{"id":1582,"date":"2025-07-10T23:34:37","date_gmt":"2025-07-10T15:34:37","guid":{"rendered":"https:\/\/healingthee.com\/?page_id=1582"},"modified":"2025-07-11T11:15:46","modified_gmt":"2025-07-11T03:15:46","slug":"intake-form-confirmed","status":"publish","type":"page","link":"https:\/\/healingthee.com\/en\/intake-form-confirmed\/","title":{"rendered":"\u9996\u6b21\u9810\u7d04\u8868\u683c"},"content":{"rendered":"<div class=\"wpforms-container wpforms-container-full wpforms-block wpforms-block-e24acbfe-2f2f-4e37-859c-599bec96c4a2 wpforms-render-modern\" id=\"wpforms-1566\"><form id=\"wpforms-form-1566\" class=\"wpforms-validate wpforms-form wpforms-ajax-form\" data-formid=\"1566\" method=\"post\" enctype=\"multipart\/form-data\" action=\"\/en\/wp-json\/wp\/v2\/pages\/1582\" data-token=\"c298409323fee6f483ba49e1c94a95f6\" data-token-time=\"1780099564\"><noscript class=\"wpforms-error-noscript\">Please enable JavaScript in your browser to complete this form.<\/noscript><div id=\"wpforms-error-noscript\" style=\"display: none;\">Please enable JavaScript in your browser to complete this form.<\/div><div class=\"wpforms-field-container\">\t\t<div id=\"wpforms-1566-field_2-container\"\n\t\t\tclass=\"wpforms-field wpforms-field-text\"\n\t\t\tdata-field-type=\"text\"\n\t\t\tdata-field-id=\"2\"\n\t\t\t>\n\t\t\t<label class=\"wpforms-field-label\" for=\"wpforms-1566-field_2\" >Layout \u8acb\u8df3\u904e) :<\/label>\n\t\t\t<input type=\"text\" id=\"wpforms-1566-field_2\" class=\"wpforms-field-medium\" name=\"wpforms[fields][2]\" >\n\t\t<\/div>\n\t\t<div id=\"wpforms-1566-field_12-container\" class=\"wpforms-field wpforms-field-checkbox special-checkbox-buttons\" data-field-type=\"checkbox\" data-field-id=\"12\"><fieldset><legend class=\"wpforms-field-label\">\u670d\u52d9\u539f\u5247\u53ca\u5951\u7d04 <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/legend><ul id=\"wpforms-1566-field_12\" class=\"wpforms-field-required\"><li class=\"choice-1 depth-1\"><input type=\"checkbox\" id=\"wpforms-1566-field_12_1\" name=\"wpforms[fields][12][]\" value=\"\u6211\u5df2\u95b1\u8b80\u53ca\u540c\u610f\u4ee5\u4e0b\u6240\u6709\u670d\u52d9\u689d\u6b3e\u7d30\u5247\u53ca\u8072\u660e\" aria-errormessage=\"wpforms-1566-field_12_1-error\" aria-describedby=\"wpforms-1566-field_12-description\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-1566-field_12_1\">\u6211\u5df2\u95b1\u8b80\u53ca\u540c\u610f\u4ee5\u4e0b\u6240\u6709\u670d\u52d9\u689d\u6b3e\u7d30\u5247\u53ca\u8072\u660e<\/label><\/li><\/ul><div id=\"wpforms-1566-field_12-description\" class=\"wpforms-field-description wpforms-disclaimer-description\">1. \u670d\u52d9\u5c0d\u8c61\u4e0d\u8ad6\u6027\u5225\u3001\u5e74\u9f61\u3001\u7a2e\u65cf\u3001\u4fe1\u4ef0\u80cc\u666f\u53ca\u80fd\u529b\u5747\u53d7\u5230\u5e73\u7b49\u5c0d\u5f85\u53ca\u5c0a\u91cd\u3002\u5728\u63a5\u53d7\u670d\u52d9\u7684\u904e\u7a0b\u4e2d\uff0c\u4f7f\u7528\u670d\u52d9\u8005\u6709\u6b0a\u53c3\u8207\u53ca\u63d0\u4f9b\u610f\u898b\u3002<br \/>\n2. \u5728\u63a5\u53d7\u8f14\u5c0e\u671f\u9593\uff0c\u4f7f\u7528\u670d\u52d9\u8005\u53ca\u4e00\u8d77\u63a5\u53d7\u8f14\u5c0e\u4e4b\u5bb6\u5ead\u6210\u54e1\u7684\u8eab\u9ad4\u53ca\u7cbe\u795e\u72c0\u6cc1\uff0c\u9808\u81ea\u884c\u8ca0\u8cac\u3002<br \/>\n3. \u4f7f\u7528\u670d\u52d9\u8005\u5982\u672a\u80fd\u4f9d\u6642\u8d74\u7d04\uff0c\u9808\u65bc\u4e00\u65e5\u524d\u901a\u77e5\uff0c\u5426\u5247\u5c11\u65bc24\u5c0f\u6642\u4ecd\u9700\u7e73\u4ed8\u9762\u8ac7\u8cbb\u7528\u3002<br \/>\n4. \ufeff\ufeff\u9664\u4e86\u8a55\u4f30\u8cbb\u7528\u53ca\u5b9a\u984d\u8f14\u5c0e\u8cbb\u7528\u5916\uff0c\u7121\u984d\u5916\u6536\u8cbb\u3002<br \/>\n5. \ufeff\ufeff\ufeff\u6240\u6709\u8f14\u5c0e\u5167\u5bb9\u7d55\u5c0d\u4fdd\u5bc6\u3002\u9664\u975e\u6848\u4e3b\u6709\u81ea\u6bba\u50be\u5411\u3001\u4f01\u5716\u50b7\u5bb3\u4ed6\u4eba\u8eab\u9ad4\u6216\u6d89\u53ca\u8650\u5f85\u4e8b\u4ef6\uff0c\u5247\u8f14\u5c0e\u54e1\u7121\u9700\u7d93\u670d\u52d9\u4f7f\u7528\u8005\u540c\u610f\uff0c\u6709\u6b0a\u5c07\u76f8\u95dc\u8cc7\u6599\u63d0\u4f9b\u7d66\u6709\u95dc\u4eba\u58eb\u3002<br \/>\n6. \ufeff\ufeff\ufeff\u70ba\u4fdd\u969c\u4f7f\u7528\u670d\u52d9\u8005\u53ca\u78ba\u4fdd\u8f14\u5c0e\u54e1\u4e4b\u64cd\u5b88\u6e96\u5247\uff0c\u8f14\u5c0e\u904e\u7a0b\u5c07\u6703\u6709\u9304\u5f71\/\u9304\u97f3\u3002\u8cc7\u6599\u53ea\u4f5c\u6a94\u6848\u5132\u5b58\u53ca\u6709\u9700\u8981\u7684\u7279\u6b8a\u60c5\u5f62\u4e0b\u4f7f\u2f64\uff0c\u6240\u6709\u8a18\u9304\u5c07\u65bc\u500b\u6848\u7d50\u675f\u5f8c\u5169\u5e74\u5167\u5b8c\u5168\u92b7\u6bc0\u3002<br \/>\n7. \u9664\u975e\u7372\u6cd5\u5ead\u8981\u6c42\uff0c\u5426\u5247\u6839\u64da\u79c1\u96b1\u689d\u4f8b\uff0c\u670d\u52d9\u4f7f\u7528\u8005\u6240\u63d0\u4f9b\u7684\u500b\u4eba\u8cc7\u6599\uff0c\u53ea\u4f9b\u672c\u516c\u53f8\u8f14\u5c0e\u670d\u52d9\u4e4b\u7528\uff0c\u672c\u516c\u53f8\u6703\u5168\u529b\u57f7\u884c\u4ee5\u4fdd\u969c\u670d\u52d9\u4f7f\u7528\u8005\u3002<br \/>\n8. \u5c0d\u6536\u8cbb\u53ca\u670d\u52d9\u689d\u6b3e\u4fdd\u5bc6: \u767b\u8a18\u670d\u52d9\u7684\u6c42\u52a9\u8005\u6216\u5c0b\u6c42\u670d\u52d9\u6a5f\u69cb\u5fc5\u9808\u78ba\u4fdd\u672c\u516c\u53f8\u8207\u60a8\u5354\u5546\u53ca\u6216\u5171\u8b58\u7684\u689d\u6b3e\u53ca\u6536\u8cbb\u52a0\u4ee5\u4fdd\u5bc6\u3002\u9664\u672c\u516c\u53f8\u5916, \u4e0d\u5bb9\u8a31\u6cc4\u9732\u6536\u8cbb\u5b89\u6392\u8207\u7b2c\u4e09\u65b9\/\u6cbb\u7642\u5e2b\u3002<br \/>\n9. \u6240\u6709\u9810\u7d04\u4e00\u7d93\u78ba\u8a8d\uff0c\u5747\u4e0d\u53ef\u9000\u6b3e\u3002\u6bcf\u6b21\u9762\u8ac7\u61c9\u5728\u672c\u5e73\u53f0\u78ba\u8a8d\u7684\u6642\u9593\u5167\u9032\u884c\uff0c\u9072\u5230\u4e0d\u5f97\u5ef6\u671f\u3002\u672c\u516c\u53f8\u50c5\u4f5c\u70ba\u63d0\u4f9b\u670d\u52d9\u8005\u548c\u7528\u6236\u4e4b\u9593\u7684\u4e2d\u4ecb\u3002\u5982\u6709\u4efb\u4f55\u722d\u8b70\uff0c\u672c\u516c\u53f8\u4fdd\u7559\u6700\u7d42\u6c7a\u5b9a\u6b0a\u3002<br \/>\n10. \u7121\u8ad6\u4efb\u4f55\u4e00\u65b9\u63d0\u51fa\u7d42\u7d50\u6cbb\u7642\u7642\u7a0b\uff0c\u9664\u975e\u7d93\u672c\u516c\u53f8\u518d\u6b21\u4ecb\u7d39\uff0c\u5426\u5247\u572812\u500b\u6708\u5167\u6c42\u52a9\u8005\/\u6a5f\u69cb\u4e0d\u80fd\u5411\u8a72\u6cbb\u7642\u5e2b\u8981\u6c42\u63d0\u4f9b\u76f8\u540c\u6216\u76f8\u4f3c\u7684\u6cbb\u7642\u6216\u76f8\u95dc\u670d\u52d9\u3002<br \/>\n11. \u5982\u679c\u4f7f\u7528\u670d\u52d9\u8005\u672a\u6eff 18 \u6b72\uff08\u300c\u672a\u6210\u5e74\u4eba\u300d\uff09\u4e26\u5e0c\u671b\u4f7f\u7528\u672c\u670d\u52d9\uff0c\u60a8\u662f\u672a\u6210\u5e74\u4eba\u7684\u7236\u6bcd\u6216\u6cd5\u5b9a\u76e3\u8b77\u4eba\uff0c\u9664\u975e\u6709\u7279\u6b8a\u60c5\u6cc1\uff0c\u5426\u5247\u6211\u5011\u8a8d\u70ba\u7372\u5f97\u7236\u6216\u6bcd\u4e00\u65b9\u7684\u540c\u610f\u5c31\u8db3\u5920\u4e86\u3002<\/div><\/fieldset><\/div><div id=\"wpforms-1566-field_19-container\" class=\"wpforms-field wpforms-field-layout\" data-field-type=\"layout\" data-field-id=\"19\"><div class=\"wpforms-field-layout-rows wpforms-field-large\"><div class=\"wpforms-layout-row\"><div class=\"wpforms-layout-column wpforms-layout-column-25\"><div id=\"wpforms-1566-field_1-container\" class=\"wpforms-field wpforms-field-name\" data-field-type=\"name\" data-field-id=\"1\"><label class=\"wpforms-field-label\" for=\"wpforms-1566-field_1\">\u7533\u8acb\u4eba\u59d3\u540d\uff1a  <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/label><input type=\"text\" id=\"wpforms-1566-field_1\" class=\"wpforms-field-medium wpforms-field-required\" name=\"wpforms[fields][1]\" aria-errormessage=\"wpforms-1566-field_1-error\" required><\/div><\/div><div class=\"wpforms-layout-column wpforms-layout-column-25\"><div id=\"wpforms-1566-field_4-container\" class=\"wpforms-field wpforms-field-select wpforms-field-select-style-classic\" data-field-type=\"select\" data-field-id=\"4\"><label class=\"wpforms-field-label\" for=\"wpforms-1566-field_4\">\u7a31\u8b02<\/label><select id=\"wpforms-1566-field_4\" class=\"wpforms-field-medium\" name=\"wpforms[fields][4]\"><option value=\"\u5148\u751f\"  class=\"choice-1 depth-1\"  >\u5148\u751f<\/option><option value=\"\u5973\u58eb\"  class=\"choice-2 depth-1\"  >\u5973\u58eb<\/option><option value=\"\u5c0f\u59d0\"  class=\"choice-3 depth-1\"  >\u5c0f\u59d0<\/option><\/select><\/div><\/div><div class=\"wpforms-layout-column wpforms-layout-column-25\"><div id=\"wpforms-1566-field_9-container\" class=\"wpforms-field wpforms-field-email\" data-field-type=\"email\" data-field-id=\"9\"><label class=\"wpforms-field-label\" for=\"wpforms-1566-field_9\">\u7533\u8acb\u4ebaEmail\uff1a <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/label><input type=\"email\" id=\"wpforms-1566-field_9\" class=\"wpforms-field-medium wpforms-field-required\" name=\"wpforms[fields][9]\" spellcheck=\"false\" aria-errormessage=\"wpforms-1566-field_9-error\" required><\/div><\/div><div class=\"wpforms-layout-column wpforms-layout-column-25\"><div id=\"wpforms-1566-field_8-container\" class=\"wpforms-field wpforms-field-phone\" data-field-type=\"phone\" data-field-id=\"8\"><label class=\"wpforms-field-label\" for=\"wpforms-1566-field_8\">\u7533\u8acb\u4eba\u624b\u63d0\u96fb\u8a71\uff1a <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/label><input type=\"tel\" id=\"wpforms-1566-field_8\" class=\"wpforms-field-small wpforms-field-required\" data-rule-int-phone-field=\"true\" name=\"wpforms[fields][8]\" aria-label=\"\u7533\u8acb\u4eba\u624b\u63d0\u96fb\u8a71\uff1a\" aria-errormessage=\"wpforms-1566-field_8-error\" required><\/div><\/div><\/div><div class=\"wpforms-layout-row\"><div class=\"wpforms-layout-column wpforms-layout-column-25\"><div