{"id":8860,"date":"2020-06-23T23:34:52","date_gmt":"2020-06-23T21:34:52","guid":{"rendered":"https:\/\/www.accompagner.be\/?page_id=8860"},"modified":"2021-09-23T16:03:22","modified_gmt":"2021-09-23T14:03:22","slug":"demander-un-accompagnement","status":"publish","type":"page","link":"https:\/\/bxl.accompagner.be\/fr\/demander-un-accompagnement\/","title":{"rendered":"Formulaire de demande d&rsquo;accompagnement ambulatoire"},"content":{"rendered":"\n<div><u>U kunt dit formulier in<\/u>\n<div class=\"wpml-ls-statics-footer wpml-ls wpml-ls-legacy-list-horizontal\">\n\t<ul><li class=\"wpml-ls-slot-footer wpml-ls-item wpml-ls-item-nl wpml-ls-first-item wpml-ls-item-legacy-list-horizontal\">\n\t\t\t\t<a href=\"https:\/\/bxl.accompagner.be\/nl\/\" class=\"wpml-ls-link\">\n                    <span class=\"wpml-ls-native\" lang=\"nl\">Nederlands<\/span><\/a>\n\t\t\t<\/li><li class=\"wpml-ls-slot-footer wpml-ls-item wpml-ls-item-en wpml-ls-last-item wpml-ls-item-legacy-list-horizontal\">\n\t\t\t\t<a href=\"https:\/\/bxl.accompagner.be\/en\/\" class=\"wpml-ls-link\">\n                    <span class=\"wpml-ls-native\" lang=\"en\">English<\/span><\/a>\n\t\t\t<\/li><\/ul>\n<\/div>\n<u>invullen.<\/u><\/div>\n\n\n\n<p>Les zones obligatoires marqu\u00e9es d&rsquo;un <span style=\"color:#cf2e2e\" class=\"tadv-color\">*<\/span> contiennent des donn\u00e9es indispensables \u00e0 l&rsquo;ouverture du dossier et au bon d\u00e9roulement de l&rsquo;accompagnement.&nbsp;Introduire la demande au moins 3-4 jours avant la date de l&rsquo;accompagnement. De pr\u00e9f\u00e9rence, pr\u00e9voyez des accompagnements \u00e0 partir de 8h30. Nous sommes tenus au secret professionnel.&nbsp;Si vous d\u00e9sirez gagner du temps lors de vos prochaines demandes, activez l&rsquo;option de saisie-automatique dans votre navigateur (Google Chrome, Mozilla Forefox, Internet Explorer 7 et 8, Microsoft Edge). Pour cela ouvrez <a aria-label=\"undefined (s\u2019ouvre dans un nouvel onglet)\" rel=\"noreferrer noopener\" href=\"http:\/\/www.accompagner.be\/wp-content\/uploads\/FORPARINT-Saisie-Automatique-Internet_FR.pdf\" target=\"_blank\">ce guide<\/a> pour la proc\u00e9dure correspondant \u00e0 votre navigateur.&nbsp;<b>Attention<\/b> : pour que notre mail de confirmation n&rsquo;atterrisse pas dans vos SPAM, veillez enregistrer notre adresse <a href=\"mailto:info.saa@accompagner.be\">info.saa@accompagner.be<\/a> dans votre carnet d&rsquo;adresse. Pour plus d&rsquo;information, contactez-nous <strong>02.580.20.33<\/strong> (de 9h \u00e0 16h).<\/p>\n\n\n\n<div class=\"wp-block-columns has-pale-cyan-blue-background-color has-background\">\n<div class=\"wp-block-column\" style=\"flex-basis:100%\">\n<h4 class=\"has-text-align-center\"><a href=\"https:\/\/accompagner.be\/wp-content\/uploads\/Conditions-Generales-de-collaboration-SAA.pdf\" target=\"_blank\" rel=\"noreferrer noopener\"><strong>Conditions G\u00e9n\u00e9rales de Collaboration<\/strong><\/a><\/h4>\n\n\n\n<h4 class=\"has-text-align-center\"><a href=\"https:\/\/accompagner.be\/wp-content\/uploads\/Clauses-de-sous-traitance.pdf\" target=\"_blank\" rel=\"noreferrer noopener\"><strong>Clause de Sous-traitance<\/strong><\/a><\/h4>\n\n\n\n<h4 class=\"has-text-align-center\"><strong><a href=\"https:\/\/accompagner.be\/wp-content\/uploads\/Accord-de-partenariat-SAA.pdf\" target=\"_blank\" rel=\"noreferrer noopener\">Accord de Partenariat<\/a><\/strong><\/h4>\n<\/div>\n<\/div>\n\n\n\n<hr class=\"wp-block-separator\"\/>\n\n\n\n<div class=\"wpforms-container wpforms-container-full\" id=\"wpforms-6401\"><form id=\"wpforms-form-6401\" class=\"wpforms-validate wpforms-form\" data-formid=\"6401\" method=\"post\" enctype=\"multipart\/form-data\" action=\"\/fr\/wp-json\/wp\/v2\/pages\/8860\"><div class=\"wpforms-field-container\"><div id=\"wpforms-6401-field_26-container\" class=\"wpforms-field wpforms-field-divider\" data-field-id=\"26\"><h3 id=\"wpforms-6401-field_26\" name=\"wpforms[fields][26]\">Vos coordonn\u00e9es [Institution demandant l&#039;accompagnement]<\/h3><\/div><div id=\"wpforms-6401-field_6-container\" class=\"wpforms-field wpforms-field-name\" data-field-id=\"6\"><label class=\"wpforms-field-label\" for=\"wpforms-6401-field_6\">Vos pr\u00e9nom et nom <span class=\"wpforms-required-label\">*<\/span><\/label><div class=\"wpforms-field-row wpforms-field-medium\"><div class=\"wpforms-field-row-block wpforms-first wpforms-one-half\"><input type=\"text\" id=\"wpforms-6401-field_6\" class=\"wpforms-field-name-first wpforms-field-required\" name=\"wpforms[fields][6][first]\" required><label for=\"wpforms-6401-field_6\" class=\"wpforms-field-sublabel after \">Pr\u00e9nom<\/label><\/div><div class=\"wpforms-field-row-block wpforms-one-half\"><input type=\"text\" id=\"wpforms-6401-field_6-last\" class=\"wpforms-field-name-last wpforms-field-required\" name=\"wpforms[fields][6][last]\" required><label for=\"wpforms-6401-field_6-last\" class=\"wpforms-field-sublabel after \">Nom<\/label><\/div><\/div><\/div><div id=\"wpforms-6401-field_11-container\" class=\"wpforms-field wpforms-field-text\" data-field-id=\"11\"><label class=\"wpforms-field-label\" for=\"wpforms-6401-field_11\">Le nom de l\u2019institution sollicitant l\u2019accompagnement <span class=\"wpforms-required-label\">*<\/span><\/label><input type=\"text\" id=\"wpforms-6401-field_11\" class=\"wpforms-field-medium wpforms-field-required\" name=\"wpforms[fields][11]\" required><\/div><div id=\"wpforms-6401-field_13-container\" class=\"wpforms-field wpforms-field-text\" data-field-id=\"13\"><label class=\"wpforms-field-label\" for=\"wpforms-6401-field_13\">Le nom de votre service<\/label><input type=\"text\" id=\"wpforms-6401-field_13\" class=\"wpforms-field-medium\" name=\"wpforms[fields][13]\" ><\/div><div id=\"wpforms-6401-field_7-container\" class=\"wpforms-field wpforms-field-email\" data-field-id=\"7\"><label class=\"wpforms-field-label\" for=\"wpforms-6401-field_7\">Votre adresse mail <span class=\"wpforms-required-label\">*<\/span><\/label><div class=\"wpforms-field-row wpforms-field-medium\"><div class=\"wpforms-field-row-block wpforms-one-half wpforms-first\"><input type=\"email\" id=\"wpforms-6401-field_7\" class=\"wpforms-field-required wpforms-field-email-primary\" name=\"wpforms[fields][7][primary]\" required><label for=\"wpforms-6401-field_7\" class=\"wpforms-field-sublabel after \">E-mail<\/label><\/div><div class=\"wpforms-field-row-block wpforms-one-half\"><input type=\"email\" id=\"wpforms-6401-field_7-secondary\" class=\"wpforms-field-email-secondary wpforms-field-required\" data-rule-confirm=\"#wpforms-6401-field_7\" name=\"wpforms[fields][7][secondary]\" required><label for=\"wpforms-6401-field_7-secondary\" class=\"wpforms-field-sublabel after \">Confirmez l\u2019e-mail<\/label><\/div><\/div><\/div><div id=\"wpforms-6401-field_78-container\" class=\"wpforms-field wpforms-field-text\" data-field-id=\"78\"><label class=\"wpforms-field-label\" for=\"wpforms-6401-field_78\">Le num\u00e9ro de t\u00e9l\u00e9phone auquel vous joindre  <span class=\"wpforms-required-label\">*<\/span><\/label><input type=\"text\" id=\"wpforms-6401-field_78\" class=\"wpforms-field-small wpforms-field-required\" name=\"wpforms[fields][78]\" required><div class=\"wpforms-field-description\">Num\u00e9ro de t\u00e9l\u00e9phone belge Fixe ou Gsm.<\/div><\/div><div id=\"wpforms-6401-field_20-container\" class=\"wpforms-field wpforms-field-divider h5\" data-field-id=\"20\"><h3 id=\"wpforms-6401-field_20\" name=\"wpforms[fields][20]\">Coordonn\u00e9es du b\u00e9n\u00e9ficiaire de l&#039;accompagnement<\/h3><\/div><div id=\"wpforms-6401-field_16-container\" class=\"wpforms-field wpforms-field-name\" data-field-id=\"16\"><label class=\"wpforms-field-label\" for=\"wpforms-6401-field_16\">Les pr\u00e9nom et nom du b\u00e9n\u00e9ficiaire <span class=\"wpforms-required-label\">*<\/span><\/label><div class=\"wpforms-field-row wpforms-field-medium\"><div class=\"wpforms-field-row-block wpforms-first wpforms-one-half\"><input type=\"text\" id=\"wpforms-6401-field_16\" class=\"wpforms-field-name-first wpforms-field-required\" name=\"wpforms[fields][16][first]\" required><label for=\"wpforms-6401-field_16\" class=\"wpforms-field-sublabel after \">Pr\u00e9nom<\/label><\/div><div class=\"wpforms-field-row-block wpforms-one-half\"><input type=\"text\" id=\"wpforms-6401-field_16-last\" class=\"wpforms-field-name-last wpforms-field-required\" name=\"wpforms[fields][16][last]\" required><label for=\"wpforms-6401-field_16-last\" class=\"wpforms-field-sublabel after \">Nom<\/label><\/div><\/div><\/div><div id=\"wpforms-6401-field_79-container\" class=\"wpforms-field wpforms-field-text\" data-field-id=\"79\"><label class=\"wpforms-field-label\" for=\"wpforms-6401-field_79\">Son num\u00e9ro de t\u00e9l\u00e9phone <span class=\"wpforms-required-label\">*<\/span><\/label><input type=\"text\" id=\"wpforms-6401-field_79\" class=\"wpforms-field-small wpforms-field-required\" name=\"wpforms[fields][79]\" required><div class=\"wpforms-field-description\">Num\u00e9ro de t\u00e9l\u00e9phone belge Fixe ou Gsm.<\/div><\/div><div id=\"wpforms-6401-field_19-container\" class=\"wpforms-field wpforms-field-radio wpforms-list-inline wpforms-conditional-trigger\" data-field-id=\"19\"><label class=\"wpforms-field-label\" for=\"wpforms-6401-field_19\">Est-ce la premi\u00e8re fois que vous demandez un accompagnement pour cette personne?  <span class=\"wpforms-required-label\">*<\/span><\/label><ul id=\"wpforms-6401-field_19\" class=\"wpforms-field-required\"><li class=\"choice-1 depth-1\"><input type=\"radio\" id=\"wpforms-6401-field_19_1\" name=\"wpforms[fields][19]\" value=\"Oui\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-6401-field_19_1\">Oui<\/label><\/li><li class=\"choice-2 depth-1\"><input type=\"radio\" id=\"wpforms-6401-field_19_2\" name=\"wpforms[fields][19]\" value=\"Non\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-6401-field_19_2\">Non<\/label><\/li><\/ul><\/div><div id=\"wpforms-6401-field_23-container\" class=\"wpforms-field wpforms-field-checkbox wpforms-conditional-field wpforms-conditional-show\" data-field-id=\"23\" style=\"display:none;\"><label class=\"wpforms-field-label\" for=\"wpforms-6401-field_23\">Veuillez confirmer que le b\u00e9n\u00e9ficiaire est inform\u00e9 de la raison pour laquelle un accompagnement est demand\u00e9 ; qu&#039;il consent \u00e0 la mani\u00e8re dont l&#039;information et les donn\u00e9es personnelles circulent entre votre service et le service d\u2019accompagnement ambulatoire des Amis d&#039;Accompagner. <span class=\"wpforms-required-label\">*<\/span><\/label><ul id=\"wpforms-6401-field_23\" class=\"wpforms-field-required\"><li class=\"choice-1 depth-1\"><input type=\"checkbox\" id=\"wpforms-6401-field_23_1\" name=\"wpforms[fields][23][]\" value=\"Oui\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-6401-field_23_1\">Oui<\/label><\/li><\/ul><\/div><div id=\"wpforms-6401-field_24-container\" class=\"wpforms-field wpforms-field-radio wpforms-list-inline wpforms-conditional-field wpforms-conditional-show\" data-field-id=\"24\" style=\"display:none;\"><label class=\"wpforms-field-label\" for=\"wpforms-6401-field_24\">Sexe <span class=\"wpforms-required-label\">*<\/span><\/label><ul id=\"wpforms-6401-field_24\" class=\"wpforms-field-required\"><li class=\"choice-1 depth-1\"><input type=\"radio\" id=\"wpforms-6401-field_24_1\" name=\"wpforms[fields][24]\" value=\"H\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-6401-field_24_1\">H<\/label><\/li><li class=\"choice-2 depth-1\"><input type=\"radio\" id=\"wpforms-6401-field_24_2\" name=\"wpforms[fields][24]\" value=\"F\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-6401-field_24_2\">F<\/label><\/li><\/ul><\/div><div id=\"wpforms-6401-field_25-container\" class=\"wpforms-field wpforms-field-date-time wpforms-conditional-field wpforms-conditional-show\" data-field-id=\"25\" style=\"display:none;\"><label class=\"wpforms-field-label\" for=\"wpforms-6401-field_25\">Sa date de naissance <span class=\"wpforms-required-label\">*<\/span><\/label><select name=\"wpforms[fields][25][date][d]\" id=\"wpforms-field_25-day\" class=\"wpforms-field-date-time-date-day wpforms-field-required\"  required><option class=\"placeholder\" selected disabled>JJ<\/option><option value=\"1\" >1<\/option><option value=\"2\" >2<\/option><option value=\"3\" >3<\/option><option value=\"4\" >4<\/option><option value=\"5\" >5<\/option><option value=\"6\" >6<\/option><option value=\"7\" >7<\/option><option value=\"8\" >8<\/option><option value=\"9\" >9<\/option><option value=\"10\" >10<\/option><option value=\"11\" >11<\/option><option value=\"12\" >12<\/option><option value=\"13\" >13<\/option><option value=\"14\" >14<\/option><option value=\"15\" >15<\/option><option value=\"16\" >16<\/option><option value=\"17\" >17<\/option><option value=\"18\" >18<\/option><option value=\"19\" >19<\/option><option value=\"20\" >20<\/option><option value=\"21\" >21<\/option><option value=\"22\" >22<\/option><option value=\"23\" >23<\/option><option value=\"24\" >24<\/option><option value=\"25\" >25<\/option><option value=\"26\" >26<\/option><option value=\"27\" >27<\/option><option value=\"28\" >28<\/option><option value=\"29\" >29<\/option><option value=\"30\" >30<\/option><option value=\"31\" >31<\/option><\/select><span class=\"wpforms-field-date-time-date-sep\">\/<\/span><select name=\"wpforms[fields][25][date][m]\" id=\"wpforms-field_25-month\" class=\"wpforms-field-date-time-date-month wpforms-field-required\"  required><option class=\"placeholder\" selected disabled>MM<\/option><option value=\"1\" >1<\/option><option value=\"2\" >2<\/option><option value=\"3\" >3<\/option><option value=\"4\" >4<\/option><option value=\"5\" >5<\/option><option value=\"6\" >6<\/option><option value=\"7\" >7<\/option><option value=\"8\" >8<\/option><option value=\"9\" >9<\/option><option value=\"10\" >10<\/option><option