{"id":26769,"date":"2024-08-01T14:29:31","date_gmt":"2024-08-01T14:29:31","guid":{"rendered":"https:\/\/yemenicanadian.club\/?page_id=26769"},"modified":"2024-08-01T14:30:49","modified_gmt":"2024-08-01T14:30:49","slug":"client-intake-form","status":"publish","type":"page","link":"https:\/\/yemenicanadian.club\/fr\/client-intake-form\/","title":{"rendered":"Formulaire d&#039;admission du client"},"content":{"rendered":"\t\t<div data-elementor-type=\"wp-page\" data-elementor-id=\"26769\" class=\"elementor elementor-26769\">\n\t\t\t\t<div class=\"elementor-element elementor-element-2a1f572 e-flex e-con-boxed e-con e-parent\" data-id=\"2a1f572\" data-element_type=\"container\" data-e-type=\"container\" data-settings=\"{&quot;background_background&quot;:&quot;classic&quot;}\">\n\t\t\t\t\t<div class=\"e-con-inner\">\n\t\t\t\t<div class=\"elementor-element elementor-element-eb5dc30 elementor-widget elementor-widget-shortcode\" data-id=\"eb5dc30\" data-element_type=\"widget\" data-e-type=\"widget\" data-widget_type=\"shortcode.default\">\n\t\t\t\t<div class=\"elementor-widget-container\">\n\t\t\t\t\t\t\t<div class=\"elementor-shortcode\"><div class='fluentform ff-default fluentform_wrapper_4 ffs_default_wrap'><form data-form_id=\"4\" id=\"fluentform_4\" class=\"frm-fluent-form fluent_form_4 ff-el-form-top ff_form_instance_4_1 ff-form-loading ffs_default\" data-form_instance=\"ff_form_instance_4_1\" method=\"POST\" ><fieldset  style=\"border: none!important;margin: 0!important;padding: 0!important;background-color: transparent!important;box-shadow: none!important;outline: none!important; min-inline-size: 100%;\">\n                    <legend class=\"ff_screen_reader_title\" style=\"display: block; margin: 0!important;padding: 0!important;height: 0!important;text-indent: -999999px;width: 0!important;overflow:hidden;\">Client intake form<\/legend><input type='hidden' name='__fluent_form_embded_post_id' value='26769' \/><input type=\"hidden\" id=\"_fluentform_4_fluentformnonce\" name=\"_fluentform_4_fluentformnonce\" value=\"170e57b43b\" \/><input type=\"hidden\" name=\"_wp_http_referer\" value=\"\/fr\/wp-json\/wp\/v2\/pages\/26769\" \/><div class=\"ff-el-group ff-el-section-break  ff_left\" data-name=\"section_break-4_1\" ><h3 class='ff-el-section-title'><\/h3><div class='ff-section_break_desk'><h3 style=\"text-align: center\"><span class=\"ui-provider cj jw jx jy jz ka kb kc kd ke kf kg kh ki kj kk kl km kn ko kp kq kr ks kt ku kv kw kx ky kz la lb lc ld\">Yemeni Canadian Club Client Intake Form<\/span><\/h3>\n<p style=\"text-align: center\"><span class=\"ui-provider cj jw jx jy jz ka kb kc kd ke kf kg kh ki kj kk kl km kn ko kp kq kr ks kt ku kv kw kx ky kz la lb lc ld\">This form is used to collect information about the clients we serve and the services we provide. Your information will be kept confidential.<\/span><\/p><\/div><hr \/><\/div><div data-type=\"name-element\" data-name=\"full_name\" class=\" ff-field_container ff-name-field-wrapper\" ><div class='ff-t-container'><div class='ff-t-cell '><div class='ff-el-group'><div class=\"ff-el-input--label ff-el-is-required asterisk-right\"><label for='ff_4_full_name_first_name_' id='label_ff_4_full_name_first_name_' >Name<\/label><\/div><div class='ff-el-input--content'><input type=\"text\" name=\"full_name[first_name]\" id=\"ff_4_full_name_first_name_\" class=\"ff-el-form-control\" placeholder=\"Enter your full name\" aria-invalid=\"false\" aria-required=true><\/div><\/div><\/div><\/div><\/div><div