id=\"wpforms-1566-field_48-container\" class=\"wpforms-field wpforms-field-password\" data-field-type=\"password\" data-field-id=\"48\"><fieldset><legend class=\"wpforms-field-label\">\u5bc6\u78bc <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/legend><div class=\"wpforms-field-row wpforms-field-medium\"><div class=\"wpforms-field-row-block wpforms-one-half wpforms-first\"><input type=\"password\" id=\"wpforms-1566-field_48\" class=\"wpforms-field-required wpforms-field-password-primary\" name=\"wpforms[fields][48][primary]\" spellcheck=\"false\" aria-errormessage=\"wpforms-1566-field_48-error\" required><label for=\"wpforms-1566-field_48\" class=\"wpforms-field-sublabel after\">Password<\/label><\/div><div class=\"wpforms-field-row-block wpforms-one-half\"><input type=\"password\" id=\"wpforms-1566-field_48-secondary\" class=\"wpforms-field-password-secondary wpforms-field-required\" data-rule-confirm=\"#wpforms-1566-field_48\" name=\"wpforms[fields][48][secondary]\" spellcheck=\"false\" aria-errormessage=\"wpforms-1566-field_48-secondary-error\" required><label for=\"wpforms-1566-field_48-secondary\" class=\"wpforms-field-sublabel after\">Confirm Password<\/label><\/div><\/div><\/fieldset><\/div><\/div><div class=\"wpforms-layout-column wpforms-layout-column-25\"><\/div><div class=\"wpforms-layout-column wpforms-layout-column-25\"><\/div><div class=\"wpforms-layout-column wpforms-layout-column-25\"><\/div><\/div><\/div><\/div><div id=\"wpforms-1566-field_20-container\" class=\"wpforms-field wpforms-field-radio wpforms-conditional-trigger\" data-field-type=\"radio\" data-field-id=\"20\"><fieldset><legend class=\"wpforms-field-label\">\u7533\u8acb\u4eba\u662f\u63a5\u53d7\u670d\u52d9\u8005\uff1a  <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/legend><ul id=\"wpforms-1566-field_20\" class=\"wpforms-field-required\"><li class=\"choice-1 depth-1\"><input type=\"radio\" id=\"wpforms-1566-field_20_1\" name=\"wpforms[fields][20]\" value=\"\u662f\" aria-errormessage=\"wpforms-1566-field_20_1-error\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-1566-field_20_1\">\u662f<\/label><\/li><li class=\"choice-2 depth-1\"><input type=\"radio\" id=\"wpforms-1566-field_20_2\" name=\"wpforms[fields][20]\" value=\"\u5426\" aria-errormessage=\"wpforms-1566-field_20_2-error\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-1566-field_20_2\">\u5426<\/label><\/li><\/ul><\/fieldset><\/div><div id=\"wpforms-1566-field_21-container\" class=\"wpforms-field wpforms-field-layout\" data-field-type=\"layout\" data-field-id=\"21\"><div class=\"wpforms-field-layout-rows wpforms-field-large\"><div class=\"wpforms-layout-row\"><div class=\"wpforms-layout-column wpforms-layout-column-25\"><div id=\"wpforms-1566-field_18-container\" class=\"wpforms-field wpforms-field-name wpforms-conditional-field wpforms-conditional-show\" data-field-type=\"name\" data-field-id=\"18\" style=\"display:none;\"><label class=\"wpforms-field-label\" for=\"wpforms-1566-field_18\">\u63a5\u53d7\u670d\u52d9\u8005\u59d3\u540d\uff1a  <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/label><input type=\"text\" id=\"wpforms-1566-field_18\" class=\"wpforms-field-medium wpforms-field-required\" name=\"wpforms[fields][18]\" aria-errormessage=\"wpforms-1566-field_18-error\" required><\/div><\/div><div class=\"wpforms-layout-column wpforms-layout-column-25\"><div id=\"wpforms-1566-field_22-container\" class=\"wpforms-field wpforms-field-select wpforms-conditional-field wpforms-conditional-show wpforms-field-select-style-classic\" data-field-type=\"select\" data-field-id=\"22\" style=\"display:none;\"><label class=\"wpforms-field-label\" for=\"wpforms-1566-field_22\">\u63a5\u53d7\u670d\u52d9\u8005\u6027\u5225\uff1a<\/label><select id=\"wpforms-1566-field_22\" class=\"wpforms-field-medium\" name=\"wpforms[fields][22]\"><option value=\"\u7537\"  class=\"choice-1 depth-1\"  >\u7537<\/option><option value=\"\u5973\"  class=\"choice-2 depth-1\"  >\u5973<\/option><\/select><\/div><\/div><div class=\"wpforms-layout-column wpforms-layout-column-25\"><div id=\"wpforms-1566-field_23-container\" class=\"wpforms-field wpforms-field-select wpforms-conditional-field wpforms-conditional-show wpforms-field-select-style-classic\" data-field-type=\"select\" data-field-id=\"23\" style=\"display:none;\"><label class=\"wpforms-field-label\" for=\"wpforms-1566-field_23\">\u4f60\u8207\u63a5\u53d7\u670d\u52d9\u8005\u95dc\u4fc2\uff1a<\/label><select id=\"wpforms-1566-field_23\" class=\"wpforms-field-medium\" name=\"wpforms[fields][23]\"><option value=\"\" class=\"placeholder\" disabled  selected='selected'>&#8212; Select Choice &#8212;<\/option><option value=\"\u7236\u5b50\"  class=\"choice-4 depth-1\"  >\u7236\u5b50<\/option><option value=\"\u6bcd\u5b50\"  