n    <span class=\"wpcf7-form-control-wrap\" data-name=\"service-services\"><span class=\"wpcf7-form-control wpcf7-checkbox\"><span class=\"wpcf7-list-item first\"><input type=\"checkbox\" name=\"service-services[]\" value=\"Psychologie\" \/><span class=\"wpcf7-list-item-label\">Psychologie<\/span><\/span><span class=\"wpcf7-list-item\"><input type=\"checkbox\" name=\"service-services[]\" value=\"\u00c9valuation diagnostique\" \/><span class=\"wpcf7-list-item-label\">\u00c9valuation diagnostique<\/span><\/span><span class=\"wpcf7-list-item\"><input type=\"checkbox\" name=\"service-services[]\" value=\"Psychoth\u00e9rapie\" \/><span class=\"wpcf7-list-item-label\">Psychoth\u00e9rapie<\/span><\/span><span class=\"wpcf7-list-item\"><input type=\"checkbox\" name=\"service-services[]\" value=\"Psychiatrie (assurez-vous de joindre la r\u00e9f\u00e9rence de votre m\u00e9decin)\" \/><span class=\"wpcf7-list-item-label\">Psychiatrie (assurez-vous de joindre la r\u00e9f\u00e9rence de votre m\u00e9decin)<\/span><\/span><span class=\"wpcf7-list-item\"><input type=\"checkbox\" name=\"service-services[]\" value=\"Analyse du comportement\" \/><span class=\"wpcf7-list-item-label\">Analyse du comportement<\/span><\/span><span class=\"wpcf7-list-item\"><input type=\"checkbox\" name=\"service-services[]\" value=\"Orthophonie\" \/><span class=\"wpcf7-list-item-label\">Orthophonie<\/span><\/span><span class=\"wpcf7-list-item last\"><input type=\"checkbox\" name=\"service-services[]\" value=\"Autre \u2013 veuillez pr\u00e9ciser\" \/><span class=\"wpcf7-list-item-label\">Autre \u2013 veuillez pr\u00e9ciser<\/span><\/span><\/span><\/span>\n<\/p> -->\n\n<!-- <p class=\"et_pb_contact_field_last\">\n    <label>Si \" Autre \" - veuillez pr\u00e9ciser :<\/label>\n    <span class=\"wpcf7-form-control-wrap\" data-name=\"service-other\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"service-other\" \/><\/span>\n<\/p> -->\n\t<section class=\"subHeading\">\n\t\t<p>Scheduling of appointments\n\t\t<\/p>\n\t<\/section>\n\t<p class=\"et_pb_contact_field_half\"><br \/>\n<label>Qui devons-nous contacter concernant les prises de rendez-vous ?<\/label><br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"scheduling-carer\"><span class=\"wpcf7-form-control wpcf7-radio\"><span class=\"wpcf7-list-item first\"><input type=\"radio\" name=\"scheduling-carer\" value=\"Parents\" \/><span class=\"wpcf7-list-item-label\">Parents<\/span><\/span><span class=\"wpcf7-list-item\"><input type=\"radio\" name=\"scheduling-carer\" value=\"Caregiver \/ Tuteur\" \/><span class=\"wpcf7-list-item-label\">Caregiver \/ Tuteur<\/span><\/span><span class=\"wpcf7-list-item last\"><input type=\"radio\" name=\"scheduling-carer\" value=\"Autre\" \/><span class=\"wpcf7-list-item-label\">Autre<\/span><\/span><\/span><\/span>\n\t<\/p>\n\t<p class=\"et_pb_contact_field_half second\"><br \/>\n<label>Nom :<\/label><br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"scheduling-name\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"scheduling-name\" \/><\/span>\n\t<\/p>\n\t<p class=\"et_pb_contact_field_half\"><br \/>\n<label>T\u00e9l\u00e9phone :<\/label><br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"scheduling-phone\"><input class=\"wpcf7-form-control wpcf7-number wpcf7-validates-as-number\" aria-invalid=\"false\" value=\"\" type=\"number\" name=\"scheduling-phone\" \/><\/span>\n\t<\/p>\n\t<p class=\"et_pb_contact_field_half second\"><br \/>\n<label>Courriel :<\/label><br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"scheduling-email\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-email wpcf7-text wpcf7-validates-as-email\" aria-invalid=\"false\" value=\"\" type=\"email\" name=\"scheduling-email\" \/><\/span>\n\t<\/p>\n\t<p class=\"et_pb_contact_field_last\">\n\t<\/p>\n\t<section class=\"subHeading\">\n\t\t<p>Information relative aux assurances\n\t\t<\/p>\n\t<\/section>\n\t<p class=\"et_pb_contact_field_half\"><br \/>\n<label>Num\u00e9ro de la RAMQ du parent si accompagne le client :<\/label><br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"ramq-number\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"ramq-number\" \/><\/span>\n\t<\/p>\n\t<p class=\"et_pb_contact_field_half second\"><br \/>\n<label>Date d\u2019expiration : (YYYY-MM-DD)<\/label><br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"ramq-expiry\"><input class=\"wpcf7-form-control wpcf7-date wpcf7-validates-as-date\" aria-invalid=\"false\" value=\"\" type=\"date\" name=\"ramq-expiry\" \/><\/span>\n\t<\/p>\n\t<p class=\"et_pb_contact_field_last\"><br \/>\n<label>Nom sur la Carte :<\/label><br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"ramq-name\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"ramq-name\" \/><\/span>\n\t<\/p>\n\t<p class=\"subHeading\">Personne responsable de la facturation\n\t<\/p>\n\t<p class=\"et_pb_contact_field_half\"><br \/>\n<label>Nom :<\/label><br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"billing-name\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"billing-name\" \/><\/span>\n\t<\/p>\n\t<p class=\"et_pb_contact_field_half second\"><br \/>\n<label>Lien avec le client :<\/label><br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"billing-relationship\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"billing-relationship\" \/><\/span>\n\t<\/p>\n\t<p class=\"et_pb_contact_field_half\"><br \/>\n<label>Courriel :<\/label><br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"billing-email\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-email wpcf7-text wpcf7-validates-as-email\" aria-invalid=\"false\" value=\"\" type=\"email\" name=\"billing-email\" \/><\/span>\n\t<\/p>\n\t<p class=\"et_pb_contact_field_half second\"><br \/>\n<label>T\u00e9l\u00e9phone Maison :<\/label><br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"billing-phone\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-tel wpcf7-text wpcf7-validates-as-tel\" aria-invalid=\"false\" value=\"\" type=\"tel\" name=\"billing-phone\" \/><\/span>\n\t<\/p>\n\t<p class=\"et_pb_contact_field_half\"><br \/>\n<label>Date de naissance : (YYYY-MM-DD)<\/label><br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"billing-dob\"><input class=\"wpcf7-form-control wpcf7-date wpcf7-validates-as-date\" aria-invalid=\"false\" value=\"\" type=\"date\" name=\"billing-dob\" \/><\/span>\n\t<\/p>\n\t<p class=\"et_pb_contact_field_half second\"><br \/>\n<label>Adresse si diff\u00e9rente du client :<\/label><br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"billing-address\"><textarea cols=\"40\" rows=\"10\" maxlength=\"2000\" class=\"wpcf7-form-control wpcf7-textarea\" aria-invalid=\"false\" name=\"billing-address\"><\/textarea><\/span>\n\t<\/p>\n\t<p class=\"et_pb_contact_field_last\">\n\t<\/p>\n\t<section class=\"subHeading\">\n\t\t<p>Pharmacie\n\t\t<\/p>\n\t<\/section>\n\t<p class=\"et_pb_contact_field_half\"><br \/>\n<label>Nom de la Pharmacie :<\/label><br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"pharmacy-name\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"pharmacy-name\" \/><\/span>\n\t<\/p>\n\t<p class=\"et_pb_contact_field_half second\"><br \/>\n<label>T\u00e9l\u00e9phone :<\/label><br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"pharmacy-phone\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-tel wpcf7-text wpcf7-validates-as-tel\" aria-invalid=\"false\" value=\"\" type=\"tel\" name=\"pharmacy-phone\" \/><\/span>\n\t<\/p>\n\t<p class=\"et_pb_contact_field_half\"><br \/>\n<label>Adresse :<\/label><br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"pharmacy-address\"><textarea cols=\"40\" rows=\"10\" maxlength=\"2000\" class=\"wpcf7-form-control wpcf7-textarea\" aria-invalid=\"false\" name=\"pharmacy-address\"><\/textarea><\/span>\n\t<\/p>\n\t<p class=\"et_pb_contact_field_half second\"><br \/>\n<label>T\u00e9l\u00e9copieur :<\/label><br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"pharmacy-fax\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-tel wpcf7-text wpcf7-validates-as-tel\" aria-invalid=\"false\" value=\"\" type=\"tel\" name=\"pharmacy-fax\" \/><\/span>\n\t<\/p>\n\t<p class=\"et_pb_contact_field_last\">\n\t<\/p>\n\t<section class=\"subHeading\">\n\t\t<p>En cas d\u2019urgence\n\t\t<\/p>\n\t<\/section>\n\t<p class=\"et_pb_contact_field_half\"><br \/>\n<label>Nom du parent ou connaissance n\u2019habitant pas \u00e0 la m\u00eame adresse :<\/label><br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"emergency-name\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"emergency-name\" \/><\/span>\n\t<\/p>\n\t<p class=\"et_pb_contact_field_half second\"><br \/>\n<label>Lien avec le client :<\/label><br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"emergency-relationship\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"emergency-relationship\" \/><\/span>\n\t<\/p>\n\t<p class=\"et_pb_contact_field_half\"><br \/>\n<label>T\u00e9l\u00e9phone Maison :<\/label><br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"emergency-phone\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-tel wpcf7-text wpcf7-validates-as-tel\" aria-invalid=\"false\" value=\"\" type=\"tel\" name=\"emergency-phone\" \/><\/span>\n\t<\/p>\n\t<p class=\"et_pb_contact_field_half second\"><br \/>\n<label>Cellulaire :<\/label><br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"emergency-cell\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-tel wpcf7-text wpcf7-validates-as-tel\" aria-invalid=\"false\" value=\"\" type=\"tel\" name=\"emergency-cell\" \/><\/span>\n\t<\/p>\n\t<p>L\u2019information contenue ci-haut est v\u00e9ridique au meilleur de ma connaissance. Je confirme que j\u2019ai sollicit\u00e9 les services de la Clinique Spectrum de ma propre initiative sans avoir \u00e9t\u00e9 sollicit\u00e9(e) par Clinique Spectrum ni aucune personne faisant partie de l\u2019\u00e9quipe.\n\t<\/p>\n\t<p>Je reconnais que toutes les informations concernant mon dossier clinique seront sauvegard\u00e9es sur notre fichier de sauvegarde \u00e9lectronique OSCAR extr\u00eamement fiable et s\u00e9curis\u00e9, et que seules les donn\u00e9es sommaires seront accessibles aux autres professionnels membres de l\u2019\u00e9quipe de la Clinique Spectrum. Je constate que j\u2019ai pris connaissance des frais pour les services non-assur\u00e9s par la RAMQ ainsi que la politique d\u2019annulation de rendez-vous (ci-bas).\n\t<\/p>\n\t<p>Prior to filling out our forms, please ensure that you have the consent of the individual for whom you are filling out the forms (in the case of a minor, or an adult with an incapacity). Please read our <a href=\"\/politique-confidentialite\/\">privacy policy<\/a> to learn more about how your personal information is protected through our website and communications.\n\t<\/p>\n\t<p>Please also read below for our cancellation policy and services that are not covered by the RAMQ.