class='ff-el-group'><div class=\"ff-el-input--label ff-el-is-required asterisk-right\"><label for='ff_4_date_of_birth' id='label_ff_4_date_of_birth' aria-label=\"Date of Birth\">Date of Birth<\/label><\/div><div class='ff-el-input--content'><input  aria-label='Date of Birth Use arrow keys to navigate dates. Press enter to select a date.'  aria-haspopup='dialog' data-type-datepicker data-format='d\/m\/Y' type=\"text\" name=\"date_of_birth\" id=\"ff_4_date_of_birth\" class=\"ff-el-form-control ff-el-datepicker\" placeholder=\"dd\/mm\/YYYY\" data-name=\"date_of_birth\"  aria-invalid='false' aria-required=true><\/div><\/div><div class=\"ff-name-address-wrapper fluent-address\" data-type=\"address-element\" data-name=\"address\" ><div class='ff-el-input--label'><label aria-label=\"Address\">Address<\/label><\/div><div class='ff-el-input--content'><div class='ff-t-container'><div class='ff-t-cell'><div class='ff-el-group'><div class=\"ff-el-input--label ff-el-is-required asterisk-right\"><label for='ff_4_address_address_line_1_' id='label_ff_4_address_address_line_1_' aria-label=\"Address\">Address<\/label><\/div><div class='ff-el-input--content'><input type=\"text\" name=\"address[address_line_1]\" id=\"ff_4_address_address_line_1_\" class=\"ff-el-form-control\" placeholder=\"Enter your address\" data-key_name=\"address_line_1\"  aria-invalid=\"false\" aria-required=true><\/div><\/div><\/div><div class='ff-t-cell'><div class='ff-el-group'><div class=\"ff-el-input--label ff-el-is-required asterisk-right\"><label for='ff_4_address_city_' id='label_ff_4_address_city_' aria-label=\"City\">City<\/label><\/div><div class='ff-el-input--content'><input type=\"text\" name=\"address[city]\" id=\"ff_4_address_city_\" class=\"ff-el-form-control\" placeholder=\"Enter your city\" data-key_name=\"city\"  aria-invalid=\"false\" aria-required=true><\/div><\/div><\/div><\/div><div class='ff-t-container'><div class='ff-t-cell'><div class='ff-el-group'><div class=\"ff-el-input--label ff-el-is-required asterisk-right\"><label for='ff_4_address_state_' id='label_ff_4_address_state_' aria-label=\"Province\">Province<\/label><\/div><div class='ff-el-input--content'><input type=\"text\" name=\"address[state]\" id=\"ff_4_address_state_\" class=\"ff-el-form-control\" placeholder=\"Enter your province\" data-key_name=\"state\"  aria-invalid=\"false\" aria-required=true><\/div><\/div><\/div><div class='ff-t-cell'><div class='ff-el-group'><div class=\"ff-el-input--label ff-el-is-required asterisk-right\"><label for='ff_4_address_zip_' id='label_ff_4_address_zip_' aria-label=\"Postal Code\">Postal Code<\/label><\/div><div class='ff-el-input--content'><input type=\"text\" name=\"address[zip]\" id=\"ff_4_address_zip_\" class=\"ff-el-form-control\" placeholder=\"Enter your postal code\" data-key_name=\"zip\"  aria-invalid=\"false\" aria-required=true><\/div><\/div><\/div><\/div><\/div><\/div><div class='ff-el-group'><div class=\"ff-el-input--label ff-el-is-required asterisk-right\"><label for='ff_4_phone_number' id='label_ff_4_phone_number' aria-label=\"Phone\">Phone<\/label><\/div><div class='ff-el-input--content'><input type=\"number\" name=\"phone_number\" id=\"ff_4_phone_number\" class=\"ff-el-form-control\" placeholder=\"Enter your phone number\" data-name=\"phone_number\" inputmode=\"numeric\" step=\"any\"  aria-invalid=\"false\" aria-required=true><\/div><\/div><div class='ff-el-group'><div class=\"ff-el-input--label ff-el-is-required asterisk-right\"><label for='ff_4_email' id='label_ff_4_email' aria-label=\"Email