{"id":5797,"date":"2019-06-24T06:34:02","date_gmt":"2019-06-24T04:34:02","guid":{"rendered":"https:\/\/santum.net\/provider-form\/"},"modified":"2026-03-10T05:11:14","modified_gmt":"2026-03-10T03:11:14","slug":"provider-form","status":"publish","type":"page","link":"https:\/\/santum.net\/za\/provider-form\/","title":{"rendered":"Provider Application Form"},"content":{"rendered":"<div class=\"wpb-content-wrapper\"><p>[vc_row][vc_column][vc_column_text]<\/p>\n<p style=\"text-align: center;\">Please complete application form below for use of the Santum platform and independent provision of your counseling and therapy services.<\/p>\n<p>[\/vc_column_text][vc_column_text]\n                <div class='gf_browser_gecko gform_wrapper gravity-theme gform-theme--no-framework' data-form-theme='gravity-theme' data-form-index='0' id='gform_wrapper_1' >\n                        <div class='gform_heading'>\n\t\t\t\t\t\t\t<p class='gform_required_legend'>&quot;<span class=\"gfield_required gfield_required_asterisk\">*<\/span>&quot; indicates required fields<\/p>\n                        <\/div><form method='post' enctype='multipart\/form-data' target='gform_ajax_frame_1' id='gform_1'  action='\/za\/wp-json\/wp\/v2\/pages\/5797' data-formid='1' novalidate><input id=\"gpnf_session_hash_1\" type=\"hidden\" name=\"gpnf_session_hash\" value=\"f79141e300b3\">\n                        <div class='gform-body gform_body'><div id='gform_fields_1' class='gform_fields top_label form_sublabel_below description_below validation_below'><div class=\"gfmc-container\"><div class=\"gfield gfmc-column gfmc-field\"><div id=\"field_1_68\" class=\"gfield gfield--type-html gfield--input-type-html gfield--width-full gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_1_68\" >* Required Fields<\/div><div id=\"field_1_46\" class=\"gfield gfield--type-text gfield--input-type-text gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_1_46\" ><label class='gfield_label gform-field-label' for='input_1_46'>Name and Last Name<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_46' id='input_1_46' type='text' value='' class='large'    placeholder='Name and Last Name' aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_1_2\" class=\"gfield gfield--type-text gfield--input-type-text gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_1_2\" ><label class='gfield_label gform-field-label' for='input_1_2'>Identity Number<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_2' id='input_1_2' type='text' value='' class='large'    placeholder='Identity Number' aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_1_4\" class=\"gfield gfield--type-email gfield--input-type-email gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_1_4\" ><label class='gfield_label gform-field-label' for='input_1_4'>Email Address<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_email'>\n                            <input name='input_4' id='input_1_4' type='email' value='' class='large'   placeholder='Email Address' aria-required=\"true\" aria-invalid=\"false\"  \/>\n                        <\/div><\/div><div id=\"field_1_5\" class=\"gfield gfield--type-phone gfield--input-type-phone gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_1_5\" ><label class='gfield_label gform-field-label' for='input_1_5'>Phone Number<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_phone'><input name='input_5' id='input_1_5' type='tel' value='' class='large'  placeholder='Phone Number' aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><fieldset id=\"field_1_6\" class=\"gfield gfield--type-address gfield--input-type-address gfield--width-full gfield_contains_required field_sublabel_above gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_1_6\" ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Physical Address<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend>    \n                    <div class='ginput_complex ginput_container has_street has_street2 has_city has_state has_zip has_country ginput_container_address gform-grid-row' id='input_1_6' >\n                         <span class='ginput_full address_line_1 ginput_address_line_1 gform-grid-col' id='input_1_6_1_container' >\n                                        <label for='input_1_6_1' id='input_1_6_1_label' class='gform-field-label gform-field-label--type-sub '>Street Address<\/label>\n                                        <input type='text' name='input_6.1' id='input_1_6_1' value=''   placeholder='Adress Line 1' aria-required='true'    \/>\n                                   <\/span><span class='ginput_full address_line_2 ginput_address_line_2 gform-grid-col' id='input_1_6_2_container' >\n                                        <label for='input_1_6_2' id='input_1_6_2_label' class='gform-field-label gform-field-label--type-sub '>Address Line 2<\/label>\n                                        <input type='text' name='input_6.2' id='input_1_6_2' value=''   placeholder='Adress Line 2'  aria-required='false'   \/>\n                                    <\/span><span class='ginput_left address_city ginput_address_city gform-grid-col' id='input_1_6_3_container' >\n                                    <label for='input_1_6_3' id='input_1_6_3_label' class='gform-field-label gform-field-label--type-sub '>City<span class='gfield_required'>*<\/span><\/label>\n                                    <input type='text' name='input_6.3' id='input_1_6_3' value=''   placeholder='City' aria-required='true'    \/>\n                                 <\/span><span class='ginput_right address_state ginput_address_state gform-grid-col' id='input_1_6_4_container' >\n                                        <label for='input_1_6_4' id='input_1_6_4_label' class='gform-field-label gform-field-label--type-sub '>Province<span class='gfield_required'>*<\/span><\/label>\n                                        <input type='text' name='input_6.4' id='input_1_6_4' value=''     placeholder='Province' aria-required='true'    \/>\n                                      <\/span><span class='ginput_left address_zip ginput_address_zip gform-grid-col' id='input_1_6_5_container' >\n                                    <label for='input_1_6_5' id='input_1_6_5_label' class='gform-field-label gform-field-label--type-sub '>Postal Code<span class='gfield_required'>*<\/span><\/label>\n                                    <input type='text' name='input_6.5' id='input_1_6_5' value=''   placeholder='Postal Code' aria-required='true'    \/>\n                                <\/span><span class='ginput_right address_country ginput_address_country gform-grid-col' id='input_1_6_6_container' >\n                                        <label for='input_1_6_6' id='input_1_6_6_label' class='gform-field-label gform-field-label--type-sub '>Country <span class='gfield_required'>*<\/span><\/label>\n                                        <select name='input_6.6' id='input_1_6_6'   aria-required='true'    ><option value='' >Country<\/option><option value='Afghanistan' >Afghanistan<\/option><option value='Albania' >Albania<\/option><option value='Algeria' >Algeria<\/option><option value='American Samoa' >American Samoa<\/option><option value='Andorra' >Andorra<\/option><option value='Angola' >Angola<\/option><option value='Anguilla' >Anguilla<\/option><option value='Antarctica' >Antarctica<\/option><option value='Antigua and Barbuda' >Antigua and Barbuda<\/option><option value='Argentina' >Argentina<\/option><option value='Armenia' >Armenia<\/option><option value='Aruba' >Aruba<\/option><option value='Australia' >Australia<\/option><option value='Austria' >Austria<\/option><option value='Azerbaijan' >Azerbaijan<\/option><option value='Bahamas' >Bahamas<\/option><option value='Bahrain' >Bahrain<\/option><option value='Bangladesh' >Bangladesh<\/option><option value='Barbados' >Barbados<\/option><option value='Belarus' >Belarus<\/option><option value='Belgium' >Belgium<\/option><option value='Belize' >Belize<\/option><option value='Benin' >Benin<\/option><option value='Bermuda' >Bermuda<\/option><option value='Bhutan' >Bhutan<\/option><option value='Bolivia' >Bolivia<\/option><option value='Bonaire, Sint Eustatius and Saba' >Bonaire, Sint Eustatius and Saba<\/option><option value='Bosnia and Herzegovina' >Bosnia and Herzegovina<\/option><option value='Botswana' >Botswana<\/option><option value='Bouvet Island' >Bouvet Island<\/option><option value='Brazil' >Brazil<\/option><option value='British Indian Ocean Territory' >British Indian Ocean Territory<\/option><option value='Brunei Darussalam' >Brunei Darussalam<\/option><option value='Bulgaria' >Bulgaria<\/option><option value='Burkina Faso' >Burkina Faso<\/option><option value='Burundi' >Burundi<\/option><option value='Cabo Verde' >Cabo Verde<\/option><option value='Cambodia' >Cambodia<\/option><option value='Cameroon' >Cameroon<\/option><option value='Canada' >Canada<\/option><option value='Cayman Islands' >Cayman Islands<\/option><option value='Central African Republic' >Central African Republic<\/option><option value='Chad' >Chad<\/option><option value='Chile' >Chile<\/option><option value='China' >China<\/option><option value='Christmas Island' >Christmas Island<\/option><option value='Cocos Islands' >Cocos Islands<\/option><option value='Colombia' >Colombia<\/option><option value='Comoros' >Comoros<\/option><option value='Congo' >Congo<\/option><option value='Congo, Democratic Republic of the' >Congo, Democratic Republic of the<\/option><option value='Cook Islands' >Cook Islands<\/option><option value='Costa Rica' >Costa Rica<\/option><option value='Croatia' >Croatia<\/option><option value='Cuba' >Cuba<\/option><option value='Cura\u00e7ao' >Cura\u00e7ao<\/option><option value='Cyprus' >Cyprus<\/option><option value='Czechia' >Czechia<\/option><option value='C\u00f4te d&#039;Ivoire' >C\u00f4te d&#039;Ivoire<\/option><option value='Denmark' >Denmark<\/option><option value='Djibouti' >Djibouti<\/option><option value='Dominica' >Dominica<\/option><option value='Dominican Republic' >Dominican Republic<\/option><option value='Ecuador' >Ecuador<\/option><option value='Egypt' >Egypt<\/option><option value='El Salvador' >El Salvador<\/option><option value='Equatorial Guinea' >Equatorial Guinea<\/option><option value='Eritrea' >Eritrea<\/option><option value='Estonia' >Estonia<\/option><option value='Eswatini' >Eswatini<\/option><option value='Ethiopia' >Ethiopia<\/option><option value='Falkland Islands' >Falkland Islands<\/option><option value='Faroe Islands' >Faroe Islands<\/option><option value='Fiji' >Fiji<\/option><option value='Finland' >Finland<\/option><option value='France' >France<\/option><option value='French Guiana' >French Guiana<\/option><option value='French Polynesia' >French Polynesia<\/option><option value='French Southern Territories' >French Southern Territories<\/option><option value='Gabon' >Gabon<\/option><option value='Gambia' >Gambia<\/option><option value='Georgia' >Georgia<\/option><option value='Germany' >Germany<\/option><option value='Ghana' >Ghana<\/option><option value='Gibraltar' >Gibraltar<\/option><option value='Greece' >Greece<\/option><option value='Greenland' >Greenland<\/option><option value='Grenada' >Grenada<\/option><option value='Guadeloupe' >Guadeloupe<\/option><option value='Guam' >Guam<\/option><option value='Guatemala' >Guatemala<\/option><option value='Guernsey' >Guernsey<\/option><option value='Guinea' >Guinea<\/option><option value='Guinea-Bissau' >Guinea-Bissau<\/option><option value='Guyana' >Guyana<\/option><option value='Haiti' >Haiti<\/option><option value='Heard Island and McDonald Islands' >Heard Island and McDonald Islands<\/option><option value='Holy See' >Holy See<\/option><option value='Honduras' >Honduras<\/option><option value='Hong Kong' >Hong Kong<\/option><option value='Hungary' >Hungary<\/option><option value='Iceland' >Iceland<\/option><option value='India' >India<\/option><option value='Indonesia' >Indonesia<\/option><option value='Iran' >Iran<\/option><option value='Iraq' >Iraq<\/option><option value='Ireland' >Ireland<\/option><option value='Isle of Man' >Isle of Man<\/option><option value='Israel' >Israel<\/option><option value='Italy' >Italy<\/option><option value='Jamaica' >Jamaica<\/option><option value='Japan' >Japan<\/option><option value='Jersey' >Jersey<\/option><option value='Jordan' >Jordan<\/option><option value='Kazakhstan' >Kazakhstan<\/option><option value='Kenya' >Kenya<\/option><option value='Kiribati' >Kiribati<\/option><option value='Korea, Democratic People&#039;s Republic of' >Korea, Democratic People&#039;s Republic of<\/option><option value='Korea, Republic of' >Korea, Republic of<\/option><option value='Kuwait' >Kuwait<\/option><option