class=\"choice-5 depth-1\"  >\u6bcd\u5b50<\/option><option value=\"\u7236\u5973\"  class=\"choice-6 depth-1\"  >\u7236\u5973<\/option><option value=\"\u6bcd\u5973\"  class=\"choice-7 depth-1\"  >\u6bcd\u5973<\/option><option value=\"\u89aa\u621a\"  class=\"choice-8 depth-1\"  >\u89aa\u621a<\/option><option value=\"\u670b\u53cb\"  class=\"choice-9 depth-1\"  >\u670b\u53cb<\/option><option value=\"\u540c\u4e8b\"  class=\"choice-10 depth-1\"  >\u540c\u4e8b<\/option><option value=\"\u5176\u4ed6\"  class=\"choice-11 depth-1\"  >\u5176\u4ed6<\/option><\/select><\/div><\/div><div class=\"wpforms-layout-column wpforms-layout-column-25\"><div id=\"wpforms-1566-field_25-container\" class=\"wpforms-field wpforms-field-number wpforms-conditional-field wpforms-conditional-show\" data-field-type=\"number\" data-field-id=\"25\" style=\"display:none;\"><label class=\"wpforms-field-label\" for=\"wpforms-1566-field_25\">\u63a5\u53d7\u670d\u52d9\u8005\u5e74\u9f61\uff1a <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/label><input type=\"number\" id=\"wpforms-1566-field_25\" class=\"wpforms-field-medium wpforms-field-required\" name=\"wpforms[fields][25]\" step=\"any\" aria-errormessage=\"wpforms-1566-field_25-error\" required><\/div><\/div><\/div><div class=\"wpforms-layout-row\"><div class=\"wpforms-layout-column wpforms-layout-column-25\"><div id=\"wpforms-1566-field_26-container\" class=\"wpforms-field wpforms-field-select wpforms-conditional-field wpforms-conditional-show wpforms-field-select-style-classic\" data-field-type=\"select\" data-field-id=\"26\" style=\"display:none;\"><label class=\"wpforms-field-label\" for=\"wpforms-1566-field_26\">\u63a5\u53d7\u670d\u52d9\u8005\u5a5a\u59fb\u72c0\u6cc1\uff1a <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/label><select id=\"wpforms-1566-field_26\" class=\"wpforms-field-medium wpforms-field-required\" name=\"wpforms[fields][26]\" required=\"required\"><option value=\"\" class=\"placeholder\" disabled  selected='selected'>&#8212; Select Choice &#8212;<\/option><option value=\"\u672a\u5a5a\"  class=\"choice-4 depth-1\"  >\u672a\u5a5a<\/option><option value=\"\u5df2\u5a5a\"  class=\"choice-5 depth-1\"  >\u5df2\u5a5a<\/option><option value=\"\u5176\u4ed6\"  class=\"choice-11 depth-1\"  >\u5176\u4ed6<\/option><\/select><\/div><\/div><div class=\"wpforms-layout-column wpforms-layout-column-25\"><div id=\"wpforms-1566-field_27-container\" class=\"wpforms-field wpforms-field-select wpforms-conditional-field wpforms-conditional-show wpforms-field-select-style-classic\" data-field-type=\"select\" data-field-id=\"27\" style=\"display:none;\"><label class=\"wpforms-field-label\" for=\"wpforms-1566-field_27\">\u63a5\u53d7\u670d\u52d9\u8005\u5b78\u6b77\uff1a <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/label><select id=\"wpforms-1566-field_27\" class=\"wpforms-field-medium wpforms-field-required\" name=\"wpforms[fields][27]\" required=\"required\"><option value=\"\" class=\"placeholder\" disabled  selected='selected'>&#8212; Select Choice &#8212;<\/option><option value=\"\u5c0f\u5b78\"  class=\"choice-4 depth-1\"  >\u5c0f\u5b78<\/option><option value=\"\u4e2d\u5b78\"  class=\"choice-5 depth-1\"  >\u4e2d\u5b78<\/option><option value=\"\u5927\u5b78\"  class=\"choice-6 depth-1\"  >\u5927\u5b78<\/option><option value=\"\u5176\u4ed6\"  class=\"choice-11 depth-1\"  >\u5176\u4ed6<\/option><\/select><\/div><\/div><div class=\"wpforms-layout-column wpforms-layout-column-25\"><div id=\"wpforms-1566-field_28-container\" class=\"wpforms-field wpforms-field-name wpforms-conditional-field wpforms-conditional-show\" data-field-type=\"name\" data-field-id=\"28\" style=\"display:none;\"><label class=\"wpforms-field-label\" for=\"wpforms-1566-field_28\">\u63a5\u53d7\u670d\u52d9\u8005\u8077\u696d\uff1a<\/label><input type=\"text\" id=\"wpforms-1566-field_28\" class=\"wpforms-field-medium\" name=\"wpforms[fields][28]\" aria-errormessage=\"wpforms-1566-field_28-error\" ><\/div><\/div><div class=\"wpforms-layout-column wpforms-layout-column-25\"><div id=\"wpforms-1566-field_49-container\" class=\"wpforms-field wpforms-field-name wpforms-conditional-field wpforms-conditional-show\" data-field-type=\"name\" data-field-id=\"49\" style=\"display:none;\"><label class=\"wpforms-field-label\" for=\"wpforms-1566-field_49\">SEN\u7279\u6b8a\u5b78\u7fd2\u9700\u8981 :<\/label><input type=\"text\" id=\"wpforms-1566-field_49\" class=\"wpforms-field-medium\" name=\"wpforms[fields][49]\" aria-errormessage=\"wpforms-1566-field_49-error\" ><\/div><\/div><\/div><\/div><\/div><div id=\"wpforms-1566-field_42-container\" class=\"wpforms-field wpforms-field-layout\" data-field-type=\"layout\" data-field-id=\"42\"><div class=\"wpforms-field-layout-rows wpforms-field-large\"><div