{"id":525,"date":"2022-01-04T11:33:57","date_gmt":"2022-01-04T16:33:57","guid":{"rendered":"https:\/\/www.hndgatineau.org\/?page_id=525"},"modified":"2022-01-04T11:36:51","modified_gmt":"2022-01-04T16:36:51","slug":"demande-de-services-pcem","status":"publish","type":"page","link":"https:\/\/hndgatineau.org\/fr\/demande-de-services-pcem\/","title":{"rendered":"Demande de services PCEM"},"content":{"rendered":"<div class=\"wpb-content-wrapper\"><p>[vc_row][vc_column]<div class=\"wpforms-container wpforms-container-full\" id=\"wpforms-528\"><form id=\"wpforms-form-528\" class=\"wpforms-validate wpforms-form wpforms-ajax-form\" data-formid=\"528\" method=\"post\" enctype=\"multipart\/form-data\" action=\"\/fr\/wp-json\/wp\/v2\/pages\/525?wpforms_form_id=528\" data-token=\"c462ff3aae22e6e90c9efd68664c6fbd\" data-token-time=\"1777985215\"><noscript class=\"wpforms-error-noscript\">Veuillez activer JavaScript dans votre navigateur pour remplir ce formulaire.<\/noscript><div class=\"wpforms-field-container\"><div id=\"wpforms-528-field_2-container\" class=\"wpforms-field wpforms-field-html\" data-field-id=\"2\"><div id=\"wpforms-528-field_2\"><h2>FORMULAIRE DE CANDIDATURE<\/h2>\r\n<p>Attribution d\u2019un logement social avec ou sans programme de suppl\u00e9ment au loyer de Cl\u00e9s en main<\/p><\/div><\/div><div id=\"wpforms-528-field_3-container\" class=\"wpforms-field wpforms-field-html\" data-field-id=\"3\"><div id=\"wpforms-528-field_3\"><h2>Informations sur le candidat ou la candidate<\/h2><\/div><\/div><div id=\"wpforms-528-field_4-container\" class=\"wpforms-field wpforms-field-name\" data-field-id=\"4\"><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-528-field_4\" class=\"wpforms-field-name-first wpforms-field-required\" name=\"wpforms[fields][4][first]\" required><label for=\"wpforms-528-field_4\" class=\"wpforms-field-sublabel after\">Pr\u00e9nom<\/label><\/div><div class=\"wpforms-field-row-block wpforms-one-half\"><input type=\"text\" id=\"wpforms-528-field_4-last\" class=\"wpforms-field-name-last wpforms-field-required\" name=\"wpforms[fields][4][last]\" required><label for=\"wpforms-528-field_4-last\" class=\"wpforms-field-sublabel after\">Nom<\/label><\/div><\/div><\/div><div id=\"wpforms-528-field_5-container\" class=\"wpforms-field wpforms-field-date-time\" data-field-id=\"5\"><label class=\"wpforms-field-label\" for=\"wpforms-528-field_5\">Date de naissance<\/label><div class=\"wpforms-datepicker-wrap\"><input type=\"text\" id=\"wpforms-528-field_5\" 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][5][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-528-field_6-container\" class=\"wpforms-field wpforms-field-phone wpforms-one-half wpforms-first\" data-field-id=\"6\"><label class=\"wpforms-field-label\" for=\"wpforms-528-field_6\">T\u00e9l<\/label><input type=\"tel\" id=\"wpforms-528-field_6\" class=\"wpforms-field-large wpforms-smart-phone-field\" data-rule-smart-phone-field=\"true\" name=\"wpforms[fields][6]\" aria-label=\"T\u00e9l\" ><\/div><div id=\"wpforms-528-field_7-container\" class=\"wpforms-field wpforms-field-email wpforms-one-half\" data-field-id=\"7\"><label class=\"wpforms-field-label\" for=\"wpforms-528-field_7\">Courriel <span class=\"wpforms-required-label\">*<\/span><\/label><input type=\"email\" id=\"wpforms-528-field_7\" class=\"wpforms-field-large wpforms-field-required\" name=\"wpforms[fields][7]\" spellcheck=\"false\" required><\/div><div id=\"wpforms-528-field_8-container\" class=\"wpforms-field wpforms-field-checkbox wpforms-list-inline\" data-field-id=\"8\"><label class=\"wpforms-field-label\">Sexe<\/label><ul id=\"wpforms-528-field_8\"><li class=\"choice-1 depth-1\"><input type=\"checkbox\" id=\"wpforms-528-field_8_1\" name=\"wpforms[fields][8][]\" value=\"F\u00e9minin\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-528-field_8_1\">F\u00e9minin<\/label><\/li><li class=\"choice-2 depth-1\"><input type=\"checkbox\" id=\"wpforms-528-field_8_2\" name=\"wpforms[fields][8][]\" value=\"Masculin\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-528-field_8_2\">Masculin<\/label><\/li><\/ul><\/div><div id=\"wpforms-528-field_9-container\" class=\"wpforms-field wpforms-field-html\" data-field-id=\"9\"><div id=\"wpforms-528-field_9\"><h2>Information sur l\u2019organisme r\u00e9f\u00e9rent<\/h2><\/div><\/div><div id=\"wpforms-528-field_10-container\" class=\"wpforms-field wpforms-field-text\" data-field-id=\"10\"><label class=\"wpforms-field-label\" for=\"wpforms-528-field_10\">Organisme r\u00e9f\u00e9rant<\/label><input type=\"text\" id=\"wpforms-528-field_10\" class=\"wpforms-field-large\" name=\"wpforms[fields][10]\" ><\/div><div id=\"wpforms-528-field_11-container\" class=\"wpforms-field wpforms-field-text wpforms-one-half wpforms-first\" data-field-id=\"11\"><label class=\"wpforms-field-label\" for=\"wpforms-528-field_11\">Intervenant<\/label><input type=\"text\" id=\"wpforms-528-field_11\" class=\"wpforms-field-large\" name=\"wpforms[fields][11]\" ><\/div><div id=\"wpforms-528-field_13-container\" class=\"wpforms-field wpforms-field-phone wpforms-one-half\" data-field-id=\"13\"><label class=\"wpforms-field-label\" for=\"wpforms-528-field_13\">Num\u00e9ro de t\u00e9l<\/label><input type=\"tel\" id=\"wpforms-528-field_13\" class=\"wpforms-field-large wpforms-smart-phone-field\" data-rule-smart-phone-field=\"true\" name=\"wpforms[fields][13]\" aria-label=\"Num\u00e9ro de t\u00e9l\" ><\/div><div id=\"wpforms-528-field_14-container\" class=\"wpforms-field wpforms-field-email\" data-field-id=\"14\"><label class=\"wpforms-field-label\" for=\"wpforms-528-field_14\">Courriel <span class=\"wpforms-required-label\">*<\/span><\/label><input type=\"email\" id=\"wpforms-528-field_14\" class=\"wpforms-field-large wpforms-field-required\" name=\"wpforms[fields][14]\" spellcheck=\"false\" required><\/div><div id=\"wpforms-528-field_15-container\" class=\"wpforms-field wpforms-field-html\" data-field-id=\"15\"><div id=\"wpforms-528-field_15\"><h2>Caract\u00e9ristique du m\u00e9nage<\/h2><\/div><\/div><div id=\"wpforms-528-field_16-container\" class=\"wpforms-field wpforms-field-checkbox wpforms-list-inline\" data-field-id=\"16\"><ul id=\"wpforms-528-field_16\"><li class=\"choice-1 depth-1\"><input type=\"checkbox\" id=\"wpforms-528-field_16_1\" name=\"wpforms[fields][16][]\" value=\"Personne seule\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-528-field_16_1\">Personne seule<\/label><\/li><li class=\"choice-2 