value=\"11\" >11<\/option><option value=\"12\" >12<\/option><\/select><span class=\"wpforms-field-date-time-date-sep\">\/<\/span><select name=\"wpforms[fields][25][date][y]\" id=\"wpforms-field_25-year\" class=\"wpforms-field-date-time-date-year wpforms-field-required\"  required><option class=\"placeholder\" selected disabled>AAAA<\/option><option value=\"2026\" >2026<\/option><option value=\"2025\" >2025<\/option><option value=\"2024\" >2024<\/option><option value=\"2023\" >2023<\/option><option value=\"2022\" >2022<\/option><option value=\"2021\" >2021<\/option><option value=\"2020\" >2020<\/option><option value=\"2019\" >2019<\/option><option value=\"2018\" >2018<\/option><option value=\"2017\" >2017<\/option><option value=\"2016\" >2016<\/option><option value=\"2015\" >2015<\/option><option value=\"2014\" >2014<\/option><option value=\"2013\" >2013<\/option><option value=\"2012\" >2012<\/option><option value=\"2011\" >2011<\/option><option value=\"2010\" >2010<\/option><option value=\"2009\" >2009<\/option><option value=\"2008\" >2008<\/option><option value=\"2007\" >2007<\/option><option value=\"2006\" >2006<\/option><option value=\"2005\" >2005<\/option><option value=\"2004\" >2004<\/option><option value=\"2003\" >2003<\/option><option value=\"2002\" >2002<\/option><option value=\"2001\" >2001<\/option><option value=\"2000\" >2000<\/option><option value=\"1999\" >1999<\/option><option value=\"1998\" >1998<\/option><option value=\"1997\" >1997<\/option><option value=\"1996\" >1996<\/option><option value=\"1995\" >1995<\/option><option value=\"1994\" >1994<\/option><option value=\"1993\" >1993<\/option><option value=\"1992\" >1992<\/option><option value=\"1991\" >1991<\/option><option value=\"1990\" >1990<\/option><option value=\"1989\" >1989<\/option><option value=\"1988\" >1988<\/option><option value=\"1987\" >1987<\/option><option value=\"1986\" >1986<\/option><option value=\"1985\" >1985<\/option><option value=\"1984\" >1984<\/option><option value=\"1983\" >1983<\/option><option value=\"1982\" >1982<\/option><option value=\"1981\" >1981<\/option><option value=\"1980\" >1980<\/option><option value=\"1979\" >1979<\/option><option value=\"1978\" >1978<\/option><option value=\"1977\" >1977<\/option><option value=\"1976\" >1976<\/option><option value=\"1975\" >1975<\/option><option value=\"1974\" >1974<\/option><option value=\"1973\" >1973<\/option><option value=\"1972\" >1972<\/option><option value=\"1971\" >1971<\/option><option value=\"1970\" >1970<\/option><option value=\"1969\" >1969<\/option><option value=\"1968\" >1968<\/option><option value=\"1967\" >1967<\/option><option value=\"1966\" >1966<\/option><option value=\"1965\" >1965<\/option><option value=\"1964\" >1964<\/option><option value=\"1963\" >1963<\/option><option value=\"1962\" >1962<\/option><option value=\"1961\" >1961<\/option><option value=\"1960\" >1960<\/option><option value=\"1959\" >1959<\/option><option value=\"1958\" >1958<\/option><option value=\"1957\" >1957<\/option><option value=\"1956\" >1956<\/option><option value=\"1955\" >1955<\/option><option value=\"1954\" >1954<\/option><option value=\"1953\" >1953<\/option><option value=\"1952\" >1952<\/option><option value=\"1951\" >1951<\/option><option value=\"1950\" >1950<\/option><option value=\"1949\" >1949<\/option><option value=\"1948\" >1948<\/option><option value=\"1947\" >1947<\/option><option value=\"1946\" >1946<\/option><option value=\"1945\" >1945<\/option><option value=\"1944\" >1944<\/option><option value=\"1943\" >1943<\/option><option value=\"1942\" >1942<\/option><option value=\"1941\" >1941<\/option><option value=\"1940\" >1940<\/option><option value=\"1939\" >1939<\/option><option value=\"1938\" >1938<\/option><option value=\"1937\" >1937<\/option><option value=\"1936\" >1936<\/option><option value=\"1935\" >1935<\/option><option value=\"1934\" >1934<\/option><option value=\"1933\" >1933<\/option><option value=\"1932\" >1932<\/option><option value=\"1931\" >1931<\/option><option value=\"1930\" >1930<\/option><option value=\"1929\" >1929<\/option><option value=\"1928\" >1928<\/option><option value=\"1927\" >1927<\/option><option value=\"1926\" >1926<\/option><option value=\"1925\" >1925<\/option><option value=\"1924\" >1924<\/option><option value=\"1923\" >1923<\/option><option value=\"1922\" >1922<\/option><option value=\"1921\" >1921<\/option><option value=\"1920\" >1920<\/option><\/select><\/div><div id=\"wpforms-6401-field_28-container\" class=\"wpforms-field wpforms-field-text wpforms-conditional-field wpforms-conditional-show\" data-field-id=\"28\" style=\"display:none;\"><label