value='Kyrgyzstan' >Kyrgyzstan<\/option><option value='Lao People&#039;s Democratic Republic' >Lao People&#039;s Democratic Republic<\/option><option value='Latvia' >Latvia<\/option><option value='Lebanon' >Lebanon<\/option><option value='Lesotho' >Lesotho<\/option><option value='Liberia' >Liberia<\/option><option value='Libya' >Libya<\/option><option value='Liechtenstein' >Liechtenstein<\/option><option value='Lithuania' >Lithuania<\/option><option value='Luxembourg' >Luxembourg<\/option><option value='Macao' >Macao<\/option><option value='Madagascar' >Madagascar<\/option><option value='Malawi' >Malawi<\/option><option value='Malaysia' >Malaysia<\/option><option value='Maldives' >Maldives<\/option><option value='Mali' >Mali<\/option><option value='Malta' >Malta<\/option><option value='Marshall Islands' >Marshall Islands<\/option><option value='Martinique' >Martinique<\/option><option value='Mauritania' >Mauritania<\/option><option value='Mauritius' >Mauritius<\/option><option value='Mayotte' >Mayotte<\/option><option value='Mexico' >Mexico<\/option><option value='Micronesia' >Micronesia<\/option><option value='Moldova' >Moldova<\/option><option value='Monaco' >Monaco<\/option><option value='Mongolia' >Mongolia<\/option><option value='Montenegro' >Montenegro<\/option><option value='Montserrat' >Montserrat<\/option><option value='Morocco' >Morocco<\/option><option value='Mozambique' >Mozambique<\/option><option value='Myanmar' >Myanmar<\/option><option value='Namibia' >Namibia<\/option><option value='Nauru' >Nauru<\/option><option value='Nepal' >Nepal<\/option><option value='Netherlands' >Netherlands<\/option><option value='New Caledonia' >New Caledonia<\/option><option value='New Zealand' >New Zealand<\/option><option value='Nicaragua' >Nicaragua<\/option><option value='Niger' >Niger<\/option><option value='Nigeria' >Nigeria<\/option><option value='Niue' >Niue<\/option><option value='Norfolk Island' >Norfolk Island<\/option><option value='North Macedonia' >North Macedonia<\/option><option value='Northern Mariana Islands' >Northern Mariana Islands<\/option><option value='Norway' >Norway<\/option><option value='Oman' >Oman<\/option><option value='Pakistan' >Pakistan<\/option><option value='Palau' >Palau<\/option><option value='Palestine, State of' >Palestine, State of<\/option><option value='Panama' >Panama<\/option><option value='Papua New Guinea' >Papua New Guinea<\/option><option value='Paraguay' >Paraguay<\/option><option value='Peru' >Peru<\/option><option value='Philippines' >Philippines<\/option><option value='Pitcairn' >Pitcairn<\/option><option value='Poland' >Poland<\/option><option value='Portugal' >Portugal<\/option><option value='Puerto Rico' >Puerto Rico<\/option><option value='Qatar' >Qatar<\/option><option value='Romania' >Romania<\/option><option value='Russian Federation' >Russian Federation<\/option><option value='Rwanda' >Rwanda<\/option><option value='R\u00e9union' >R\u00e9union<\/option><option value='Saint Barth\u00e9lemy' >Saint Barth\u00e9lemy<\/option><option value='Saint Helena, Ascension and Tristan da Cunha' >Saint Helena, Ascension and Tristan da Cunha<\/option><option value='Saint Kitts and Nevis' >Saint Kitts and Nevis<\/option><option value='Saint Lucia' >Saint Lucia<\/option><option value='Saint Martin' >Saint Martin<\/option><option value='Saint Pierre and Miquelon' >Saint Pierre and Miquelon<\/option><option value='Saint Vincent and the Grenadines' >Saint Vincent and the Grenadines<\/option><option value='Samoa' >Samoa<\/option><option value='San Marino' >San Marino<\/option><option value='Sao Tome and Principe' >Sao Tome and Principe<\/option><option value='Saudi Arabia' >Saudi Arabia<\/option><option value='Senegal' >Senegal<\/option><option value='Serbia' >Serbia<\/option><option value='Seychelles' >Seychelles<\/option><option value='Sierra Leone' >Sierra Leone<\/option><option value='Singapore' >Singapore<\/option><option value='Sint Maarten' >Sint Maarten<\/option><option value='Slovakia' >Slovakia<\/option><option value='Slovenia' >Slovenia<\/option><option value='Solomon Islands' >Solomon Islands<\/option><option value='Somalia' >Somalia<\/option><option value='South Africa' selected='selected'>South Africa<\/option><option value='South Georgia and the South Sandwich Islands' >South Georgia and the South Sandwich Islands<\/option><option value='South Sudan' >South Sudan<\/option><option value='Spain' >Spain<\/option><option value='Sri Lanka' >Sri Lanka<\/option><option value='Sudan' >Sudan<\/option><option value='Suriname' >Suriname<\/option><option value='Svalbard and Jan Mayen' >Svalbard and Jan Mayen<\/option><option value='Sweden' >Sweden<\/option><option value='Switzerland' >Switzerland<\/option><option value='Syria Arab Republic' >Syria Arab Republic<\/option><option value='Taiwan' >Taiwan<\/option><option value='Tajikistan' >Tajikistan<\/option><option value='Tanzania, the United Republic of' >Tanzania, the United Republic of<\/option><option value='Thailand' >Thailand<\/option><option value='Timor-Leste' >Timor-Leste<\/option><option value='Togo' >Togo<\/option><option value='Tokelau' >Tokelau<\/option><option value='Tonga' >Tonga<\/option><option value='Trinidad and Tobago' >Trinidad and Tobago<\/option><option value='Tunisia' >Tunisia<\/option><option value='Turkmenistan' >Turkmenistan<\/option><option value='Turks and Caicos Islands' >Turks and Caicos Islands<\/option><option value='Tuvalu' >Tuvalu<\/option><option value='T\u00fcrkiye' >T\u00fcrkiye<\/option><option value='US Minor Outlying Islands' >US Minor Outlying Islands<\/option><option value='Uganda' >Uganda<\/option><option value='Ukraine' >Ukraine<\/option><option value='United Arab Emirates' >United Arab Emirates<\/option><option value='United Kingdom' >United Kingdom<\/option><option value='United States' >United States<\/option><option value='Uruguay' >Uruguay<\/option><option value='Uzbekistan' >Uzbekistan<\/option><option value='Vanuatu' >Vanuatu<\/option><option value='Venezuela' >Venezuela<\/option><option value='Viet Nam' >Viet Nam<\/option><option value='Virgin Islands, British' >Virgin Islands, British<\/option><option value='Virgin Islands, U.S.' >Virgin Islands, U.S.