depth-1\"><input type=\"checkbox\" id=\"wpforms-528-field_16_2\" name=\"wpforms[fields][16][]\" value=\"Couple\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-528-field_16_2\">Couple<\/label><\/li><li class=\"choice-3 depth-1\"><input type=\"checkbox\" id=\"wpforms-528-field_16_3\" name=\"wpforms[fields][16][]\" value=\"Couple avec enfant(s)\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-528-field_16_3\">Couple avec enfant(s)<\/label><\/li><li class=\"choice-4 depth-1\"><input type=\"checkbox\" id=\"wpforms-528-field_16_4\" name=\"wpforms[fields][16][]\" value=\"Famille monoparentale\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-528-field_16_4\">Famille monoparentale<\/label><\/li><li class=\"choice-5 depth-1\"><input type=\"checkbox\" id=\"wpforms-528-field_16_5\" name=\"wpforms[fields][16][]\" value=\"Adulte apparent\u00e9 (p\u00e8re, m\u00e8re, fr\u00e8re, s\u0153ur, enfants adultes, etc.) \"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-528-field_16_5\">Adulte apparent\u00e9 (p\u00e8re, m\u00e8re, fr\u00e8re, s\u0153ur, enfants adultes, etc.)<\/label><\/li><li class=\"choice-6 depth-1\"><input type=\"checkbox\" id=\"wpforms-528-field_16_6\" name=\"wpforms[fields][16][]\" value=\"Adulte non apparent\u00e9 (amis, colocataire, etc.) \"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-528-field_16_6\">Adulte non apparent\u00e9 (amis, colocataire, etc.)<\/label><\/li><li class=\"choice-7 depth-1\"><input type=\"checkbox\" id=\"wpforms-528-field_16_7\" name=\"wpforms[fields][16][]\" value=\"Autre\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-528-field_16_7\">Autre<\/label><\/li><\/ul><\/div><div id=\"wpforms-528-field_17-container\" class=\"wpforms-field wpforms-field-text\" data-field-id=\"17\"><label class=\"wpforms-field-label\" for=\"wpforms-528-field_17\">Autre <\/label><input type=\"text\" id=\"wpforms-528-field_17\" class=\"wpforms-field-large\" name=\"wpforms[fields][17]\" ><\/div><div id=\"wpforms-528-field_18-container\" class=\"wpforms-field wpforms-field-text wpforms-one-half wpforms-first\" data-field-id=\"18\"><label class=\"wpforms-field-label\" for=\"wpforms-528-field_18\">Nombre d\u2019enfant(s) \u00e0 charge<\/label><input type=\"text\" id=\"wpforms-528-field_18\" class=\"wpforms-field-large\" name=\"wpforms[fields][18]\" ><\/div><div id=\"wpforms-528-field_19-container\" class=\"wpforms-field wpforms-field-text wpforms-one-half\" data-field-id=\"19\"><label class=\"wpforms-field-label\" for=\"wpforms-528-field_19\">\u00c2ge(s) <\/label><input type=\"text\" id=\"wpforms-528-field_19\" class=\"wpforms-field-large\" name=\"wpforms[fields][19]\" ><\/div><div id=\"wpforms-528-field_20-container\" class=\"wpforms-field wpforms-field-html\" data-field-id=\"20\"><div id=\"wpforms-528-field_20\"><h2>Crit\u00e8res d\u2019admissibilit\u00e9<\/h2><\/div><\/div><div id=\"wpforms-528-field_27-container\" class=\"wpforms-field wpforms-field-html\" data-field-id=\"27\"><div id=\"wpforms-528-field_27\"><h3>1. Trouble de sant\u00e9 mentale reconnu<\/h3><\/div><\/div><div id=\"wpforms-528-field_21-container\" class=\"wpforms-field wpforms-field-checkbox wpforms-list-inline\" data-field-id=\"21\"><ul id=\"wpforms-528-field_21\"><li class=\"choice-1 depth-1\"><input type=\"checkbox\" id=\"wpforms-528-field_21_1\" name=\"wpforms[fields][21][]\" value=\"Oui\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-528-field_21_1\">Oui<\/label><\/li><li class=\"choice-2 depth-1\"><input type=\"checkbox\" id=\"wpforms-528-field_21_2\" name=\"wpforms[fields][21][]\" value=\"Non\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-528-field_21_2\">Non<\/label><\/li><\/ul><\/div><div id=\"wpforms-528-field_22-container\" class=\"wpforms-field wpforms-field-text\" data-field-id=\"22\"><label class=\"wpforms-field-label\" for=\"wpforms-528-field_22\">Diagnostique<\/label><input type=\"text\" id=\"wpforms-528-field_22\" class=\"wpforms-field-large\" name=\"wpforms[fields][22]\" ><\/div><div id=\"wpforms-528-field_23-container\" class=\"wpforms-field wpforms-field-file-upload wpforms-one-half wpforms-first\" data-field-id=\"23\"><label class=\"wpforms-field-label\" for=\"wpforms-528-field_23\">*joindre une copie de la derni\u00e8re \u00e9valuation psychiatrique<\/label><div\n\t\tclass=\"wpforms-uploader \"\n\t\tdata-field-id=\"23\"\n\t\tdata-form-id=\"528\"\n\t\tdata-input-name=\"wpforms_528_23\"\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,ttf,otf,eot,woff,woff2,svg,redux\"\n\t\tdata-max-size=\"104857600\"\n\t\tdata-max-file-number=\"1\"\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; Drop Files, \t\t\t\t<span>Choose Files to Upload<\/span>\n\t\t\t\t\t<\/span>\n\n\t\t\t<\/div>\n<\/div>\n\n<input\n\t\ttype=\"text\"\n\t\tautocomplete=\"off\"\n\t\treadonly\n\t\tclass=\"dropzone-input\"\n\t\tstyle=\"position:absolute!important;clip:rect(0,0,0,0)!important;height:1px!important;width:1px!important;border:0!important;overflow:hidden!important;padding:0!important;margin:0!important;\"\n\t\tid=\"wpforms-528-field_23\"\n\t\tname=\"wpforms_528_23\" \t\tvalue=\"\">\n<\/div><div id=\"wpforms-528-field_24-container\" class=\"wpforms-field wpforms-field-file-upload wpforms-one-half\" data-field-id=\"24\"><label class=\"wpforms-field-label\" for=\"wpforms-528-field_24\">*joindre une copie du dernier plan d\u2019intervention<\/label><div\n\t\tclass=\"wpforms-uploader \"\n\t\tdata-field-id=\"24\"\n\t\tdata-form-id=\"528\"\n\t\tdata-input-name=\"wpforms_528_24\"\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,ttf,otf,eot,woff,woff2,svg,redux\"\n\t\tdata-max-size=\"104857600\"\n\t\tdata-max-file-number=\"1\"\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; Drop Files, \t\t\t\t<span>Choose Files to Upload<\/span>\n\t\t\t\t\t<\/span>\n\n\t\t\t<\/div>\n<\/div>\n\n<input\n\t\ttype=\"text\"\n\t\tautocomplete=\"off\"\n\t\treadonly\n\t\tclass=\"dropzone-input\"\n\t\tstyle=\"position:absolute!important;clip:rect(0,0,0,0)!important;height:1px!important;width:1px!important;border:0!important;overflow:hidden!important;padding:0!important;margin:0!important;\"\n\t\tid=\"wpforms-528-field_24\"\n\t\tname=\"wpforms_528_24\" \t\tvalue=\"\">\n<\/div><div id=\"wpforms-528-field_25-container\" class=\"wpforms-field wpforms-field-text\" data-field-id=\"25\"><label class=\"wpforms-field-label\" for=\"wpforms-528-field_25\">Par la pr\u00e9sente, je,<\/label><input type=\"text\" id=\"wpforms-528-field_25\" class=\"wpforms-field-large\" name=\"wpforms[fields][25]\" ><\/div><div