class=\"wpforms-field-label\" for=\"wpforms-6401-field_28\">Son adresse <span class=\"wpforms-required-label\">*<\/span><\/label><input type=\"text\" id=\"wpforms-6401-field_28\" class=\"wpforms-field-medium wpforms-field-required\" name=\"wpforms[fields][28]\" placeholder=\"Si n\u00e9cessaire, merci de bien d\u00e9tailler cette adresse : sonnette, n\u00b0, \u00e9tage, etc\" required><\/div><div id=\"wpforms-6401-field_29-container\" class=\"wpforms-field wpforms-field-text wpforms-conditional-field wpforms-conditional-show\" data-field-id=\"29\" style=\"display:none;\"><label class=\"wpforms-field-label\" for=\"wpforms-6401-field_29\">Sa nationalit\u00e9 <span class=\"wpforms-required-label\">*<\/span><\/label><input type=\"text\" id=\"wpforms-6401-field_29\" class=\"wpforms-field-medium wpforms-field-required\" name=\"wpforms[fields][29]\" required><\/div><div id=\"wpforms-6401-field_30-container\" class=\"wpforms-field wpforms-field-html wpforms-conditional-field wpforms-conditional-show\" data-field-id=\"30\" style=\"display:none;\"><div id=\"wpforms-6401-field_30\"><div><hr style=\"border-top: 2px dashed red;\" ;=\"\"> --- Si votre b\u00e9n\u00e9ficiaire n'est pas belge ou naturalis\u00e9 belge ---<\/div><\/div><\/div><div id=\"wpforms-6401-field_31-container\" class=\"wpforms-field wpforms-field-date-time wpforms-conditional-field wpforms-conditional-show\" data-field-id=\"31\" style=\"display:none;\"><label class=\"wpforms-field-label\" for=\"wpforms-6401-field_31\">Sa date d&#039;arriv\u00e9e en Belgique <span class=\"wpforms-required-label\">*<\/span><\/label><select name=\"wpforms[fields][31][date][d]\" id=\"wpforms-field_31-day\" class=\"wpforms-field-date-time-date-day wpforms-field-required\"  required><option class=\"placeholder\" selected disabled>JJ<\/option><option value=\"1\" >1<\/option><option value=\"2\" >2<\/option><option value=\"3\" >3<\/option><option value=\"4\" >4<\/option><option value=\"5\" >5<\/option><option value=\"6\" >6<\/option><option value=\"7\" >7<\/option><option value=\"8\" >8<\/option><option value=\"9\" >9<\/option><option value=\"10\" >10<\/option><option value=\"11\" >11<\/option><option value=\"12\" >12<\/option><option value=\"13\" >13<\/option><option value=\"14\" >14<\/option><option value=\"15\" >15<\/option><option value=\"16\" >16<\/option><option value=\"17\" >17<\/option><option value=\"18\" >18<\/option><option value=\"19\" >19<\/option><option value=\"20\" >20<\/option><option value=\"21\" >21<\/option><option value=\"22\" >22<\/option><option value=\"23\" >23<\/option><option value=\"24\" >24<\/option><option value=\"25\" >25<\/option><option value=\"26\" >26<\/option><option value=\"27\" >27<\/option><option value=\"28\" >28<\/option><option value=\"29\" >29<\/option><option value=\"30\" >30<\/option><option value=\"31\" >31<\/option><\/select><span class=\"wpforms-field-date-time-date-sep\">\/<\/span><select name=\"wpforms[fields][31][date][m]\" id=\"wpforms-field_31-month\" class=\"wpforms-field-date-time-date-month wpforms-field-required\"  required><option class=\"placeholder\" selected disabled>MM<\/option><option value=\"1\" >1<\/option><option value=\"2\" >2<\/option><option value=\"3\" >3<\/option><option value=\"4\" >4<\/option><option value=\"5\" >5<\/option><option value=\"6\" >6<\/option><option value=\"7\" >7<\/option><option value=\"8\" >8<\/option><option value=\"9\" >9<\/option><option value=\"10\" >10<\/option><option value=\"11\" >11<\/option><option value=\"12\" >12<\/option><\/select><span class=\"wpforms-field-date-time-date-sep\">\/<\/span><select name=\"wpforms[fields][31][date][y]\" id=\"wpforms-field_31-year\" class=\"wpforms-field-date-time-date-year wpforms-field-required\"  required><option class=\"placeholder\" selected disabled>AAAA<\/option><option value=\"2026\" >2026<\/option><option value=\"2025\" >2025<\/option><option value=\"2024\" >2024<\/option><option value=\"2023\" >2023<\/option><option value=\"2022\" >2022<\/option><option value=\"2021\" >2021<\/option><option value=\"2020\" >2020<\/option><option value=\"2019\" >2019<\/option><option value=\"2018\" >2018<\/option><option value=\"2017\" >2017<\/option><option value=\"2016\" >2016<\/option><option value=\"2015\" >2015<\/option><option value=\"2014\" >2014<\/option><option value=\"2013\" >2013<\/option><option value=\"2012\" >2012<\/option><option value=\"2011\" >2011<\/option><option value=\"2010\" >2010<\/option><option value=\"2009\" >2009<\/option><option value=\"2008\" >2008<\/option><option value=\"2007\" >2007<\/option><option value=\"2006\" >2006<\/option><option value=\"2005\" >2005<\/option><option value=\"2004\" >2004<\/option><option