{"id":327,"date":"2021-11-30T14:55:55","date_gmt":"2021-11-30T19:55:55","guid":{"rendered":"https:\/\/www.hndgatineau.org\/?page_id=327"},"modified":"2021-12-02T12:21:00","modified_gmt":"2021-12-02T17:21:00","slug":"demande-de-services","status":"publish","type":"page","link":"https:\/\/hndgatineau.org\/fr\/demande-de-services\/","title":{"rendered":"Demande de services"},"content":{"rendered":"<div class=\"wpb-content-wrapper\"><p>[vc_row css=\u00a0\u00bb.vc_custom_1638302299835{padding-top: 0px !important;padding-bottom: 0px !important;}\u00a0\u00bb][vc_column]<div class=\"wpforms-container wpforms-container-full\" id=\"wpforms-313\"><form id=\"wpforms-form-313\" class=\"wpforms-validate wpforms-form wpforms-ajax-form\" data-formid=\"313\" method=\"post\" enctype=\"multipart\/form-data\" action=\"\/fr\/wp-json\/wp\/v2\/pages\/327?wpforms_form_id=313\" data-token=\"33072849898b98dbe89ef9b3eb29090b\" data-token-time=\"1775301840\"><noscript class=\"wpforms-error-noscript\">Veuillez activer JavaScript dans votre navigateur pour remplir ce formulaire.<\/noscript><div class=\"wpforms-field-container\"><div id=\"wpforms-313-field_7-container\" class=\"wpforms-field wpforms-field-html\" data-field-id=\"7\"><div id=\"wpforms-313-field_7\"><h2 class=\"first\">Crit\u00e8res d\u2019accessibilit\u00e9 pour obtenir les services des Habitations Nouveau D\u00e9part<\/h2>\r\n<p>L\u2019admission aux HND se fait toujours sur une base volontaire. Afin de b\u00e9n\u00e9ficier de nos services, toute personne doit faire compl\u00e9ter sa demande de services par son \u00e9quipe de suivi et \u00eatre achemin\u00e9e aux Habitations Nouveau D\u00e9part. Une premi\u00e8re rencontre est d\u2019abord effectu\u00e9e afin d\u2019\u00e9valuer les besoins de la personne qui fait la demande et une visite du milieu est ensuite effectu\u00e9e.<\/p>\r\n<p>Les personnes qui d\u00e9sirent b\u00e9n\u00e9ficier de nos services doivent satisfaire, avant d\u2019envoyer une demande de services, aux crit\u00e8res d\u2019admissibilit\u00e9 suivant :<\/p>\r\n<ul style=\"margin: 15px 0px 15px 15px !important;\">\r\n<li>Avoir des objectifs \u00e0 d\u00e9velopper en lien avec le soutien au logement;<\/li>\r\n<li>Avoir un plan d\u2019intervention et poss\u00e9der une \u00e9quipe de suivi qui demeurera impliqu\u00e9e dans le dossier durant un minimum de 2 ans ;<\/li>\r\n<li>Avoir re\u00e7u un diagnostic psychiatrique d\u2019un trouble de sant\u00e9 mentale grave ou de d\u00e9ficience intellectuelle ou de TSA;<\/li>\r\n<li>\u00catre autonome dans la prise de la m\u00e9dication;<\/li>\r\n<li>Poss\u00e9der une autonomie suffisante pour fonctionner sans la pr\u00e9sence d\u2019un intervenant 24\/7;<\/li>\r\n<li>\u00catre \u00e2g\u00e9(e) d\u2019au moins 18 ans;<\/li>\r\n<\/ul>\r\n<p>*Selon les milieux de vie, le revenu annuel doit se situer entre 10 000 et 13 000$<\/p>\r\n<p>**Certaines r\u00e9sidences subventionn\u00e9es demandent d\u2019avoir r\u00e9sid\u00e9 \u00e0 Gatineau comme crit\u00e8re de subvention.<\/p><\/div><\/div><div id=\"wpforms-313-field_8-container\" class=\"wpforms-field wpforms-field-checkbox wpforms-list-inline\" data-field-id=\"8\"><ul id=\"wpforms-313-field_8\"><li class=\"choice-1 depth-1\"><input type=\"checkbox\" id=\"wpforms-313-field_8_1\" name=\"wpforms[fields][8][]\" value=\"Sant\u00e9 mentale\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-313-field_8_1\">Sant\u00e9 mentale<\/label><\/li><li class=\"choice-2 depth-1\"><input type=\"checkbox\" id=\"wpforms-313-field_8_2\" name=\"wpforms[fields][8][]\" value=\"D\u00e9ficience intellectuelle\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-313-field_8_2\">D\u00e9ficience intellectuelle<\/label><\/li><li class=\"choice-3 depth-1\"><input type=\"checkbox\" id=\"wpforms-313-field_8_3\" name=\"wpforms[fields][8][]\" value=\"TSA\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-313-field_8_3\">TSA<\/label><\/li><\/ul><\/div><div id=\"wpforms-313-field_9-container\" class=\"wpforms-field wpforms-field-text\" data-field-id=\"9\"><label class=\"wpforms-field-label\" for=\"wpforms-313-field_9\">Provenance du dossier<\/label><input type=\"text\" id=\"wpforms-313-field_9\" class=\"wpforms-field-medium\" name=\"wpforms[fields][9]\" ><\/div><div id=\"wpforms-313-field_10-container\" class=\"wpforms-field wpforms-field-html\" data-field-id=\"10\"><div id=\"wpforms-313-field_10\"><h2>Identification de l'usager<\/h2><\/div><\/div><div id=\"wpforms-313-field_12-container\" class=\"wpforms-field wpforms-field-name\" data-field-id=\"12\"><label class=\"wpforms-field-label\">Name <span class=\"wpforms-required-label\">*<\/span><\/label><div class=\"wpforms-field-row wpforms-field-large\"><div class=\"wpforms-field-row-block wpforms-first wpforms-one-half\"><input type=\"text\" id=\"wpforms-313-field_12\" class=\"wpforms-field-name-first wpforms-field-required\" name=\"wpforms[fields][12][first]\" required><label for=\"wpforms-313-field_12\" class=\"wpforms-field-sublabel after\">Pr\u00e9nom<\/label><\/div><div class=\"wpforms-field-row-block wpforms-one-half\"><input type=\"text\" id=\"wpforms-313-field_12-last\" class=\"wpforms-field-name-last wpforms-field-required\" name=\"wpforms[fields][12][last]\" required><label for=\"wpforms-313-field_12-last\" class=\"wpforms-field-sublabel after\">Nom<\/label><\/div><\/div><\/div><div id=\"wpforms-313-field_13-container\" class=\"wpforms-field wpforms-field-address\" data-field-id=\"13\"><label class=\"wpforms-field-label\">Adresse<\/label><div class=\"wpforms-field-row wpforms-field-large\"><div ><input type=\"text\" id=\"wpforms-313-field_13\" class=\"wpforms-field-address-address1\" name=\"wpforms[fields][13][address1]\" ><label for=\"wpforms-313-field_13\" class=\"wpforms-field-sublabel after\">Adresse ligne\u00a01<\/label><\/div><\/div><div class=\"wpforms-field-row wpforms-field-large\"><div ><input type=\"text\" id=\"wpforms-313-field_13-address2\" class=\"wpforms-field-address-address2\" name=\"wpforms[fields][13][address2]\" ><label for=\"wpforms-313-field_13-address2\" class=\"wpforms-field-sublabel after\">Adresse ligne 2<\/label><\/div><\/div><div class=\"wpforms-field-row wpforms-field-large\"><div class=\"wpforms-field-row-block wpforms-one-half wpforms-first\"><input type=\"text\" id=\"wpforms-313-field_13-city\" class=\"wpforms-field-address-city\" name=\"wpforms[fields][13][city]\" ><label for=\"wpforms-313-field_13-city\" class=\"wpforms-field-sublabel after\">Ville<\/label><\/div><div class=\"wpforms-field-row-block wpforms-one-half\"><input type=\"text\" id=\"wpforms-313-field_13-state\" class=\"wpforms-field-address-state\" name=\"wpforms[fields][13][state]\" ><label for=\"wpforms-313-field_13-state\" class=\"wpforms-field-sublabel after\">\u00c9tat \/ Province \/ R\u00e9gion<\/label><\/div><\/div><div class=\"wpforms-field-row wpforms-field-large\"><div class=\"wpforms-field-row-block wpforms-one-half wpforms-first\"><input type=\"text\" id=\"wpforms-313-field_13-postal\" class=\"wpforms-field-address-postal\" name=\"wpforms[fields][13][postal]\" ><label for=\"wpforms-313-field_13-postal\" class=\"wpforms-field-sublabel after\">Code postal<\/label><\/div><div class=\"wpforms-field-row-block wpforms-one-half\"><select id=\"wpforms-313-field_13-country\" class=\"wpforms-field-address-country\" name=\"wpforms[fields][13][country]\" ><option class=\"placeholder\" value=\"\" selected disabled>--- S\u00e9lectionner\u00a0: country ---<\/option><option value=\"AF\" >Afghanistan<\/option><option value=\"ZA\" >Afrique du Sud<\/option><option value=\"AL\" >Albanie<\/option><option value=\"DZ\" >Alg\u00e9rie<\/option><option value=\"DE\" >Allemagne<\/option><option value=\"AD\" >Andorre<\/option><option value=\"AO\" >Angola<\/option><option value=\"AI\" >Anguilla<\/option><option value=\"AQ\" >Antarctique<\/option><option value=\"AG\" >Antigua-et-Barbuda<\/option><option value=\"SA\" >Arabie Saoudite<\/option><option value=\"AR\" >Argentine<\/option><option value=\"AM\" >Arm\u00e9nie<\/option><option value=\"AW\" >Aruba<\/option><option value=\"AU\" >Australie<\/option><option value=\"AT\" >Autriche<\/option><option value=\"AZ\" >Azerba\u00efdjan<\/option><option value=\"BS\" >Bahamas<\/option><option value=\"BH\" >Bahre\u00efn<\/option><option value=\"BD\" >Bangladesh<\/option><option value=\"BB\" >Barbade<\/option><option value=\"BE\" >Belgique<\/option><option value=\"BZ\" >Belize<\/option><option value=\"BM\" >Bermudes<\/option><option value=\"BT\" >Bhoutan<\/option><option value=\"BY\" >Bi\u00e9lorussie<\/option><option value=\"BO\" >Bolivie (\u00c9tat plurinational de)<\/option><option value=\"BQ\" >Bonaire, Saint Eustatius and Saba<\/option><option value=\"BA\" >Bosnie-Herz\u00e9govine<\/option><option value=\"BW\" >Botswana<\/option><option value=\"BR\" >Br\u00e9sil<\/option><option value=\"BG\" >Bulgarie<\/option><option value=\"BF\" >Burkina Faso<\/option><option value=\"BI\" >Burundi<\/option><option value=\"BJ\" >B\u00e9nin<\/option><option value=\"KH\" >Cambodge<\/option><option value=\"CM\" >Cameroun<\/option><option value=\"CA\" >Canada<\/option><option value=\"CV\" >Cap-Vert<\/option><option value=\"CL\" >Chili<\/option><option value=\"CN\" >Chine<\/option><option value=\"CY\" >Chypre<\/option><option value=\"CO\" >Colombie<\/option><option value=\"KM\" >Comores<\/option><option value=\"CG\" >Congo<\/option><option value=\"CD\" >Congo (R\u00e9publique d\u00e9mocratique du)<\/option><option value=\"KR\" >Cor\u00e9e (R\u00e9publique de)<\/option><option value=\"KP\" >Cor\u00e9e (R\u00e9publique populaire d\u00e9mocratique de)<\/option><option value=\"CR\" >Costa Rica<\/option><option value=\"HR\" >Croatie<\/option><option value=\"CU\" >Cuba<\/option><option value=\"CW\" >Cura\u00e7ao<\/option><option value=\"CI\" >C\u00f4te d\u2019Ivoire<\/option><option value=\"DK\" >Danemark<\/option><option value=\"DJ\" >Djibouti<\/option><option value=\"DM\" >Dominique<\/option><option value=\"ES\" >Espagne<\/option><option value=\"EE\" >Estonie<\/option><option value=\"SZ\" >Eswatini (Royaume de)<\/option><option value=\"FJ\" >Fidji<\/option><option value=\"FI\" >Finlande<\/option><option value=\"FR\" >France<\/option><option value=\"RU\" >F\u00e9d\u00e9ration Russe<\/option><option value=\"GA\" >Gabon<\/option><option value=\"GM\" >Gambie<\/option><option value=\"GH\" >Ghana<\/option><option value=\"GI\" >Gibraltar<\/option><option value=\"GD\" >Grenade<\/option><option value=\"GL\" >Groenland<\/option><option value=\"GR\" >Gr\u00e8ce<\/option><option