\n\t<\/p>\n<\/div>\n<p><input class=\"wpcf7-form-control wpcf7-submit has-spinner\" type=\"submit\" value=\"Soumettre\" \/>\n<\/p>\n<section class=\"subHeading\">\n\t<p>Services non-assur\u00e9s par la RAMQ\n\t<\/p>\n<\/section>\n<p><img decoding=\"async\" src=\"https:\/\/cliniquespectrum.com\/wp-content\/uploads\/2018\/11\/ramq.jpg\" alt=\"Services non-assur\u00e9s par la RAMQ\" class=\"aligncenter\" \/>\n<\/p>\n<section class=\"subHeading\">\n\t<p>Cancellation Policy\n\t<\/p>\n<\/section>\n<p>Nous exigeons un pr\u00e9avis de 24 heures pour toute annulation de rendez-vous. Lorsque possible, nous d\u00e9placerons votre rendez-vous. Cependant, si nous ne recevons pas d\u2019avis d\u2019annulation de rendez-vous au <a href=\"mailto:info@cliniquespectrum.com\">info@cliniquespectrum.com<\/a>, nous serons oblig\u00e9s de vous facturer le taux horaire pour votre rencontre.\n<\/p>\n<p>Voir <em>le Code de d\u00e9ontologie des psychologues art. 54 no. 3 & Code de d\u00e9ontologie des m\u00e9decins, art. 104 \u00e0 106<\/em>.\n<\/p><p style=\"display: none !important;\" class=\"akismet-fields-container\" data-prefix=\"_wpcf7_ak_\"><label>&#916;<textarea name=\"_wpcf7_ak_hp_textarea\" cols=\"45\" rows=\"8\" maxlength=\"100\"><\/textarea><\/label><input type=\"hidden\" id=\"ak_js_1\" name=\"_wpcf7_ak_js\" value=\"149\"\/><script>document.getElementById( \"ak_js_1\" ).setAttribute( \"value\", ( new Date() ).getTime() );<\/script><\/p><div class=\"wpcf7-response-output\" aria-hidden=\"true\"><\/div>\n<\/form>\n<\/div>\n[\/et_pb_text][\/et_pb_column][\/et_pb_row][\/et_pb_section]<\/p>\n","protected":false},"excerpt":{"rendered":"<p>Formulaire d\u2019inscription \u0161&rsquo;il vous pla\u00eet compl\u00e9ter et soumettrer afin d\u2019assurer votre place sur notre liste d\u2019attente \n<div class=\"wpcf7 no-js\" id=\"wpcf7-f1877-o2\" lang=\"fr-FR\" dir=\"ltr\" data-wpcf7-id=\"1877\">\n<div class=\"screen-reader-response\"><p role=\"status\" aria-live=\"polite\" aria-atomic=\"true\"><\/p> <ul><\/ul><\/div>\n<form action=\"\/fr\/wp-json\/wp\/v2\/pages\/1873#wpcf7-f1877-o2\" method=\"post\" class=\"wpcf7-form init\" aria-label=\"Formulaire de contact\" enctype=\"multipart\/form-data\" novalidate=\"novalidate\" data-status=\"init\">\n<fieldset class=\"hidden-fields-container\"><input type=\"hidden\" name=\"_wpcf7\" value=\"1877\" \/><input type=\"hidden\" name=\"_wpcf7_version\" value=\"6.1.5\" \/><input type=\"hidden\" name=\"_wpcf7_locale\" value=\"fr_FR\" \/><input type=\"hidden\" name=\"_wpcf7_unit_tag\" value=\"wpcf7-f1877-o2\" \/><input type=\"hidden\" name=\"_wpcf7_container_post\" value=\"0\" \/><input type=\"hidden\" name=\"_wpcf7_posted_data_hash\" value=\"\" \/>\n<\/fieldset>\n<div class=\"et_pb_contact reg\">\n\t<p class=\"et_pb_contact_field_half\"><br \/>\n<label>Personne compl\u00e9tant ce formulaire : (requis)<\/label><br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"contacter\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"contacter\" \/><\/span>\n\t<\/p>\n\t<p class=\"et_pb_contact_field_half second\"><br \/>\n<label>Date : (required) (YYYY-MM-DD)<\/label><br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"date\"><input class=\"wpcf7-form-control wpcf7-date wpcf7-validates-as-required wpcf7-validates-as-date\" aria-required=\"true\" aria-invalid=\"false\" value=\"\" type=\"date\" name=\"date\" \/><\/span>\n\t<\/p>\n\t<p class=\"et_pb_contact_field_last\">\n\t<\/p>\n\t<section class=\"subHeading\">\n\t\t<p>Information concernant le \/ la client(e)\n\t\t<\/p>\n\t<\/section>\n\t<p class=\"et_pb_contact_field_half\"><br \/>\n<label>Nom de famille : (requis)<\/label><br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"last-name\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"last-name\" \/><\/span>\n\t<\/p>\n\t<p class=\"et_pb_contact_field_half second\"><br \/>\n<label>Pr\u00e9nom : (requis)<\/label><br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"first-name\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"first-name\" \/><\/span>\n\t<\/p>\n\t<p class=\"et_pb_contact_field_half\"><br \/>\n<label>\u00c2ge :<\/label><br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"age\"><input class=\"wpcf7-form-control wpcf7-number wpcf7-validates-as-number\" aria-invalid=\"false\" value=\"\" type=\"number\" name=\"age\" \/><\/span>\n\t<\/p>\n\t<p class=\"et_pb_contact_field_half second\"><br \/>\n<label>Date de naissance : (YYYY-MM-DD)<\/label><br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"dob\"><input class=\"wpcf7-form-control wpcf7-date wpcf7-validates-as-required wpcf7-validates-as-date\" aria-required=\"true\" aria-invalid=\"false\" value=\"\" type=\"date\" name=\"dob\" \/><\/span>\n\t<\/p>\n\t<p class=\"et_pb_contact_field_last\"><br \/>\n<label>Gender Identity :<\/label><br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"sex\"><span class=\"wpcf7-form-control wpcf7-radio\"><span class=\"wpcf7-list-item first\"><input type=\"radio\" name=\"sex\" value=\"Male\/Man\" \/><span class=\"wpcf7-list-item-label\">Male\/Man<\/span><\/span><span class=\"wpcf7-list-item\"><input type=\"radio\" name=\"sex\" value=\"Female\/Woman\" \/><span class=\"wpcf7-list-item-label\">Female\/Woman<\/span><\/span><span class=\"wpcf7-list-item\"><input type=\"radio\" name=\"sex\" value=\"TransMale\/TransMan\" \/><span class=\"wpcf7-list-item-label\">TransMale\/TransMan<\/span><\/span><span class=\"wpcf7-list-item\"><input