<\/option><option value='Wallis and Futuna' >Wallis and Futuna<\/option><option value='Western Sahara' >Western Sahara<\/option><option value='Yemen' >Yemen<\/option><option value='Zambia' >Zambia<\/option><option value='Zimbabwe' >Zimbabwe<\/option><option value='\u00c5land Islands' >\u00c5land Islands<\/option> <\/select>\n                                    <\/span>\n                    <div class='gf_clear gf_clear_complex'><\/div>\n                <\/div><\/fieldset><div id=\"field_1_63\" class=\"gfield gfield--type-fileupload gfield--input-type-fileupload gfield--width-full field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_1_63\" ><label class='gfield_label gform-field-label' for='input_1_63'>UPLOAD YOUR ID (pdf, png, jpg)<\/label><div class='ginput_container ginput_container_fileupload'><input type='hidden' name='MAX_FILE_SIZE' value='67108864' \/><input name='input_63' id='input_1_63' type='file' class='large' aria-describedby=\"gfield_upload_rules_1_63\" onchange='javascript:gformValidateFileSize( this, 67108864 );'  \/><span class='gfield_description gform_fileupload_rules' id='gfield_upload_rules_1_63'>Accepted file types: png, jpg, pdf, Max. file size: 64 MB.<\/span><div class='gfield_description validation_message gfield_validation_message validation_message--hidden-on-empty' id='live_validation_message_1_63'><\/div><\/div><\/div><div id=\"field_1_64\" class=\"gfield gfield--type-fileupload gfield--input-type-fileupload gfield--width-full field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_1_64\" ><label class='gfield_label gform-field-label' for='input_1_64'>UPLOAD YOUR MOST RECENT PHOTO (pdf, png, jpg)<\/label><div class='ginput_container ginput_container_fileupload'><input type='hidden' name='MAX_FILE_SIZE' value='67108864' \/><input name='input_64' id='input_1_64' type='file' class='large' aria-describedby=\"gfield_upload_rules_1_64\" onchange='javascript:gformValidateFileSize( this, 67108864 );'  \/><span class='gfield_description gform_fileupload_rules' id='gfield_upload_rules_1_64'>Accepted file types: png, jpg, pdf, Max. file size: 64 MB.<\/span><div class='gfield_description validation_message gfield_validation_message validation_message--hidden-on-empty' id='live_validation_message_1_64'><\/div><\/div><\/div><div id=\"field_1_65\" class=\"gfield gfield--type-fileupload gfield--input-type-fileupload gfield--width-full field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_1_65\" ><label class='gfield_label gform-field-label' for='input_1_65'>UPLOAD YOUR CV  (pdf, png, jpg)<\/label><div class='ginput_container ginput_container_fileupload'><input type='hidden' name='MAX_FILE_SIZE' value='67108864' \/><input name='input_65' id='input_1_65' type='file' class='large' aria-describedby=\"gfield_upload_rules_1_65\" onchange='javascript:gformValidateFileSize( this, 67108864 );'  \/><span class='gfield_description gform_fileupload_rules' id='gfield_upload_rules_1_65'>Accepted file types: png, jpg, pdf, jpeg, Max. file size: 64 MB.<\/span><div class='gfield_description validation_message gfield_validation_message validation_message--hidden-on-empty' id='live_validation_message_1_65'><\/div><\/div><\/div><div id=\"field_1_66\" class=\"gfield gfield--type-fileupload gfield--input-type-fileupload gfield--width-full field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_1_66\" ><label class='gfield_label gform-field-label' for='input_1_66'>UPLOAD YOUR HPCSA\/SACSSP\/ASCHP REGISTRATION DOCUMENT  (pdf, png, jpg)<\/label><div class='ginput_container ginput_container_fileupload'><input type='hidden' name='MAX_FILE_SIZE' value='67108864' \/><input name='input_66' id='input_1_66' type='file' class='large' aria-describedby=\"gfield_upload_rules_1_66\" onchange='javascript:gformValidateFileSize( this, 67108864 );'  \/><span class='gfield_description gform_fileupload_rules' id='gfield_upload_rules_1_66'>Accepted file types: png, jpg, pdf, jpeg, Max. file size: 64 MB.<\/span><div class='gfield_description validation_message gfield_validation_message validation_message--hidden-on-empty' id='live_validation_message_1_66'><\/div><\/div><\/div><div id=\"field_1_67\" class=\"gfield gfield--type-fileupload gfield--input-type-fileupload gfield--width-full field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_1_67\" ><label class='gfield_label gform-field-label' for='input_1_67'>UPLOAD YOUR PRACTICE NUMBER REGISTRATION DOCUMENT (pdf, png, jpg)<\/label><div class='ginput_container ginput_container_fileupload'><input type='hidden' name='MAX_FILE_SIZE' value='67108864' \/><input name='input_67' id='input_1_67' type='file' class='large' aria-describedby=\"gfield_upload_rules_1_67\" onchange='javascript:gformValidateFileSize( this, 67108864 );'  \/><span class='gfield_description gform_fileupload_rules' id='gfield_upload_rules_1_67'>Accepted file types: png, jpg, pdf, jpeg, Max. file size: 64 MB.<\/span><div class='gfield_description validation_message gfield_validation_message validation_message--hidden-on-empty' id='live_validation_message_1_67'><\/div><\/div><\/div><div id=\"field_1_51\" class=\"gfield gfield--type-text gfield--input-type-text gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_1_51\" ><label class='gfield_label gform-field-label' for='input_1_51'>HPCSA\/SACSSP\/ASCHP Registration Number<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_51' id='input_1_51' type='text' value='' class='large'    placeholder='Registration Number' aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_1_47\" class=\"gfield gfield--type-text gfield--input-type-text field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_1_47\" ><label class='gfield_label gform-field-label' for='input_1_47'>Do you practice under a different name?<\/label><div class='ginput_container ginput_container_text'><input name='input_47' id='input_1_47' type='text' value='' class='large'    placeholder='Practice \/ Company Name'  aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_1_48\" class=\"gfield gfield--type-text gfield--input-type-text gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_1_48\" ><label class='gfield_label gform-field-label' for='input_1_48'>Practice registration number<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_48' id='input_1_48' type='text' value='' class='large'    placeholder='Practice \/ Company Registration Number' aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_1_49\" class=\"gfield gfield--type-text gfield--input-type-text field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_1_49\" ><label class='gfield_label gform-field-label' for='input_1_49'>Private\/Company VAT Number<\/label><div class='ginput_container ginput_container_text'><input name='input_49' id='input_1_49' type='text' value='' class='large'    placeholder='VAT Number'  aria-invalid=\"false\"   \/><\/div><\/div><\/div><\/div><div class=\"gfmc-container\"><div class=\"gfield gfmc-column gfmc-field\"><\/div><\/div><div id=\"field_1_50\" class=\"gfield gfield--type-select gfield--input-type-select has-input-name field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_1_50\" ><label class='gfield_label gform-field-label' for='input_1_50'>How Would you like to be billed?