class=\"wpforms-layout-row\"><div class=\"wpforms-layout-column wpforms-layout-column-25\"><div id=\"wpforms-1566-field_41-container\" class=\"wpforms-field wpforms-field-number wpforms-conditional-field wpforms-conditional-show\" data-field-type=\"number\" data-field-id=\"41\" style=\"display:none;\"><label class=\"wpforms-field-label\" for=\"wpforms-1566-field_41\">\u5e74\u9f61\uff1a <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/label><input type=\"number\" id=\"wpforms-1566-field_41\" class=\"wpforms-field-medium wpforms-field-required\" name=\"wpforms[fields][41]\" step=\"any\" aria-errormessage=\"wpforms-1566-field_41-error\" required><\/div><\/div><div class=\"wpforms-layout-column wpforms-layout-column-25\"><div id=\"wpforms-1566-field_30-container\" class=\"wpforms-field wpforms-field-select wpforms-conditional-field wpforms-conditional-show wpforms-field-select-style-classic\" data-field-type=\"select\" data-field-id=\"30\" style=\"display:none;\"><label class=\"wpforms-field-label\" for=\"wpforms-1566-field_30\">\u5b78\u6b77\uff1a <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/label><select id=\"wpforms-1566-field_30\" class=\"wpforms-field-medium wpforms-field-required\" name=\"wpforms[fields][30]\" required=\"required\"><option value=\"\" class=\"placeholder\" disabled  selected='selected'>&#8212; Select Choice &#8212;<\/option><option value=\"\u5c0f\u5b78\"  class=\"choice-4 depth-1\"  >\u5c0f\u5b78<\/option><option value=\"\u4e2d\u5b78\"  class=\"choice-5 depth-1\"  >\u4e2d\u5b78<\/option><option value=\"\u5927\u5b78\"  class=\"choice-6 depth-1\"  >\u5927\u5b78<\/option><option value=\"\u5176\u4ed6\"  class=\"choice-11 depth-1\"  >\u5176\u4ed6<\/option><\/select><\/div><\/div><div class=\"wpforms-layout-column wpforms-layout-column-25\"><div id=\"wpforms-1566-field_31-container\" class=\"wpforms-field wpforms-field-name wpforms-conditional-field wpforms-conditional-show\" data-field-type=\"name\" data-field-id=\"31\" style=\"display:none;\"><label class=\"wpforms-field-label\" for=\"wpforms-1566-field_31\">\u8077\u696d\uff1a <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/label><input type=\"text\" id=\"wpforms-1566-field_31\" class=\"wpforms-field-medium wpforms-field-required\" name=\"wpforms[fields][31]\" aria-errormessage=\"wpforms-1566-field_31-error\" required><\/div><\/div><div class=\"wpforms-layout-column wpforms-layout-column-25\"><div id=\"wpforms-1566-field_29-container\" class=\"wpforms-field wpforms-field-select wpforms-conditional-field wpforms-conditional-show wpforms-field-select-style-classic\" data-field-type=\"select\" data-field-id=\"29\" style=\"display:none;\"><label class=\"wpforms-field-label\" for=\"wpforms-1566-field_29\">\u5a5a\u59fb\u72c0\u6cc1\uff1a <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/label><select id=\"wpforms-1566-field_29\" class=\"wpforms-field-medium wpforms-field-required\" name=\"wpforms[fields][29]\" required=\"required\"><option value=\"\" class=\"placeholder\" disabled  selected='selected'>&#8212; Select Choice &#8212;<\/option><option value=\"\u672a\u5a5a\"  class=\"choice-4 depth-1\"  >\u672a\u5a5a<\/option><option value=\"\u5df2\u5a5a\"  class=\"choice-5 depth-1\"  >\u5df2\u5a5a<\/option><option value=\"\u5176\u4ed6\"  class=\"choice-11 depth-1\"  >\u5176\u4ed6<\/option><\/select><\/div><\/div><\/div><\/div><\/div><div id=\"wpforms-1566-field_35-container\" class=\"wpforms-field wpforms-field-radio wpforms-list-inline wpforms-conditional-trigger\" data-field-type=\"radio\" data-field-id=\"35\"><fieldset><legend class=\"wpforms-field-label\">\u8f14\u5c0e\u670d\u52d9\u5c0d\u8c61\/\u6cbb\u7642\u670d\u52d9\uff1a <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/legend><ul id=\"wpforms-1566-field_35\" class=\"wpforms-field-required\"><li class=\"choice-4 depth-1\"><input type=\"radio\" id=\"wpforms-1566-field_35_4\" name=\"wpforms[fields][35]\" value=\"\u500b\u4eba\" aria-errormessage=\"wpforms-1566-field_35_4-error\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-1566-field_35_4\">\u500b\u4eba<\/label><\/li><li class=\"choice-5 depth-1\"><input type=\"radio\" id=\"wpforms-1566-field_35_5\" name=\"wpforms[fields][35]\" value=\"\u592b\u5a66\/\u4f34\u4fb6\" aria-errormessage=\"wpforms-1566-field_35_5-error\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-1566-field_35_5\">\u592b\u5a66\/\u4f34\u4fb6<\/label><\/li><li class=\"choice-6 depth-1\"><input type=\"radio\" id=\"wpforms-1566-field_35_6\" name=\"wpforms[fields][35]\" value=\"\u5bb6\u5ead\" aria-errormessage=\"wpforms-1566-field_35_6-error\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-1566-field_35_6\">\u5bb6\u5ead<\/label><\/li><li class=\"choice-7 depth-1\"><input