type=\"radio\" name=\"sex\" value=\"TransFemale\/TransWoman\" \/><span class=\"wpcf7-list-item-label\">TransFemale\/TransWoman<\/span><\/span><span class=\"wpcf7-list-item\"><input type=\"radio\" name=\"sex\" value=\"Gender Neutral\/Gender Nonconforming\" \/><span class=\"wpcf7-list-item-label\">Gender Neutral\/Gender Nonconforming<\/span><\/span><span class=\"wpcf7-list-item\"><input type=\"radio\" name=\"sex\" value=\"Something else\" \/><span class=\"wpcf7-list-item-label\">Something else<\/span><\/span><span class=\"wpcf7-list-item last\"><input type=\"radio\" name=\"sex\" value=\"Decline to answer\" \/><span class=\"wpcf7-list-item-label\">Decline to answer<\/span><\/span><\/span><\/span>\n\t<\/p>\n\t<p class=\"et_pb_contact_field_last\"><br \/>\n<label>\u00c9tat civil du client :<\/label><br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"maritalStatus\"><span class=\"wpcf7-form-control wpcf7-radio\"><span class=\"wpcf7-list-item first\"><input type=\"radio\" name=\"maritalStatus\" value=\"Mari\u00e9 (e)\" \/><span class=\"wpcf7-list-item-label\">Mari\u00e9 (e)<\/span><\/span><span class=\"wpcf7-list-item\"><input type=\"radio\" name=\"maritalStatus\" value=\"C\u00e9libataire\" \/><span class=\"wpcf7-list-item-label\">C\u00e9libataire<\/span><\/span><span class=\"wpcf7-list-item\"><input type=\"radio\" name=\"maritalStatus\" value=\"S\u00e9par\u00e9(e)\" \/><span class=\"wpcf7-list-item-label\">S\u00e9par\u00e9(e)<\/span><\/span><span class=\"wpcf7-list-item\"><input type=\"radio\" name=\"maritalStatus\" value=\"Divorc\u00e9(e)\" \/><span class=\"wpcf7-list-item-label\">Divorc\u00e9(e)<\/span><\/span><span class=\"wpcf7-list-item last\"><input type=\"radio\" name=\"maritalStatus\" value=\"N\/A\" \/><span class=\"wpcf7-list-item-label\">N\/A<\/span><\/span><\/span><\/span>\n\t<\/p>\n\t<p class=\"et_pb_contact_field_last\"><br \/>\n<label>Person with limited mobility:<\/label><br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"mobility\"><span class=\"wpcf7-form-control wpcf7-radio\"><span class=\"wpcf7-list-item first\"><input type=\"radio\" name=\"mobility\" value=\"Oui\" \/><span class=\"wpcf7-list-item-label\">Oui<\/span><\/span><span class=\"wpcf7-list-item last\"><input type=\"radio\" name=\"mobility\" value=\"Non\" \/><span class=\"wpcf7-list-item-label\">Non<\/span><\/span><\/span><\/span>\n\t<\/p>\n\t<p class=\"et_pb_contact_field_last\"><br \/>\n<label>Adresse :<\/label><br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"address\"><textarea cols=\"40\" rows=\"10\" maxlength=\"2000\" class=\"wpcf7-form-control wpcf7-textarea\" aria-invalid=\"false\" name=\"address\"><\/textarea><\/span>\n\t<\/p>\n\t<p class=\"et_pb_contact_field_last\"><br \/>\n<label>Si le \/ la client(e) est sous une garde l\u00e9gale, veuillez indiquer qui a la garde l\u00e9gale :<\/label><br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"guardianship\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"guardianship\" \/><\/span>\n\t<\/p>\n\t<p class=\"et_pb_contact_field_third\"><br \/>\n<label>T\u00e9l\u00e9phone maison du client :<\/label><br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"homePhone\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-tel wpcf7-text wpcf7-validates-as-tel\" aria-invalid=\"false\" value=\"\" type=\"tel\" name=\"homePhone\" \/><\/span>\n\t<\/p>\n\t<p class=\"et_pb_contact_field_third second\"><br \/>\n<label>T\u00e9l\u00e9phone cellulaire du client :<\/label><br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"cellPhone\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-tel wpcf7-text wpcf7-validates-as-tel\" aria-invalid=\"false\" value=\"\" type=\"tel\" name=\"cellPhone\" \/><\/span>\n\t<\/p>\n\t<p class=\"et_pb_contact_field_third second\"><br \/>\n<label>T\u00e9l\u00e9phone travail\/occupation du client :<\/label><br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"workPhone\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-tel wpcf7-text wpcf7-validates-as-tel\" aria-invalid=\"false\" value=\"\" type=\"tel\" name=\"workPhone\" \/><\/span>\n\t<\/p>\n\t<p class=\"et_pb_contact_field_half\"><br \/>\n<label>Courriel du client :<\/label><br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"email\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-email wpcf7-text wpcf7-validates-as-email\" aria-invalid=\"false\" value=\"\" type=\"email\" name=\"email\" \/><\/span>\n\t<\/p>\n\t<p class=\"et_pb_contact_field_half second\"><br \/>\n<label>Veuillez noter que nous pouvons vous contacter par courriel :<\/label><br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"emailContact\"><span class=\"wpcf7-form-control wpcf7-radio\"><span class=\"wpcf7-list-item first\"><input type=\"radio\" name=\"emailContact\" value=\"Oui\" checked=\"checked\" \/><span class=\"wpcf7-list-item-label\">Oui<\/span><\/span><span class=\"wpcf7-list-item last\"><input type=\"radio\" name=\"emailContact\" value=\"Non\" \/><span class=\"wpcf7-list-item-label\">Non<\/span><\/span><\/span><\/span>\n\t<\/p>\n<hr \/>\n\t<p class=\"et_pb_contact_field_half\"><br \/>\n<label>Nom du parent ou tuteur :<\/label><br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"caregiver1Name\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"caregiver1Name\" \/><\/span>\n\t<\/p>\n\t<p class=\"et_pb_contact_field_half second\"><br \/>\n<label>T\u00e9l\u00e9phone du parent ou tuteur :<\/label><br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"caregiver1Phone\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-tel wpcf7-text wpcf7-validates-as-tel\" aria-invalid=\"false\" value=\"\" type=\"tel\" name=\"caregiver1Phone\" \/><\/span>\n\t<\/p>\n\t<p class=\"et_pb_contact_field_last\"><br \/>\n<label>Courriel du parent ou tuteur :<\/label><br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"caregiver1Email\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-email wpcf7-text wpcf7-validates-as-email\" aria-invalid=\"false\" value=\"\" type=\"email\" name=\"caregiver1Email\" \/><\/span>\n\t<\/p>\n\t<p class=\"et_pb_contact_field_half\"><br \/>\n<label>Relation du parent ou tuteur avec le \/ la client(e) :<\/label><br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"caregiver1Relationship\"><span class=\"wpcf7-form-control wpcf7-radio\"><span class=\"wpcf7-list-item first\"><input type=\"radio\" name=\"caregiver1Relationship\" value=\"M\u00e8re\" \/><span class=\"wpcf7-list-item-label\">M\u00e8re<\/span><\/span><span class=\"wpcf7-list-item\"><input type=\"radio\" name=\"caregiver1Relationship\" value=\"P\u00e8re\" \/><span class=\"wpcf7-list-item-label\">P\u00e8re<\/span><\/span><span class=\"wpcf7-list-item\"><input type=\"radio\" name=\"caregiver1Relationship\" value=\"Tuteur\" \/><span class=\"wpcf7-list-item-label\">Tuteur<\/span><\/span><span class=\"wpcf7-list-item last\"><input type=\"radio\" name=\"caregiver1Relationship\" value=\"Autre\" \/><span class=\"wpcf7-list-item-label\">Autre<\/span><\/span><\/span><\/span>\n\t<\/p>\n\t<p class=\"et_pb_contact_field_half second\"><br \/>\n<label>Parent ou tuteur habite \u00e0 la m\u00eame adresse ?<\/label><br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"caregiver1Address\"><span class=\"wpcf7-form-control wpcf7-radio\"><span class=\"wpcf7-list-item first\"><input type=\"radio\" name=\"caregiver1Address\" value=\"Oui\" \/><span class=\"wpcf7-list-item-label\">Oui<\/span><\/span><span class=\"wpcf7-list-item last\"><input type=\"radio\" name=\"caregiver1Address\" value=\"Non\" \/><span class=\"wpcf7-list-item-label\">Non<\/span><\/span><\/span><\/span>\n\t<\/p>\n<hr \/>\n\t<p class=\"et_pb_contact_field_half\"><br \/>\n<label>Nom du deuxieme parent ou tuteur:<\/label><br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"caregiver2Name\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"caregiver2Name\" \/><\/span>\n\t<\/p>\n\t<p class=\"et_pb_contact_field_half second\"><br \/>\n<label>T\u00e9l\u00e9phone du deuxieme parent ou tuteur :<\/label><br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"caregiver2Phone\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-tel wpcf7-text wpcf7-validates-as-tel\" aria-invalid=\"false\" value=\"\" type=\"tel\" name=\"caregiver2Phone\" \/><\/span>\n\t<\/p>\n\t<p class=\"et_pb_contact_field_last\"><br \/>\n<label>Courriel du deuxieme parent ou tuteur :<\/label><br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"caregiver2Email\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-email wpcf7-text wpcf7-validates-as-email\" aria-invalid=\"false\" value=\"\" type=\"email\" name=\"caregiver2Email\" \/><\/span>\n\t<\/p>\n\t<p class=\"et_pb_contact_field_half\"><br \/>\n<label>Relation du deuxieme parent ou tuteur avec le \/ la client(e) :<\/label><br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"caregiver2Relationship\"><span class=\"wpcf7-form-control wpcf7-radio\"><span class=\"wpcf7-list-item first\"><input type=\"radio\" name=\"caregiver2Relationship\" value=\"M\u00e8re\" \/><span class=\"wpcf7-list-item-label\">M\u00e8re<\/span><\/span><span class=\"wpcf7-list-item\"><input type=\"radio\" name=\"caregiver2Relationship\" value=\"P\u00e8re\" \/><span class=\"wpcf7-list-item-label\">P\u00e8re<\/span><\/span><span class=\"wpcf7-list-item\"><input type=\"radio\" name=\"caregiver2Relationship\" value=\"Tuteur\" \/><span class=\"wpcf7-list-item-label\">Tuteur<\/span><\/span><span class=\"wpcf7-list-item last\"><input type=\"radio\" name=\"caregiver2Relationship\" value=\"Autre\" \/><span class=\"wpcf7-list-item-label\">Autre<\/span><\/span><\/span><\/span>\n\t<\/p>\n\t<p class=\"et_pb_contact_field_half second\"><br \/>\n<label>Deuxieme parent ou tuteur habite \u00e0 la m\u00eame adresse ?<\/label><br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"caregiver2Address\"><span class=\"wpcf7-form-control wpcf7-radio\"><span class=\"wpcf7-list-item first\"><input type=\"radio\" name=\"caregiver2Address\" value=\"Oui\" \/><span class=\"wpcf7-list-item-label\">Oui<\/span><\/span><span class=\"wpcf7-list-item last\"><input type=\"radio\" name=\"caregiver2Address\" value=\"Non\" \/><span class=\"wpcf7-list-item-label\">Non<\/span><\/span><\/span><\/span>\n\t<\/p>\n<hr \/>\n\t<p class=\"et_pb_contact_field_half\"><br \/>\n<label>Num\u00e9ro de la RAMQ du client :<\/label><br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"ramqNo\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"ramqNo\" \/><\/span>\n\t<\/p>\n\t<p class=\"et_pb_contact_field_half second\"><br \/>\n<label>Date d\u2019expiration : (YYYY-MM-DD)<\/label><br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"exp\"><input class=\"wpcf7-form-control wpcf7-date wpcf7-validates-as-date\" aria-invalid=\"false\" value=\"\" type=\"date\" name=\"exp\" \/><\/span>\n\t<\/p>\n\t<p class=\"et_pb_contact_field_last\"><br \/>\n<label>Nom sur la carte :<\/label><br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"ramqName\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"ramqName\" \/><\/span>\n\t<\/p>\n\t<p class=\"et_pb_contact_field_last\"><br \/>\n<label>Comment avez-vous entendu parler de Clinique Spectrum ?