id=\"wpforms-528-field_26-container\" class=\"wpforms-field wpforms-field-html\" data-field-id=\"26\"><div id=\"wpforms-528-field_26\"><p>autorise que les documents suivants<\/p>\r\n<ul style=\"margin: 15px 0px 15px 15px !important;\">\r\n<li>Copie de la derni\u00e8re \u00e9valuation psychiatrique<\/li>\r\n<li>Copie du dernier plan d\u2019intervention<\/li>\r\n<\/ul>\r\n<p>soient achemin\u00e9s au Comit\u00e9 de s\u00e9lection du programme Cl\u00e9s en main<\/p><\/div><\/div><div id=\"wpforms-528-field_28-container\" class=\"wpforms-field wpforms-field-html\" data-field-id=\"28\"><div id=\"wpforms-528-field_28\"><h3>2. Suivi dans la communaut\u00e9<\/h3><\/div><\/div><div id=\"wpforms-528-field_29-container\" class=\"wpforms-field wpforms-field-text\" data-field-id=\"29\"><label class=\"wpforms-field-label\" for=\"wpforms-528-field_29\">par quel(s) organisme(s) ? <\/label><input type=\"text\" id=\"wpforms-528-field_29\" class=\"wpforms-field-large\" name=\"wpforms[fields][29]\" ><\/div><div id=\"wpforms-528-field_30-container\" class=\"wpforms-field wpforms-field-text\" data-field-id=\"30\"><label class=\"wpforms-field-label\" for=\"wpforms-528-field_30\">Depuis combien de temps ?<\/label><input type=\"text\" id=\"wpforms-528-field_30\" class=\"wpforms-field-large\" name=\"wpforms[fields][30]\" ><\/div><div id=\"wpforms-528-field_31-container\" class=\"wpforms-field wpforms-field-text\" data-field-id=\"31\"><label class=\"wpforms-field-label\" for=\"wpforms-528-field_31\">\u00c0 quelle fr\u00e9quence ?<\/label><input type=\"text\" id=\"wpforms-528-field_31\" class=\"wpforms-field-large\" name=\"wpforms[fields][31]\" ><\/div><div id=\"wpforms-528-field_32-container\" class=\"wpforms-field wpforms-field-text\" data-field-id=\"32\"><label class=\"wpforms-field-label\" for=\"wpforms-528-field_32\">Quel type de suivi recevez-vous ?<\/label><input type=\"text\" id=\"wpforms-528-field_32\" class=\"wpforms-field-large\" name=\"wpforms[fields][32]\" ><\/div><div id=\"wpforms-528-field_33-container\" class=\"wpforms-field wpforms-field-html\" data-field-id=\"33\"><div id=\"wpforms-528-field_33\"><h3>3. \u00cates-vous en mesure d\u2019assurer de fa\u00e7on autonome la satisfaction de vos besoins essentiels, telle que<\/h3><\/div><\/div><div id=\"wpforms-528-field_34-container\" class=\"wpforms-field wpforms-field-checkbox wpforms-list-inline\" data-field-id=\"34\"><label class=\"wpforms-field-label\">les soins personnels (hygi\u00e8ne)<\/label><ul id=\"wpforms-528-field_34\"><li class=\"choice-1 depth-1\"><input type=\"checkbox\" id=\"wpforms-528-field_34_1\" name=\"wpforms[fields][34][]\" value=\"Oui de fa\u00e7on autonome\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-528-field_34_1\">Oui de fa\u00e7on autonome<\/label><\/li><li class=\"choice-2 depth-1\"><input type=\"checkbox\" id=\"wpforms-528-field_34_2\" name=\"wpforms[fields][34][]\" value=\"Oui mais avec un soutien de l\u2019ext\u00e9rieur\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-528-field_34_2\">Oui mais avec un soutien de l\u2019ext\u00e9rieur<\/label><\/li><li class=\"choice-3 depth-1\"><input type=\"checkbox\" id=\"wpforms-528-field_34_3\" name=\"wpforms[fields][34][]\" value=\"Oui avec l\u2019aide d\u2019une personne qui vit avec moi\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-528-field_34_3\">Oui avec l\u2019aide d\u2019une personne qui vit avec moi<\/label><\/li><li class=\"choice-4 depth-1\"><input type=\"checkbox\" id=\"wpforms-528-field_34_4\" name=\"wpforms[fields][34][]\" value=\"Non\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-528-field_34_4\">Non<\/label><\/li><\/ul><\/div><div id=\"wpforms-528-field_35-container\" class=\"wpforms-field wpforms-field-textarea\" data-field-id=\"35\"><label class=\"wpforms-field-label\" for=\"wpforms-528-field_35\">Si non, d\u00e9crivez le type d\u2019aide dont vous avez besoin ?<\/label><textarea id=\"wpforms-528-field_35\" class=\"wpforms-field-medium\" name=\"wpforms[fields][35]\" ><\/textarea><\/div><div id=\"wpforms-528-field_36-container\" class=\"wpforms-field wpforms-field-checkbox wpforms-list-inline\" data-field-id=\"36\"><label class=\"wpforms-field-label\">La pr\u00e9paration de vos repas ?<\/label><ul id=\"wpforms-528-field_36\"><li class=\"choice-1 depth-1\"><input type=\"checkbox\" id=\"wpforms-528-field_36_1\" name=\"wpforms[fields][36][]\" value=\"Oui de fa\u00e7on autonome\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-528-field_36_1\">Oui de fa\u00e7on autonome<\/label><\/li><li class=\"choice-2 depth-1\"><input type=\"checkbox\" id=\"wpforms-528-field_36_2\" name=\"wpforms[fields][36][]\" value=\"Oui mais avec un soutien de l\u2019ext\u00e9rieur\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-528-field_36_2\">Oui mais avec un soutien de l\u2019ext\u00e9rieur<\/label><\/li><li class=\"choice-3 depth-1\"><input type=\"checkbox\" id=\"wpforms-528-field_36_3\" name=\"wpforms[fields][36][]\" value=\"Oui avec l\u2019aide d\u2019une personne qui vit avec moi\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-528-field_36_3\">Oui avec l\u2019aide d\u2019une personne qui vit avec moi<\/label><\/li><li class=\"choice-4 depth-1\"><input type=\"checkbox\" id=\"wpforms-528-field_36_4\" name=\"wpforms[fields][36][]\" value=\"Non\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-528-field_36_4\">Non<\/label><\/li><\/ul><\/div><div id=\"wpforms-528-field_37-container\" class=\"wpforms-field wpforms-field-textarea\" data-field-id=\"37\"><label class=\"wpforms-field-label\" for=\"wpforms-528-field_37\">Si non, d\u00e9crivez le type d\u2019aide dont vous avez besoin ?<\/label><textarea id=\"wpforms-528-field_37\" class=\"wpforms-field-medium\" name=\"wpforms[fields][37]\" ><\/textarea><\/div><div id=\"wpforms-528-field_38-container\" class=\"wpforms-field wpforms-field-checkbox wpforms-list-inline\" data-field-id=\"38\"><label class=\"wpforms-field-label\">L\u2019entretien de votre logement ?  (t\u00e2ches m\u00e9nag\u00e8res r\u00e9guli\u00e8res)<\/label><ul id=\"wpforms-528-field_38\"><li class=\"choice-1 depth-1\"><input type=\"checkbox\" id=\"wpforms-528-field_38_1\" name=\"wpforms[fields][38][]\" value=\"Oui de fa\u00e7on autonome\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-528-field_38_1\">Oui de fa\u00e7on autonome<\/label><\/li><li class=\"choice-2 depth-1\"><input type=\"checkbox\" id=\"wpforms-528-field_38_2\" name=\"wpforms[fields][38][]\" value=\"Oui mais avec un soutien de l\u2019ext\u00e9rieur\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-528-field_38_2\">Oui mais avec un soutien de l\u2019ext\u00e9rieur<\/label><\/li><li class=\"choice-3 depth-1\"><input type=\"checkbox\" id=\"wpforms-528-field_38_3\" name=\"wpforms[fields][38][]\" value=\"Oui avec l\u2019aide d\u2019une personne qui vit avec moi\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-528-field_38_3\">Oui avec l\u2019aide d\u2019une personne qui vit avec moi<\/label><\/li><li class=\"choice-4 depth-1\"><input type=\"checkbox\" id=\"wpforms-528-field_38_4\" name=\"wpforms[fields][38][]\" value=\"Non\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-528-field_38_4\">Non<\/label><\/li><\/ul><\/div><div id=\"wpforms-528-field_39-container\" class=\"wpforms-field wpforms-field-textarea\" data-field-id=\"39\"><label class=\"wpforms-field-label\" for=\"wpforms-528-field_39\">Si non, d\u00e9crivez le type d\u2019aide dont vous avez besoin ?<\/label><textarea id=\"wpforms-528-field_39\" class=\"wpforms-field-medium\" name=\"wpforms[fields][39]\" ><\/textarea><\/div><div id=\"wpforms-528-field_40-container\" class=\"wpforms-field wpforms-field-checkbox wpforms-list-inline\" data-field-id=\"40\"><label class=\"wpforms-field-label\">La gestion de votre budget ?<\/label><ul id=\"wpforms-528-field_40\"><li class=\"choice-1 depth-1\"><input type=\"checkbox\" id=\"wpforms-528-field_40_1\" name=\"wpforms[fields][40][]\" value=\"Oui de fa\u00e7on autonome\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-528-field_40_1\">Oui de fa\u00e7on autonome<\/label><\/li><li class=\"choice-2 depth-1\"><input type=\"checkbox\" id=\"wpforms-528-field_40_2\" name=\"wpforms[fields][40][]\" value=\"Oui mais avec un soutien de l\u2019ext\u00e9rieur\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-528-field_40_2\">Oui mais avec un soutien de l\u2019ext\u00e9rieur<\/label><\/li><li class=\"choice-3 depth-1\"><input type=\"checkbox\" id=\"wpforms-528-field_40_3\" name=\"wpforms[fields][40][]\" value=\"Oui avec l\u2019aide d\u2019une personne qui vit avec moi\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-528-field_40_3\">Oui avec l\u2019aide d\u2019une personne qui vit avec moi<\/label><\/li><li class=\"choice-4 depth-1\"><input type=\"checkbox\" id=\"wpforms-528-field_40_4\" name=\"wpforms[fields][40][]\" value=\"Non\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-528-field_40_4\">Non<\/label><\/li><\/ul><\/div><div id=\"wpforms-528-field_41-container\" class=\"wpforms-field wpforms-field-textarea\" data-field-id=\"41\"><label class=\"wpforms-field-label\" for=\"wpforms-528-field_41\">Si non, d\u00e9crivez le type d\u2019aide dont vous avez besoin ?<\/label><textarea id=\"wpforms-528-field_41\" class=\"wpforms-field-medium\" name=\"wpforms[fields][41]\" ><\/textarea><\/div><div id=\"wpforms-528-field_42-container\" class=\"wpforms-field wpforms-field-html\" data-field-id=\"42\"><div id=\"wpforms-528-field_42\"><h3>4. Habitez-vous le territoire souhait\u00e9 ?<\/h3><\/div><\/div><div id=\"wpforms-528-field_43-container\" class=\"wpforms-field wpforms-field-checkbox wpforms-list-inline\" data-field-id=\"43\"><ul id=\"wpforms-528-field_43\"><li class=\"choice-1 depth-1\"><input type=\"checkbox\" id=\"wpforms-528-field_43_1\" name=\"wpforms[fields][43][]\" value=\"Oui\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-528-field_43_1\">Oui<\/label><\/li><li class=\"choice-2 depth-1\"><input type=\"checkbox\" id=\"wpforms-528-field_43_2\" name=\"wpforms[fields][43][]\" value=\"Non\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-528-field_43_2\">Non<\/label><\/li><\/ul><\/div><div id=\"wpforms-528-field_44-container\" class=\"wpforms-field wpforms-field-text\" data-field-id=\"44\"><label class=\"wpforms-field-label\" for=\"wpforms-528-field_44\">4a. Si non, quel est le territoire souhait\u00e9 ?<\/label><input type=\"text\" id=\"wpforms-528-field_44\" class=\"wpforms-field-large\" name=\"wpforms[fields][44]\" ><\/div><div id=\"wpforms-528-field_45-container\" class=\"wpforms-field wpforms-field-textarea\" data-field-id=\"45\"><label class=\"wpforms-field-label\" for=\"wpforms-528-field_45\">4b. Quelles sont vos motivations \u00e0 habiter ce territoire ?<\/label><textarea id=\"wpforms-528-field_45\" class=\"wpforms-field-medium\" name=\"wpforms[fields][45]\" ><\/textarea><\/div><div id=\"wpforms-528-field_46-container\" class=\"wpforms-field wpforms-field-html\" data-field-id=\"46\"><div id=\"wpforms-528-field_46\"><h3>5. Taux d\u2019effort au logement<\/h3><\/div><\/div><div id=\"wpforms-528-field_47-container\" class=\"wpforms-field wpforms-field-text\" data-field-id=\"47\"><label class=\"wpforms-field-label\" for=\"wpforms-528-field_47\">Veuillez indiquer votre revenu moyen brut (par mois)<\/label><input type=\"text\" id=\"wpforms-528-field_47\" class=\"wpforms-field-large\" name=\"wpforms[fields][47]\" ><\/div><div id=\"wpforms-528-field_48-container\" class=\"wpforms-field wpforms-field-text\" data-field-id=\"48\"><label class=\"wpforms-field-label\" for=\"wpforms-528-field_48\">Veuillez indiquer le co\u00fbt actuel du logement ?<\/label><input type=\"text\" id=\"wpforms-528-field_48\" class=\"wpforms-field-large\" name=\"wpforms[fields][48]\" ><\/div><div id=\"wpforms-528-field_49-container\" class=\"wpforms-field wpforms-field-checkbox wpforms-list-inline\" data-field-id=\"49\"><label class=\"wpforms-field-label\">Veuillez indiquer les services inclus au co\u00fbt de votre logement<\/label><ul id=\"wpforms-528-field_49\"><li class=\"choice-1 depth-1\"><input type=\"checkbox\" id=\"wpforms-528-field_49_1\" name=\"wpforms[fields][49][]\" value=\"Chauff\u00e9\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-528-field_49_1\">Chauff\u00e9<\/label><\/li><li class=\"choice-2 depth-1\"><input type=\"checkbox\" id=\"wpforms-528-field_49_2\" name=\"wpforms[fields][49][]\" value=\"\u00c9clair\u00e9\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-528-field_49_2\">\u00c9clair\u00e9<\/label><\/li><li class=\"choice-5 depth-1\"><input type=\"checkbox\" id=\"wpforms-528-field_49_5\" name=\"wpforms[fields][49][]\" value=\"Chambre et pension\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-528-field_49_5\">Chambre et pension<\/label><\/li><\/ul><\/div><div id=\"wpforms-528-field_51-container\" class=\"wpforms-field wpforms-field-html\" data-field-id=\"51\"><div id=\"wpforms-528-field_51\"><p>Si le chauffage et