type=\"radio\" id=\"wpforms-1566-field_35_7\" name=\"wpforms[fields][35]\" value=\"\u5718\u9ad4\" aria-errormessage=\"wpforms-1566-field_35_7-error\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-1566-field_35_7\">\u5718\u9ad4<\/label><\/li><li class=\"choice-10 depth-1\"><input type=\"radio\" id=\"wpforms-1566-field_35_10\" name=\"wpforms[fields][35]\" value=\"\u85dd\u8853\u6cbb\u7642\/\u8868\u9054\u85dd\u8853\u6cbb\u7642: 1\u5c0d1\" aria-errormessage=\"wpforms-1566-field_35_10-error\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-1566-field_35_10\">\u85dd\u8853\u6cbb\u7642\/\u8868\u9054\u85dd\u8853\u6cbb\u7642: 1\u5c0d1<\/label><\/li><li class=\"choice-9 depth-1\"><input type=\"radio\" id=\"wpforms-1566-field_35_9\" name=\"wpforms[fields][35]\" value=\"\u85dd\u8853\u6cbb\u7642 \/\u8868\u9054\u85dd\u8853\u6cbb\u7642: \u5c0f\u7d44\" aria-errormessage=\"wpforms-1566-field_35_9-error\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-1566-field_35_9\">\u85dd\u8853\u6cbb\u7642 \/\u8868\u9054\u85dd\u8853\u6cbb\u7642: \u5c0f\u7d44<\/label><\/li><li class=\"choice-11 depth-1\"><input type=\"radio\" id=\"wpforms-1566-field_35_11\" name=\"wpforms[fields][35]\" value=\"\u5404\u985e\u5152\u7ae5\u5b78\u7fd2\u8a55\u4f30\u53ca\u5831\u544a (\u667a\u529b\u8a55\u4f30\/ADHD\/ASD\/\u5c08\u6ce8\u529b\u4e0d\u8db3\/\u8b80\u5beb\u969c\u7919\u7b49)\" aria-errormessage=\"wpforms-1566-field_35_11-error\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-1566-field_35_11\">\u5404\u985e\u5152\u7ae5\u5b78\u7fd2\u8a55\u4f30\u53ca\u5831\u544a (\u667a\u529b\u8a55\u4f30\/ADHD\/ASD\/\u5c08\u6ce8\u529b\u4e0d\u8db3\/\u8b80\u5beb\u969c\u7919\u7b49)<\/label><\/li><li class=\"choice-8 depth-1\"><input type=\"radio\" id=\"wpforms-1566-field_35_8\" name=\"wpforms[fields][35]\" value=\"\u5176\u4ed6\" aria-errormessage=\"wpforms-1566-field_35_8-error\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-1566-field_35_8\">\u5176\u4ed6<\/label><\/li><\/ul><\/fieldset><\/div><div id=\"wpforms-1566-field_52-container\" class=\"wpforms-field wpforms-field-checkbox special-checkbox-buttons wpforms-list-inline wpforms-conditional-field wpforms-conditional-show\" data-field-type=\"checkbox\" data-field-id=\"52\" style=\"display:none;\"><fieldset><legend class=\"wpforms-field-label wpforms-label-hide\" aria-hidden=\"false\">\u8a55\u4f30\u5b78\u7ae5\u7279\u6b8a\u5b78\u7fd2\u9700\u8981\u53ca\u5831\u544a<\/legend><ul id=\"wpforms-1566-field_52\"><li class=\"choice-1 depth-1\"><input type=\"checkbox\" id=\"wpforms-1566-field_52_1\" name=\"wpforms[fields][52][]\" value=\"\u8a55\u4f30\u5b78\u7ae5\u7279\u6b8a\u5b78\u7fd2\u9700\u8981\u53ca\u5831\u544a\" aria-errormessage=\"wpforms-1566-field_52_1-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-1566-field_52_1\">\u8a55\u4f30\u5b78\u7ae5\u7279\u6b8a\u5b78\u7fd2\u9700\u8981\u53ca\u5831\u544a<\/label><\/li><\/ul><\/fieldset><\/div><div id=\"wpforms-1566-field_40-container\" class=\"wpforms-field wpforms-field-radio wpforms-list-inline wpforms-conditional-field wpforms-conditional-show\" data-field-type=\"radio\" data-field-id=\"40\" style=\"display:none;\"><fieldset><legend class=\"wpforms-field-label\">\u8f14\u5c0e\u5f62\u5f0f\uff1a <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/legend><ul id=\"wpforms-1566-field_40\" class=\"wpforms-field-required\"><li class=\"choice-4 depth-1\"><input type=\"radio\" id=\"wpforms-1566-field_40_4\" name=\"wpforms[fields][40]\" value=\"\u5be6\u9ad4\u9762\u8ac7\" aria-errormessage=\"wpforms-1566-field_40_4-error\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-1566-field_40_4\">\u5be6\u9ad4\u9762\u8ac7<\/label><\/li><li class=\"choice-5 depth-1\"><input type=\"radio\" id=\"wpforms-1566-field_40_5\" name=\"wpforms[fields][40]\" value=\"\u7db2\u4e0a\u9762\u8ac7\" aria-errormessage=\"wpforms-1566-field_40_5-error\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-1566-field_40_5\">\u7db2\u4e0a\u9762\u8ac7<\/label><\/li><li class=\"choice-6 depth-1\"><input type=\"radio\" id=\"wpforms-1566-field_40_6\" name=\"wpforms[fields][40]\" value=\"\u96fb\u8a71\u5c0d\u8ac7\" aria-errormessage=\"wpforms-1566-field_40_6-error\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-1566-field_40_6\">\u96fb\u8a71\u5c0d\u8ac7<\/label><\/li><\/ul><\/fieldset><\/div><div id=\"wpforms-1566-field_46-container\" class=\"wpforms-field wpforms-field-checkbox special-checkbox-buttons wpforms-list-inline\" data-field-type=\"checkbox\" data-field-id=\"46\"><fieldset><legend class=\"wpforms-field-label\">\u5efa\u8b70\u65e5\u5b50\uff1a(\u5982\u9810\u7d04\u6642\u9593\u5df2\u5b9a, \u8acb\u8df3\u904e)<\/legend><ul id=\"wpforms-1566-field_46\"><li class=\"choice-17 depth-1\"><input