value=\"GP\" >Guadeloupe<\/option><option value=\"GU\" >Guam<\/option><option value=\"GT\" >Guatemala<\/option><option value=\"GG\" >Guernesey<\/option><option value=\"GN\" >Guin\u00e9e<\/option><option value=\"GQ\" >Guin\u00e9e \u00e9quatoriale<\/option><option value=\"GW\" >Guin\u00e9e-Bissau<\/option><option value=\"GF\" >Guyane<\/option><option value=\"GY\" >Guyane<\/option><option value=\"GE\" >G\u00e9orgie<\/option><option value=\"GS\" >G\u00e9orgie du Sud et \u00eeles Sandwich du Sud<\/option><option value=\"HT\" >Ha\u00efti<\/option><option value=\"HN\" >Honduras<\/option><option value=\"HK\" >Hong Kong<\/option><option value=\"HU\" >Hongrie<\/option><option value=\"IN\" >Inde<\/option><option value=\"ID\" >Indon\u00e9sie<\/option><option value=\"IQ\" >Irak<\/option><option value=\"IR\" >Iran (R\u00e9publique islamique d\u2019)<\/option><option value=\"IE\" >Irlande (R\u00e9publique d\u2019)<\/option><option value=\"IS\" >Islande<\/option><option value=\"IL\" >Isra\u00ebl<\/option><option value=\"IT\" >Italie<\/option><option value=\"JM\" >Jama\u00efque<\/option><option value=\"JP\" >Japon<\/option><option value=\"JE\" >Jersey<\/option><option value=\"JO\" >Jordanie<\/option><option value=\"KZ\" >Kazakhstan<\/option><option value=\"KE\" >Kenya<\/option><option value=\"KG\" >Kirghizistan<\/option><option value=\"KI\" >Kiribati<\/option><option value=\"XK\" >Kosovo<\/option><option value=\"KW\" >Kowe\u00eft<\/option><option value=\"RE\" >La R\u00e9union<\/option><option value=\"LS\" >Lesotho<\/option><option value=\"LV\" >Lettonie<\/option><option value=\"LB\" >Liban<\/option><option value=\"LR\" >Liberia<\/option><option value=\"LY\" >Libye<\/option><option value=\"LI\" >Liechtenstein<\/option><option value=\"LT\" >Lituanie<\/option><option value=\"LU\" >Luxembourg<\/option><option value=\"MO\" >Macao<\/option><option value=\"MK\" >Mac\u00e9doine du Nord (R\u00e9publique de)<\/option><option value=\"MG\" >Madagascar<\/option><option value=\"MY\" >Malaisie<\/option><option value=\"MW\" >Malawi<\/option><option value=\"MV\" >Maldives<\/option><option value=\"ML\" >Mali<\/option><option value=\"MT\" >Malte<\/option><option value=\"MA\" >Maroc<\/option><option value=\"MQ\" >Martinique<\/option><option value=\"MR\" >Mauritanie<\/option><option value=\"YT\" >Mayotte<\/option><option value=\"MX\" >Mexique<\/option><option value=\"FM\" >Micron\u00e9sie (\u00c9tats f\u00e9d\u00e9r\u00e9s de)<\/option><option value=\"MD\" >Moldova (R\u00e9publique de)<\/option><option value=\"MC\" >Monaco<\/option><option value=\"MN\" >Mongolie<\/option><option value=\"MS\" >Montserrat<\/option><option value=\"ME\" >Mont\u00e9n\u00e9gro<\/option><option value=\"MZ\" >Mozambique<\/option><option value=\"MM\" >Myanmar<\/option><option value=\"NA\" >Namibie<\/option><option value=\"NR\" >Nauru<\/option><option value=\"BN\" >Negara Brunei Darussalam<\/option><option value=\"NI\" >Nicaragua<\/option><option value=\"NE\" >Niger<\/option><option value=\"NG\" >Nig\u00e9ria<\/option><option value=\"NU\" >Niue<\/option><option value=\"NO\" >Norv\u00e8ge<\/option><option value=\"NC\" >Nouvelle-Cal\u00e9donie<\/option><option value=\"NZ\" >Nouvelle-Z\u00e9lande<\/option><option value=\"NP\" >N\u00e9pal<\/option><option value=\"OM\" >Oman<\/option><option value=\"UG\" >Ouganda<\/option><option value=\"UZ\" >Ouzb\u00e9kistan<\/option><option value=\"PK\" >Pakistan<\/option><option value=\"PW\" >Palau<\/option><option value=\"PS\" >Palestine (\u00c9tat de)<\/option><option value=\"PA\" >Panama<\/option><option value=\"PG\" >Papouasie-Nouvelle-Guin\u00e9e<\/option><option value=\"PY\" >Paraguay<\/option><option value=\"NL\" >Pays-Bas<\/option><option value=\"PH\" >Philippines<\/option><option value=\"PL\" >Pologne<\/option><option value=\"PF\" >Polyn\u00e9sie fran\u00e7aise<\/option><option value=\"PR\" >Porto Rico<\/option><option value=\"PT\" >Portugal<\/option><option value=\"PE\" >P\u00e9rou<\/option><option value=\"QA\" >Qatar<\/option><option value=\"RO\" >Roumanie<\/option><option value=\"GB\" >Royaume-Uni de Grande-Bretagne et d\u2019Irlande du Nord<\/option><option value=\"RW\" >Rwanda<\/option><option value=\"SY\" >R\u00e9publique arabe syrienne<\/option><option value=\"CF\" >R\u00e9publique centrafricaine<\/option><option value=\"DO\" >R\u00e9publique dominicaine<\/option><option value=\"LA\" >R\u00e9publique d\u00e9mocratique populaire du Laos<\/option><option value=\"CZ\" >R\u00e9publique tch\u00e8que<\/option><option value=\"EH\" >Sahara occidental<\/option><option value=\"BL\" >Saint Barth\u00e9lemy<\/option><option value=\"PM\" >Saint Pierre et Miquelon<\/option><option value=\"KN\" >Saint-Christophe-et-Nevis<\/option><option value=\"SM\" >Saint-Marin<\/option><option value=\"MF\" >Saint-Martin (partie fran\u00e7aise)<\/option><option value=\"VC\" >Saint-Vincent-et-les Grenadines<\/option><option value=\"SH\" >Sainte-H\u00e9l\u00e8ne, Ascension et Tristan da Cunha<\/option><option value=\"LC\" >Sainte-Lucie<\/option><option value=\"SV\" >Salvador<\/option><option value=\"WS\" >Samoa<\/option><option value=\"AS\" >Samoa am\u00e9ricaines<\/option><option value=\"ST\" >Sao Tom\u00e9 et Principe<\/option><option value=\"RS\" >Serbie<\/option><option value=\"SC\" >Seychelles<\/option><option value=\"SL\" >Sierra Leone<\/option><option value=\"SG\" >Singapour<\/option><option value=\"SX\" >Sint Maarten (partie hollandaise)<\/option><option value=\"SK\" >Slovaquie<\/option><option value=\"SI\" >Slov\u00e9nie<\/option><option value=\"SO\" >Somalie<\/option><option value=\"SD\" >Soudan<\/option><option value=\"SS\" >Soudan du Sud<\/option><option value=\"LK\" >Sri Lanka<\/option><option value=\"CH\" >Suisse<\/option><option value=\"SR\" >Surinam<\/option><option value=\"SE\" >Su\u00e8de<\/option><option value=\"SN\" >S\u00e9n\u00e9gal<\/option><option value=\"TJ\" >Tadjikistan<\/option><option value=\"TW\" >Taiwan, R\u00e9publique de Chine<\/option><option value=\"TZ\" >Tanzanie (R\u00e9publique-Unie de)<\/option><option value=\"TD\" >Tchad<\/option><option value=\"TF\" >Terres Australes Fran\u00e7aises<\/option><option value=\"IO\" >Territoire britannique de l\u2019oc\u00e9an Indien<\/option><option value=\"TH\" >Tha\u00eflande<\/option><option value=\"TL\" >Timor oriental<\/option><option value=\"TG\" >Togo<\/option><option value=\"TK\" >Tokelau<\/option><option value=\"TO\" >Tonga<\/option><option value=\"TT\" >Trinit\u00e9 et Tobago<\/option><option value=\"TN\" >Tunisie<\/option><option value=\"TM\" >Turkm\u00e9nistan<\/option><option value=\"TR\" >Turquie<\/option><option value=\"TV\" >Tuvalu<\/option><option value=\"UA\" >Ukraine<\/option><option value=\"UY\" >Uruguay<\/option><option value=\"VU\" >Vanuatu<\/option><option value=\"VE\" >Venezuela (R\u00e9publique bolivarienne du)<\/option><option value=\"VN\" >Vietnam<\/option><option value=\"WF\" >Wallis et Futuna<\/option><option value=\"YE\" >Y\u00e9men<\/option><option value=\"ZM\" >Zambie<\/option><option value=\"ZW\" >Zimbabwe<\/option><option value=\"EG\" >\u00c9gypte<\/option><option value=\"AE\" >\u00c9mirats arabes unis<\/option><option value=\"EC\" >\u00c9quateur<\/option><option value=\"ER\" >\u00c9rythr\u00e9e<\/option><option value=\"VA\" >\u00c9tat de la cit\u00e9 du Vatican<\/option><option value=\"US\" >\u00c9tats-Unis d\u2019Am\u00e9rique<\/option><option value=\"ET\" >\u00c9thiopie<\/option><option value=\"BV\" >\u00cele Bouvet<\/option><option value=\"CX\" >\u00cele Christmas<\/option><option value=\"MU\" >\u00cele Maurice<\/option><option value=\"NF\" >\u00cele Norfolk<\/option><option value=\"IM\" >\u00cele de Man<\/option><option value=\"KY\" >\u00celes Ca\u00efmans<\/option><option value=\"CC\" >\u00celes Cocos (Keeling)<\/option><option value=\"CK\" >\u00celes Cook<\/option><option value=\"FK\" >\u00celes Falkland (Malvinas)<\/option><option value=\"FO\" >\u00celes F\u00e9ro\u00e9<\/option><option value=\"HM\" >\u00celes Heard et McDonald<\/option><option value=\"MP\" >\u00celes Mariannes du Nord<\/option><option value=\"MH\" >\u00celes Marshall<\/option><option value=\"PN\" >\u00celes Pitcairn<\/option><option value=\"SB\" >\u00celes Salomon<\/option><option value=\"TC\" >\u00celes Turques et Ca\u00efques<\/option><option value=\"VI\" >\u00celes Vierges (Am\u00e9ricaines)<\/option><option value=\"VG\" >\u00celes Vierges (Britanniques)<\/option><option value=\"SJ\" >\u00celes de Svalbard et Jan Mayen<\/option><option value=\"UM\" >\u00celes mineures am\u00e9ricaines<\/option><option value=\"AX\" >\u00celes \u00c5land<\/option><\/select><label for=\"wpforms-313-field_13-country\" class=\"wpforms-field-sublabel after\">Pays<\/label><\/div><\/div><\/div><div id=\"wpforms-313-field_14-container\" class=\"wpforms-field wpforms-field-date-time\" data-field-id=\"14\"><label class=\"wpforms-field-label\" for=\"wpforms-313-field_14\">Date de naissance<\/label><div class=\"wpforms-datepicker-wrap\"><input type=\"text\" id=\"wpforms-313-field_14\" class=\"wpforms-field-date-time-date wpforms-datepicker wpforms-field-large\" data-date-format=\"m\/d\/Y\" data-disable-past-dates=\"0\" data-input=\"true\" name=\"wpforms[fields][14][date]\" ><a title=\"Effacer la date\" data-clear role=\"button\" tabindex=\"0\" class=\"wpforms-datepicker-clear\" aria-label=\"Effacer la date\" style=\"display:none;\"><\/a><\/div><\/div><div id=\"wpforms-313-field_15-container\" class=\"wpforms-field wpforms-field-phone wpforms-one-half wpforms-first\" data-field-id=\"15\"><label class=\"wpforms-field-label\" for=\"wpforms-313-field_15\">T\u00e9l\u00e9phone<\/label><input type=\"tel\" id=\"wpforms-313-field_15\" class=\"wpforms-field-large wpforms-smart-phone-field\" data-rule-smart-phone-field=\"true\" name=\"wpforms[fields][15]\" aria-label=\"T\u00e9l\u00e9phone\" ><\/div><div id=\"wpforms-313-field_17-container\" class=\"wpforms-field wpforms-field-text wpforms-one-half\" data-field-id=\"17\"><label class=\"wpforms-field-label\" for=\"wpforms-313-field_17\">Allergies<\/label><input type=\"text\" id=\"wpforms-313-field_17\" class=\"wpforms-field-large\" name=\"wpforms[fields][17]\" ><\/div><div id=\"wpforms-313-field_18-container\" class=\"wpforms-field wpforms-field-text\" data-field-id=\"18\"><label class=\"wpforms-field-label\" for=\"wpforms-313-field_18\">Dans les 24 derniers mois, la personne a-t-elle r\u00e9sid\u00e9e en Outaouais durant 12 mois cons\u00e9cutifs?