<\/label><div class='ginput_container ginput_container_select'><select name='input_50' id='input_1_50' class='large gfield_select'     aria-invalid=\"false\" ><option value='Select Applicable...' selected='selected'>Select Applicable...<\/option><option value='Bill me personaly' >Bill Me Personaly<\/option><option value='Bill my Practice \/ Company' >Bill My Practice \/ Company<\/option><\/select><\/div><\/div><div id=\"field_1_52\" class=\"gfield gfield--type-text gfield--input-type-text field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_1_52\" ><label class='gfield_label gform-field-label' for='input_1_52'>Name of your prefessional medical malpractice insurance<\/label><div class='ginput_container ginput_container_text'><input name='input_52' id='input_1_52' type='text' value='' class='large'    placeholder='Name of Insurance Company'  aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_1_53\" class=\"gfield gfield--type-text gfield--input-type-text field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_1_53\" ><label class='gfield_label gform-field-label' for='input_1_53'>Membership Number<\/label><div class='ginput_container ginput_container_text'><input name='input_53' id='input_1_53' type='text' value='' class='large'    placeholder='Insurance Membership Number'  aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_1_54\" class=\"gfield gfield--type-select gfield--input-type-select has-input-name field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_1_54\" ><label class='gfield_label gform-field-label' for='input_1_54'>Amount Of Cover<\/label><div class='ginput_container ginput_container_select'><select name='input_54' id='input_1_54' class='large gfield_select'     aria-invalid=\"false\" ><option value='Select Applicable' >Select Applicable<\/option><option value='1 - 5 Million Rand' >1 - 5 Million Rand<\/option><option value='5 - 10 Million Rand' >5 - 10 Million Rand<\/option><option value='Over 10 Million Rand' >Over 10 Million Rand<\/option><\/select><\/div><\/div><div id=\"field_1_9\" class=\"gfield gfield--type-form gfield--input-type-form gform-theme__no-reset--children field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_1_9\" ><label class='gfield_label gform-field-label' for='input_1_9'>Provide Details of Your Education<\/label><div class=\"gpnf-nested-entries-container ginput_container\">\n\n\t<table class=\"gpnf-nested-entries\">\n\n\t\t<thead>\n\t\t<tr>\n\t\t\t\t\t\t\t<th class=\"gpnf-field-3\">\n\t\t\t\t\tDiploma \/ Degree\t\t\t\t<\/th>\n\t\t\t\t\t\t\t<th class=\"gpnf-field-2\">\n\t\t\t\t\tField\t\t\t\t<\/th>\n\t\t\t\t\t\t\t<th class=\"gpnf-field-1\">\n\t\t\t\t\tInstitution\t\t\t\t<\/th>\n\t\t\t\t\t\t\t<th class=\"gpnf-field-5\">\n\t\t\t\t\tYear Completed\t\t\t\t<\/th>\n\t\t\t\t\t\t<th class=\"gpnf-row-actions\"><span class=\"screen-reader-text\">Actions<\/span><\/th>\n\t\t<\/tr>\n\t\t<\/thead>\n\n\t\t<tbody data-bind=\"visible: entries().length, foreach: entries\">\n\t\t<tr data-bind=\"attr: { 'data-entryid': id }\">\n\t\t\t\t\t\t\t<td class=\"gpnf-field\"\n\t\t\t\t\tdata-bind=\"html: f3.label, attr: { 'data-value': f3.label }\"\n\t\t\t\t\tdata-heading=\"Diploma \/ Degree\"\n\t\t\t\t>&nbsp;<\/td>\n\t\t\t\t\t\t\t<td class=\"gpnf-field\"\n\t\t\t\t\tdata-bind=\"html: f2.label, attr: { 'data-value': f2.label }\"\n\t\t\t\t\tdata-heading=\"Field\"\n\t\t\t\t>&nbsp;<\/td>\n\t\t\t\t\t\t\t<td class=\"gpnf-field\"\n\t\t\t\t\tdata-bind=\"html: f1.label, attr: { 'data-value': f1.label }\"\n\t\t\t\t\tdata-heading=\"Institution\"\n\t\t\t\t>&nbsp;<\/td>\n\t\t\t\t\t\t\t<td class=\"gpnf-field\"\n\t\t\t\t\tdata-bind=\"html: f5.label, attr: { 'data-value': f5.label }\"\n\t\t\t\t\tdata-heading=\"Year Completed\"\n\t\t\t\t>&nbsp;<\/td>\n\t\t\t\t\t\t<td class=\"gpnf-row-actions\" style=\"display: none;\" data-bind=\"visible: true\">\n\t\t\t\t<ul>\n\t\t\t\t\t<li class=\"edit\"><button type=\"button\" class=\"edit-button gform-theme-button--secondary\" data-bind=\"click: $parent.editEntry, attr: { 'aria-label': 'Edit Your Highest Qualification {0} where Diploma \/ Degree is {1}.'.gformFormat( $index() + 1, f3.label ) }\">Edit<\/button><\/li>\n\t\t\t\t\t\t\t\t\t\t<li class=\"delete\"><button type=\"button\" class=\"delete-button gform-theme-button--simple gform-theme-button--size-md\" data-bind=\"click: $parent.deleteEntry, attr: { 'aria-label': 'Delete Your Highest Qualification {0} where Diploma \/ Degree is {1}.'.gformFormat( $index() + 1, f3.label ) }\">Delete<\/button><\/li>\n\t\t\t\t<\/ul>\n\t\t\t<\/td>\n\t\t<\/tr>\n\t\t<\/tbody>\n\n\t\t<tbody data-bind=\"visible: entries().length <= 0\">\n\t\t<tr class=\"gpnf-no-entries\" data-bind=\"visible: entries().length <= 0\" style=\"display: none;\">\n\t\t\t<td colspan=\"5\">\n\t\t\t\tThere are no <span>Entries.<\/span>\t\t\t<\/td>\n\t\t<\/tr>\n\t\t<\/tbody>\n\n\t<\/table>\n\n\t<button type=\"button\" class=\"gpnf-add-entry\"\n\t\t        data-formid=\"1\"\n\t\t        data-nestedformid=\"2\"\n\t\t\t\tdata-bind=\"attr: { disabled: isMaxed }, css: { 'gf-default-disabled': isMaxed }\"\n\t\t\t\t>\n\t\t\t\tAdd Your Highest Qualification\n\t\t\t<\/button>\t\n\t\t\t<p class=\"gpnf-add-entry-max\" data-bind=\"visible: isMaxed\" style=\"display: none;\">\n\t\t\t\tMaximum number of entries reached.