<\/label><br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"hearAbout\"><span class=\"wpcf7-form-control wpcf7-radio\"><span class=\"wpcf7-list-item first\"><input type=\"radio\" name=\"hearAbout\" value=\"Famille \/ Amis\" \/><span class=\"wpcf7-list-item-label\">Famille \/ Amis<\/span><\/span><span class=\"wpcf7-list-item\"><input type=\"radio\" name=\"hearAbout\" value=\"M\u00e9dias sociaux\" \/><span class=\"wpcf7-list-item-label\">M\u00e9dias sociaux<\/span><\/span><span class=\"wpcf7-list-item\"><input type=\"radio\" name=\"hearAbout\" value=\"M\u00e9decin Dr\" \/><span class=\"wpcf7-list-item-label\">M\u00e9decin Dr<\/span><\/span><span class=\"wpcf7-list-item last\"><input type=\"radio\" name=\"hearAbout\" value=\"Autre\" \/><span class=\"wpcf7-list-item-label\">Autre<\/span><\/span><\/span><\/span>\n\t<\/p>\n\t<section class=\"subHeading\">\n\t\t<p>Type de service recherch\u00e9\n\t\t<\/p>\n\t<\/section>\n\n<!-- <p class=\"et_pb_contact_field_half\">\n    <label>Pour une demande de consultation en <b>Psychiatrie<\/b>, qui est votre m\u00e9decin r\u00e9f\u00e9rant ?<\/label>\n    <span class=\"wpcf7-form-control-wrap\" data-name=\"service-referrer\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"service-referrer\" \/><\/span>\n<\/p>\n<p class=\"et_pb_contact_field_half second\">\n    <label>\u0161'il vous pla\u00eet joindre la r\u00e9f\u00e9rence du m\u00e9decin \u00e0 ce formulaire :<\/label>\n    <span class=\"wpcf7-form-control-wrap\" data-name=\"file-upload\"><input size=\"40\" class=\"wpcf7-form-control wpcf7-file wpcf7-validates-as-required\" accept=\".doc,.docx,.pdf,.txt,.odt\" aria-required=\"true\" aria-invalid=\"false\" type=\"file\" name=\"file-upload\" \/><\/span>\n<\/p> -->\n\t<p class=\"et_pb_contact_field_last listBlock\"><br \/>\n<label>Quel type de service recherchez-vous ?<\/label><br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"service-services\"><span class=\"wpcf7-form-control wpcf7-checkbox\"><span class=\"wpcf7-list-item first\"><input type=\"checkbox\" name=\"service-services[]\" value=\"\u00c9valuation diagnostique\" \/><span class=\"wpcf7-list-item-label\">\u00c9valuation diagnostique<\/span><\/span><span class=\"wpcf7-list-item\"><input type=\"checkbox\" name=\"service-services[]\" value=\"\u00c9valuation diagnostique de l&#039;autisme + \u00e9valuation psychiatrique compl\u00e8te\" \/><span class=\"wpcf7-list-item-label\">\u00c9valuation diagnostique de l&#039;autisme + \u00e9valuation psychiatrique compl\u00e8te<\/span><\/span><span class=\"wpcf7-list-item\"><input type=\"checkbox\" name=\"service-services[]\" value=\"\u00c9valuation psychiatrique (pour patients d\u00e9j\u00e0 ayant obtenus un diagnostic d\u2019autisme)\" \/><span class=\"wpcf7-list-item-label\">\u00c9valuation psychiatrique (pour patients d\u00e9j\u00e0 ayant obtenus un diagnostic d\u2019autisme)<\/span><\/span><span class=\"wpcf7-list-item last\"><input type=\"checkbox\" name=\"service-services[]\" value=\"Psychoth\u00e9rapie\" \/><span class=\"wpcf7-list-item-label\">Psychoth\u00e9rapie<\/span><\/span><\/span><\/span>\n\t<\/p>\n\n<!-- <p class=\"et_pb_contact_field_last\">\n    <label>Quel type de service recherchez-vous ?<\/label>\n    <span class=\"wpcf7-form-control-wrap\" data-name=\"service-services\"><span class=\"wpcf7-form-control wpcf7-checkbox\"><span class=\"wpcf7-list-item first\"><input type=\"checkbox\" name=\"service-services[]\" value=\"Psychologie\" \/><span class=\"wpcf7-list-item-label\">Psychologie<\/span><\/span><span class=\"wpcf7-list-item\"><input type=\"checkbox\" name=\"service-services[]\" value=\"\u00c9valuation diagnostique\" \/><span class=\"wpcf7-list-item-label\">\u00c9valuation diagnostique<\/span><\/span><span class=\"wpcf7-list-item\"><input type=\"checkbox\" name=\"service-services[]\" value=\"Psychoth\u00e9rapie\" \/><span class=\"wpcf7-list-item-label\">Psychoth\u00e9rapie<\/span><\/span><span class=\"wpcf7-list-item\"><input type=\"checkbox\" name=\"service-services[]\" value=\"Psychiatrie (assurez-vous de joindre la r\u00e9f\u00e9rence de votre m\u00e9decin)\" \/><span class=\"wpcf7-list-item-label\">Psychiatrie (assurez-vous de joindre la r\u00e9f\u00e9rence de votre m\u00e9decin)<\/span><\/span><span class=\"wpcf7-list-item\"><input type=\"checkbox\" name=\"service-services[]\" value=\"Analyse du comportement\" \/><span class=\"wpcf7-list-item-label\">Analyse du comportement<\/span><\/span><span class=\"wpcf7-list-item\"><input type=\"checkbox\" name=\"service-services[]\" value=\"Orthophonie\" \/><span class=\"wpcf7-list-item-label\">Orthophonie<\/span><\/span><span class=\"wpcf7-list-item last\"><input type=\"checkbox\" name=\"service-services[]\" value=\"Autre \u2013 veuillez pr\u00e9ciser\" \/><span class=\"wpcf7-list-item-label\">Autre \u2013 veuillez pr\u00e9ciser<\/span><\/span><\/span><\/span>\n<\/p> -->\n\n<!-- <p class=\"et_pb_contact_field_last\">\n    <label>Si \" Autre \" - veuillez pr\u00e9ciser :<\/label>\n    <span class=\"wpcf7-form-control-wrap\" data-name=\"service-other\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"service-other\" \/><\/span>\n<\/p> -->\n\t<section class=\"subHeading\">\n\t\t<p>Scheduling of appointments\n\t\t<\/p>\n\t<\/section>\n\t<p class=\"et_pb_contact_field_half\"><br \/>\n<label>Qui devons-nous contacter concernant les prises de rendez-vous ?