<\/label><input type=\"text\" id=\"wpforms-313-field_18\" class=\"wpforms-field-large\" name=\"wpforms[fields][18]\" ><\/div><div id=\"wpforms-313-field_19-container\" class=\"wpforms-field wpforms-field-html\" data-field-id=\"19\"><div id=\"wpforms-313-field_19\"><h2>Suivi dans la communaut\u00e9<\/h2><\/div><\/div><div id=\"wpforms-313-field_20-container\" class=\"wpforms-field wpforms-field-text\" data-field-id=\"20\"><label class=\"wpforms-field-label\" for=\"wpforms-313-field_20\">Par quel organisme?<\/label><input type=\"text\" id=\"wpforms-313-field_20\" class=\"wpforms-field-large\" name=\"wpforms[fields][20]\" ><\/div><div id=\"wpforms-313-field_21-container\" class=\"wpforms-field wpforms-field-text\" data-field-id=\"21\"><label class=\"wpforms-field-label\" for=\"wpforms-313-field_21\">Depuis quand?<\/label><input type=\"text\" id=\"wpforms-313-field_21\" class=\"wpforms-field-large\" name=\"wpforms[fields][21]\" ><\/div><div id=\"wpforms-313-field_22-container\" class=\"wpforms-field wpforms-field-text\" data-field-id=\"22\"><label class=\"wpforms-field-label\" for=\"wpforms-313-field_22\">\u00c0 quelle fr\u00e9quence?<\/label><input type=\"text\" id=\"wpforms-313-field_22\" class=\"wpforms-field-large\" name=\"wpforms[fields][22]\" ><\/div><div id=\"wpforms-313-field_23-container\" class=\"wpforms-field wpforms-field-text\" data-field-id=\"23\"><label class=\"wpforms-field-label\" for=\"wpforms-313-field_23\">Quel type de suivi est offert?<\/label><input type=\"text\" id=\"wpforms-313-field_23\" class=\"wpforms-field-large\" name=\"wpforms[fields][23]\" ><\/div><div id=\"wpforms-313-field_24-container\" class=\"wpforms-field wpforms-field-html\" data-field-id=\"24\"><div id=\"wpforms-313-field_24\"><h2>Personnes impliqu\u00e9es aupr\u00e8s de l'usager<\/h2><\/div><\/div><div id=\"wpforms-313-field_25-container\" class=\"wpforms-field wpforms-field-text wpforms-two-thirds wpforms-first\" data-field-id=\"25\"><label class=\"wpforms-field-label\" for=\"wpforms-313-field_25\">M\u00e9decin de famille<\/label><input type=\"text\" id=\"wpforms-313-field_25\" class=\"wpforms-field-large\" name=\"wpforms[fields][25]\" ><\/div><div id=\"wpforms-313-field_26-container\" class=\"wpforms-field wpforms-field-phone wpforms-one-third\" data-field-id=\"26\"><label class=\"wpforms-field-label\" for=\"wpforms-313-field_26\">T\u00e9l\u00e9phone<\/label><input type=\"tel\" id=\"wpforms-313-field_26\" class=\"wpforms-field-large wpforms-smart-phone-field\" data-rule-smart-phone-field=\"true\" name=\"wpforms[fields][26]\" aria-label=\"T\u00e9l\u00e9phone\" ><\/div><div id=\"wpforms-313-field_27-container\" class=\"wpforms-field wpforms-field-text wpforms-two-thirds wpforms-first\" data-field-id=\"27\"><label class=\"wpforms-field-label\" for=\"wpforms-313-field_27\">Psychiatre<\/label><input type=\"text\" id=\"wpforms-313-field_27\" class=\"wpforms-field-large\" name=\"wpforms[fields][27]\" ><\/div><div id=\"wpforms-313-field_28-container\" class=\"wpforms-field wpforms-field-phone wpforms-one-third\" data-field-id=\"28\"><label class=\"wpforms-field-label\" for=\"wpforms-313-field_28\">T\u00e9l\u00e9phone<\/label><input type=\"tel\" id=\"wpforms-313-field_28\" class=\"wpforms-field-large wpforms-smart-phone-field\" data-rule-smart-phone-field=\"true\" name=\"wpforms[fields][28]\" aria-label=\"T\u00e9l\u00e9phone\" ><\/div><div id=\"wpforms-313-field_29-container\" class=\"wpforms-field wpforms-field-text wpforms-two-thirds wpforms-first\" data-field-id=\"29\"><label class=\"wpforms-field-label\" for=\"wpforms-313-field_29\">Psychologue<\/label><input type=\"text\" id=\"wpforms-313-field_29\" class=\"wpforms-field-large\" name=\"wpforms[fields][29]\" ><\/div><div id=\"wpforms-313-field_30-container\" class=\"wpforms-field wpforms-field-phone wpforms-one-third\" data-field-id=\"30\"><label class=\"wpforms-field-label\" for=\"wpforms-313-field_30\">T\u00e9l\u00e9phone<\/label><input type=\"tel\" id=\"wpforms-313-field_30\" class=\"wpforms-field-large wpforms-smart-phone-field\" data-rule-smart-phone-field=\"true\" name=\"wpforms[fields][30]\" aria-label=\"T\u00e9l\u00e9phone\" ><\/div><div id=\"wpforms-313-field_31-container\" class=\"wpforms-field wpforms-field-text wpforms-two-thirds wpforms-first\" data-field-id=\"31\"><label class=\"wpforms-field-label\" for=\"wpforms-313-field_31\">Intervenants<\/label><input type=\"text\" id=\"wpforms-313-field_31\" class=\"wpforms-field-large\" name=\"wpforms[fields][31]\" ><\/div><div id=\"wpforms-313-field_32-container\" class=\"wpforms-field wpforms-field-phone wpforms-one-third\" data-field-id=\"32\"><label class=\"wpforms-field-label\" for=\"wpforms-313-field_32\">T\u00e9l\u00e9phone<\/label><input type=\"tel\" id=\"wpforms-313-field_32\" class=\"wpforms-field-large wpforms-smart-phone-field\" data-rule-smart-phone-field=\"true\" name=\"wpforms[fields][32]\" aria-label=\"T\u00e9l\u00e9phone\" ><\/div><div id=\"wpforms-313-field_33-container\" class=\"wpforms-field wpforms-field-text wpforms-two-thirds wpforms-first\" data-field-id=\"33\"><label class=\"wpforms-field-label\" for=\"wpforms-313-field_33\">Famille<\/label><input type=\"text\" id=\"wpforms-313-field_33\" class=\"wpforms-field-large\" name=\"wpforms[fields][33]\" ><\/div><div id=\"wpforms-313-field_34-container\" class=\"wpforms-field wpforms-field-phone wpforms-one-third\" data-field-id=\"34\"><label class=\"wpforms-field-label\" for=\"wpforms-313-field_34\">T\u00e9l\u00e9phone<\/label><input type=\"tel\" id=\"wpforms-313-field_34\" class=\"wpforms-field-large wpforms-smart-phone-field\" data-rule-smart-phone-field=\"true\" name=\"wpforms[fields][34]\" aria-label=\"T\u00e9l\u00e9phone\" ><\/div><div id=\"wpforms-313-field_35-container\" class=\"wpforms-field wpforms-field-text wpforms-two-thirds wpforms-first\" data-field-id=\"35\"><label class=\"wpforms-field-label\" for=\"wpforms-313-field_35\">Autres<\/label><input type=\"text\" id=\"wpforms-313-field_35\" class=\"wpforms-field-large\" name=\"wpforms[fields][35]\" ><\/div><div id=\"wpforms-313-field_36-container\" class=\"wpforms-field wpforms-field-phone wpforms-one-third\" data-field-id=\"36\"><label class=\"wpforms-field-label\" for=\"wpforms-313-field_36\">T\u00e9l\u00e9phone<\/label><input type=\"tel\" id=\"wpforms-313-field_36\" class=\"wpforms-field-large wpforms-smart-phone-field\" data-rule-smart-phone-field=\"true\" name=\"wpforms[fields][36]\" aria-label=\"T\u00e9l\u00e9phone\" ><\/div><div id=\"wpforms-313-field_37-container\" class=\"wpforms-field wpforms-field-html\" data-field-id=\"37\"><div id=\"wpforms-313-field_37\"><h2>Informations m\u00e9dicales<\/h2><\/div><\/div><div id=\"wpforms-313-field_38-container\" class=\"wpforms-field wpforms-field-text\" data-field-id=\"38\"><label class=\"wpforms-field-label\" for=\"wpforms-313-field_38\">Diagnostique psychiatrique<\/label><input type=\"text\" id=\"wpforms-313-field_38\" class=\"wpforms-field-large\" name=\"wpforms[fields][38]\" ><\/div><div id=\"wpforms-313-field_39-container\" class=\"wpforms-field wpforms-field-text\" data-field-id=\"39\"><label class=\"wpforms-field-label\" for=\"wpforms-313-field_39\">Handicap physique<\/label><input type=\"text\" id=\"wpforms-313-field_39\" class=\"wpforms-field-large\" name=\"wpforms[fields][39]\" ><\/div><div id=\"wpforms-313-field_40-container\" class=\"wpforms-field wpforms-field-html\" data-field-id=\"40\"><div id=\"wpforms-313-field_40\"><p>Veuillez noter qu\u2019il y a une \u00e9valuation du risque d\u2019influence par rapport \u00e0 l\u2019abus de substance, donc, si le demandeur est fragile au niveau de la consommation, il est possible que sa demande soit refus\u00e9e.<\/p><\/div><\/div><div id=\"wpforms-313-field_41-container\" class=\"wpforms-field wpforms-field-checkbox wpforms-list-inline\" data-field-id=\"41\"><label class=\"wpforms-field-label\">Probl\u00e9matiques multiples<\/label><ul id=\"wpforms-313-field_41\"><li class=\"choice-1 depth-1\"><input type=\"checkbox\" id=\"wpforms-313-field_41_1\" name=\"wpforms[fields][41][]\" value=\"Alcoolisme\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-313-field_41_1\">Alcoolisme<\/label><\/li><li class=\"choice-2 depth-1\"><input type=\"checkbox\" id=\"wpforms-313-field_41_2\" name=\"wpforms[fields][41][]\" value=\"Itin\u00e9rance\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-313-field_41_2\">Itin\u00e9rance<\/label><\/li><li class=\"choice-3 depth-1\"><input type=\"checkbox\" id=\"wpforms-313-field_41_3\" name=\"wpforms[fields][41][]\" value=\"Violence\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-313-field_41_3\">Violence<\/label><\/li><li class=\"choice-4 depth-1\"><input type=\"checkbox\" id=\"wpforms-313-field_41_4\" name=\"wpforms[fields][41][]\" value=\"Abus de substance\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-313-field_41_4\">Abus de substance<\/label><\/li><li class=\"choice-5 depth-1\"><input type=\"checkbox\" id=\"wpforms-313-field_41_5\" name=\"wpforms[fields][41][]\" value=\"Troubles d\u2019apprentissage\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-313-field_41_5\">Troubles d\u2019apprentissage<\/label><\/li><\/ul><\/div><div id=\"wpforms-313-field_42-container\" class=\"wpforms-field wpforms-field-textarea\" data-field-id=\"42\"><label class=\"wpforms-field-label\" for=\"wpforms-313-field_42\">Pr\u00e9cisions sur la probl\u00e9matique<\/label><textarea id=\"wpforms-313-field_42\" class=\"wpforms-field-medium\" name=\"wpforms[fields][42]\" ><\/textarea><\/div><div id=\"wpforms-313-field_43-container\" class=\"wpforms-field wpforms-field-textarea\" data-field-id=\"43\"><label class=\"wpforms-field-label\" for=\"wpforms-313-field_43\">(Fr\u00e9quence, type de substance, etc.)