Address\">Email Address<\/label><\/div><div class='ff-el-input--content'><input type=\"email\" name=\"email\" id=\"ff_4_email\" class=\"ff-el-form-control\" placeholder=\"Enter your email address\" data-name=\"email\"  aria-invalid=\"false\" aria-required=true><\/div><\/div><div class='ff-el-group'><div class=\"ff-el-input--label ff-el-is-required asterisk-right\"><label   aria-label=\"Type of Services Requested:\">Type of Services Requested:<\/label><\/div><div class='ff-el-input--content'><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for='services_requested_f6db7170a23b7b0b66e383123fe30424'><input  type=\"checkbox\" name=\"services_requested[]\" data-name=\"services_requested\" class=\"ff-el-form-check-input ff-el-form-check-checkbox\" value=\"Settlement Assistance\"  id='services_requested_f6db7170a23b7b0b66e383123fe30424' aria-label='Settlement Assistance' aria-invalid='false' aria-required=true> <span>Settlement Assistance<\/span><\/label><\/div><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for='services_requested_e49363ccfc2397fb0fd9142a0ee2fef8'><input  type=\"checkbox\" name=\"services_requested[]\" data-name=\"services_requested\" class=\"ff-el-form-check-input ff-el-form-check-checkbox\" value=\"Employment Support\"  id='services_requested_e49363ccfc2397fb0fd9142a0ee2fef8' aria-label='Employment Support' aria-invalid='false' aria-required=true> <span>Employment Support<\/span><\/label><\/div><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for='services_requested_5f22c49dc2a953af37dc182058e621c9'><input  type=\"checkbox\" name=\"services_requested[]\" data-name=\"services_requested\" class=\"ff-el-form-check-input ff-el-form-check-checkbox\" value=\"Educational Programs\"  id='services_requested_5f22c49dc2a953af37dc182058e621c9' aria-label='Educational Programs' aria-invalid='false' aria-required=true> <span>Educational Programs<\/span><\/label><\/div><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for='services_requested_e3ffac8cf54770795aff26ad9cebea1d'><input  type=\"checkbox\" name=\"services_requested[]\" data-name=\"services_requested\" class=\"ff-el-form-check-input ff-el-form-check-checkbox\" value=\"Health and Wellness Support\"  id='services_requested_e3ffac8cf54770795aff26ad9cebea1d' aria-label='Health and Wellness Support' aria-invalid='false' aria-required=true> <span>Health and Wellness Support<\/span><\/label><\/div><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for='services_requested_5485a8f19c47ba711905f5bea04ad4b0'><input  type=\"checkbox\" name=\"services_requested[]\" data-name=\"services_requested\" class=\"ff-el-form-check-input ff-el-form-check-checkbox\" value=\"Cultural Integration\"  id='services_requested_5485a8f19c47ba711905f5bea04ad4b0' aria-label='Cultural Integration' aria-invalid='false' aria-required=true> <span>Cultural Integration<\/span><\/label><\/div><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for='services_requested_236b2da6fa91913ed25c409c30da8a6b'><input  type=\"checkbox\" name=\"services_requested[]\" data-name=\"services_requested\" class=\"ff-el-form-check-input ff-el-form-check-checkbox\" value=\"Other (please specify)\"  id='services_requested_236b2da6fa91913ed25c409c30da8a6b' aria-label='Other (please specify)' aria-invalid='false' aria-required=true> <span>Other (please specify)<\/span><\/label><\/div><\/div><\/div><div class='ff-el-group has-conditions'><div class=\"ff-el-input--label ff-el-is-required asterisk-right\"><label