{"id":1859,"date":"2017-07-07T12:30:13","date_gmt":"2017-07-07T16:30:13","guid":{"rendered":"https:\/\/cs.molecularcodedev.com\/referral-form\/"},"modified":"2026-09-19T20:39:46","modified_gmt":"2026-09-20T00:39:46","slug":"formulaire-recommandation","status":"publish","type":"page","link":"https:\/\/cs.molecularcodedev.com\/fr\/formulaire-recommandation\/","title":{"rendered":"Formulaire de recommandation"},"content":{"rendered":"<div class=\"et_pb_section_0 et_pb_section et_section_regular et_block_section\"><div class=\"et_pb_row_0 et_pb_row et_block_row\"><div class=\"et_pb_column_0 et_pb_column et_pb_column_4_4 et-last-child et_block_column et_pb_css_mix_blend_mode_passthrough\"><div class=\"et_pb_text_0 et_pb_text et_pb_bg_layout_light et_pb_module et_block_module\"><div class=\"et_pb_text_inner\"><h1>Formulaire de recommandation<\/h1>\n<\/div><\/div><div class=\"et_pb_contact_form_0 et_pb_contact_form_container clearfix et_pb_module et_flex_module\" data-form_unique_num=\"0\" data-form_unique_id=\"7067d836e5cc6b8d0df5f1ee01accc26\" id=\"et_pb_contact_form_7067d836e5cc6b8d0df5f1ee01accc26\"><div class=\"et-pb-contact-message\"><\/div><div class=\"et_pb_contact\"><form class=\"et_pb_contact_form et_flex_module\" method=\"post\" action=\"https:\/\/cs.molecularcodedev.com\/fr\/wp-json\/wp\/v2\/pages\/1859\"><div class=\"et_pb_contact_field_0 et_pb_contact_field et_pb_module et_flex_module et_flex_column_24_24 et_flex_column_24_24_tablet et_flex_column_24_24_phone\" data-id=\"date\" data-type=\"input\"><label class=\"et_pb_contact_form_label\" for=\"et_pb_contact_0_date_0\">Date<\/label><input type=\"text\" name=\"et_pb_contact_0_date_0\" id=\"et_pb_contact_0_date_0\" class=\"input\" data-required_mark=\"required\" data-field_type=\"input\" data-original_id=\"date\" placeholder=\"Date\" title=\"\" value=\"\" \/><\/div><div class=\"et_pb_contact_field_1 et_pb_contact_field et_pb_module et_flex_module et_flex_column_12_24 et_flex_column_12_24_tablet et_flex_column_12_24_phone\" data-id=\"name\" data-type=\"input\"><label class=\"et_pb_contact_form_label\" for=\"et_pb_contact_0_name_1\">Nom et pr\u00e9nom<\/label><input type=\"text\" name=\"et_pb_contact_0_name_1\" id=\"et_pb_contact_0_name_1\" class=\"input\" data-required_mark=\"required\" data-field_type=\"input\" data-original_id=\"name\" placeholder=\"Nom et pr\u00e9nom\" title=\"\" value=\"\" \/><\/div><div class=\"et_pb_contact_field_2 et_pb_contact_field et_pb_module et_flex_module et_flex_column_12_24 et_flex_column_12_24_tablet et_flex_column_12_24_phone\" data-id=\"email\" data-type=\"email\"><label class=\"et_pb_contact_form_label\" for=\"et_pb_contact_0_email_2\">Courriel<\/label><input type=\"text\" name=\"et_pb_contact_0_email_2\" id=\"et_pb_contact_0_email_2\" class=\"input\" data-required_mark=\"required\" data-field_type=\"email\" data-original_id=\"email\" placeholder=\"Courriel\" title=\"\" value=\"\" \/><\/div><div class=\"et_pb_contact_field_3 et_pb_contact_field et_pb_module et_flex_module et_flex_column_24_24 et_flex_column_24_24_tablet et_flex_column_24_24_phone\" data-id=\"details\" data-type=\"text\"><label class=\"et_pb_contact_form_label\" for=\"et_pb_contact_0_details_3\">Description<\/label><textarea name=\"et_pb_contact_0_details_3\" id=\"et_pb_contact_0_details_3\" class=\"et_pb_contact_message input\" data-required_mark=\"required\" data-field_type=\"text\" data-original_id=\"details\" placeholder=\"Description\"><\/textarea><\/div><div class=\"et_pb_contact_field_4 et_pb_contact_field et_pb_module et_flex_module et_flex_column_24_24 et_flex_column_24_24_tablet et_flex_column_24_24_phone\" data-id=\"request\" data-type=\"checkbox\"><label class=\"et_pb_contact_form_label\">DEMANDE DE SUIVI DE LA CLINIQUE SPECTRUM (COCHEZ TOUTES LES CASES PERTINENTES)  J\u2019aimerais recevoir plus d\u2019informations sur :<\/label><input type=\"hidden\" name=\"et_pb_contact_0_request_4\" class=\"et_pb_checkbox_handle\" data-required_mark=\"not_required\" data-field_type=\"checkbox\" data-original_id=\"request\" \/><span