<\/label><textarea id=\"wpforms-313-field_43\" class=\"wpforms-field-medium\" name=\"wpforms[fields][43]\" ><\/textarea><\/div><div id=\"wpforms-313-field_44-container\" class=\"wpforms-field wpforms-field-textarea\" data-field-id=\"44\"><label class=\"wpforms-field-label\" for=\"wpforms-313-field_44\">Comportements particuliers observ\u00e9s en lien avec la consommation<\/label><textarea id=\"wpforms-313-field_44\" class=\"wpforms-field-medium\" name=\"wpforms[fields][44]\" ><\/textarea><\/div><div id=\"wpforms-313-field_45-container\" class=\"wpforms-field wpforms-field-checkbox wpforms-list-inline\" data-field-id=\"45\"><label class=\"wpforms-field-label\">Potentiel d&#039;agressivit\u00e9 - Envers personne<\/label><ul id=\"wpforms-313-field_45\"><li class=\"choice-1 depth-1\"><input type=\"checkbox\" id=\"wpforms-313-field_45_1\" name=\"wpforms[fields][45][]\" value=\"3 derniers mois\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-313-field_45_1\">3 derniers mois<\/label><\/li><li class=\"choice-2 depth-1\"><input type=\"checkbox\" id=\"wpforms-313-field_45_2\" name=\"wpforms[fields][45][]\" value=\"6 derniers mois\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-313-field_45_2\">6 derniers mois<\/label><\/li><li class=\"choice-3 depth-1\"><input type=\"checkbox\" id=\"wpforms-313-field_45_3\" name=\"wpforms[fields][45][]\" value=\"12 derniers mois\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-313-field_45_3\">12 derniers mois<\/label><\/li><\/ul><\/div><div id=\"wpforms-313-field_46-container\" class=\"wpforms-field wpforms-field-checkbox wpforms-list-inline\" data-field-id=\"46\"><label class=\"wpforms-field-label\">Potentiel d&#039;agressivit\u00e9 - Envers objet<\/label><ul id=\"wpforms-313-field_46\"><li class=\"choice-1 depth-1\"><input type=\"checkbox\" id=\"wpforms-313-field_46_1\" name=\"wpforms[fields][46][]\" value=\"3 derniers mois\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-313-field_46_1\">3 derniers mois<\/label><\/li><li class=\"choice-2 depth-1\"><input type=\"checkbox\" id=\"wpforms-313-field_46_2\" name=\"wpforms[fields][46][]\" value=\"6 derniers mois\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-313-field_46_2\">6 derniers mois<\/label><\/li><li class=\"choice-3 depth-1\"><input type=\"checkbox\" id=\"wpforms-313-field_46_3\" name=\"wpforms[fields][46][]\" value=\"12 derniers mois\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-313-field_46_3\">12 derniers mois<\/label><\/li><\/ul><\/div><div id=\"wpforms-313-field_47-container\" class=\"wpforms-field wpforms-field-textarea\" data-field-id=\"47\"><label class=\"wpforms-field-label\" for=\"wpforms-313-field_47\">R\u00e9sum\u00e9 des \u00e9v\u00e9nements (joindre documents l\u00e9gaux)<\/label><textarea id=\"wpforms-313-field_47\" class=\"wpforms-field-medium\" name=\"wpforms[fields][47]\" ><\/textarea><\/div><div id=\"wpforms-313-field_48-container\" class=\"wpforms-field wpforms-field-html\" data-field-id=\"48\"><div id=\"wpforms-313-field_48\"><h2>R\u00e9sidence cibl\u00e9e<\/h2><\/div><\/div><div id=\"wpforms-313-field_49-container\" class=\"wpforms-field wpforms-field-html\" data-field-id=\"49\"><div id=\"wpforms-313-field_49\"><h3 align=\"center\">Secteur Gatineau<\/h3><\/div><\/div><div id=\"wpforms-313-field_50-container\" class=\"wpforms-field wpforms-field-checkbox wpforms-list-inline\" data-field-id=\"50\"><label class=\"wpforms-field-label\">Charles Desnoyer<\/label><ul id=\"wpforms-313-field_50\"><li class=\"choice-1 depth-1\"><input type=\"checkbox\" id=\"wpforms-313-field_50_1\" name=\"wpforms[fields][50][]\" value=\"R\u00e9sidence de groupe\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-313-field_50_1\">R\u00e9sidence de groupe<\/label><\/li><\/ul><\/div><div id=\"wpforms-313-field_51-container\" class=\"wpforms-field wpforms-field-checkbox wpforms-list-inline\" data-field-id=\"51\"><label class=\"wpforms-field-label\">Oak<\/label><ul id=\"wpforms-313-field_51\"><li class=\"choice-1 depth-1\"><input type=\"checkbox\" id=\"wpforms-313-field_51_1\" name=\"wpforms[fields][51][]\" value=\"Studios\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-313-field_51_1\">Studios<\/label><\/li><\/ul><\/div><div id=\"wpforms-313-field_52-container\" class=\"wpforms-field wpforms-field-checkbox wpforms-list-inline\" data-field-id=\"52\"><label class=\"wpforms-field-label\">137<\/label><ul id=\"wpforms-313-field_52\"><li class=\"choice-1 depth-1\"><input type=\"checkbox\" id=\"wpforms-313-field_52_1\" name=\"wpforms[fields][52][]\" value=\"Studios\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-313-field_52_1\">Studios<\/label><\/li><li class=\"choice-4 depth-1\"><input type=\"checkbox\" id=\"wpforms-313-field_52_4\" name=\"wpforms[fields][52][]\" value=\"Appartement 1 chambre \u00e0 coucher\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-313-field_52_4\">Appartement 1 chambre \u00e0 coucher<\/label><\/li><li class=\"choice-5 depth-1\"><input type=\"checkbox\" id=\"wpforms-313-field_52_5\" name=\"wpforms[fields][52][]\" value=\"Appartements en colocation \u00e0 3\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-313-field_52_5\">Appartements en colocation \u00e0 3<\/label><\/li><\/ul><\/div><div id=\"wpforms-313-field_53-container\" class=\"wpforms-field wpforms-field-checkbox wpforms-list-inline\" data-field-id=\"53\"><label class=\"wpforms-field-label\">Maloney<\/label><ul id=\"wpforms-313-field_53\"><li class=\"choice-1 depth-1\"><input type=\"checkbox\" id=\"wpforms-313-field_53_1\" name=\"wpforms[fields][53][]\" value=\"Appartements en colocation \u00e0 3\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-313-field_53_1\">Appartements en colocation \u00e0 3<\/label><\/li><\/ul><\/div><div id=\"wpforms-313-field_54-container\" class=\"wpforms-field wpforms-field-checkbox wpforms-list-inline\" data-field-id=\"54\"><label class=\"wpforms-field-label\">Berthe<\/label><ul id=\"wpforms-313-field_54\"><li class=\"choice-1 depth-1\"><input type=\"checkbox\" id=\"wpforms-313-field_54_1\" name=\"wpforms[fields][54][]\" value=\"R\u00e9sidence de groupe\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-313-field_54_1\">R\u00e9sidence de groupe<\/label><\/li><\/ul><\/div><div id=\"wpforms-313-field_56-container\" class=\"wpforms-field wpforms-field-html\" data-field-id=\"56\"><div id=\"wpforms-313-field_56\"><h3 align=\"center\">Secteur Hull<\/h3><\/div><\/div><div id=\"wpforms-313-field_55-container\" class=\"wpforms-field wpforms-field-checkbox wpforms-list-inline\" data-field-id=\"55\"><label class=\"wpforms-field-label\">St-Cyr<\/label><ul id=\"wpforms-313-field_55\"><li class=\"choice-1 depth-1\"><input type=\"checkbox\" id=\"wpforms-313-field_55_1\" name=\"wpforms[fields][55][]\" value=\"R\u00e9sidence de groupe en D.I.\/T.S.A.\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-313-field_55_1\">R\u00e9sidence de groupe en D.I.\/T.S.A.<\/label><\/li><\/ul><\/div><div id=\"wpforms-313-field_57-container\" class=\"wpforms-field wpforms-field-html\" data-field-id=\"57\"><div id=\"wpforms-313-field_57\"><h2>Profil social<\/h2><\/div><\/div><div id=\"wpforms-313-field_58-container\" class=\"wpforms-field wpforms-field-checkbox wpforms-list-inline\" data-field-id=\"58\"><label class=\"wpforms-field-label\">Millieu de vie actuel<\/label><ul id=\"wpforms-313-field_58\"><li class=\"choice-1 depth-1\"><input type=\"checkbox\" id=\"wpforms-313-field_58_1\" name=\"wpforms[fields][58][]\" value=\"H\u00f4pital\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-313-field_58_1\">H\u00f4pital<\/label><\/li><li class=\"choice-6 depth-1\"><input type=\"checkbox\" id=\"wpforms-313-field_58_6\" name=\"wpforms[fields][58][]\" value=\"Familial\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-313-field_58_6\">Familial<\/label><\/li><li class=\"choice-7 depth-1\"><input type=\"checkbox\" id=\"wpforms-313-field_58_7\" name=\"wpforms[fields][58][]\" value=\"RTF\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-313-field_58_7\">RTF<\/label><\/li><li class=\"choice-8 depth-1\"><input type=\"checkbox\" id=\"wpforms-313-field_58_8\" name=\"wpforms[fields][58][]\" value=\"Autre\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-313-field_58_8\">Autre<\/label><\/li><\/ul><\/div><div id=\"wpforms-313-field_59-container\" class=\"wpforms-field wpforms-field-text\" data-field-id=\"59\"><label class=\"wpforms-field-label\" for=\"wpforms-313-field_59\">Autre<\/label><input type=\"text\" id=\"wpforms-313-field_59\" class=\"wpforms-field-large\" name=\"wpforms[fields][59]\" ><\/div><div id=\"wpforms-313-field_60-container\" class=\"wpforms-field wpforms-field-checkbox wpforms-list-inline\" data-field-id=\"60\"><label class=\"wpforms-field-label\">Urgence de la demande<\/label><ul id=\"wpforms-313-field_60\"><li class=\"choice-1 depth-1\"><input type=\"checkbox\" id=\"wpforms-313-field_60_1\" name=\"wpforms[fields][60][]\" value=\"Oui\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-313-field_60_1\">Oui<\/label><\/li><li class=\"choice-6 depth-1\"><input type=\"checkbox\" id=\"wpforms-313-field_60_6\" name=\"wpforms[fields][60][]\" value=\"Non\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-313-field_60_6\">Non<\/label><\/li><\/ul><\/div><div id=\"wpforms-313-field_61-container\" class=\"wpforms-field wpforms-field-textarea\" data-field-id=\"61\"><label class=\"wpforms-field-label\" for=\"wpforms-313-field_61\">Si oui, pourquoi<\/label><textarea id=\"wpforms-313-field_61\" class=\"wpforms-field-medium\" name=\"wpforms[fields][61]\" ><\/textarea><\/div><div id=\"wpforms-313-field_62-container\" class=\"wpforms-field wpforms-field-checkbox wpforms-list-inline\" data-field-id=\"62\"><label class=\"wpforms-field-label\">Ordonnance de la cour, restrictions l\u00e9gales ou mandat<\/label><ul id=\"wpforms-313-field_62\"><li class=\"choice-1 depth-1\"><input type=\"checkbox\" id=\"wpforms-313-field_62_1\" name=\"wpforms[fields][62][]\" value=\"Oui\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-313-field_62_1\">Oui<\/label><\/li><li class=\"choice-6 depth-1\"><input type=\"checkbox\" id=\"wpforms-313-field_62_6\" name=\"wpforms[fields][62][]\" value=\"Non\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-313-field_62_6\">Non<\/label><\/li><\/ul><\/div><div id=\"wpforms-313-field_63-container\" class=\"wpforms-field wpforms-field-checkbox wpforms-list-inline\" data-field-id=\"63\"><label class=\"wpforms-field-label\">Curatelle publique ou priv\u00e9e<\/label><ul id=\"wpforms-313-field_63\"><li class=\"choice-1 depth-1\"><input type=\"checkbox\" id=\"wpforms-313-field_63_1\" name=\"wpforms[fields][63][]\" value=\"Oui\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-313-field_63_1\">Oui<\/label><\/li><li class=\"choice-6 depth-1\"><input type=\"checkbox\" id=\"wpforms-313-field_63_6\" name=\"wpforms[fields][63][]\" value=\"Non\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-313-field_63_6\">Non<\/label><\/li><\/ul><\/div><div id=\"wpforms-313-field_64-container\" class=\"wpforms-field wpforms-field-textarea\" data-field-id=\"64\"><label class=\"wpforms-field-label\" for=\"wpforms-313-field_64\">Pr\u00e9cisions sur ordonnances ou curatelle<\/label><textarea id=\"wpforms-313-field_64\" class=\"wpforms-field-medium\" name=\"wpforms[fields][64]\" ><\/textarea><\/div><div id=\"wpforms-313-field_65-container\" class=\"wpforms-field wpforms-field-html\" data-field-id=\"65\"><div id=\"wpforms-313-field_65\"><h2>Objectif de la r\u00e9f\u00e9rence<\/h2><\/div><\/div><div id=\"wpforms-313-field_66-container\" class=\"wpforms-field wpforms-field-textarea\" data-field-id=\"66\"><label class=\"wpforms-field-label\" for=\"wpforms-313-field_66\">D\u00e9crire le motif de la demande, les objectifs de vie en lien avec le soutien au logement<\/label><textarea id=\"wpforms-313-field_66\" class=\"wpforms-field-medium\" name=\"wpforms[fields][66]\" ><\/textarea><\/div><div id=\"wpforms-313-field_68-container\" class=\"wpforms-field wpforms-field-textarea\" data-field-id=\"68\"><label class=\"wpforms-field-label\" for=\"wpforms-313-field_68\">Les besoins exprim\u00e9s par l\u2019usager et ses proches sont<\/label><textarea id=\"wpforms-313-field_68\" class=\"wpforms-field-medium\" name=\"wpforms[fields][68]\" ><\/textarea><\/div><div id=\"wpforms-313-field_69-container\" class=\"wpforms-field wpforms-field-html\" data-field-id=\"69\"><div id=\"wpforms-313-field_69\"><h2>Activit\u00e9s de la vie quotidienne et domestique<\/h2><\/div><\/div><div id=\"wpforms-313-field_70-container\" class=\"wpforms-field wpforms-field-html\" data-field-id=\"70\"><div id=\"wpforms-313-field_70\"><p>\u00cates-vous en mesure d\u2019assurer de fa\u00e7on autonome la satisfaction de vos besoins essentiels, tel que<\/p><\/div><\/div><div id=\"wpforms-313-field_72-container\" class=\"wpforms-field wpforms-field-checkbox wpforms-list-inline\" data-field-id=\"72\"><label class=\"wpforms-field-label\">Les besoins personnels (hygi\u00e8ne) ?