\n\t\t\t<\/p>\n<\/div>\n<input type=\"hidden\"\n                name=\"input_9\"\n                id=\"input_1_9\"\n                data-bind=\"value: entryIds\"\n                value=\"\" \/><\/div><div id=\"field_1_29\" class=\"gfield gfield--type-form gfield--input-type-form gform-theme__no-reset--children field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_1_29\" ><label class='gfield_label gform-field-label' for='input_1_29'>Provide Details of Your Experience<\/label><div class=\"gpnf-nested-entries-container ginput_container\">\n\n\t<table class=\"gpnf-nested-entries\">\n\n\t\t<thead>\n\t\t<tr>\n\t\t\t\t\t\t\t<th class=\"gpnf-field-1\">\n\t\t\t\t\tCompany\t\t\t\t<\/th>\n\t\t\t\t\t\t\t<th class=\"gpnf-field-2\">\n\t\t\t\t\tIndustry\t\t\t\t<\/th>\n\t\t\t\t\t\t\t<th class=\"gpnf-field-3\">\n\t\t\t\t\tTitle\t\t\t\t<\/th>\n\t\t\t\t\t\t\t<th class=\"gpnf-field-4\">\n\t\t\t\t\tSummary\t\t\t\t<\/th>\n\t\t\t\t\t\t\t<th class=\"gpnf-field-5\">\n\t\t\t\t\tFrom\t\t\t\t<\/th>\n\t\t\t\t\t\t\t<th class=\"gpnf-field-6\">\n\t\t\t\t\tTo\t\t\t\t<\/th>\n\t\t\t\t\t\t<th class=\"gpnf-row-actions\"><span class=\"screen-reader-text\">Actions<\/span><\/th>\n\t\t<\/tr>\n\t\t<\/thead>\n\n\t\t<tbody data-bind=\"visible: entries().length, foreach: entries\">\n\t\t<tr data-bind=\"attr: { 'data-entryid': id }\">\n\t\t\t\t\t\t\t<td class=\"gpnf-field\"\n\t\t\t\t\tdata-bind=\"html: f1.label, attr: { 'data-value': f1.label }\"\n\t\t\t\t\tdata-heading=\"Company\"\n\t\t\t\t>&nbsp;<\/td>\n\t\t\t\t\t\t\t<td class=\"gpnf-field\"\n\t\t\t\t\tdata-bind=\"html: f2.label, attr: { 'data-value': f2.label }\"\n\t\t\t\t\tdata-heading=\"Industry\"\n\t\t\t\t>&nbsp;<\/td>\n\t\t\t\t\t\t\t<td class=\"gpnf-field\"\n\t\t\t\t\tdata-bind=\"html: f3.label, attr: { 'data-value': f3.label }\"\n\t\t\t\t\tdata-heading=\"Title\"\n\t\t\t\t>&nbsp;<\/td>\n\t\t\t\t\t\t\t<td class=\"gpnf-field\"\n\t\t\t\t\tdata-bind=\"html: f4.label, attr: { 'data-value': f4.label }\"\n\t\t\t\t\tdata-heading=\"Summary\"\n\t\t\t\t>&nbsp;<\/td>\n\t\t\t\t\t\t\t<td class=\"gpnf-field\"\n\t\t\t\t\tdata-bind=\"html: f5.label, attr: { 'data-value': f5.label }\"\n\t\t\t\t\tdata-heading=\"From\"\n\t\t\t\t>&nbsp;<\/td>\n\t\t\t\t\t\t\t<td class=\"gpnf-field\"\n\t\t\t\t\tdata-bind=\"html: f6.label, attr: { 'data-value': f6.label }\"\n\t\t\t\t\tdata-heading=\"To\"\n\t\t\t\t>&nbsp;<\/td>\n\t\t\t\t\t\t<td class=\"gpnf-row-actions\" style=\"display: none;\" data-bind=\"visible: true\">\n\t\t\t\t<ul>\n\t\t\t\t\t<li class=\"edit\"><button type=\"button\" class=\"edit-button gform-theme-button--secondary\" data-bind=\"click: $parent.editEntry, attr: { 'aria-label': 'Edit Your Last Job Experience {0} where Company is {1}.'.gformFormat( $index() + 1, f1.label ) }\">Edit<\/button><\/li>\n\t\t\t\t\t\t\t\t\t\t<li class=\"delete\"><button type=\"button\" class=\"delete-button gform-theme-button--simple gform-theme-button--size-md\" data-bind=\"click: $parent.deleteEntry, attr: { 'aria-label': 'Delete Your Last Job Experience {0} where Company is {1}.'.gformFormat( $index() + 1, f1.label ) }\">Delete<\/button><\/li>\n\t\t\t\t<\/ul>\n\t\t\t<\/td>\n\t\t<\/tr>\n\t\t<\/tbody>\n\n\t\t<tbody data-bind=\"visible: entries().length <= 0\">\n\t\t<tr class=\"gpnf-no-entries\" data-bind=\"visible: entries().length <= 0\" style=\"display: none;\">\n\t\t\t<td colspan=\"7\">\n\t\t\t\tThere are no <span>Entries.<\/span>\t\t\t<\/td>\n\t\t<\/tr>\n\t\t<\/tbody>\n\n\t<\/table>\n\n\t<button type=\"button\" class=\"gpnf-add-entry\"\n\t\t        data-formid=\"1\"\n\t\t        data-nestedformid=\"3\"\n\t\t\t\tdata-bind=\"attr: { disabled: isMaxed }, css: { 'gf-default-disabled': isMaxed }\"\n\t\t\t\t>\n\t\t\t\tAdd Your Last Job Experience\n\t\t\t<\/button>\t\n\t\t\t<p class=\"gpnf-add-entry-max\" data-bind=\"visible: isMaxed\" style=\"display: none;\">\n\t\t\t\tMaximum number of entries reached.\n\t\t\t<\/p>\n<\/div>\n<input type=\"hidden\"\n                name=\"input_29\"\n                id=\"input_1_29\"\n                data-bind=\"value: entryIds\"\n                value=\"\" \/><\/div><fieldset id=\"field_1_44\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield--input-type-checkbox has-input-name gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_1_44\" ><legend class='gfield_label gform-field-label gfield_label_before_complex' >What do you specialize in?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox ' id='input_1_44'><div class='gchoice gchoice_1_44_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_44.1' type='checkbox'  value='Depression'  id='choice_1_44_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_1_44_1' id='label_1_44_1' class='gform-field-label gform-field-label--type-inline'>Depression<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_1_44_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_44.2' type='checkbox'  value='Anxiety &amp; Panic'  id='choice_1_44_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_1_44_2' id='label_1_44_2' class='gform-field-label gform-field-label--type-inline'>Anxiety &amp; Panic<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_1_44_3'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_44.3' type='checkbox'  value='Bipolar disorders'  id='choice_1_44_3'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_1_44_3' id='label_1_44_3' class='gform-field-label gform-field-label--type-inline'>Bipolar disorders<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_1_44_4'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_44.4' type='checkbox'  value='Trauma &amp; PTSD'  id='choice_1_44_4'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_1_44_4' id='label_1_44_4' class='gform-field-label gform-field-label--type-inline'>Trauma &amp; PTSD<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_1_44_5'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_44.5' type='checkbox'  value='Stress'  id='choice_1_44_5'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_1_44_5' id='label_1_44_5' class='gform-field-label gform-field-label--type-inline'>Stress<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_1_44_6'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_44.6' type='checkbox'  value='Anger issues'  id='choice_1_44_6'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_1_44_6' id='label_1_44_6' class='gform-field-label gform-field-label--type-inline'>Anger issues<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_1_44_7'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_44.7' type='checkbox'  value='Addictions'  id='choice_1_44_7'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_1_44_7' id='label_1_44_7' class='gform-field-label gform-field-label--type-inline'>Addictions<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_1_44_8'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_44.8' type='checkbox'  value='Eating disorders'  