<\/label><br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"scheduling-carer\"><span class=\"wpcf7-form-control wpcf7-radio\"><span class=\"wpcf7-list-item first\"><input type=\"radio\" name=\"scheduling-carer\" value=\"Parents\" \/><span class=\"wpcf7-list-item-label\">Parents<\/span><\/span><span class=\"wpcf7-list-item\"><input type=\"radio\" name=\"scheduling-carer\" value=\"Caregiver \/ Tuteur\" \/><span class=\"wpcf7-list-item-label\">Caregiver \/ Tuteur<\/span><\/span><span class=\"wpcf7-list-item last\"><input type=\"radio\" name=\"scheduling-carer\" value=\"Autre\" \/><span class=\"wpcf7-list-item-label\">Autre<\/span><\/span><\/span><\/span>\n\t<\/p>\n\t<p class=\"et_pb_contact_field_half second\"><br \/>\n<label>Nom :<\/label><br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"scheduling-name\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"scheduling-name\" \/><\/span>\n\t<\/p>\n\t<p class=\"et_pb_contact_field_half\"><br \/>\n<label>T\u00e9l\u00e9phone :<\/label><br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"scheduling-phone\"><input class=\"wpcf7-form-control wpcf7-number wpcf7-validates-as-number\" aria-invalid=\"false\" value=\"\" type=\"number\" name=\"scheduling-phone\" \/><\/span>\n\t<\/p>\n\t<p class=\"et_pb_contact_field_half second\"><br \/>\n<label>Courriel :<\/label><br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"scheduling-email\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-email wpcf7-text wpcf7-validates-as-email\" aria-invalid=\"false\" value=\"\" type=\"email\" name=\"scheduling-email\" \/><\/span>\n\t<\/p>\n\t<p class=\"et_pb_contact_field_last\">\n\t<\/p>\n\t<section class=\"subHeading\">\n\t\t<p>Information relative aux assurances\n\t\t<\/p>\n\t<\/section>\n\t<p class=\"et_pb_contact_field_half\"><br \/>\n<label>Num\u00e9ro de la RAMQ du parent si accompagne le client :<\/label><br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"ramq-number\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"ramq-number\" \/><\/span>\n\t<\/p>\n\t<p class=\"et_pb_contact_field_half second\"><br \/>\n<label>Date d\u2019expiration : (YYYY-MM-DD)<\/label><br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"ramq-expiry\"><input class=\"wpcf7-form-control wpcf7-date wpcf7-validates-as-date\" aria-invalid=\"false\" value=\"\" type=\"date\" name=\"ramq-expiry\" \/><\/span>\n\t<\/p>\n\t<p class=\"et_pb_contact_field_last\"><br \/>\n<label>Nom sur la Carte :<\/label><br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"ramq-name\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"ramq-name\" \/><\/span>\n\t<\/p>\n\t<p class=\"subHeading\">Personne responsable de la facturation\n\t<\/p>\n\t<p class=\"et_pb_contact_field_half\"><br \/>\n<label>Nom :<\/label><br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"billing-name\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"billing-name\" \/><\/span>\n\t<\/p>\n\t<p class=\"et_pb_contact_field_half second\"><br \/>\n<label>Lien avec le client :<\/label><br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"billing-relationship\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"billing-relationship\" \/><\/span>\n\t<\/p>\n\t<p class=\"et_pb_contact_field_half\"><br \/>\n<label>Courriel :<\/label><br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"billing-email\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-email wpcf7-text wpcf7-validates-as-email\" aria-invalid=\"false\" value=\"\" type=\"email\" name=\"billing-email\" \/><\/span>\n\t<\/p>\n\t<p class=\"et_pb_contact_field_half second\"><br \/>\n<label>T\u00e9l\u00e9phone Maison :<\/label><br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"billing-phone\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-tel wpcf7-text wpcf7-validates-as-tel\" aria-invalid=\"false\" value=\"\" type=\"tel\" name=\"billing-phone\" \/><\/span>\n\t<\/p>\n\t<p class=\"et_pb_contact_field_half\"><br \/>\n<label>Date de naissance : (YYYY-MM-DD)<\/label><br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"billing-dob\"><input class=\"wpcf7-form-control wpcf7-date wpcf7-validates-as-date\" aria-invalid=\"false\" value=\"\" type=\"date\" name=\"billing-dob\" \/><\/span>\n\t<\/p>\n\t<p class=\"et_pb_contact_field_half second\"><br \/>\n<label>Adresse si diff\u00e9rente du client :<\/label><br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"billing-address\"><textarea cols=\"40\" rows=\"10\" maxlength=\"2000\" class=\"wpcf7-form-control wpcf7-textarea\" aria-invalid=\"false\" name=\"billing-address\"><\/textarea><\/span>\n\t<\/p>\n\t<p class=\"et_pb_contact_field_last\">\n\t<\/p>\n\t<section class=\"subHeading\">\n\t\t<p>Pharmacie\n\t\t<\/p>\n\t<\/section>\n\t<p class=\"et_pb_contact_field_half\"><br \/>\n<label>Nom de la Pharmacie :<\/label><br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"pharmacy-name\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"pharmacy-name\" \/><\/span>\n\t<\/p>\n\t<p class=\"et_pb_contact_field_half second\"><br \/>\n<label>T\u00e9l\u00e9phone :<\/label><br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"pharmacy-phone\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-tel wpcf7-text wpcf7-validates-as-tel\" aria-invalid=\"false\" value=\"\" type=\"tel\" name=\"pharmacy-phone\" \/><\/span>\n\t<\/p>\n\t<p