value=\"2003\" >2003<\/option><option value=\"2002\" >2002<\/option><option value=\"2001\" >2001<\/option><option value=\"2000\" >2000<\/option><option value=\"1999\" >1999<\/option><option value=\"1998\" >1998<\/option><option value=\"1997\" >1997<\/option><option value=\"1996\" >1996<\/option><option value=\"1995\" >1995<\/option><option value=\"1994\" >1994<\/option><option value=\"1993\" >1993<\/option><option value=\"1992\" >1992<\/option><option value=\"1991\" >1991<\/option><option value=\"1990\" >1990<\/option><option value=\"1989\" >1989<\/option><option value=\"1988\" >1988<\/option><option value=\"1987\" >1987<\/option><option value=\"1986\" >1986<\/option><option value=\"1985\" >1985<\/option><option value=\"1984\" >1984<\/option><option value=\"1983\" >1983<\/option><option value=\"1982\" >1982<\/option><option value=\"1981\" >1981<\/option><option value=\"1980\" >1980<\/option><option value=\"1979\" >1979<\/option><option value=\"1978\" >1978<\/option><option value=\"1977\" >1977<\/option><option value=\"1976\" >1976<\/option><option value=\"1975\" >1975<\/option><option value=\"1974\" >1974<\/option><option value=\"1973\" >1973<\/option><option value=\"1972\" >1972<\/option><option value=\"1971\" >1971<\/option><option value=\"1970\" >1970<\/option><option value=\"1969\" >1969<\/option><option value=\"1968\" >1968<\/option><option value=\"1967\" >1967<\/option><option value=\"1966\" >1966<\/option><option value=\"1965\" >1965<\/option><option value=\"1964\" >1964<\/option><option value=\"1963\" >1963<\/option><option value=\"1962\" >1962<\/option><option value=\"1961\" >1961<\/option><option value=\"1960\" >1960<\/option><option value=\"1959\" >1959<\/option><option value=\"1958\" >1958<\/option><option value=\"1957\" >1957<\/option><option value=\"1956\" >1956<\/option><option value=\"1955\" >1955<\/option><option value=\"1954\" >1954<\/option><option value=\"1953\" >1953<\/option><option value=\"1952\" >1952<\/option><option value=\"1951\" >1951<\/option><option value=\"1950\" >1950<\/option><option value=\"1949\" >1949<\/option><option value=\"1948\" >1948<\/option><option value=\"1947\" >1947<\/option><option value=\"1946\" >1946<\/option><option value=\"1945\" >1945<\/option><option value=\"1944\" >1944<\/option><option value=\"1943\" >1943<\/option><option value=\"1942\" >1942<\/option><option value=\"1941\" >1941<\/option><option value=\"1940\" >1940<\/option><option value=\"1939\" >1939<\/option><option value=\"1938\" >1938<\/option><option value=\"1937\" >1937<\/option><option value=\"1936\" >1936<\/option><option value=\"1935\" >1935<\/option><option value=\"1934\" >1934<\/option><option value=\"1933\" >1933<\/option><option value=\"1932\" >1932<\/option><option value=\"1931\" >1931<\/option><option value=\"1930\" >1930<\/option><option value=\"1929\" >1929<\/option><option value=\"1928\" >1928<\/option><option value=\"1927\" >1927<\/option><option value=\"1926\" >1926<\/option><option value=\"1925\" >1925<\/option><option value=\"1924\" >1924<\/option><option value=\"1923\" >1923<\/option><option value=\"1922\" >1922<\/option><option value=\"1921\" >1921<\/option><option value=\"1920\" >1920<\/option><\/select><\/div><div id=\"wpforms-6401-field_32-container\" class=\"wpforms-field wpforms-field-select wpforms-conditional-field wpforms-conditional-show\" data-field-id=\"32\" style=\"display:none;\"><label class=\"wpforms-field-label\" for=\"wpforms-6401-field_32\">Son titre de s\u00e9jour <span class=\"wpforms-required-label\">*<\/span><\/label><select id=\"wpforms-6401-field_32\" class=\"wpforms-field-medium wpforms-field-required\" name=\"wpforms[fields][32]\" required=\"required\"><option value=\"-- Choisir --\" >-- Choisir --<\/option><option value=\"Autorisation provisoire de s\u00e9jour\" >Autorisation provisoire de s\u00e9jour<\/option><option value=\"Carte de r\u00e9fugi\u00e9(e)\" >Carte de r\u00e9fugi\u00e9(e)<\/option><option value=\"Demande d&#039;asile\" >Demande d&#039;asile<\/option><option value=\"Demande de r\u00e9gularisation\" >Demande de r\u00e9gularisation<\/option><option value=\"Inscrit au Registre des \u00e9trangers\" >Inscrit au Registre des \u00e9trangers<\/option><option value=\"Sans statut\" >Sans statut<\/option><\/select><\/div><div id=\"wpforms-6401-field_36-container\" class=\"wpforms-field wpforms-field-html wpforms-conditional-field wpforms-conditional-show\" data-field-id=\"36\" style=\"display:none;\"><div id=\"wpforms-6401-field_36\"><hr style=\"border-top: 2px dashed red;\"><\/div><\/div><div id=\"wpforms-6401-field_34-container\" class=\"wpforms-field wpforms-field-select wpforms-conditional-field