id='choice_1_44_8'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_1_44_8' id='label_1_44_8' class='gform-field-label gform-field-label--type-inline'>Eating disorders<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_1_44_9'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_44.9' type='checkbox'  value='LGBTQ'  id='choice_1_44_9'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_1_44_9' id='label_1_44_9' class='gform-field-label gform-field-label--type-inline'>LGBTQ<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_1_44_11'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_44.11' type='checkbox'  value='Grief and Loss'  id='choice_1_44_11'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_1_44_11' id='label_1_44_11' class='gform-field-label gform-field-label--type-inline'>Grief and Loss<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_1_44_12'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_44.12' type='checkbox'  value='Relationships'  id='choice_1_44_12'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_1_44_12' id='label_1_44_12' class='gform-field-label gform-field-label--type-inline'>Relationships<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_1_44_13'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_44.13' type='checkbox'  value='Children'  id='choice_1_44_13'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_1_44_13' id='label_1_44_13' class='gform-field-label gform-field-label--type-inline'>Children<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_1_60\" class=\"gfield gfield--type-select gfield--input-type-select gfield--width-full has-input-name populated field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_1_60\" ><label class='gfield_label gform-field-label' for='input_1_60'>What are your current counseling Fees?<\/label><div class='ginput_container ginput_container_select'><select name='input_60' id='input_1_60' class='large gfield_select'     aria-invalid=\"false\" ><option value='' >Select Applicable<\/option><option value='Less than R500 Per Hour' >Less than R500 per hour<\/option><option value='R500 - R1000 Per Hour' >R500 - R1000 per hour<\/option><option value='R1000 - R2000 Per Hour' >R1000 - R2000 per hour<\/option><option value='More than R2000 per hour' >More than R2000 per hour<\/option><\/select><\/div><\/div><div id=\"field_1_41\" class=\"gfield gfield--type-select gfield--input-type-select has-input-name populated gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_1_41\" ><label class='gfield_label gform-field-label' for='input_1_41'>How much time can you devote to working through the Santum platform?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_select'><select name='input_41' id='input_1_41' class='large gfield_select'    aria-required=\"true\" aria-invalid=\"false\" ><option value='' >Select Applicable...<\/option><option value='Half Day (up to 8hrs daily)' >Half Day (up to 8hrs daily)<\/option><option value='Full Day (up to 15hrs daily)' >Full Day (up to 15hrs daily)<\/option><option value='7 Days a Week (unlimited time \/ including weekends)' >7 Days a Week (unlmited time \/ 7 days a week)<\/option><\/select><\/div><\/div><div id=\"field_1_36\" class=\"gfield gfield--type-select gfield--input-type-select has-input-name populated gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_1_36\" ><label class='gfield_label gform-field-label' for='input_1_36'>Are you willing to conduct live video counseling sessions?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_select'><select name='input_36' id='input_1_36' class='large gfield_select'    aria-required=\"true\" aria-invalid=\"false\" ><option value='' >Select Applicable...<\/option><option value='yes' >Yes<\/option><option value='no' >No<\/option><\/select><\/div><\/div><div id=\"field_1_37\" class=\"gfield gfield--type-select gfield--input-type-select has-input-name populated gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_1_37\" ><label class='gfield_label gform-field-label' for='input_1_37'>Do you have adequate power supply to ensure uninterrupted sessions during load shedding?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_select'><select name='input_37' id='input_1_37' class='large gfield_select'    aria-required=\"true\" aria-invalid=\"false\" ><option value='' >Select Applicable...<\/option><option value='Yes' >Yes<\/option><option value='No' >No<\/option><\/select><\/div><\/div><div id=\"field_1_59\" class=\"gfield gfield--type-select gfield--input-type-select gfield--width-full has-input-name populated gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_1_59\" ><label class='gfield_label gform-field-label' for='input_1_59'>How many years have you been practicing counseling?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_select'><select name='input_59' id='input_1_59' class='large gfield_select'    aria-required=\"true\" aria-invalid=\"false\" ><option value='' >Select Applicable...<\/option><option value='1 Year' >1 Year<\/option><option value='2 Years' >2 Years<\/option><option value='3 Years' >3 Years<\/option><option value='4 Years' >4 Years<\/option><option value='5 Years' >5 Years<\/option><option value='6 Years' >6 Years<\/option><option value='7 Years' >7 Years<\/option><option value='8 Years' >8 Years<\/option><option value='9 Years' >9 Years<\/option><option value='10 Years' >10 Years<\/option><option value='over 10 Years' >Over 10 Years<\/option><\/select><\/div><\/div><div id=\"field_1_38\" class=\"gfield gfield--type-select gfield--input-type-select has-input-name populated gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_1_38\" ><label class='gfield_label gform-field-label' for='input_1_38'>How Many Counseling Hours Do You Have?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_select'><select name='input_38' id='input_1_38' class='large gfield_select'    aria-required=\"true\" aria-invalid=\"false\" ><option value='' >Select Applicable...<\/option><option value='Less than 250 hours' >Less than 250 hours<\/option><option value='250 - 500 hours' >250 - 500 hours<\/option><option value='500 - 1000 hours' >500 - 1000 hours<\/option><option value='More than 1000 hours' >More than 1000 hours<\/option><\/select><\/div><\/div><div id=\"field_1_39\" class=\"gfield gfield--type-select gfield--input-type-select has-input-name populated gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_1_39\" ><label class='gfield_label gform-field-label' for='input_1_39'>Are you currently required to have supervision in order to provide counseling services?