class=\"et_pb_contact_field_options_wrapper et_pb_field_module_checkbox\"><span class=\"et_pb_contact_field_options_title\">DEMANDE DE SUIVI DE LA CLINIQUE SPECTRUM (COCHEZ TOUTES LES CASES PERTINENTES)  J\u2019aimerais recevoir plus d\u2019informations sur :<\/span><span class=\"et_pb_contact_field_options_list\"><span class=\"et_pb_contact_field_checkbox\"><input type=\"checkbox\" id=\"et_pb_contact_0_request_4_0\" class=\"input\" value=\"L\u2019\u00e9valuation d\u2019un(e) jeune enfant\" data-required_mark=\"not_required\" data-field_type=\"checkbox\" data-original_id=\"request\" \/><label for=\"et_pb_contact_0_request_4_0\"><i><\/i>L\u2019\u00e9valuation d\u2019un(e) jeune enfant<\/label><\/span><span class=\"et_pb_contact_field_checkbox\"><input type=\"checkbox\" id=\"et_pb_contact_0_request_4_1\" class=\"input\" value=\"L\u2019\u00e9valuation en pr\u00e9vision de la transition vers l\u2019\u00e9cole primaire ou secondaire\" data-required_mark=\"not_required\" data-field_type=\"checkbox\" data-original_id=\"request\" \/><label for=\"et_pb_contact_0_request_4_1\"><i><\/i>L\u2019\u00e9valuation en pr\u00e9vision de la transition vers l\u2019\u00e9cole primaire ou secondaire<\/label><\/span><span class=\"et_pb_contact_field_checkbox\"><input type=\"checkbox\" id=\"et_pb_contact_0_request_4_2\" class=\"input\" value=\"L\u2019\u00e9valuation d\u2019un(e) adulte\" data-required_mark=\"not_required\" data-field_type=\"checkbox\" data-original_id=\"request\" \/><label for=\"et_pb_contact_0_request_4_2\"><i><\/i>L\u2019\u00e9valuation d\u2019un(e) adulte<\/label><\/span><span class=\"et_pb_contact_field_checkbox\"><input type=\"checkbox\" id=\"et_pb_contact_0_request_4_3\" class=\"input\" value=\"Les interventions pr\u00e9coces offertes \u00e0 mon enfant\" data-required_mark=\"not_required\" data-field_type=\"checkbox\" data-original_id=\"request\" \/><label for=\"et_pb_contact_0_request_4_3\"><i><\/i>Les interventions pr\u00e9coces offertes \u00e0 mon enfant<\/label><\/span><span class=\"et_pb_contact_field_checkbox\"><input type=\"checkbox\" id=\"et_pb_contact_0_request_4_4\" class=\"input\" value=\"Les ateliers offerts aux parents\" data-required_mark=\"not_required\" data-field_type=\"checkbox\" data-original_id=\"request\" \/><label for=\"et_pb_contact_0_request_4_4\"><i><\/i>Les ateliers offerts aux parents<\/label><\/span><span class=\"et_pb_contact_field_checkbox\"><input type=\"checkbox\" id=\"et_pb_contact_0_request_4_5\" class=\"input\" value=\"Les ateliers offerts aux \u00e9ducateurs en garderie\" data-required_mark=\"not_required\" data-field_type=\"checkbox\" data-original_id=\"request\" \/><label for=\"et_pb_contact_0_request_4_5\"><i><\/i>Les ateliers offerts aux \u00e9ducateurs en garderie<\/label><\/span><span class=\"et_pb_contact_field_checkbox\"><input type=\"checkbox\" id=\"et_pb_contact_0_request_4_6\" class=\"input\" value=\"Les services d\u2019orthophonie\" data-required_mark=\"not_required\" data-field_type=\"checkbox\" data-original_id=\"request\" \/><label for=\"et_pb_contact_0_request_4_6\"><i><\/i>Les services d\u2019orthophonie<\/label><\/span><span class=\"et_pb_contact_field_checkbox\"><input type=\"checkbox\" id=\"et_pb_contact_0_request_4_7\" class=\"input\" value=\"L\u2019\u00e9ducation en sant\u00e9 sexuelle\" data-required_mark=\"not_required\" data-field_type=\"checkbox\" data-original_id=\"request\" \/><label for=\"et_pb_contact_0_request_4_7\"><i><\/i>L\u2019\u00e9ducation en sant\u00e9 sexuelle<\/label><\/span><span class=\"et_pb_contact_field_checkbox\"><input type=\"checkbox\" id=\"et_pb_contact_0_request_4_8\" class=\"input\" value=\"Les formations et ateliers offerts aux professionnels\" data-required_mark=\"not_required\" data-field_type=\"checkbox\" data-original_id=\"request\" \/><label for=\"et_pb_contact_0_request_4_8\"><i><\/i>Les formations et ateliers offerts aux