for='ff_4_services_requested_other' id='label_ff_4_services_requested_other' aria-label=\"Type of Service Requested:(other)\">Type of Service Requested:(other)<\/label><\/div><div class='ff-el-input--content'><input type=\"text\" name=\"services_requested_other\" class=\"ff-el-form-control\" data-name=\"services_requested_other\" id=\"ff_4_services_requested_other\"  aria-invalid=\"false\" aria-required=true><\/div><\/div><div class='ff-el-group'><div class=\"ff-el-input--label ff-el-is-required asterisk-right\"><label for='ff_4_date_of_service_request' id='label_ff_4_date_of_service_request' aria-label=\"Date of Service Request:\">Date of Service Request:<\/label><\/div><div class='ff-el-input--content'><input  aria-label='Date of Service Request: Use arrow keys to navigate dates. Press enter to select a date.'  aria-haspopup='dialog' data-type-datepicker data-format='d\/m\/Y' type=\"text\" name=\"date_of_service_request\" id=\"ff_4_date_of_service_request\" class=\"ff-el-form-control ff-el-datepicker\" placeholder=\"dd\/mm\/YYYY\" data-name=\"date_of_service_request\"  aria-invalid='false' aria-required=true><\/div><\/div><div class='ff-el-group'><div class=\"ff-el-input--label ff-el-is-required asterisk-right\"><label for='ff_4_service_provided_description' id='label_ff_4_service_provided_description' aria-label=\"Service Provided:\">Service Provided:<\/label><\/div><div class='ff-el-input--content'><textarea aria-required=\"true\" aria-labelledby=\"label_ff_4_service_provided_description\" name=\"service_provided_description\" id=\"ff_4_service_provided_description\" class=\"ff-el-form-control\" placeholder=\"Describe the service provided\" rows=\"3\" cols=\"2\" data-name=\"service_provided_description\" ><\/textarea><\/div><\/div><div class='ff-el-group'><div class=\"ff-el-input--label ff-el-is-required asterisk-right\"><label for='ff_4_date_service_provided' id='label_ff_4_date_service_provided' aria-label=\"Date Service Provided:\">Date Service Provided:<\/label><\/div><div class='ff-el-input--content'><input  aria-label='Date Service Provided: Use arrow keys to navigate dates. Press enter to select a date.'  aria-haspopup='dialog' data-type-datepicker data-format='d\/m\/Y' type=\"text\" name=\"date_service_provided\" id=\"ff_4_date_service_provided\" class=\"ff-el-form-control ff-el-datepicker\" placeholder=\"dd\/mm\/YY\" data-name=\"date_service_provided\"  aria-invalid='false' aria-required=true><\/div><\/div><div class='ff-el-group'><div class=\"ff-el-input--label asterisk-right\"><label for='ff_4_comments_or_additional_requests' id='label_ff_4_comments_or_additional_requests' aria-label=\"Comments or Additional Requests:\">Comments or Additional Requests:<\/label><\/div><div class='ff-el-input--content'><textarea aria-required=\"false\" aria-labelledby=\"label_ff_4_comments_or_additional_requests\" name=\"comments_or_additional_requests\" id=\"ff_4_comments_or_additional_requests\" class=\"ff-el-form-control\" placeholder=\"Enter any additional comments or requests\" rows=\"3\" cols=\"2\" data-name=\"comments_or_additional_requests\" ><\/textarea><\/div><\/div><div class='ff-el-group    ff-el-input--content'><div class='ff-el-form-check ff-el-tc'><label aria-label='I, the undersigned, consent to the Yemeni Canadian Club collecting and using my personal information for the purpose of providing the services I have requested. I understand that my information will be kept confidential and only shared with relevant authorities if