type=\"checkbox\" id=\"wpforms-1566-field_46_17\" name=\"wpforms[fields][46][]\" value=\"\u661f\u671f\u4e00\" aria-errormessage=\"wpforms-1566-field_46_17-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-1566-field_46_17\">\u661f\u671f\u4e00<\/label><\/li><li class=\"choice-18 depth-1\"><input type=\"checkbox\" id=\"wpforms-1566-field_46_18\" name=\"wpforms[fields][46][]\" value=\"\u661f\u671f\u4e8c\" aria-errormessage=\"wpforms-1566-field_46_18-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-1566-field_46_18\">\u661f\u671f\u4e8c<\/label><\/li><li class=\"choice-19 depth-1\"><input type=\"checkbox\" id=\"wpforms-1566-field_46_19\" name=\"wpforms[fields][46][]\" value=\"\u661f\u671f\u4e09\" aria-errormessage=\"wpforms-1566-field_46_19-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-1566-field_46_19\">\u661f\u671f\u4e09<\/label><\/li><li class=\"choice-20 depth-1\"><input type=\"checkbox\" id=\"wpforms-1566-field_46_20\" name=\"wpforms[fields][46][]\" value=\"\u661f\u671f\u56db\" aria-errormessage=\"wpforms-1566-field_46_20-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-1566-field_46_20\">\u661f\u671f\u56db<\/label><\/li><li class=\"choice-21 depth-1\"><input type=\"checkbox\" id=\"wpforms-1566-field_46_21\" name=\"wpforms[fields][46][]\" value=\"\u661f\u671f\u4e94\" aria-errormessage=\"wpforms-1566-field_46_21-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-1566-field_46_21\">\u661f\u671f\u4e94<\/label><\/li><li class=\"choice-22 depth-1\"><input type=\"checkbox\" id=\"wpforms-1566-field_46_22\" name=\"wpforms[fields][46][]\" value=\"\u661f\u671f\u516d\" aria-errormessage=\"wpforms-1566-field_46_22-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-1566-field_46_22\">\u661f\u671f\u516d<\/label><\/li><li class=\"choice-23 depth-1\"><input type=\"checkbox\" id=\"wpforms-1566-field_46_23\" name=\"wpforms[fields][46][]\" value=\"\u661f\u671f\u65e5\" aria-errormessage=\"wpforms-1566-field_46_23-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-1566-field_46_23\">\u661f\u671f\u65e5<\/label><\/li><\/ul><\/fieldset><\/div><div id=\"wpforms-1566-field_47-container\" class=\"wpforms-field wpforms-field-checkbox special-checkbox-buttons wpforms-list-inline\" data-field-type=\"checkbox\" data-field-id=\"47\"><fieldset><legend class=\"wpforms-field-label\">\u5efa\u8b70\u6642\u9593\uff1a(\u5982\u9810\u7d04\u6642\u9593\u5df2\u5b9a, \u8acb\u8df3\u904e)<\/legend><ul id=\"wpforms-1566-field_47\"><li class=\"choice-17 depth-1\"><input type=\"checkbox\" id=\"wpforms-1566-field_47_17\" name=\"wpforms[fields][47][]\" value=\"\u65e9\u4e0a (08:00 ~ 12:00)\" aria-errormessage=\"wpforms-1566-field_47_17-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-1566-field_47_17\">\u65e9\u4e0a (08:00 ~ 12:00)<\/label><\/li><li class=\"choice-18 depth-1\"><input type=\"checkbox\" id=\"wpforms-1566-field_47_18\" name=\"wpforms[fields][47][]\" value=\"\u4e0b\u5348 (13:00 ~ 18:00)\" aria-errormessage=\"wpforms-1566-field_47_18-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-1566-field_47_18\">\u4e0b\u5348 (13:00 ~ 18:00)<\/label><\/li><li class=\"choice-19 depth-1\"><input type=\"checkbox\" id=\"wpforms-1566-field_47_19\" name=\"wpforms[fields][47][]\" value=\"\u665a\u4e0a (19:00 ~ 23:00)\" aria-errormessage=\"wpforms-1566-field_47_19-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-1566-field_47_19\">\u665a\u4e0a (19:00 ~ 23:00)<\/label><\/li><\/ul><\/fieldset><\/div><div id=\"wpforms-1566-field_45-container\" class=\"wpforms-field wpforms-field-layout\" data-field-type=\"layout\" data-field-id=\"45\"><div class=\"wpforms-field-layout-rows wpforms-field-large\"><div class=\"wpforms-layout-row\"><div class=\"wpforms-layout-column wpforms-layout-column-67\"><div id=\"wpforms-1566-field_36-container\" class=\"wpforms-field wpforms-field-checkbox special-checkbox-buttons wpforms-list-inline wpforms-conditional-trigger\" data-field-type=\"checkbox\" data-field-id=\"36\"><fieldset><legend class=\"wpforms-field-label\">\u6c42\u52a9\u539f\u56e0\uff1a <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/legend><ul id=\"wpforms-1566-field_36\" class=\"wpforms-field-required\"><li class=\"choice-4 depth-1\"><input type=\"checkbox\" id=\"wpforms-1566-field_36_4\" name=\"wpforms[fields][36][]\" value=\"\u60c5\u7dd2\u5bb9\u6613\u5931\u63a7\" aria-errormessage=\"wpforms-1566-field_36_4-error\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-1566-field_36_4\">\u60c5\u7dd2\u5bb9\u6613\u5931\u63a7<\/label><\/li><li class=\"choice-5 depth-1\"><input type=\"checkbox\" id=\"wpforms-1566-field_36_5\" name=\"wpforms[fields][36][]\" value=\"\u54c0\u50b7\u53ca\u5275\u50b7\u7d93\u9a57\" aria-errormessage=\"wpforms-1566-field_36_5-error\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-1566-field_36_5\">\u54c0\u50b7\u53ca\u5275\u50b7\u7d93\u9a57<\/label><\/li><li class=\"choice-16 depth-1\"><input