professionnels<\/label><\/span><\/span><\/span><\/div><div class=\"et_pb_contact_field_5 et_pb_contact_field et_pb_module et_flex_module et_flex_column_24_24 et_flex_column_24_24_tablet et_flex_column_24_24_phone\" data-id=\"referrername\" data-type=\"input\"><label class=\"et_pb_contact_form_label\" for=\"et_pb_contact_0_referrername_5\">Nom du professionnel qui a fait la recommandation<\/label><input type=\"text\" name=\"et_pb_contact_0_referrername_5\" id=\"et_pb_contact_0_referrername_5\" class=\"input\" data-required_mark=\"required\" data-field_type=\"input\" data-original_id=\"referrername\" placeholder=\"Nom du professionnel qui a fait la recommandation\" title=\"\" value=\"\" \/><\/div><div class=\"et_pb_contact_field_6 et_pb_contact_field et_pb_module et_flex_module et_flex_column_12_24 et_flex_column_12_24_tablet et_flex_column_12_24_phone\" data-id=\"referrerprofession\" data-type=\"input\"><label class=\"et_pb_contact_form_label\" for=\"et_pb_contact_0_referrerprofession_6\">Profession du r\u00e9f\u00e9rent<\/label><input type=\"text\" name=\"et_pb_contact_0_referrerprofession_6\" id=\"et_pb_contact_0_referrerprofession_6\" class=\"input\" data-required_mark=\"required\" data-field_type=\"input\" data-original_id=\"referrerprofession\" placeholder=\"Profession du r\u00e9f\u00e9rent\" title=\"\" value=\"\" \/><\/div><div class=\"et_pb_contact_field_7 et_pb_contact_field et_pb_module et_flex_module et_flex_column_12_24 et_flex_column_12_24_tablet et_flex_column_12_24_phone\" data-id=\"referrernumber\" data-type=\"input\"><label class=\"et_pb_contact_form_label\" for=\"et_pb_contact_0_referrernumber_7\">Num\u00e9ro de licence<\/label><input type=\"text\" name=\"et_pb_contact_0_referrernumber_7\" id=\"et_pb_contact_0_referrernumber_7\" class=\"input\" data-required_mark=\"required\" data-field_type=\"input\" data-original_id=\"referrernumber\" placeholder=\"Num\u00e9ro de licence\" title=\"\" value=\"\" \/><\/div><input type=\"hidden\" name=\"et_pb_contactform_submit_7067d836e5cc6b8d0df5f1ee01accc26\" value=\"et_contact_proccess\" \/><div class=\"et_contact_bottom_container\"><div class=\"et_pb_contact_right et_pb_contact_field\"><p class=\"clearfix\"><label><span class=\"et_pb_contact_captcha_question\">4 + 1<\/span> = <input type=\"text\" size=\"2\" class=\"input et_pb_contact_captcha\" data-first_digit=\"4\" data-second_digit=\"1\" data-required_mark=\"required\" name=\"et_pb_contact_captcha_7067d836e5cc6b8d0df5f1ee01accc26\" autocomplete=\"off\" \/><\/label><\/p><\/div><div class=\"et_pb_button_wrapper\"><button type=\"submit\" name=\"et_builder_submit_button\" class=\"et_pb_button et_pb_contact_submit\">Soumettre<\/button><\/div><\/div><input type=\"hidden\" id=\"_wpnonce-et-pb-contact-form-submitted-7067d836e5cc6b8d0df5f1ee01accc26\" name=\"_wpnonce-et-pb-contact-form-submitted-7067d836e5cc6b8d0df5f1ee01accc26\" value=\"e8d4877508\" \/><input type=\"hidden\" name=\"_wp_http_referer\" value=\"\/fr\/wp-json\/wp\/v2\/pages\/1859\" \/><\/form><\/div><\/div><\/div><\/div><\/div>","protected":false},"excerpt":{"rendered":"","protected":false},"author":1,"featured_media":0,"parent":0,"menu_order":61,"comment_status":"closed","ping_status":"closed","template":"","meta":{"footnotes":""},"class_list":["post-1859","page","type-page","status-publish","hentry"],"yoast_head":"<!-- This site is optimized with the Yoast SEO plugin v28.5 - https:\/\/yoast.com\/product\/yoast-seo-wordpress\/ -->\n<title>Referral Form | Clinique Spectrum<\/title>\n<meta name=\"robots\" content=\"index, follow, max-snippet:-1, max-image-preview:large, max-video-preview:-1\" \/>\n<link rel=\"canonical\" href=\"https:\/\/cs.molecularcodedev.com\/referral-form\/\" \/>\n<meta property=\"og:locale\" content=\"fr_FR\" \/>\n<meta property=\"og:type\" content=\"article\" \/>\n<meta property=\"og:title\" content=\"Referral Form | Clinique Spectrum\" \/>\n<meta property=\"og:url\" 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