l\u2019\u00e9lectricit\u00e9 ne sont pas inclus, veuillez indiquer le montant d\u00e9bours\u00e9 mensuellement<\/p><\/div><\/div><div id=\"wpforms-528-field_52-container\" class=\"wpforms-field wpforms-field-text wpforms-one-half wpforms-first\" data-field-id=\"52\"><label class=\"wpforms-field-label\" for=\"wpforms-528-field_52\">Chauffage<\/label><input type=\"text\" id=\"wpforms-528-field_52\" class=\"wpforms-field-large\" name=\"wpforms[fields][52]\" ><\/div><div id=\"wpforms-528-field_53-container\" class=\"wpforms-field wpforms-field-text wpforms-one-half\" data-field-id=\"53\"><label class=\"wpforms-field-label\" for=\"wpforms-528-field_53\">\u00c9lectricit\u00e9<\/label><input type=\"text\" id=\"wpforms-528-field_53\" class=\"wpforms-field-large\" name=\"wpforms[fields][53]\" ><\/div><div id=\"wpforms-528-field_50-container\" class=\"wpforms-field wpforms-field-checkbox wpforms-list-inline\" data-field-id=\"50\"><label class=\"wpforms-field-label\">Avez-vous des animaux ?<\/label><ul id=\"wpforms-528-field_50\"><li class=\"choice-1 depth-1\"><input type=\"checkbox\" id=\"wpforms-528-field_50_1\" name=\"wpforms[fields][50][]\" value=\"Oui\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-528-field_50_1\">Oui<\/label><\/li><li class=\"choice-2 depth-1\"><input type=\"checkbox\" id=\"wpforms-528-field_50_2\" name=\"wpforms[fields][50][]\" value=\"Non\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-528-field_50_2\">Non<\/label><\/li><\/ul><\/div><div id=\"wpforms-528-field_54-container\" class=\"wpforms-field wpforms-field-checkbox wpforms-list-inline\" data-field-id=\"54\"><label class=\"wpforms-field-label\">Type d\u2019animal et nombre ?<\/label><ul id=\"wpforms-528-field_54\"><li class=\"choice-1 depth-1\"><input type=\"checkbox\" id=\"wpforms-528-field_54_1\" name=\"wpforms[fields][54][]\" value=\"Chat\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-528-field_54_1\">Chat<\/label><\/li><li class=\"choice-6 depth-1\"><input type=\"checkbox\" id=\"wpforms-528-field_54_6\" name=\"wpforms[fields][54][]\" value=\"Chien\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-528-field_54_6\">Chien<\/label><\/li><li class=\"choice-7 depth-1\"><input type=\"checkbox\" id=\"wpforms-528-field_54_7\" name=\"wpforms[fields][54][]\" value=\"Autre\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-528-field_54_7\">Autre<\/label><\/li><\/ul><\/div><div id=\"wpforms-528-field_55-container\" class=\"wpforms-field wpforms-field-text\" data-field-id=\"55\"><label class=\"wpforms-field-label\" for=\"wpforms-528-field_55\">Autre<\/label><input type=\"text\" id=\"wpforms-528-field_55\" class=\"wpforms-field-large\" name=\"wpforms[fields][55]\" ><\/div><div id=\"wpforms-528-field_56-container\" class=\"wpforms-field wpforms-field-html\" data-field-id=\"56\"><div id=\"wpforms-528-field_56\"><h3>6. La formule d\u2019habitation actuelle <\/h3><\/div><\/div><div id=\"wpforms-528-field_57-container\" class=\"wpforms-field wpforms-field-text\" data-field-id=\"57\"><label class=\"wpforms-field-label\" for=\"wpforms-528-field_57\">Adresse<\/label><input type=\"text\" id=\"wpforms-528-field_57\" class=\"wpforms-field-large\" name=\"wpforms[fields][57]\" ><\/div><div id=\"wpforms-528-field_58-container\" class=\"wpforms-field wpforms-field-text\" data-field-id=\"58\"><label class=\"wpforms-field-label\" for=\"wpforms-528-field_58\">Quel est le type d\u2019habitation (1\u00bd, 3\u00bd  4\u00bd) ?  <\/label><input type=\"text\" id=\"wpforms-528-field_58\" class=\"wpforms-field-large\" name=\"wpforms[fields][58]\" ><\/div><div id=\"wpforms-528-field_59-container\" class=\"wpforms-field wpforms-field-text\" data-field-id=\"59\"><label class=\"wpforms-field-label\" for=\"wpforms-528-field_59\">Depuis combien de temps demeurez-vous \u00e0 cet endroit ?<\/label><input type=\"text\" id=\"wpforms-528-field_59\" class=\"wpforms-field-large\" name=\"wpforms[fields][59]\" ><\/div><div id=\"wpforms-528-field_60-container\" class=\"wpforms-field wpforms-field-textarea\" data-field-id=\"60\"><label class=\"wpforms-field-label\" for=\"wpforms-528-field_60\">Bref, r\u00e9sum\u00e9 de votre historique de logement des derni\u00e8res ann\u00e9es<\/label><textarea id=\"wpforms-528-field_60\" class=\"wpforms-field-medium\" name=\"wpforms[fields][60]\" ><\/textarea><\/div><div id=\"wpforms-528-field_61-container\" class=\"wpforms-field wpforms-field-html\" data-field-id=\"61\"><div id=\"wpforms-528-field_61\"><h3>7. La formule d\u2019habitation actuelle convient-elle \u00e0 vos besoins ? <\/h3><\/div><\/div><div id=\"wpforms-528-field_62-container\" class=\"wpforms-field wpforms-field-checkbox wpforms-list-inline\" data-field-id=\"62\"><ul id=\"wpforms-528-field_62\"><li class=\"choice-1 depth-1\"><input type=\"checkbox\" id=\"wpforms-528-field_62_1\" name=\"wpforms[fields][62][]\" value=\"Oui\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-528-field_62_1\">Oui<\/label><\/li><li class=\"choice-6 depth-1\"><input type=\"checkbox\" id=\"wpforms-528-field_62_6\" name=\"wpforms[fields][62][]\" value=\"Non\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-528-field_62_6\">Non<\/label><\/li><\/ul><\/div><div id=\"wpforms-528-field_63-container\" class=\"wpforms-field wpforms-field-html\" data-field-id=\"63\"><div id=\"wpforms-528-field_63\"><h3>8. Quels besoins ne sont pas r\u00e9pondus par cette formule ? <\/h3><\/div><\/div><div id=\"wpforms-528-field_64-container\" class=\"wpforms-field wpforms-field-checkbox wpforms-list-inline\" data-field-id=\"64\"><ul id=\"wpforms-528-field_64\"><li class=\"choice-1 depth-1\"><input type=\"checkbox\" id=\"wpforms-528-field_64_1\" name=\"wpforms[fields][64][]\" value=\"Insalubrit\u00e9 du logement\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-528-field_64_1\">Insalubrit\u00e9 du logement<\/label><\/li><li class=\"choice-6 depth-1\"><input type=\"checkbox\" id=\"wpforms-528-field_64_6\" name=\"wpforms[fields][64][]\" value=\"Exigu\u00eft\u00e9 des lieux\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-528-field_64_6\">Exigu\u00eft\u00e9 des lieux<\/label><\/li><li class=\"choice-8 depth-1\"><input type=\"checkbox\" id=\"wpforms-528-field_64_8\" name=\"wpforms[fields][64][]\" value=\"Co\u00fbt trop \u00e9lev\u00e9 du loyer\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-528-field_64_8\">Co\u00fbt trop \u00e9lev\u00e9 du loyer<\/label><\/li><li class=\"choice-9 depth-1\"><input