type=\"checkbox\" id=\"wpforms-1566-field_36_16\" name=\"wpforms[fields][36][]\" value=\"\u500b\u4eba\u6210\u9577\" aria-errormessage=\"wpforms-1566-field_36_16-error\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-1566-field_36_16\">\u500b\u4eba\u6210\u9577<\/label><\/li><li class=\"choice-6 depth-1\"><input type=\"checkbox\" id=\"wpforms-1566-field_36_6\" name=\"wpforms[fields][36][]\" value=\"\u4eba\u969b\u95dc\u4fc2\" aria-errormessage=\"wpforms-1566-field_36_6-error\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-1566-field_36_6\">\u4eba\u969b\u95dc\u4fc2<\/label><\/li><li class=\"choice-7 depth-1\"><input type=\"checkbox\" id=\"wpforms-1566-field_36_7\" name=\"wpforms[fields][36][]\" value=\"\u5de5\u4f5c\u5354\u8abf\" aria-errormessage=\"wpforms-1566-field_36_7-error\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-1566-field_36_7\">\u5de5\u4f5c\u5354\u8abf<\/label><\/li><li class=\"choice-17 depth-1\"><input type=\"checkbox\" id=\"wpforms-1566-field_36_17\" name=\"wpforms[fields][36][]\" value=\"\u5a5a\u524d\u8f14\u5c0e\" aria-errormessage=\"wpforms-1566-field_36_17-error\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-1566-field_36_17\">\u5a5a\u524d\u8f14\u5c0e<\/label><\/li><li class=\"choice-8 depth-1\"><input type=\"checkbox\" id=\"wpforms-1566-field_36_8\" name=\"wpforms[fields][36][]\" value=\"\u5a5a\u59fb\/\u4f34\u4fb6\u95dc\u4fc2\" aria-errormessage=\"wpforms-1566-field_36_8-error\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-1566-field_36_8\">\u5a5a\u59fb\/\u4f34\u4fb6\u95dc\u4fc2<\/label><\/li><li class=\"choice-18 depth-1\"><input type=\"checkbox\" id=\"wpforms-1566-field_36_18\" 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name=\"wpforms[fields][36][]\" value=\"\u5b50\u5973\u5b78\u7fd2\" aria-errormessage=\"wpforms-1566-field_36_11-error\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-1566-field_36_11\">\u5b50\u5973\u5b78\u7fd2<\/label><\/li><li class=\"choice-19 depth-1\"><input type=\"checkbox\" id=\"wpforms-1566-field_36_19\" name=\"wpforms[fields][36][]\" value=\"\u6c89\u6eba\u7159\u9152\" aria-errormessage=\"wpforms-1566-field_36_19-error\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-1566-field_36_19\">\u6c89\u6eba\u7159\u9152<\/label><\/li><li class=\"choice-12 depth-1\"><input type=\"checkbox\" id=\"wpforms-1566-field_36_12\" name=\"wpforms[fields][36][]\" value=\"\u6c89\u6eba\u7db2\u7d61\u904a\u6232\" aria-errormessage=\"wpforms-1566-field_36_12-error\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-1566-field_36_12\">\u6c89\u6eba\u7db2\u7d61\u904a\u6232<\/label><\/li><li class=\"choice-13 depth-1\"><input type=\"checkbox\" 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id=\"wpforms-1566-field_36_21\" name=\"wpforms[fields][36][]\" value=\"\u5152\u7ae5\u5b78\u7fd2\u8a55\u4f30\u53ca\u5831\u544a\" aria-errormessage=\"wpforms-1566-field_36_21-error\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-1566-field_36_21\">\u5152\u7ae5\u5b78\u7fd2\u8a55\u4f30\u53ca\u5831\u544a<\/label><\/li><li class=\"choice-15 depth-1\"><input type=\"checkbox\" id=\"wpforms-1566-field_36_15\" name=\"wpforms[fields][36][]\" value=\"\u5176\u4ed6\" aria-errormessage=\"wpforms-1566-field_36_15-error\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-1566-field_36_15\">\u5176\u4ed6<\/label><\/li><\/ul><\/fieldset><\/div><\/div><div class=\"wpforms-layout-column wpforms-layout-column-33\"><div id=\"wpforms-1566-field_44-container\" class=\"wpforms-field wpforms-field-name wpforms-conditional-field wpforms-conditional-show\" data-field-type=\"name\" data-field-id=\"44\" style=\"display:none;\"><label class=\"wpforms-field-label\" 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id=\"wpforms-1566-field_38\" class=\"wpforms-field-medium\" name=\"wpforms[fields][38]\"><option value=\"\" class=\"placeholder\" disabled  selected='selected'>&#8212; Select Choice &#8212;<\/option><option value=\"\u7537\"  class=\"choice-13 depth-1\"  >\u7537<\/option><option value=\"\u5973\"  class=\"choice-14 depth-1\"  >\u5973<\/option><option value=\"\u4e0d\u9069\u7528\"  class=\"choice-15 depth-1\"  >\u4e0d\u9069\u7528<\/option><\/select><\/div><\/div><div class=\"wpforms-layout-column wpforms-layout-column-50\"><div id=\"wpforms-1566-field_39-container\" class=\"wpforms-field wpforms-field-name\" data-field-type=\"name\" data-field-id=\"39\"><label class=\"wpforms-field-label\" for=\"wpforms-1566-field_39\">\u5c0d\u670d\u52d9\u63d0\u4f9b\u8005\u5176\u4ed6\u8981\u6c42\uff1a<\/label><input type=\"text\" id=\"wpforms-1566-field_39\" class=\"wpforms-field-medium\" name=\"wpforms[fields][39]\" aria-errormessage=\"wpforms-1566-field_39-error\" ><\/div><\/div><\/div><\/div><\/div><div 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