required.' class='ff-el-form-check-label ff_tc_label' for=Consent_2512e218b16ae1caaaa0f72f1136a097><span class='ff_tc_checkbox'><input type=\"checkbox\" name=\"Consent\" class=\"ff-el-form-check-input\" data-name=\"Consent\" id=\"Consent_2512e218b16ae1caaaa0f72f1136a097\"  value='on' aria-invalid='false' aria-required=true><\/span> <div class='ff_t_c'><p><span class=\"ui-provider cj jw jx jy jz ka kb kc kd ke kf kg kh ki kj kk kl km kn ko kp kq kr ks kt ku kv kw kx ky kz la lb lc ld\"> I, the undersigned, consent to the Yemeni Canadian Club collecting and using my personal information for the purpose of providing the services I have requested. I understand that my information will be kept confidential and only shared with relevant authorities if required.<\/span><\/p><\/div><\/label><\/div><\/div><div data-type=\"name-element\" data-name=\"client_signature\" class=\" ff-field_container ff-name-field-wrapper\" ><div class='ff-t-container'><div class='ff-t-cell '><div class='ff-el-group ff-el-form-top'><div class=\"ff-el-input--label ff-el-is-required asterisk-right\"><label for='ff_4_client_signature_first_name_' id='label_ff_4_client_signature_first_name_' >Client Signature:<\/label><\/div><div class='ff-el-input--content'><input type=\"text\" name=\"client_signature[first_name]\" id=\"ff_4_client_signature_first_name_\" class=\"ff-el-form-control\" placeholder=\"Enter your full name as a signature\" aria-invalid=\"false\" aria-required=true><\/div><\/div><\/div><\/div><\/div><div class='ff-el-group'><div class=\"ff-el-input--label ff-el-is-required asterisk-right\"><label for='ff_4_date' id='label_ff_4_date' aria-label=\"Date:\">Date:<\/label><\/div><div class='ff-el-input--content'><input  aria-label='Date: Use arrow keys to navigate dates. Press enter to select a date.'  aria-haspopup='dialog' data-type-datepicker data-format='d\/m\/Y' type=\"text\" name=\"date\" id=\"ff_4_date\" class=\"ff-el-form-control ff-el-datepicker\" placeholder=\"dd\/mm\/YYY\" data-name=\"date\"  aria-invalid='false' aria-required=true><\/div><\/div><div data-type=\"name-element\" data-name=\"intake_officer_name\" class=\" ff-field_container ff-name-field-wrapper\" ><div class='ff-t-container'><div class='ff-t-cell '><div class='ff-el-group ff-el-form-top'><div class=\"ff-el-input--label ff-el-is-required asterisk-right\"><label for='ff_4_intake_officer_name_first_name_' id='label_ff_4_intake_officer_name_first_name_' >Intake Officer Name:<\/label><\/div><div class='ff-el-input--content'><input type=\"text\" name=\"intake_officer_name[first_name]\" id=\"ff_4_intake_officer_name_first_name_\" class=\"ff-el-form-control\" placeholder=\"Enter the intake officer&#039;s name\" aria-invalid=\"false\" aria-required=true><\/div><\/div><\/div><\/div><\/div><div class='ff-el-group'><div class=\"ff-el-input--label ff-el-is-required asterisk-right\"><label for='ff_4_date_received' id='label_ff_4_date_received' aria-label=\"Date Received:\">Date Received:<\/label><\/div><div class='ff-el-input--content'><input  aria-label='Date Received: Use arrow keys to navigate dates. Press enter to select a date.'  aria-haspopup='dialog' data-type-datepicker data-format='d\/m\/Y' type=\"text\" name=\"date_received\" id=\"ff_4_date_received\" class=\"ff-el-form-control ff-el-datepicker\" placeholder=\"dd\/mm\/YYYY\" data-name=\"date_received\"  aria-invalid='false' aria-required=true><\/div><\/div><div class='ff-el-group'><div class=\"ff-el-input--label asterisk-right\"><label