type=\"checkbox\" id=\"wpforms-528-field_64_9\" name=\"wpforms[fields][64][]\" value=\"\u00c9puisement des proches\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-528-field_64_9\">\u00c9puisement des proches<\/label><\/li><li class=\"choice-11 depth-1\"><input type=\"checkbox\" id=\"wpforms-528-field_64_11\" name=\"wpforms[fields][64][]\" value=\"Environnement malsain\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-528-field_64_11\">Environnement malsain<\/label><\/li><li class=\"choice-12 depth-1\"><input type=\"checkbox\" id=\"wpforms-528-field_64_12\" name=\"wpforms[fields][64][]\" value=\"Difficult\u00e9 \u00e0 assumer seul la gestion du loyer\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-528-field_64_12\">Difficult\u00e9 \u00e0 assumer seul la gestion du loyer<\/label><\/li><li class=\"choice-13 depth-1\"><input type=\"checkbox\" id=\"wpforms-528-field_64_13\" name=\"wpforms[fields][64][]\" value=\"Besoin d\u2019autonomie\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-528-field_64_13\">Besoin d\u2019autonomie<\/label><\/li><li class=\"choice-14 depth-1\"><input type=\"checkbox\" id=\"wpforms-528-field_64_14\" name=\"wpforms[fields][64][]\" value=\"Difficult\u00e9 \u00e0 assumer les obligations de locataire\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-528-field_64_14\">Difficult\u00e9 \u00e0 assumer les obligations de locataire<\/label><\/li><li class=\"choice-15 depth-1\"><input type=\"checkbox\" id=\"wpforms-528-field_64_15\" name=\"wpforms[fields][64][]\" value=\"Manque d\u2019encadrement\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-528-field_64_15\">Manque d\u2019encadrement<\/label><\/li><li class=\"choice-16 depth-1\"><input type=\"checkbox\" id=\"wpforms-528-field_64_16\" name=\"wpforms[fields][64][]\" value=\"Manque de soutien dans mon milieu de vie\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-528-field_64_16\">Manque de soutien dans mon milieu de vie<\/label><\/li><li class=\"choice-17 depth-1\"><input type=\"checkbox\" id=\"wpforms-528-field_64_17\" name=\"wpforms[fields][64][]\" value=\"Manque de services \u00e0 proximit\u00e9\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-528-field_64_17\">Manque de services \u00e0 proximit\u00e9<\/label><\/li><li class=\"choice-18 depth-1\"><input type=\"checkbox\" id=\"wpforms-528-field_64_18\" name=\"wpforms[fields][64][]\" value=\"Autres\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-528-field_64_18\">Autres<\/label><\/li><\/ul><\/div><div id=\"wpforms-528-field_65-container\" class=\"wpforms-field wpforms-field-text\" data-field-id=\"65\"><label class=\"wpforms-field-label\" for=\"wpforms-528-field_65\">Autres<\/label><input type=\"text\" id=\"wpforms-528-field_65\" class=\"wpforms-field-large\" name=\"wpforms[fields][65]\" ><\/div><div id=\"wpforms-528-field_67-container\" class=\"wpforms-field wpforms-field-html\" data-field-id=\"67\"><div id=\"wpforms-528-field_67\"><h3>9. Y a-t-il, dans votre situation actuelle, des \u00e9l\u00e9ments importants motivant une urgence d\u2019intervention ? Expliquez <\/h3><\/div><\/div><div id=\"wpforms-528-field_66-container\" class=\"wpforms-field wpforms-field-textarea\" data-field-id=\"66\"><textarea id=\"wpforms-528-field_66\" class=\"wpforms-field-medium\" name=\"wpforms[fields][66]\" ><\/textarea><\/div><div id=\"wpforms-528-field_69-container\" class=\"wpforms-field wpforms-field-html\" data-field-id=\"69\"><div id=\"wpforms-528-field_69\"><h3>10.\tSi applicable, \u00eates-vous<\/h3><\/div><\/div><div id=\"wpforms-528-field_68-container\" class=\"wpforms-field wpforms-field-checkbox wpforms-list-inline\" data-field-id=\"68\"><ul id=\"wpforms-528-field_68\"><li class=\"choice-1 depth-1\"><input type=\"checkbox\" id=\"wpforms-528-field_68_1\" name=\"wpforms[fields][68][]\" value=\"Sur la liste d\u2019attente pour un HLM ? \"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-528-field_68_1\">Sur la liste d\u2019attente pour un HLM ?<\/label><\/li><\/ul><\/div><div id=\"wpforms-528-field_70-container\" class=\"wpforms-field wpforms-field-text wpforms-one-half wpforms-first\" data-field-id=\"70\"><label class=\"wpforms-field-label\" for=\"wpforms-528-field_70\">Quel rang ?<\/label><input type=\"text\" id=\"wpforms-528-field_70\" class=\"wpforms-field-large\" name=\"wpforms[fields][70]\" ><\/div><div id=\"wpforms-528-field_71-container\" class=\"wpforms-field wpforms-field-text wpforms-one-half\" data-field-id=\"71\"><label class=\"wpforms-field-label\" for=\"wpforms-528-field_71\">Depuis ?<\/label><input type=\"text\" id=\"wpforms-528-field_71\" class=\"wpforms-field-large\" name=\"wpforms[fields][71]\" ><\/div><div id=\"wpforms-528-field_72-container\" class=\"wpforms-field wpforms-field-checkbox wpforms-list-inline\" data-field-id=\"72\"><ul id=\"wpforms-528-field_72\"><li class=\"choice-1 depth-1\"><input type=\"checkbox\" id=\"wpforms-528-field_72_1\" name=\"wpforms[fields][72][]\" value=\"Sur une liste d\u2019attente pour une Coop ? \"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-528-field_72_1\">Sur une liste d\u2019attente pour une Coop ?<\/label><\/li><\/ul><\/div><div id=\"wpforms-528-field_73-container\" class=\"wpforms-field wpforms-field-checkbox wpforms-list-inline\" data-field-id=\"73\"><ul id=\"wpforms-528-field_73\"><li class=\"choice-1 depth-1\"><input type=\"checkbox\" id=\"wpforms-528-field_73_1\" name=\"wpforms[fields][73][]\" value=\"Sur une liste d\u2019attente pour un autre type de logement ? \"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-528-field_73_1\">Sur une liste d\u2019attente pour un autre type de logement ?<\/label><\/li><\/ul><\/div><div id=\"wpforms-528-field_74-container\" class=\"wpforms-field wpforms-field-text\" data-field-id=\"74\"><label class=\"wpforms-field-label\" for=\"wpforms-528-field_74\">Si oui, lequel ?<\/label><input type=\"text\" id=\"wpforms-528-field_74\" class=\"wpforms-field-large\" name=\"wpforms[fields][74]\" ><\/div><div id=\"wpforms-528-field_75-container\" class=\"wpforms-field wpforms-field-html\" data-field-id=\"75\"><div id=\"wpforms-528-field_75\"><h3>11.\tDans le cas o\u00f9 vous ne seriez pas s\u00e9lectionn\u00e9 pour une subvention au loyer, seriez-vous int\u00e9ress\u00e9 par un logement social, abordable, veuillez indiquer vos pr\u00e9f\u00e9rences ?