<\/label><ul id=\"wpforms-313-field_72\"><li class=\"choice-1 depth-1\"><input type=\"checkbox\" id=\"wpforms-313-field_72_1\" name=\"wpforms[fields][72][]\" value=\"Oui de fa\u00e7on autonome\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-313-field_72_1\">Oui de fa\u00e7on autonome<\/label><\/li><li class=\"choice-6 depth-1\"><input type=\"checkbox\" id=\"wpforms-313-field_72_6\" name=\"wpforms[fields][72][]\" value=\"Oui mais avec un soutien de l\u2019ext\u00e9rieur\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-313-field_72_6\">Oui mais avec un soutien de l\u2019ext\u00e9rieur<\/label><\/li><li class=\"choice-9 depth-1\"><input type=\"checkbox\" id=\"wpforms-313-field_72_9\" name=\"wpforms[fields][72][]\" value=\"Non\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-313-field_72_9\">Non<\/label><\/li><\/ul><\/div><div id=\"wpforms-313-field_73-container\" class=\"wpforms-field wpforms-field-textarea\" data-field-id=\"73\"><label class=\"wpforms-field-label\" for=\"wpforms-313-field_73\">Si non, d\u00e9crivez le type d\u2019aide dont vous avez besoin<\/label><textarea id=\"wpforms-313-field_73\" class=\"wpforms-field-medium\" name=\"wpforms[fields][73]\" ><\/textarea><\/div><div id=\"wpforms-313-field_74-container\" class=\"wpforms-field wpforms-field-checkbox wpforms-list-inline\" data-field-id=\"74\"><label class=\"wpforms-field-label\">La pr\u00e9paration de vos repas ?<\/label><ul id=\"wpforms-313-field_74\"><li class=\"choice-1 depth-1\"><input type=\"checkbox\" id=\"wpforms-313-field_74_1\" name=\"wpforms[fields][74][]\" value=\"Oui de fa\u00e7on autonome\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-313-field_74_1\">Oui de fa\u00e7on autonome<\/label><\/li><li class=\"choice-6 depth-1\"><input type=\"checkbox\" id=\"wpforms-313-field_74_6\" name=\"wpforms[fields][74][]\" value=\"Oui mais avec un soutien de l\u2019ext\u00e9rieur\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-313-field_74_6\">Oui mais avec un soutien de l\u2019ext\u00e9rieur<\/label><\/li><li class=\"choice-9 depth-1\"><input type=\"checkbox\" id=\"wpforms-313-field_74_9\" name=\"wpforms[fields][74][]\" value=\"Non\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-313-field_74_9\">Non<\/label><\/li><\/ul><\/div><div id=\"wpforms-313-field_75-container\" class=\"wpforms-field wpforms-field-textarea\" data-field-id=\"75\"><label class=\"wpforms-field-label\" for=\"wpforms-313-field_75\">Si non, d\u00e9crivez le type d\u2019aide dont vous avez besoin<\/label><textarea id=\"wpforms-313-field_75\" class=\"wpforms-field-medium\" name=\"wpforms[fields][75]\" ><\/textarea><\/div><div id=\"wpforms-313-field_76-container\" class=\"wpforms-field wpforms-field-checkbox wpforms-list-inline\" data-field-id=\"76\"><label class=\"wpforms-field-label\">L\u2019entretien de votre logement (t\u00e2ches m\u00e9nag\u00e8res r\u00e9guli\u00e8res) ?<\/label><ul id=\"wpforms-313-field_76\"><li class=\"choice-1 depth-1\"><input type=\"checkbox\" id=\"wpforms-313-field_76_1\" name=\"wpforms[fields][76][]\" value=\"Oui de fa\u00e7on autonome\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-313-field_76_1\">Oui de fa\u00e7on autonome<\/label><\/li><li class=\"choice-6 depth-1\"><input type=\"checkbox\" id=\"wpforms-313-field_76_6\" name=\"wpforms[fields][76][]\" value=\"Oui mais avec un soutien de l\u2019ext\u00e9rieur\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-313-field_76_6\">Oui mais avec un soutien de l\u2019ext\u00e9rieur<\/label><\/li><li class=\"choice-9 depth-1\"><input type=\"checkbox\" id=\"wpforms-313-field_76_9\" name=\"wpforms[fields][76][]\" value=\"Non\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-313-field_76_9\">Non<\/label><\/li><\/ul><\/div><div id=\"wpforms-313-field_77-container\" class=\"wpforms-field wpforms-field-textarea\" data-field-id=\"77\"><label class=\"wpforms-field-label\" for=\"wpforms-313-field_77\">Si non, d\u00e9crivez le type d\u2019aide dont vous avez besoin<\/label><textarea id=\"wpforms-313-field_77\" class=\"wpforms-field-medium\" name=\"wpforms[fields][77]\" ><\/textarea><\/div><div id=\"wpforms-313-field_78-container\" class=\"wpforms-field wpforms-field-checkbox wpforms-list-inline\" data-field-id=\"78\"><label class=\"wpforms-field-label\">La gestion de votre budget ?<\/label><ul id=\"wpforms-313-field_78\"><li class=\"choice-1 depth-1\"><input type=\"checkbox\" id=\"wpforms-313-field_78_1\" name=\"wpforms[fields][78][]\" value=\"Oui de fa\u00e7on autonome\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-313-field_78_1\">Oui de fa\u00e7on autonome<\/label><\/li><li class=\"choice-6 depth-1\"><input type=\"checkbox\" id=\"wpforms-313-field_78_6\" name=\"wpforms[fields][78][]\" value=\"Oui mais avec un soutien de l\u2019ext\u00e9rieur\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-313-field_78_6\">Oui mais avec un soutien de l\u2019ext\u00e9rieur<\/label><\/li><li class=\"choice-9 depth-1\"><input type=\"checkbox\" id=\"wpforms-313-field_78_9\" name=\"wpforms[fields][78][]\" value=\"Non\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-313-field_78_9\">Non<\/label><\/li><\/ul><\/div><div id=\"wpforms-313-field_79-container\" class=\"wpforms-field wpforms-field-textarea\" data-field-id=\"79\"><label class=\"wpforms-field-label\" for=\"wpforms-313-field_79\">Si non, d\u00e9crivez le type d\u2019aide dont vous avez besoin<\/label><textarea id=\"wpforms-313-field_79\" class=\"wpforms-field-medium\" name=\"wpforms[fields][79]\" ><\/textarea><\/div><div id=\"wpforms-313-field_80-container\" class=\"wpforms-field wpforms-field-checkbox wpforms-list-inline\" data-field-id=\"80\"><label class=\"wpforms-field-label\">L\u2019utilisation de transport en commun ?<\/label><ul id=\"wpforms-313-field_80\"><li class=\"choice-1 depth-1\"><input type=\"checkbox\" id=\"wpforms-313-field_80_1\" name=\"wpforms[fields][80][]\" value=\"Oui de fa\u00e7on autonome\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-313-field_80_1\">Oui de fa\u00e7on autonome<\/label><\/li><li class=\"choice-6 depth-1\"><input type=\"checkbox\" id=\"wpforms-313-field_80_6\" name=\"wpforms[fields][80][]\" value=\"Oui mais avec un soutien de l\u2019ext\u00e9rieur\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-313-field_80_6\">Oui mais avec un soutien de l\u2019ext\u00e9rieur<\/label><\/li><li class=\"choice-9 depth-1\"><input type=\"checkbox\" id=\"wpforms-313-field_80_9\" name=\"wpforms[fields][80][]\" value=\"Non\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-313-field_80_9\">Non<\/label><\/li><\/ul><\/div><div id=\"wpforms-313-field_81-container\" class=\"wpforms-field wpforms-field-textarea\" data-field-id=\"81\"><label class=\"wpforms-field-label\" for=\"wpforms-313-field_81\">Si non, d\u00e9crivez le type d\u2019aide dont vous avez besoin<\/label><textarea id=\"wpforms-313-field_81\" class=\"wpforms-field-medium\" name=\"wpforms[fields][81]\" ><\/textarea><\/div><div id=\"wpforms-313-field_82-container\" class=\"wpforms-field wpforms-field-checkbox wpforms-list-inline\" data-field-id=\"82\"><label class=\"wpforms-field-label\">Faire un menu et le respecter ?<\/label><ul id=\"wpforms-313-field_82\"><li class=\"choice-1 depth-1\"><input type=\"checkbox\" id=\"wpforms-313-field_82_1\" name=\"wpforms[fields][82][]\" value=\"Oui de fa\u00e7on autonome\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-313-field_82_1\">Oui de fa\u00e7on autonome<\/label><\/li><li class=\"choice-6 depth-1\"><input type=\"checkbox\" id=\"wpforms-313-field_82_6\" name=\"wpforms[fields][82][]\" value=\"Oui mais avec un soutien de l\u2019ext\u00e9rieur\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-313-field_82_6\">Oui mais avec un soutien de l\u2019ext\u00e9rieur<\/label><\/li><li class=\"choice-9 depth-1\"><input type=\"checkbox\" id=\"wpforms-313-field_82_9\" name=\"wpforms[fields][82][]\" value=\"Non\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-313-field_82_9\">Non<\/label><\/li><\/ul><\/div><div id=\"wpforms-313-field_83-container\" class=\"wpforms-field wpforms-field-textarea\" data-field-id=\"83\"><label class=\"wpforms-field-label\" for=\"wpforms-313-field_83\">Si non, d\u00e9crivez le type d\u2019aide dont vous avez besoin<\/label><textarea id=\"wpforms-313-field_83\" class=\"wpforms-field-medium\" name=\"wpforms[fields][83]\" ><\/textarea><\/div><div id=\"wpforms-313-field_84-container\" class=\"wpforms-field wpforms-field-checkbox wpforms-list-inline\" data-field-id=\"84\"><label class=\"wpforms-field-label\">Faire le lavage de ses effets personnels ?