wpforms-conditional-show wpforms-conditional-trigger\" data-field-id=\"34\" style=\"display:none;\"><label class=\"wpforms-field-label\" for=\"wpforms-6401-field_34\">L&#039;origine de ses ressources  <span class=\"wpforms-required-label\">*<\/span><\/label><select id=\"wpforms-6401-field_34\" class=\"wpforms-field-medium wpforms-field-required\" name=\"wpforms[fields][34]\" required=\"required\"><option value=\"\" class=\"placeholder\" disabled  selected='selected'>-- Il s&#039;agit de la ressource principale de votre b\u00e9n\u00e9ficiaire --<\/option><option value=\"Travail\" >Travail<\/option><option value=\"Allocation de ch\u00f4mage\" >Allocation de ch\u00f4mage<\/option><option value=\"Revenu d&#039;int\u00e9gration (CPAS)\" >Revenu d&#039;int\u00e9gration (CPAS)<\/option><option value=\"Pension de retraite\" >Pension de retraite<\/option><option value=\"Allocations familiales\" >Allocations familiales<\/option><option value=\"Pension alimentaire\" >Pension alimentaire<\/option><option value=\"Bourse d&#039;\u00e9tude\" >Bourse d&#039;\u00e9tude<\/option><option value=\"Sans revenus\" >Sans revenus<\/option><option value=\"Autre\" >Autre<\/option><\/select><\/div><div id=\"wpforms-6401-field_77-container\" class=\"wpforms-field wpforms-field-text wpforms-conditional-field wpforms-conditional-show\" data-field-id=\"77\" style=\"display:none;\"><label class=\"wpforms-field-label\" for=\"wpforms-6401-field_77\">Veuillez pr\u00e9cisez <span class=\"wpforms-required-label\">*<\/span><\/label><input type=\"text\" id=\"wpforms-6401-field_77\" class=\"wpforms-field-medium wpforms-field-required\" name=\"wpforms[fields][77]\" required><\/div><div id=\"wpforms-6401-field_35-container\" class=\"wpforms-field wpforms-field-select wpforms-conditional-field wpforms-conditional-show\" data-field-id=\"35\" style=\"display:none;\"><label class=\"wpforms-field-label\" for=\"wpforms-6401-field_35\">Sa situation familiale <span class=\"wpforms-required-label\">*<\/span><\/label><select id=\"wpforms-6401-field_35\" class=\"wpforms-field-small wpforms-field-required\" name=\"wpforms[fields][35]\" required=\"required\"><option value=\"-- Choisir --\" >-- Choisir --<\/option><option value=\"Isol\u00e9(e)\" >Isol\u00e9(e)<\/option><option value=\"Couple sans enfant\" >Couple sans enfant<\/option><option value=\"Couple avec enfant(s)\" >Couple avec enfant(s)<\/option><option value=\"Cohabitant(e) de fait\" >Cohabitant(e) de fait<\/option><option value=\"Famille monoparentale\" >Famille monoparentale<\/option><\/select><\/div><div id=\"wpforms-6401-field_63-container\" class=\"wpforms-field wpforms-field-number wpforms-conditional-field wpforms-conditional-show\" data-field-id=\"63\" style=\"display:none;\"><label class=\"wpforms-field-label\" for=\"wpforms-6401-field_63\">Le nombre de personnes \u00e0 sa charge <span class=\"wpforms-required-label\">*<\/span><\/label><input type=\"number\" pattern=\"[0-9]*\" id=\"wpforms-6401-field_63\" class=\"wpforms-field-small wpforms-field-required\" name=\"wpforms[fields][63]\" required><\/div><div id=\"wpforms-6401-field_37-container\" class=\"wpforms-field wpforms-field-select wpforms-conditional-field wpforms-conditional-show\" data-field-id=\"37\" style=\"display:none;\"><label class=\"wpforms-field-label\" for=\"wpforms-6401-field_37\">Son \u00e9tat civil <span class=\"wpforms-required-label\">*<\/span><\/label><select id=\"wpforms-6401-field_37\" class=\"wpforms-field-small wpforms-field-required\" name=\"wpforms[fields][37]\" required=\"required\"><option value=\"-- Choisir --\" >-- Choisir --<\/option><option value=\"C\u00e9libataire\" >C\u00e9libataire<\/option><option value=\"Mari\u00e9(e)\" >Mari\u00e9(e)<\/option><option value=\"S\u00e9par\u00e9(e)\" >S\u00e9par\u00e9(e)<\/option><option value=\"Divorc\u00e9(e)\" >Divorc\u00e9(e)<\/option><option value=\"Veuf(ve)\" >Veuf(ve)<\/option><\/select><\/div><div id=\"wpforms-6401-field_39-container\" class=\"wpforms-field wpforms-field-divider\" data-field-id=\"39\"><h3 id=\"wpforms-6401-field_39\" name=\"wpforms[fields][39]\">Accompagnement \u00e0 effectuer<\/h3><\/div><div id=\"wpforms-6401-field_40-container\" class=\"wpforms-field wpforms-field-date-time wpforms-conditional-field wpforms-conditional-show\" data-field-id=\"40\" style=\"display:none;\"><label class=\"wpforms-field-label\" for=\"wpforms-6401-field_40\">Date de l&#039;accompagnement <span class=\"wpforms-required-label\">*<\/span><\/label><select name=\"wpforms[fields][40][date][d]\" id=\"wpforms-field_40-day\" class=\"wpforms-field-date-time-date-day wpforms-field-required\"  required><option class=\"placeholder\" selected