class=\"et_pb_contact_field_half\"><br \/>\n<label>Adresse :<\/label><br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"pharmacy-address\"><textarea cols=\"40\" rows=\"10\" maxlength=\"2000\" class=\"wpcf7-form-control wpcf7-textarea\" aria-invalid=\"false\" name=\"pharmacy-address\"><\/textarea><\/span>\n\t<\/p>\n\t<p class=\"et_pb_contact_field_half second\"><br \/>\n<label>T\u00e9l\u00e9copieur :<\/label><br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"pharmacy-fax\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-tel wpcf7-text wpcf7-validates-as-tel\" aria-invalid=\"false\" value=\"\" type=\"tel\" name=\"pharmacy-fax\" \/><\/span>\n\t<\/p>\n\t<p class=\"et_pb_contact_field_last\">\n\t<\/p>\n\t<section class=\"subHeading\">\n\t\t<p>En cas d\u2019urgence\n\t\t<\/p>\n\t<\/section>\n\t<p class=\"et_pb_contact_field_half\"><br \/>\n<label>Nom du parent ou connaissance n\u2019habitant pas \u00e0 la m\u00eame adresse :<\/label><br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"emergency-name\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"emergency-name\" \/><\/span>\n\t<\/p>\n\t<p class=\"et_pb_contact_field_half second\"><br \/>\n<label>Lien avec le client :<\/label><br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"emergency-relationship\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"emergency-relationship\" \/><\/span>\n\t<\/p>\n\t<p class=\"et_pb_contact_field_half\"><br \/>\n<label>T\u00e9l\u00e9phone Maison :<\/label><br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"emergency-phone\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-tel wpcf7-text wpcf7-validates-as-tel\" aria-invalid=\"false\" value=\"\" type=\"tel\" name=\"emergency-phone\" \/><\/span>\n\t<\/p>\n\t<p class=\"et_pb_contact_field_half second\"><br \/>\n<label>Cellulaire :<\/label><br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"emergency-cell\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-tel wpcf7-text wpcf7-validates-as-tel\" aria-invalid=\"false\" value=\"\" type=\"tel\" name=\"emergency-cell\" \/><\/span>\n\t<\/p>\n\t<p>L\u2019information contenue ci-haut est v\u00e9ridique au meilleur de ma connaissance. Je confirme que j\u2019ai sollicit\u00e9 les services de la Clinique Spectrum de ma propre initiative sans avoir \u00e9t\u00e9 sollicit\u00e9(e) par Clinique Spectrum ni aucune personne faisant partie de l\u2019\u00e9quipe.\n\t<\/p>\n\t<p>Je reconnais que toutes les informations concernant mon dossier clinique seront sauvegard\u00e9es sur notre fichier de sauvegarde \u00e9lectronique OSCAR extr\u00eamement fiable et s\u00e9curis\u00e9, et que seules les donn\u00e9es sommaires seront accessibles aux autres professionnels membres de l\u2019\u00e9quipe de la Clinique Spectrum. Je constate que j\u2019ai pris connaissance des frais pour les services non-assur\u00e9s par la RAMQ ainsi que la politique d\u2019annulation de rendez-vous (ci-bas).\n\t<\/p>\n\t<p>Prior to filling out our forms, please ensure that you have the consent of the individual for whom you are filling out the forms (in the case of a minor, or an adult with an incapacity). Please read our <a href=\"\/politique-confidentialite\/\">privacy policy<\/a> to learn more about how your personal information is protected through our website and communications.\n\t<\/p>\n\t<p>Please also read below for our cancellation policy and services that are not covered by the RAMQ.\n\t<\/p>\n<\/div>\n<p><input class=\"wpcf7-form-control wpcf7-submit has-spinner\" type=\"submit\" value=\"Soumettre\" \/>\n<\/p>\n<section class=\"subHeading\">\n\t<p>Services non-assur\u00e9s par la RAMQ\n\t<\/p>\n<\/section>\n<p><img decoding=\"async\" src=\"https:\/\/cliniquespectrum.com\/wp-content\/uploads\/2018\/11\/ramq.jpg\" alt=\"Services non-assur\u00e9s par la RAMQ\" class=\"aligncenter\" \/>\n<\/p>\n<section class=\"subHeading\">\n\t<p>Cancellation Policy\n\t<\/p>\n<\/section>\n<p>Nous exigeons un pr\u00e9avis de 24 heures pour toute annulation de rendez-vous. Lorsque possible, nous d\u00e9placerons votre rendez-vous. Cependant, si nous ne recevons pas d\u2019avis d\u2019annulation de rendez-vous au <a href=\"mailto:info@cliniquespectrum.com\">info@cliniquespectrum.com<\/a>, nous serons oblig\u00e9s de vous facturer le taux horaire pour votre rencontre.\n<\/p>\n<p>Voir <em>le Code de d\u00e9ontologie des psychologues art. 54 no. 3 & Code de d\u00e9ontologie des m\u00e9decins, art. 104 \u00e0 106<\/em>.\n<\/p><p style=\"display: none !important;\" class=\"akismet-fields-container\" data-prefix=\"_wpcf7_ak_\"><label>&#916;<textarea name=\"_wpcf7_ak_hp_textarea\" cols=\"45\" rows=\"8\" maxlength=\"100\"><\/textarea><\/label><input type=\"hidden\" id=\"ak_js_2\" name=\"_wpcf7_ak_js\" value=\"159\"\/><script>document.getElementById( \"ak_js_2\" ).setAttribute( \"value\", ( new Date() ).getTime() );<\/script><\/p><div class=\"wpcf7-response-output\" aria-hidden=\"true\"><\/div>\n<\/form>\n<\/div>\n<\/p>\n","protected":false},"author":1,"featured_media":0,"parent":0,"menu_order":8,"comment_status":"closed","ping_status":"closed","template":"","meta":{"_et_pb_use_builder":"on","_et_pb_old_content":"","_et_gb_content_width":"","footnotes":""},"class_list":["post-1873","page","type-page","status-publish","hentry"],"yoast_head":"<!-- This site is optimized with the Yoast SEO plugin v27.3 - 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