<\/label><ul id=\"wpforms-313-field_84\"><li class=\"choice-1 depth-1\"><input type=\"checkbox\" id=\"wpforms-313-field_84_1\" name=\"wpforms[fields][84][]\" value=\"Oui de fa\u00e7on autonome\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-313-field_84_1\">Oui de fa\u00e7on autonome<\/label><\/li><li class=\"choice-6 depth-1\"><input type=\"checkbox\" id=\"wpforms-313-field_84_6\" name=\"wpforms[fields][84][]\" value=\"Oui mais avec un soutien de l\u2019ext\u00e9rieur\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-313-field_84_6\">Oui mais avec un soutien de l\u2019ext\u00e9rieur<\/label><\/li><li class=\"choice-9 depth-1\"><input type=\"checkbox\" id=\"wpforms-313-field_84_9\" name=\"wpforms[fields][84][]\" value=\"Non\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-313-field_84_9\">Non<\/label><\/li><\/ul><\/div><div id=\"wpforms-313-field_85-container\" class=\"wpforms-field wpforms-field-textarea\" data-field-id=\"85\"><label class=\"wpforms-field-label\" for=\"wpforms-313-field_85\">Si non, d\u00e9crivez le type d\u2019aide dont vous avez besoin<\/label><textarea id=\"wpforms-313-field_85\" class=\"wpforms-field-medium\" name=\"wpforms[fields][85]\" ><\/textarea><\/div><div id=\"wpforms-313-field_86-container\" class=\"wpforms-field wpforms-field-html\" data-field-id=\"86\"><div id=\"wpforms-313-field_86\"><h2>Sant\u00e9 mentale et physique<\/h2><\/div><\/div><div id=\"wpforms-313-field_87-container\" class=\"wpforms-field wpforms-field-textarea\" data-field-id=\"87\"><label class=\"wpforms-field-label\" for=\"wpforms-313-field_87\">Quels moyens utilisez-vous pour prendre soin de votre sant\u00e9 mentale et physique ?<\/label><textarea id=\"wpforms-313-field_87\" class=\"wpforms-field-medium\" name=\"wpforms[fields][87]\" ><\/textarea><\/div><div id=\"wpforms-313-field_88-container\" class=\"wpforms-field wpforms-field-textarea\" data-field-id=\"88\"><label class=\"wpforms-field-label\" for=\"wpforms-313-field_88\">Connaissez-vous les signes pr\u00e9curseurs lorsque vous allez moins bien ?<\/label><textarea id=\"wpforms-313-field_88\" class=\"wpforms-field-medium\" name=\"wpforms[fields][88]\" ><\/textarea><\/div><div id=\"wpforms-313-field_89-container\" class=\"wpforms-field wpforms-field-textarea\" data-field-id=\"89\"><label class=\"wpforms-field-label\" for=\"wpforms-313-field_89\">Que faites-vous lorsqu\u2019ils se manifestent ?<\/label><textarea id=\"wpforms-313-field_89\" class=\"wpforms-field-medium\" name=\"wpforms[fields][89]\" ><\/textarea><\/div><div id=\"wpforms-313-field_90-container\" class=\"wpforms-field wpforms-field-textarea\" data-field-id=\"90\"><label class=\"wpforms-field-label\" for=\"wpforms-313-field_90\">Que connaissez-vous de votre m\u00e9dication actuelle ?<\/label><textarea id=\"wpforms-313-field_90\" class=\"wpforms-field-medium\" name=\"wpforms[fields][90]\" ><\/textarea><\/div><div id=\"wpforms-313-field_92-container\" class=\"wpforms-field wpforms-field-checkbox wpforms-list-inline\" data-field-id=\"92\"><label class=\"wpforms-field-label\">\u00cates-vous autonome dans la prise de votre m\u00e9dication ?<\/label><ul id=\"wpforms-313-field_92\"><li class=\"choice-1 depth-1\"><input type=\"checkbox\" id=\"wpforms-313-field_92_1\" name=\"wpforms[fields][92][]\" value=\"Oui\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-313-field_92_1\">Oui<\/label><\/li><li class=\"choice-6 depth-1\"><input type=\"checkbox\" id=\"wpforms-313-field_92_6\" name=\"wpforms[fields][92][]\" value=\"Oui mais avec un soutien de l\u2019ext\u00e9rieur\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-313-field_92_6\">Oui mais avec un soutien de l\u2019ext\u00e9rieur<\/label><\/li><li class=\"choice-9 depth-1\"><input type=\"checkbox\" id=\"wpforms-313-field_92_9\" name=\"wpforms[fields][92][]\" value=\"Non\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-313-field_92_9\">Non<\/label><\/li><\/ul><\/div><div id=\"wpforms-313-field_93-container\" class=\"wpforms-field wpforms-field-textarea\" data-field-id=\"93\"><label class=\"wpforms-field-label\" for=\"wpforms-313-field_93\">Si non, d\u00e9crivez le type d\u2019aide dont vous avez besoin<\/label><textarea id=\"wpforms-313-field_93\" class=\"wpforms-field-medium\" name=\"wpforms[fields][93]\" ><\/textarea><\/div><div id=\"wpforms-313-field_94-container\" class=\"wpforms-field wpforms-field-html\" data-field-id=\"94\"><div id=\"wpforms-313-field_94\"><h2>Habilet\u00e9s sociales<\/h2><\/div><\/div><div id=\"wpforms-313-field_95-container\" class=\"wpforms-field wpforms-field-textarea\" data-field-id=\"95\"><label class=\"wpforms-field-label\" for=\"wpforms-313-field_95\">Quelle importance donnez-vous \u00e0 la r\u00e9solution de conflits ?<\/label><textarea id=\"wpforms-313-field_95\" class=\"wpforms-field-medium\" name=\"wpforms[fields][95]\" ><\/textarea><\/div><div id=\"wpforms-313-field_96-container\" class=\"wpforms-field wpforms-field-textarea\" data-field-id=\"96\"><label class=\"wpforms-field-label\" for=\"wpforms-313-field_96\">Quels sont vos loisirs, vos passions ?<\/label><textarea id=\"wpforms-313-field_96\" class=\"wpforms-field-medium\" name=\"wpforms[fields][96]\" ><\/textarea><\/div><div id=\"wpforms-313-field_97-container\" class=\"wpforms-field wpforms-field-textarea\" data-field-id=\"97\"><label class=\"wpforms-field-label\" for=\"wpforms-313-field_97\">Est-ce que vous travaillez ?<\/label><textarea id=\"wpforms-313-field_97\" class=\"wpforms-field-medium\" name=\"wpforms[fields][97]\" ><\/textarea><\/div><div id=\"wpforms-313-field_98-container\" class=\"wpforms-field wpforms-field-textarea\" data-field-id=\"98\"><label class=\"wpforms-field-label\" for=\"wpforms-313-field_98\">Faites-vous du b\u00e9n\u00e9volat ?<\/label><textarea id=\"wpforms-313-field_98\" class=\"wpforms-field-medium\" name=\"wpforms[fields][98]\" ><\/textarea><\/div><div id=\"wpforms-313-field_99-container\" class=\"wpforms-field wpforms-field-textarea\" data-field-id=\"99\"><label class=\"wpforms-field-label\" for=\"wpforms-313-field_99\">\u00cates-vous \u00e0 l\u2019aise de vivre seul en appartement ?<\/label><textarea id=\"wpforms-313-field_99\" class=\"wpforms-field-medium\" name=\"wpforms[fields][99]\" ><\/textarea><\/div><div id=\"wpforms-313-field_100-container\" class=\"wpforms-field wpforms-field-html\" data-field-id=\"100\"><div id=\"wpforms-313-field_100\"><h2>Risque suicidaire<\/h2><\/div><\/div><div id=\"wpforms-313-field_101-container\" class=\"wpforms-field wpforms-field-checkbox wpforms-list-inline\" data-field-id=\"101\"><label class=\"wpforms-field-label\">Risque<\/label><ul id=\"wpforms-313-field_101\"><li class=\"choice-1 depth-1\"><input type=\"checkbox\" id=\"wpforms-313-field_101_1\" name=\"wpforms[fields][101][]\" value=\"\u00c9lev\u00e9\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-313-field_101_1\">\u00c9lev\u00e9<\/label><\/li><li class=\"choice-6 depth-1\"><input type=\"checkbox\" id=\"wpforms-313-field_101_6\" name=\"wpforms[fields][101][]\" value=\"Moyen\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-313-field_101_6\">Moyen<\/label><\/li><li class=\"choice-9 depth-1\"><input type=\"checkbox\" id=\"wpforms-313-field_101_9\" name=\"wpforms[fields][101][]\" value=\"Faible\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-313-field_101_9\">Faible<\/label><\/li><\/ul><\/div><div id=\"wpforms-313-field_102-container\" class=\"wpforms-field wpforms-field-textarea\" data-field-id=\"102\"><label class=\"wpforms-field-label\" for=\"wpforms-313-field_102\">\u00c9v\u00e9nements r\u00e9cents<\/label><textarea id=\"wpforms-313-field_102\" class=\"wpforms-field-medium\" name=\"wpforms[fields][102]\" ><\/textarea><\/div><div id=\"wpforms-313-field_103-container\" class=\"wpforms-field wpforms-field-html\" data-field-id=\"103\"><div id=\"wpforms-313-field_103\"><h2>Documents exig\u00e9s<\/h2><\/div><\/div><div id=\"wpforms-313-field_104-container\" class=\"wpforms-field wpforms-field-checkbox wpforms-list-3-columns\" data-field-id=\"104\"><ul id=\"wpforms-313-field_104\"><li class=\"choice-1 depth-1\"><input type=\"checkbox\" id=\"wpforms-313-field_104_1\" name=\"wpforms[fields][104][]\" value=\"\u00c9valuation psychiatrique, si disponible\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-313-field_104_1\">\u00c9valuation psychiatrique, si disponible<\/label><\/li><li class=\"choice-6 depth-1\"><input type=\"checkbox\" id=\"wpforms-313-field_104_6\" name=\"wpforms[fields][104][]\" value=\"\u00c9valuation psychologique, si disponible\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-313-field_104_6\">\u00c9valuation psychologique, si disponible<\/label><\/li><li class=\"choice-9 depth-1\"><input type=\"checkbox\" id=\"wpforms-313-field_104_9\" name=\"wpforms[fields][104][]\" value=\"R\u00e9sum\u00e9 derni\u00e8re hospitalisation, si disponible\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-313-field_104_9\">R\u00e9sum\u00e9 derni\u00e8re hospitalisation, si disponible<\/label><\/li><li class=\"choice-10 depth-1\"><input type=\"checkbox\" id=\"wpforms-313-field_104_10\" name=\"wpforms[fields][104][]\" value=\"\u00c9valuation psychosociale, si disponible\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-313-field_104_10\">\u00c9valuation psychosociale, si disponible<\/label><\/li><li class=\"choice-11 depth-1\"><input type=\"checkbox\" id=\"wpforms-313-field_104_11\" name=\"wpforms[fields][104][]\" value=\"Bilan fonctionnel, si disponible\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-313-field_104_11\">Bilan fonctionnel, si disponible<\/label><\/li><li class=\"choice-12 depth-1\"><input type=\"checkbox\" id=\"wpforms-313-field_104_12\" name=\"wpforms[fields][104][]\" value=\"Autorisation \u00e0 transmettre les renseignements*\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-313-field_104_12\">Autorisation \u00e0 transmettre les renseignements*<\/label><\/li><li class=\"choice-13 depth-1\"><input type=\"checkbox\" id=\"wpforms-313-field_104_13\" name=\"wpforms[fields][104][]\" value=\"Plan d\u2019intervention*\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-313-field_104_13\">Plan d\u2019intervention*<\/label><\/li><li class=\"choice-14 depth-1\"><input type=\"checkbox\" id=\"wpforms-313-field_104_14\" name=\"wpforms[fields][104][]\" value=\"Liste des m\u00e9dicaments prescrits*\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-313-field_104_14\">Liste des m\u00e9dicaments prescrits*<\/label><\/li><li class=\"choice-15 depth-1\"><input type=\"checkbox\" id=\"wpforms-313-field_104_15\" name=\"wpforms[fields][104][]\" value=\"Autres\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-313-field_104_15\">Autres<\/label><\/li><\/ul><\/div><div id=\"wpforms-313-field_105-container\" class=\"wpforms-field wpforms-field-html\" data-field-id=\"105\"><div id=\"wpforms-313-field_105\"><h2>Signatures<\/h2><\/div><\/div><div id=\"wpforms-313-field_106-container\" class=\"wpforms-field wpforms-field-text wpforms-one-half wpforms-first\" data-field-id=\"106\"><label class=\"wpforms-field-label\" for=\"wpforms-313-field_106\">Intervenant r\u00e9f\u00e9rent<\/label><input