for='ff_4_notes' id='label_ff_4_notes' aria-label=\"Notes:\">Notes:<\/label><\/div><div class='ff-el-input--content'><textarea aria-required=\"false\" aria-labelledby=\"label_ff_4_notes\" name=\"notes\" id=\"ff_4_notes\" class=\"ff-el-form-control\" placeholder=\"Enter any notes\" rows=\"3\" cols=\"2\" data-name=\"notes\" ><\/textarea><\/div><\/div><div class='ff-el-group ff-text-right ff_submit_btn_wrapper'><button type=\"submit\" class=\"ff-btn ff-btn-submit ff-btn-md ff_btn_style\"  aria-label=\"Submit\">Submit<\/button><\/div><\/fieldset><\/form><div id='fluentform_4_errors' class='ff-errors-in-stack ff_form_instance_4_1 ff-form-loading_errors ff_form_instance_4_1_errors'><\/div><\/div>            <script type=\"text\/javascript\">\n                window.fluent_form_ff_form_instance_4_1 = {\"id\":\"4\",\"ajaxUrl\":\"https:\\\/\\\/yemenicanadian.club\\\/wp-admin\\\/admin-ajax.php\",\"settings\":{\"layout\":{\"labelPlacement\":\"top\",\"helpMessagePlacement\":\"with_label\",\"errorMessagePlacement\":\"inline\",\"cssClassName\":\"\",\"asteriskPlacement\":\"asterisk-right\"},\"restrictions\":{\"denyEmptySubmission\":{\"enabled\":false}}},\"form_instance\":\"ff_form_instance_4_1\",\"form_id_selector\":\"fluentform_4\",\"rules\":{\"full_name[first_name]\":{\"required\":{\"value\":true,\"message\":\"This field is required\",\"global\":true,\"global_message\":\"This field is required\"}},\"full_name[middle_name]\":{\"required\":{\"value\":false,\"message\":\"This field is required\",\"global\":true,\"global_message\":\"This field is required\"}},\"full_name[last_name]\":{\"required\":{\"value\":false,\"message\":\"This field is required\",\"global\":true,\"global_message\":\"This field is required\"}},\"date_of_birth\":{\"required\":{\"value\":true,\"message\":\"This field is required\",\"global_message\":\"This field is required\",\"global\":true}},\"address[address_line_1]\":{\"required\":{\"value\":true,\"message\":\"This field is required\",\"global_message\":\"This field is required\",\"global\":true}},\"address[address_line_2]\":{\"required\":{\"value\":false,\"message\":\"This field is required\",\"global_message\":\"This field is required\",\"global\":true}},\"address[city]\":{\"required\":{\"value\":true,\"message\":\"This field is required\",\"global_message\":\"This field is required\",\"global\":true}},\"address[state]\":{\"required\":{\"value\":true,\"message\":\"This field is required\",\"global_message\":\"This field is 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for limited digits\",\"global_message\":\"Validation fails for limited digits\",\"global\":true}},\"email\":{\"required\":{\"value\":true,\"message\":\"This field is required\",\"global_message\":\"This field is required\",\"global\":true},\"email\":{\"value\":true,\"message\":\"This field must contain a valid email\",\"global_message\":\"This field must contain a valid email\",\"global\":true}},\"services_requested\":{\"required\":{\"value\":true,\"message\":\"This field is required\",\"global_message\":\"This field is required\",\"global\":true}},\"services_requested_other\":{\"required\":{\"value\":true,\"message\":\"This field is required\",\"global_message\":\"This field is required\",\"global\":true}},\"date_of_service_request\":{\"required\":{\"value\":true,\"message\":\"This field is required\",\"global_message\":\"This field is required\",\"global\":true}},\"service_provided_description\":{\"required\":{\"value\":true,\"message\":\"This field is 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