<\/h3><\/div><\/div><div id=\"wpforms-528-field_76-container\" class=\"wpforms-field wpforms-field-checkbox wpforms-list-inline\" data-field-id=\"76\"><ul id=\"wpforms-528-field_76\"><li class=\"choice-1 depth-1\"><input type=\"checkbox\" id=\"wpforms-528-field_76_1\" name=\"wpforms[fields][76][]\" value=\"Logement abordable\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-528-field_76_1\">Logement abordable<\/label><\/li><li class=\"choice-2 depth-1\"><input type=\"checkbox\" id=\"wpforms-528-field_76_2\" name=\"wpforms[fields][76][]\" value=\"Coop\u00e9rative d\u2019habitation\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-528-field_76_2\">Coop\u00e9rative d\u2019habitation<\/label><\/li><li class=\"choice-3 depth-1\"><input type=\"checkbox\" id=\"wpforms-528-field_76_3\" name=\"wpforms[fields][76][]\" value=\"OBNL d\u2019habitation\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-528-field_76_3\">OBNL d\u2019habitation<\/label><\/li><\/ul><\/div><div id=\"wpforms-528-field_77-container\" class=\"wpforms-field wpforms-field-html\" data-field-id=\"77\"><div id=\"wpforms-528-field_77\"><p><strong>Secteur<\/strong><\/p><\/div><\/div><div id=\"wpforms-528-field_78-container\" class=\"wpforms-field wpforms-field-checkbox wpforms-list-inline\" data-field-id=\"78\"><ul id=\"wpforms-528-field_78\"><li class=\"choice-1 depth-1\"><input type=\"checkbox\" id=\"wpforms-528-field_78_1\" name=\"wpforms[fields][78][]\" value=\"Hull\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-528-field_78_1\">Hull<\/label><\/li><li class=\"choice-2 depth-1\"><input type=\"checkbox\" id=\"wpforms-528-field_78_2\" name=\"wpforms[fields][78][]\" value=\"Gatineau\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-528-field_78_2\">Gatineau<\/label><\/li><li class=\"choice-4 depth-1\"><input type=\"checkbox\" id=\"wpforms-528-field_78_4\" name=\"wpforms[fields][78][]\" value=\"Aylmer\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-528-field_78_4\">Aylmer<\/label><\/li><li class=\"choice-5 depth-1\"><input type=\"checkbox\" id=\"wpforms-528-field_78_5\" name=\"wpforms[fields][78][]\" value=\"Masson-Angers\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-528-field_78_5\">Masson-Angers<\/label><\/li><li class=\"choice-6 depth-1\"><input type=\"checkbox\" id=\"wpforms-528-field_78_6\" name=\"wpforms[fields][78][]\" value=\"Buckingham\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-528-field_78_6\">Buckingham<\/label><\/li><li class=\"choice-7 depth-1\"><input type=\"checkbox\" id=\"wpforms-528-field_78_7\" name=\"wpforms[fields][78][]\" value=\"Autre\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-528-field_78_7\">Autre<\/label><\/li><\/ul><\/div><div id=\"wpforms-528-field_79-container\" class=\"wpforms-field wpforms-field-text\" data-field-id=\"79\"><label class=\"wpforms-field-label\" for=\"wpforms-528-field_79\">(Pr\u00e9cisez)<\/label><input type=\"text\" id=\"wpforms-528-field_79\" class=\"wpforms-field-large\" name=\"wpforms[fields][79]\" ><\/div><div id=\"wpforms-528-field_80-container\" class=\"wpforms-field wpforms-field-textarea\" data-field-id=\"80\"><label class=\"wpforms-field-label\" for=\"wpforms-528-field_80\">Quels sont vos besoins au maintien en logement ?<\/label><textarea id=\"wpforms-528-field_80\" class=\"wpforms-field-medium\" name=\"wpforms[fields][80]\" ><\/textarea><\/div><div id=\"wpforms-528-field_81-container\" class=\"wpforms-field wpforms-field-html\" data-field-id=\"81\"><div id=\"wpforms-528-field_81\"><h3>12.\tEn quoi l\u2019obtention d\u2019une unit\u00e9 de programme de suppl\u00e9ment au loyer (\u00abPSL\u00bb), \u00e0 ce moment-ci,  vous aiderait dans votre processus de r\u00e9tablissement, \u00e0 court, moyen et long terme ?<\/h3><\/div><\/div><div id=\"wpforms-528-field_82-container\" class=\"wpforms-field wpforms-field-textarea\" data-field-id=\"82\"><label class=\"wpforms-field-label\" for=\"wpforms-528-field_82\">(Impacts sur vos \u00e9tudes, votre travail, vos implications sociales, sur votre vie familiale et sociale, votre sant\u00e9 physique et mentale, etc)<\/label><textarea id=\"wpforms-528-field_82\" class=\"wpforms-field-medium\" name=\"wpforms[fields][82]\" ><\/textarea><\/div><div id=\"wpforms-528-field_83-container\" class=\"wpforms-field wpforms-field-html\" data-field-id=\"83\"><div id=\"wpforms-528-field_83\"><h3>13.\tQuels sont vos r\u00eaves, vos projets de vie ? (buts, objectifs, priorit\u00e9, forces, \u2026 )<\/h3><\/div><\/div><div id=\"wpforms-528-field_84-container\" class=\"wpforms-field wpforms-field-textarea\" data-field-id=\"84\"><label class=\"wpforms-field-label\" for=\"wpforms-528-field_84\">D\u00e9taillez<\/label><textarea id=\"wpforms-528-field_84\" class=\"wpforms-field-medium\" name=\"wpforms[fields][84]\" ><\/textarea><\/div><div id=\"wpforms-528-field_85-container\" class=\"wpforms-field wpforms-field-html\" data-field-id=\"85\"><div id=\"wpforms-528-field_85\"><h3>14. Commentaires<\/h3><\/div><\/div><div id=\"wpforms-528-field_86-container\" class=\"wpforms-field wpforms-field-textarea\" data-field-id=\"86\"><textarea id=\"wpforms-528-field_86\" class=\"wpforms-field-medium\" name=\"wpforms[fields][86]\" ><\/textarea><\/div><div id=\"wpforms-528-field_87-container\" class=\"wpforms-field wpforms-field-text wpforms-one-half wpforms-first\" data-field-id=\"87\"><label class=\"wpforms-field-label\" for=\"wpforms-528-field_87\">Signature de la ou du candidat(e)<\/label><input type=\"text\" id=\"wpforms-528-field_87\" class=\"wpforms-field-large\" name=\"wpforms[fields][87]\" ><\/div><div id=\"wpforms-528-field_88-container\" class=\"wpforms-field wpforms-field-date-time wpforms-one-half\" data-field-id=\"88\"><label class=\"wpforms-field-label\" for=\"wpforms-528-field_88\">Date<\/label><div class=\"wpforms-datepicker-wrap\"><input type=\"text\" id=\"wpforms-528-field_88\" 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][88][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-528-field_89-container\" class=\"wpforms-field wpforms-field-text wpforms-one-half wpforms-first\" data-field-id=\"89\"><label class=\"wpforms-field-label\" for=\"wpforms-528-field_89\">Signature de l\u2019intervenant(e)<\/label><input type=\"text\" id=\"wpforms-528-field_89\" class=\"wpforms-field-large\" name=\"wpforms[fields][89]\" ><\/div><div id=\"wpforms-528-field_90-container\" class=\"wpforms-field wpforms-field-date-time wpforms-one-half\" data-field-id=\"90\"><label class=\"wpforms-field-label\" for=\"wpforms-528-field_90\">Date<\/label><div class=\"wpforms-datepicker-wrap\"><input type=\"text\" id=\"wpforms-528-field_90\" 