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_select'><select name='input_39' id='input_1_39' class='large gfield_select'    aria-required=\"true\" aria-invalid=\"false\" ><option value='' >Select Applicable...<\/option><option value='Yes' >Yes<\/option><option value='No' >No<\/option><\/select><\/div><\/div><div id=\"field_1_40\" class=\"gfield gfield--type-select gfield--input-type-select has-input-name populated gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_1_40\" ><label class='gfield_label gform-field-label' for='input_1_40'>How many times do you check your email?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_select'><select name='input_40' id='input_1_40' class='large gfield_select'    aria-required=\"true\" aria-invalid=\"false\" ><option value='' >Select Applicable...<\/option><option value='Once a Week' >Once a Week<\/option><option value='Once a Day' >Once a Day<\/option><option value='Few Times a Day' >Few Times a Day<\/option><\/select><\/div><\/div><div id=\"field_1_10\" class=\"gfield gfield--type-textarea gfield--input-type-textarea gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_1_10\" ><label class='gfield_label gform-field-label' for='input_1_10'>Cover letter<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_10' id='input_1_10' class='textarea medium'     aria-required=\"true\" aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/div><div id=\"field_1_11\" class=\"gfield gfield--type-textarea gfield--input-type-textarea gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_1_11\" ><label class='gfield_label gform-field-label' for='input_1_11'>Please provide your registration information in all countries your are registered in, the registration number(s), and the expiration date(s).<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_11' id='input_1_11' class='textarea medium'     aria-required=\"true\" aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/div><div id=\"field_1_12\" class=\"gfield gfield--type-textarea gfield--input-type-textarea field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_1_12\" ><label class='gfield_label gform-field-label' for='input_1_12'>Do you have experience in providing counseling online? If so, please tell us about it.<\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_12' id='input_1_12' class='textarea medium'      aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/div><div id=\"field_1_13\" class=\"gfield gfield--type-textarea gfield--input-type-textarea field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_1_13\" ><label class='gfield_label gform-field-label' for='input_1_13'>Why are you interested in providing services online?<\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_13' id='input_1_13' class='textarea medium'      aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/div><div id=\"field_1_14\" class=\"gfield gfield--type-textarea gfield--input-type-textarea field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_1_14\" ><label class='gfield_label gform-field-label' for='input_1_14'>Please provide contact information of at least one registered therapist who can be your reference.<\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_14' id='input_1_14' class='textarea medium'      aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/div><div id=\"field_1_22\" class=\"gfield gfield--type-textarea gfield--input-type-textarea field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_1_22\" ><label class='gfield_label gform-field-label' for='input_1_22'>Do you have a history of any arrests, charges, convictions, or legal proceedings? If so, please provide details.<\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_22' id='input_1_22' class='textarea medium'      aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/div><div id=\"field_1_23\" class=\"gfield gfield--type-textarea gfield--input-type-textarea field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_1_23\" ><label class='gfield_label gform-field-label' for='input_1_23'>Have you ever been investigated or reviewed by the registering board? If so, please provide details.<\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_23' id='input_1_23' class='textarea medium'      aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/div><div id=\"field_1_24\" class=\"gfield gfield--type-textarea gfield--input-type-textarea field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_1_24\" ><label class='gfield_label gform-field-label' for='input_1_24'>Have you ever been subject to disciplinary actions by the registering board? If so, please provide details.<\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_24' id='input_1_24' class='textarea medium'      aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/div><div id=\"field_1_25\" class=\"gfield gfield--type-textarea gfield--input-type-textarea field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_1_25\" ><label class='gfield_label gform-field-label' for='input_1_25'>Which languages are you able to provide counselling in?<\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_25' id='input_1_25' class='textarea medium'      aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/div><div id=\"field_1_26\" class=\"gfield gfield--type-textarea gfield--input-type-textarea field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_1_26\" ><label class='gfield_label gform-field-label' for='input_1_26'>Please provide some details about your counseling style and approach<\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_26' id='input_1_26' class='textarea medium'      aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/div><div id=\"field_1_27\" class=\"gfield gfield--type-textarea gfield--input-type-textarea field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_1_27\" ><label class='gfield_label gform-field-label' for='input_1_27'>Do you understand that you will not be a Santum employee but an independent provider who provides services through the platform?<\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_27' id='input_1_27' class='textarea medium'      aria-invalid=\"false\"   rows='10' 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