type=\"text\" id=\"wpforms-313-field_106\" class=\"wpforms-field-large\" name=\"wpforms[fields][106]\" ><\/div><div id=\"wpforms-313-field_107-container\" class=\"wpforms-field wpforms-field-text wpforms-one-half\" data-field-id=\"107\"><label class=\"wpforms-field-label\" for=\"wpforms-313-field_107\">Usager<\/label><input type=\"text\" id=\"wpforms-313-field_107\" class=\"wpforms-field-large\" name=\"wpforms[fields][107]\" ><\/div><div id=\"wpforms-313-field_109-container\" class=\"wpforms-field wpforms-field-phone\" data-field-id=\"109\"><label class=\"wpforms-field-label\" for=\"wpforms-313-field_109\"># de t\u00e9l\u00e9phone<\/label><input type=\"tel\" id=\"wpforms-313-field_109\" class=\"wpforms-field-large wpforms-smart-phone-field\" data-rule-smart-phone-field=\"true\" name=\"wpforms[fields][109]\" aria-label=\"# de t\u00e9l\u00e9phone\" ><\/div><div id=\"wpforms-313-field_110-container\" class=\"wpforms-field wpforms-field-date-time\" data-field-id=\"110\"><label class=\"wpforms-field-label\" for=\"wpforms-313-field_110\">Date de la demande<\/label><div class=\"wpforms-datepicker-wrap\"><input type=\"text\" id=\"wpforms-313-field_110\" class=\"wpforms-field-date-time-date wpforms-datepicker wpforms-field-large\" data-date-format=\"m\/d\/Y\" data-disable-past-dates=\"0\" data-input=\"true\" name=\"wpforms[fields][110][date]\" ><a title=\"Effacer la date\" data-clear role=\"button\" tabindex=\"0\" class=\"wpforms-datepicker-clear\" aria-label=\"Effacer la date\" style=\"display:none;\"><\/a><\/div><\/div><div id=\"wpforms-313-field_111-container\" class=\"wpforms-field wpforms-field-html\" data-field-id=\"111\"><div id=\"wpforms-313-field_111\"><h2>Autorisation \u00e0 communiquer des renseignements contenus au dossier<\/h2><\/div><\/div><div id=\"wpforms-313-field_112-container\" class=\"wpforms-field wpforms-field-name\" data-field-id=\"112\"><label class=\"wpforms-field-label\">Nom <span class=\"wpforms-required-label\">*<\/span><\/label><div class=\"wpforms-field-row wpforms-field-large\"><div class=\"wpforms-field-row-block wpforms-first wpforms-one-half\"><input type=\"text\" id=\"wpforms-313-field_112\" class=\"wpforms-field-name-first wpforms-field-required\" name=\"wpforms[fields][112][first]\" required><label for=\"wpforms-313-field_112\" class=\"wpforms-field-sublabel after\">Pr\u00e9nom<\/label><\/div><div class=\"wpforms-field-row-block wpforms-one-half\"><input type=\"text\" id=\"wpforms-313-field_112-last\" class=\"wpforms-field-name-last wpforms-field-required\" name=\"wpforms[fields][112][last]\" required><label for=\"wpforms-313-field_112-last\" class=\"wpforms-field-sublabel after\">Nom<\/label><\/div><\/div><\/div><div id=\"wpforms-313-field_113-container\" class=\"wpforms-field wpforms-field-date-time\" data-field-id=\"113\"><label class=\"wpforms-field-label\" for=\"wpforms-313-field_113\">Date de naissance<\/label><div class=\"wpforms-datepicker-wrap\"><input type=\"text\" id=\"wpforms-313-field_113\" class=\"wpforms-field-date-time-date wpforms-datepicker wpforms-field-large\" data-date-format=\"m\/d\/Y\" data-disable-past-dates=\"0\" data-input=\"true\" name=\"wpforms[fields][113][date]\" ><a title=\"Effacer la date\" data-clear role=\"button\" tabindex=\"0\" class=\"wpforms-datepicker-clear\" aria-label=\"Effacer la date\" style=\"display:none;\"><\/a><\/div><\/div><div id=\"wpforms-313-field_114-container\" class=\"wpforms-field wpforms-field-address\" data-field-id=\"114\"><label class=\"wpforms-field-label\">Adresse<\/label><div class=\"wpforms-field-row wpforms-field-large\"><div ><input type=\"text\" id=\"wpforms-313-field_114\" class=\"wpforms-field-address-address1\" name=\"wpforms[fields][114][address1]\" ><label for=\"wpforms-313-field_114\" class=\"wpforms-field-sublabel after\">Adresse ligne\u00a01<\/label><\/div><\/div><div class=\"wpforms-field-row wpforms-field-large\"><div ><input type=\"text\" id=\"wpforms-313-field_114-address2\" class=\"wpforms-field-address-address2\" name=\"wpforms[fields][114][address2]\" ><label for=\"wpforms-313-field_114-address2\" class=\"wpforms-field-sublabel after\">Adresse ligne 2<\/label><\/div><\/div><div class=\"wpforms-field-row wpforms-field-large\"><div class=\"wpforms-field-row-block wpforms-one-half wpforms-first\"><input type=\"text\" id=\"wpforms-313-field_114-city\" class=\"wpforms-field-address-city\" name=\"wpforms[fields][114][city]\" ><label for=\"wpforms-313-field_114-city\" class=\"wpforms-field-sublabel after\">Ville<\/label><\/div><div class=\"wpforms-field-row-block wpforms-one-half\"><input type=\"text\" id=\"wpforms-313-field_114-state\" class=\"wpforms-field-address-state\" name=\"wpforms[fields][114][state]\" ><label for=\"wpforms-313-field_114-state\" class=\"wpforms-field-sublabel after\">\u00c9tat \/ Province \/ R\u00e9gion<\/label><\/div><\/div><div class=\"wpforms-field-row wpforms-field-large\"><div class=\"wpforms-field-row-block wpforms-one-half wpforms-first\"><input type=\"text\" id=\"wpforms-313-field_114-postal\" class=\"wpforms-field-address-postal\" name=\"wpforms[fields][114][postal]\" ><label for=\"wpforms-313-field_114-postal\" class=\"wpforms-field-sublabel after\">Code postal<\/label><\/div><div class=\"wpforms-field-row-block wpforms-one-half\"><select id=\"wpforms-313-field_114-country\" class=\"wpforms-field-address-country\" name=\"wpforms[fields][114][country]\" ><option class=\"placeholder\" value=\"\" selected disabled>--- S\u00e9lectionner\u00a0: country ---<\/option><option value=\"AF\" >Afghanistan<\/option><option value=\"ZA\" >Afrique du Sud<\/option><option value=\"AL\" >Albanie<\/option><option value=\"DZ\" >Alg\u00e9rie<\/option><option value=\"DE\" >Allemagne<\/option><option value=\"AD\" >Andorre<\/option><option value=\"AO\" >Angola<\/option><option value=\"AI\" >Anguilla<\/option><option value=\"AQ\" >Antarctique<\/option><option value=\"AG\" >Antigua-et-Barbuda<\/option><option value=\"SA\" >Arabie Saoudite<\/option><option value=\"AR\" >Argentine<\/option><option value=\"AM\" >Arm\u00e9nie<\/option><option value=\"AW\" >Aruba<\/option><option value=\"AU\" >Australie<\/option><option value=\"AT\" >Autriche<\/option><option value=\"AZ\" >Azerba\u00efdjan<\/option><option value=\"BS\" >Bahamas<\/option><option value=\"BH\" >Bahre\u00efn<\/option><option value=\"BD\" >Bangladesh<\/option><option value=\"BB\" >Barbade<\/option><option value=\"BE\" >Belgique<\/option><option value=\"BZ\" >Belize<\/option><option value=\"BM\" >Bermudes<\/option><option value=\"BT\" >Bhoutan<\/option><option value=\"BY\" >Bi\u00e9lorussie<\/option><option value=\"BO\" >Bolivie (\u00c9tat plurinational de)<\/option><option value=\"BQ\" >Bonaire, Saint Eustatius and Saba<\/option><option value=\"BA\" >Bosnie-Herz\u00e9govine<\/option><option value=\"BW\" >Botswana<\/option><option value=\"BR\" >Br\u00e9sil<\/option><option value=\"BG\" >Bulgarie<\/option><option value=\"BF\" >Burkina Faso<\/option><option value=\"BI\" >Burundi<\/option><option value=\"BJ\" >B\u00e9nin<\/option><option value=\"KH\" >Cambodge<\/option><option value=\"CM\" >Cameroun<\/option><option value=\"CA\" >Canada<\/option><option value=\"CV\" >Cap-Vert<\/option><option value=\"CL\" >Chili<\/option><option value=\"CN\" >Chine<\/option><option value=\"CY\" >Chypre<\/option><option value=\"CO\" >Colombie<\/option><option value=\"KM\" >Comores<\/option><option value=\"CG\" >Congo<\/option><option value=\"CD\" >Congo (R\u00e9publique d\u00e9mocratique du)<\/option><option value=\"KR\" >Cor\u00e9e (R\u00e9publique de)<\/option><option value=\"KP\" >Cor\u00e9e (R\u00e9publique populaire d\u00e9mocratique de)<\/option><option value=\"CR\" >Costa Rica<\/option><option value=\"HR\" >Croatie<\/option><option value=\"CU\" >Cuba<\/option><option value=\"CW\" >Cura\u00e7ao<\/option><option value=\"CI\" >C\u00f4te d\u2019Ivoire<\/option><option value=\"DK\" >Danemark<\/option><option value=\"DJ\" >Djibouti<\/option><option value=\"DM\" >Dominique<\/option><option value=\"ES\" >Espagne<\/option><option value=\"EE\" >Estonie<\/option><option value=\"SZ\" >Eswatini (Royaume de)<\/option><option value=\"FJ\" >Fidji<\/option><option value=\"FI\" >Finlande<\/option><option value=\"FR\" >France<\/option><option value=\"RU\" >F\u00e9d\u00e9ration Russe<\/option><option value=\"GA\" >Gabon<\/option><option value=\"GM\" >Gambie<\/option><option value=\"GH\" >Ghana<\/option><option value=\"GI\" >Gibraltar<\/option><option value=\"GD\" >Grenade<\/option><option value=\"GL\" >Groenland<\/option><option value=\"GR\" >Gr\u00e8ce<\/option><option value=\"GP\" >Guadeloupe<\/option><option value=\"GU\" >Guam<\/option><option value=\"GT\" >Guatemala<\/option><option value=\"GG\" >Guernesey<\/option><option value=\"GN\" >Guin\u00e9e<\/option><option value=\"GQ\" >Guin\u00e9e \u00e9quatoriale<\/option><option value=\"GW\" >Guin\u00e9e-Bissau<\/option><option value=\"GF\" >Guyane<\/option><option value=\"GY\" >Guyane<\/option><option value=\"GE\" >G\u00e9orgie<\/option><option value=\"GS\" >G\u00e9orgie du Sud et \u00eeles Sandwich du Sud<\/option><option value=\"HT\" >Ha\u00efti<\/option><option value=\"HN\" >Honduras<\/option><option value=\"HK\" >Hong Kong<\/option><option value=\"HU\" >Hongrie<\/option><option value=\"IN\" >Inde<\/option><option value=\"ID\" >Indon\u00e9sie<\/option><option value=\"IQ\" >Irak<\/option><option value=\"IR\" >Iran (R\u00e9publique islamique d\u2019)<\/option><option value=\"IE\" >Irlande (R\u00e9publique d\u2019)<\/option><option value=\"IS\" >Islande<\/option><option value=\"IL\" >Isra\u00ebl<\/option><option value=\"IT\" >Italie<\/option><option value=\"JM\" >Jama\u00efque<\/option><option value=\"JP\" >Japon<\/option><option value=\"JE\" >Jersey<\/option><option value=\"JO\" >Jordanie<\/option><option value=\"KZ\" >Kazakhstan<\/option><option value=\"KE\" >Kenya<\/option><option value=\"KG\" >Kirghizistan<\/option><option value=\"KI\" >Kiribati<\/option><option value=\"XK\" >Kosovo<\/option><option value=\"KW\" >Kowe\u00eft<\/option><option value=\"RE\" >La R\u00e9union<\/option><option value=\"LS\" >Lesotho<\/option><option value=\"LV\" >Lettonie<\/option><option value=\"LB\" >Liban<\/option><option value=\"LR\" >Liberia<\/option><option value=\"LY\" >Libye<\/option><option value=\"LI\" >Liechtenstein<\/option><option value=\"LT\" >Lituanie<\/option><option value=\"LU\" >Luxembourg<\/option><option value=\"MO\" >Macao<\/option><option value=\"MK\" >Mac\u00e9doine du Nord (R\u00e9publique de)<\/option><option value=\"MG\" >Madagascar<\/option><option