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][90][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-528-field_91-container\" class=\"wpforms-field wpforms-field-html wpforms-one-half wpforms-first\" data-field-id=\"91\"><div id=\"wpforms-528-field_91\"><h2>Autorisation \u00e0 communiquer des renseignements contenus au dossier<\/h2><\/div><\/div><div id=\"wpforms-528-field_92-container\" class=\"wpforms-field wpforms-field-html wpforms-one-half\" data-field-id=\"92\"><div id=\"wpforms-528-field_92\"><h2>Programme Cl\u00e9s en main<\/h2><\/div><\/div><div id=\"wpforms-528-field_93-container\" class=\"wpforms-field wpforms-field-name\" data-field-id=\"93\"><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-528-field_93\" class=\"wpforms-field-name-first wpforms-field-required\" name=\"wpforms[fields][93][first]\" required><label for=\"wpforms-528-field_93\" class=\"wpforms-field-sublabel after\">Pr\u00e9nom<\/label><\/div><div class=\"wpforms-field-row-block wpforms-one-half\"><input type=\"text\" id=\"wpforms-528-field_93-last\" class=\"wpforms-field-name-last wpforms-field-required\" name=\"wpforms[fields][93][last]\" required><label for=\"wpforms-528-field_93-last\" class=\"wpforms-field-sublabel after\">Nom<\/label><\/div><\/div><\/div><div id=\"wpforms-528-field_94-container\" class=\"wpforms-field wpforms-field-date-time\" data-field-id=\"94\"><label class=\"wpforms-field-label\" for=\"wpforms-528-field_94\">Date de naissance<\/label><div class=\"wpforms-datepicker-wrap\"><input type=\"text\" id=\"wpforms-528-field_94\" 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][94][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-528-field_95-container\" class=\"wpforms-field wpforms-field-address\" data-field-id=\"95\"><label class=\"wpforms-field-label\">Adresse<\/label><div class=\"wpforms-field-row wpforms-field-large\"><div ><input type=\"text\" id=\"wpforms-528-field_95\" class=\"wpforms-field-address-address1\" name=\"wpforms[fields][95][address1]\" ><label for=\"wpforms-528-field_95\" 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-528-field_95-address2\" class=\"wpforms-field-address-address2\" name=\"wpforms[fields][95][address2]\" ><label for=\"wpforms-528-field_95-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-528-field_95-city\" class=\"wpforms-field-address-city\" name=\"wpforms[fields][95][city]\" ><label for=\"wpforms-528-field_95-city\" class=\"wpforms-field-sublabel after\">Ville<\/label><\/div><div class=\"wpforms-field-row-block wpforms-one-half\"><input type=\"text\" id=\"wpforms-528-field_95-state\" class=\"wpforms-field-address-state\" name=\"wpforms[fields][95][state]\" ><label for=\"wpforms-528-field_95-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-528-field_95-postal\" class=\"wpforms-field-address-postal\" name=\"wpforms[fields][95][postal]\" ><label for=\"wpforms-528-field_95-postal\" class=\"wpforms-field-sublabel after\">Code postal<\/label><\/div><div class=\"wpforms-field-row-block wpforms-one-half\"><select id=\"wpforms-528-field_95-country\" class=\"wpforms-field-address-country\" name=\"wpforms[fields][95][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-528-field_95-country\" class=\"wpforms-field-sublabel after\">Pays<\/label><\/div><\/div><\/div><div id=\"wpforms-528-field_96-container\" class=\"wpforms-field wpforms-field-html\" data-field-id=\"96\"><div id=\"wpforms-528-field_96\"><p>Je soussign\u00e9(e),<\/p><\/div><\/div><div id=\"wpforms-528-field_97-container\" class=\"wpforms-field wpforms-field-text\" data-field-id=\"97\"><label class=\"wpforms-field-label\" for=\"wpforms-528-field_97\">Pr\u00e9nom et Nom<\/label><input type=\"text\" id=\"wpforms-528-field_97\" class=\"wpforms-field-large\" name=\"wpforms[fields][97]\" ><\/div><div id=\"wpforms-528-field_98-container\" class=\"wpforms-field wpforms-field-html\" data-field-id=\"98\"><div id=\"wpforms-528-field_98\"><p>en tant qu\u2019usager, autorise<\/p><\/div><\/div><div id=\"wpforms-528-field_99-container\" class=\"wpforms-field wpforms-field-html\" data-field-id=\"99\"><div id=\"wpforms-528-field_99\"><h3>L\u2019Office d\u2019habitation de l\u2019Outaouais<\/h3><\/div><\/div><div id=\"wpforms-528-field_100-container\" class=\"wpforms-field wpforms-field-html\" data-field-id=\"100\"><div id=\"wpforms-528-field_100\"><p>\u00c0 transmettre au personnel du <strong>PROGRAMME CLES EN MAIN DES HABITATIONS NOUVEAU D\u00c9PART<\/strong> toutes informations contenues dans mon dossier, et ce, r\u00e9ciproquement.  Cette autorisation est valide pour la p\u00e9riode du<\/p><\/div><\/div><div id=\"wpforms-528-field_101-container\" class=\"wpforms-field wpforms-field-date-time wpforms-one-third wpforms-first\" data-field-id=\"101\"><label class=\"wpforms-field-label\" for=\"wpforms-528-field_101\">Date<\/label><div class=\"wpforms-datepicker-wrap\"><input type=\"text\" id=\"wpforms-528-field_101\" 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][101][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-528-field_102-container\" class=\"wpforms-field wpforms-field-html wpforms-one-third\" data-field-id=\"102\"><div id=\"wpforms-528-field_102\"><p align=\"center\">au<\/p><\/div><\/div><div id=\"wpforms-528-field_103-container\" class=\"wpforms-field wpforms-field-date-time wpforms-one-third\" data-field-id=\"103\"><label class=\"wpforms-field-label\" for=\"wpforms-528-field_103\">Date<\/label><div class=\"wpforms-datepicker-wrap\"><input type=\"text\" id=\"wpforms-528-field_103\" 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][103][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-528-field_104-container\" class=\"wpforms-field wpforms-field-html\" data-field-id=\"104\"><div id=\"wpforms-528-field_104\"><p>pour un maximum de un an.<\/p><\/div><\/div><div id=\"wpforms-528-field_107-container\" class=\"wpforms-field wpforms-field-html\" data-field-id=\"107\"><div id=\"wpforms-528-field_107\"><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-528-field_108-container\" class=\"wpforms-field wpforms-field-file-upload\" data-field-id=\"108\"><label class=\"wpforms-field-label\" for=\"wpforms-528-field_108\">Joindre des documents<\/label><div\n\t\tclass=\"wpforms-uploader \"\n\t\tdata-field-id=\"108\"\n\t\tdata-form-id=\"528\"\n\t\tdata-input-name=\"wpforms_528_108\"\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,ttf,otf,eot,woff,woff2,svg,redux\"\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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