value=\"MY\" >Malaisie<\/option><option value=\"MW\" >Malawi<\/option><option value=\"MV\" >Maldives<\/option><option value=\"ML\" >Mali<\/option><option value=\"MT\" >Malte<\/option><option value=\"MA\" >Maroc<\/option><option value=\"MQ\" >Martinique<\/option><option value=\"MR\" >Mauritanie<\/option><option value=\"YT\" >Mayotte<\/option><option value=\"MX\" >Mexique<\/option><option value=\"FM\" >Micron\u00e9sie (\u00c9tats f\u00e9d\u00e9r\u00e9s de)<\/option><option value=\"MD\" >Moldova (R\u00e9publique de)<\/option><option value=\"MC\" >Monaco<\/option><option value=\"MN\" >Mongolie<\/option><option value=\"MS\" >Montserrat<\/option><option value=\"ME\" >Mont\u00e9n\u00e9gro<\/option><option value=\"MZ\" >Mozambique<\/option><option value=\"MM\" >Myanmar<\/option><option value=\"NA\" >Namibie<\/option><option value=\"NR\" >Nauru<\/option><option value=\"BN\" >Negara Brunei Darussalam<\/option><option value=\"NI\" >Nicaragua<\/option><option value=\"NE\" >Niger<\/option><option value=\"NG\" >Nig\u00e9ria<\/option><option value=\"NU\" >Niue<\/option><option value=\"NO\" >Norv\u00e8ge<\/option><option value=\"NC\" >Nouvelle-Cal\u00e9donie<\/option><option value=\"NZ\" >Nouvelle-Z\u00e9lande<\/option><option value=\"NP\" >N\u00e9pal<\/option><option value=\"OM\" >Oman<\/option><option value=\"UG\" >Ouganda<\/option><option value=\"UZ\" >Ouzb\u00e9kistan<\/option><option value=\"PK\" >Pakistan<\/option><option value=\"PW\" >Palau<\/option><option value=\"PS\" >Palestine (\u00c9tat de)<\/option><option value=\"PA\" >Panama<\/option><option value=\"PG\" >Papouasie-Nouvelle-Guin\u00e9e<\/option><option value=\"PY\" >Paraguay<\/option><option value=\"NL\" >Pays-Bas<\/option><option value=\"PH\" >Philippines<\/option><option value=\"PL\" >Pologne<\/option><option value=\"PF\" >Polyn\u00e9sie fran\u00e7aise<\/option><option value=\"PR\" >Porto Rico<\/option><option value=\"PT\" >Portugal<\/option><option value=\"PE\" >P\u00e9rou<\/option><option value=\"QA\" >Qatar<\/option><option value=\"RO\" >Roumanie<\/option><option value=\"GB\" >Royaume-Uni de Grande-Bretagne et d\u2019Irlande du Nord<\/option><option value=\"RW\" >Rwanda<\/option><option value=\"SY\" >R\u00e9publique arabe syrienne<\/option><option value=\"CF\" >R\u00e9publique centrafricaine<\/option><option value=\"DO\" >R\u00e9publique dominicaine<\/option><option value=\"LA\" >R\u00e9publique d\u00e9mocratique populaire du Laos<\/option><option value=\"CZ\" >R\u00e9publique tch\u00e8que<\/option><option value=\"EH\" >Sahara occidental<\/option><option value=\"BL\" >Saint Barth\u00e9lemy<\/option><option value=\"PM\" >Saint Pierre et Miquelon<\/option><option value=\"KN\" >Saint-Christophe-et-Nevis<\/option><option value=\"SM\" >Saint-Marin<\/option><option value=\"MF\" >Saint-Martin (partie fran\u00e7aise)<\/option><option value=\"VC\" >Saint-Vincent-et-les Grenadines<\/option><option value=\"SH\" >Sainte-H\u00e9l\u00e8ne, Ascension et Tristan da Cunha<\/option><option value=\"LC\" >Sainte-Lucie<\/option><option value=\"SV\" >Salvador<\/option><option value=\"WS\" >Samoa<\/option><option value=\"AS\" >Samoa am\u00e9ricaines<\/option><option value=\"ST\" >Sao Tom\u00e9 et Principe<\/option><option value=\"RS\" >Serbie<\/option><option value=\"SC\" >Seychelles<\/option><option value=\"SL\" >Sierra Leone<\/option><option value=\"SG\" >Singapour<\/option><option value=\"SX\" >Sint Maarten (partie hollandaise)<\/option><option value=\"SK\" >Slovaquie<\/option><option value=\"SI\" >Slov\u00e9nie<\/option><option value=\"SO\" >Somalie<\/option><option value=\"SD\" >Soudan<\/option><option value=\"SS\" >Soudan du Sud<\/option><option value=\"LK\" >Sri Lanka<\/option><option value=\"CH\" >Suisse<\/option><option value=\"SR\" >Surinam<\/option><option value=\"SE\" >Su\u00e8de<\/option><option value=\"SN\" >S\u00e9n\u00e9gal<\/option><option value=\"TJ\" >Tadjikistan<\/option><option value=\"TW\" >Taiwan, R\u00e9publique de Chine<\/option><option value=\"TZ\" >Tanzanie (R\u00e9publique-Unie de)<\/option><option value=\"TD\" >Tchad<\/option><option value=\"TF\" >Terres Australes Fran\u00e7aises<\/option><option value=\"IO\" >Territoire britannique de l\u2019oc\u00e9an Indien<\/option><option value=\"TH\" >Tha\u00eflande<\/option><option value=\"TL\" >Timor oriental<\/option><option value=\"TG\" >Togo<\/option><option value=\"TK\" >Tokelau<\/option><option value=\"TO\" >Tonga<\/option><option value=\"TT\" >Trinit\u00e9 et Tobago<\/option><option value=\"TN\" >Tunisie<\/option><option value=\"TM\" >Turkm\u00e9nistan<\/option><option value=\"TR\" >Turquie<\/option><option value=\"TV\" >Tuvalu<\/option><option value=\"UA\" >Ukraine<\/option><option value=\"UY\" >Uruguay<\/option><option value=\"VU\" >Vanuatu<\/option><option value=\"VE\" >Venezuela (R\u00e9publique bolivarienne du)<\/option><option value=\"VN\" >Vietnam<\/option><option value=\"WF\" >Wallis et Futuna<\/option><option value=\"YE\" >Y\u00e9men<\/option><option value=\"ZM\" >Zambie<\/option><option value=\"ZW\" >Zimbabwe<\/option><option value=\"EG\" >\u00c9gypte<\/option><option value=\"AE\" >\u00c9mirats arabes unis<\/option><option value=\"EC\" >\u00c9quateur<\/option><option value=\"ER\" >\u00c9rythr\u00e9e<\/option><option value=\"VA\" >\u00c9tat de la cit\u00e9 du Vatican<\/option><option value=\"US\" >\u00c9tats-Unis d\u2019Am\u00e9rique<\/option><option value=\"ET\" >\u00c9thiopie<\/option><option value=\"BV\" >\u00cele Bouvet<\/option><option value=\"CX\" >\u00cele Christmas<\/option><option value=\"MU\" >\u00cele Maurice<\/option><option value=\"NF\" >\u00cele Norfolk<\/option><option value=\"IM\" >\u00cele de Man<\/option><option value=\"KY\" >\u00celes Ca\u00efmans<\/option><option value=\"CC\" >\u00celes Cocos (Keeling)<\/option><option value=\"CK\" >\u00celes Cook<\/option><option value=\"FK\" >\u00celes Falkland (Malvinas)<\/option><option value=\"FO\" >\u00celes F\u00e9ro\u00e9<\/option><option value=\"HM\" >\u00celes Heard et McDonald<\/option><option value=\"MP\" >\u00celes Mariannes du Nord<\/option><option value=\"MH\" >\u00celes Marshall<\/option><option value=\"PN\" >\u00celes Pitcairn<\/option><option value=\"SB\" >\u00celes Salomon<\/option><option value=\"TC\" >\u00celes Turques et Ca\u00efques<\/option><option value=\"VI\" >\u00celes Vierges (Am\u00e9ricaines)<\/option><option value=\"VG\" >\u00celes Vierges (Britanniques)<\/option><option value=\"SJ\" >\u00celes de Svalbard et Jan Mayen<\/option><option value=\"UM\" >\u00celes mineures am\u00e9ricaines<\/option><option value=\"AX\" >\u00celes \u00c5land<\/option><\/select><label for=\"wpforms-313-field_114-country\" class=\"wpforms-field-sublabel after\">Pays<\/label><\/div><\/div><\/div><div id=\"wpforms-313-field_115-container\" class=\"wpforms-field wpforms-field-html\" data-field-id=\"115\"><div id=\"wpforms-313-field_115\"><p>Je soussign\u00e9(e)<\/p><\/div><\/div><div id=\"wpforms-313-field_116-container\" class=\"wpforms-field wpforms-field-text\" data-field-id=\"116\"><label class=\"wpforms-field-label\" for=\"wpforms-313-field_116\">Pr\u00e9nom et Nom<\/label><input type=\"text\" id=\"wpforms-313-field_116\" class=\"wpforms-field-large\" name=\"wpforms[fields][116]\" ><\/div><div id=\"wpforms-313-field_117-container\" class=\"wpforms-field wpforms-field-html\" data-field-id=\"117\"><div id=\"wpforms-313-field_117\"><p>en tant qu\u2019usager(\u00e8re) de Les Habitations Nouveau D\u00e9part, autorise l\u2019\u00e9tablissement suivant<\/p><\/div><\/div><div id=\"wpforms-313-field_118-container\" class=\"wpforms-field wpforms-field-textarea\" data-field-id=\"118\"><textarea id=\"wpforms-313-field_118\" class=\"wpforms-field-medium\" name=\"wpforms[fields][118]\" ><\/textarea><\/div><div id=\"wpforms-313-field_119-container\" class=\"wpforms-field wpforms-field-html\" data-field-id=\"119\"><div id=\"wpforms-313-field_119\"><p>\u00e0 transmettre au personnel de <strong>LES HABITATIONS NOUVEAU D\u00c9PART<\/strong> toutes informations \r\ncontenues dans mon dossier et ce, r\u00e9ciproquement.  Cette autorisation est valide pour la p\u00e9riode de votre s\u00e9jour aux Habitations Nouveau D\u00e9part.<\/p><\/div><\/div><div id=\"wpforms-313-field_122-container\" class=\"wpforms-field wpforms-field-html\" data-field-id=\"122\"><div id=\"wpforms-313-field_122\"><p>*  Ceci n\u2019exclut pas la possibilit\u00e9 de mettre fin \u00e0 cette autorisation avant la fin de la p\u00e9riode inscrite.<\/p><\/div><\/div><div id=\"wpforms-313-field_123-container\" class=\"wpforms-field wpforms-field-file-upload\" data-field-id=\"123\"><label class=\"wpforms-field-label\" for=\"wpforms-313-field_123\">Joindre des documents<\/label><div\n\t\tclass=\"wpforms-uploader \"\n\t\tdata-field-id=\"123\"\n\t\tdata-form-id=\"313\"\n\t\tdata-input-name=\"wpforms_313_123\"\n\t\tdata-extensions=\"jpg,jpeg,jpe,gif,png,bmp,tiff,tif,webp,avif,ico,heic,heif,heics,heifs,asf,asx,wmv,wmx,wm,avi,divx,mov,qt,mpeg,mpg,mpe,mp4,m4v,ogv,webm,mkv,3gp,3gpp,3g2,3gp2,txt,asc,c,cc,h,srt,csv,tsv,ics,rtx,css,vtt,mp3,m4a,m4b,aac,ra,ram,wav,x-wav,ogg,oga,flac,mid,midi,wma,wax,mka,rtf,pdf,class,tar,zip,gz,gzip,rar,7z,psd,xcf,doc,pot,pps,ppt,wri,xla,xls,xlt,xlw,mpp,docx,docm,dotx,dotm,xlsx,xlsm,xlsb,xltx,xltm,xlam,pptx,pptm,ppsx,ppsm,potx,potm,ppam,sldx,sldm,onetoc,onetoc2,onepkg,oxps,xps,odt,odp,ods,odg,odc,odb,odf,wp,wpd,key,numbers,pages,redux,ttf,woff,svg,eot\"\n\t\tdata-max-size=\"104857600\"\n\t\tdata-max-file-number=\"10\"\n\t\tdata-post-max-size=\"104857600\"\n\t\tdata-max-parallel-uploads=\"4\"\n\t\tdata-parallel-uploads=\"true\"\n\t\tdata-file-chunk-size=\"2097152\">\n\t<div class=\"dz-message\">\n\t\t<svg  viewBox=\"0 0 640 640\" focusable=\"false\" data-icon=\"inbox\" width=\"50px\" height=\"50px\" fill=\"currentColor\" aria-hidden=\"true\">\n\t\t\t<path d=\"M352 173.3L352 384C352 401.7 337.7 416 320 416C302.3 416 288 401.7 288 384L288 173.3L246.6 214.7C234.1 227.2 213.8 227.2 201.3 214.7C188.8 202.2 188.8 181.9 201.3 169.4L297.3 73.4C309.8 60.9 330.1 60.9 342.6 73.4L438.6 169.4C451.1 181.9 451.1 202.2 438.6 214.7C426.1 227.2 405.8 227.2 393.3 214.7L352 173.3zM320 464C364.2 464 400 428.2 400 384L480 384C515.3 384 544 412.7 544 448L544 480C544 515.3 515.3 544 480 544L160 544C124.7 544 96 515.3 96 480L96 448C96 412.7 124.7 384 160 384L240 384C240 428.2 275.8 464 320 464zM464 488C477.3 488 488 477.3 488 464C488 450.7 477.3 440 464 440C450.7 440 440 450.7 440 464C440 477.3 450.7 488 464 488z\"\/>\n\t\t<\/svg>\n\n\t\t<span class=\"modern-title\">\n\t\t\t\t\t\t\tDrag &amp; 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