disabled>JJ<\/option><option value=\"1\" >1<\/option><option value=\"2\" >2<\/option><option value=\"3\" >3<\/option><option value=\"4\" >4<\/option><option value=\"5\" >5<\/option><option value=\"6\" >6<\/option><option value=\"7\" >7<\/option><option value=\"8\" >8<\/option><option value=\"9\" >9<\/option><option value=\"10\" >10<\/option><option value=\"11\" >11<\/option><option value=\"12\" >12<\/option><option value=\"13\" >13<\/option><option value=\"14\" >14<\/option><option value=\"15\" >15<\/option><option value=\"16\" >16<\/option><option value=\"17\" >17<\/option><option value=\"18\" >18<\/option><option value=\"19\" >19<\/option><option value=\"20\" >20<\/option><option value=\"21\" >21<\/option><option value=\"22\" >22<\/option><option value=\"23\" >23<\/option><option value=\"24\" >24<\/option><option value=\"25\" >25<\/option><option value=\"26\" >26<\/option><option value=\"27\" >27<\/option><option value=\"28\" >28<\/option><option value=\"29\" >29<\/option><option value=\"30\" >30<\/option><option value=\"31\" >31<\/option><\/select><span class=\"wpforms-field-date-time-date-sep\">\/<\/span><select name=\"wpforms[fields][40][date][m]\" id=\"wpforms-field_40-month\" class=\"wpforms-field-date-time-date-month wpforms-field-required\"  required><option class=\"placeholder\" selected disabled>MM<\/option><option value=\"1\" >1<\/option><option value=\"2\" >2<\/option><option value=\"3\" >3<\/option><option value=\"4\" >4<\/option><option value=\"5\" >5<\/option><option value=\"6\" >6<\/option><option value=\"7\" >7<\/option><option value=\"8\" >8<\/option><option value=\"9\" >9<\/option><option value=\"10\" >10<\/option><option value=\"11\" >11<\/option><option value=\"12\" >12<\/option><\/select><span class=\"wpforms-field-date-time-date-sep\">\/<\/span><select name=\"wpforms[fields][40][date][y]\" id=\"wpforms-field_40-year\" class=\"wpforms-field-date-time-date-year wpforms-field-required\"  required><option class=\"placeholder\" selected disabled>AAAA<\/option><option value=\"2026\" >2026<\/option><option value=\"2027\" >2027<\/option><\/select><\/div><div id=\"wpforms-6401-field_73-container\" class=\"wpforms-field wpforms-field-date-time wpf_6pct\" data-field-id=\"73\"><label class=\"wpforms-field-label\" for=\"wpforms-6401-field_73\">Heure du rendez-vous entre le b\u00e9n\u00e9ficiaire et l\u2019accompagnant (HH:MM) <span class=\"wpforms-required-label\">*<\/span><\/label><input type=\"text\" id=\"wpforms-6401-field_73-time\" class=\"wpforms-field-date-time-time\" data-rule-time24h=\"true\" data-time-format=\"H:i\" data-step=\"30\" name=\"wpforms[fields][73][time]\" placeholder=\"HH:MM\" required><\/div><div id=\"wpforms-6401-field_46-container\" class=\"wpforms-field wpforms-field-text\" data-field-id=\"46\"><label class=\"wpforms-field-label\" for=\"wpforms-6401-field_46\">Adresse et lieu du rendez-vous b\u00e9n\u00e9ficiaire\/accompagnant <span class=\"wpforms-required-label\">*<\/span><\/label><input type=\"text\" id=\"wpforms-6401-field_46\" class=\"wpforms-field-medium wpforms-field-required\" name=\"wpforms[fields][46]\" placeholder=\"Si possible, merci de bien d\u00e9tailler cette adresse : sonnette, n\u00b0, \u00e9tage, etc.\" required><\/div><div id=\"wpforms-6401-field_47-container\" class=\"wpforms-field wpforms-field-text\" data-field-id=\"47\"><label class=\"wpforms-field-label\" for=\"wpforms-6401-field_47\">Nom du lieu o\u00f9 se rendre <span class=\"wpforms-required-label\">*<\/span><\/label><input type=\"text\" id=\"wpforms-6401-field_47\" class=\"wpforms-field-medium wpforms-field-required\" name=\"wpforms[fields][47]\" required><\/div><div id=\"wpforms-6401-field_66-container\" class=\"wpforms-field wpforms-field-text wpforms-two-fourths wpforms-first\" data-field-id=\"66\"><label class=\"wpforms-field-label\" for=\"wpforms-6401-field_66\">Adresse du lieu o\u00f9 se rendre <span class=\"wpforms-required-label\">*<\/span><\/label><input type=\"text\" id=\"wpforms-6401-field_66\" class=\"wpforms-field-large wpforms-field-required\" name=\"wpforms[fields][66]\" placeholder=\"-- Nom de la rue --\" required><\/div><div id=\"wpforms-6401-field_68-container\" class=\"wpforms-field wpforms-field-text wpforms-one-fourth\" data-field-id=\"68\"><label class=\"wpforms-field-label\" for=\"wpforms-6401-field_68\">Num\u00e9ro <span class=\"wpforms-required-label\">*<\/span><\/label><input type=\"text\" id=\"wpforms-6401-field_68\" class=\"wpforms-field-medium wpforms-field-required\" name=\"wpforms[fields][68]\" placeholder=\"num\u00e9ro dans la rue\" required><\/div><div id=\"wpforms-6401-field_69-container\" class=\"wpforms-field wpforms-field-text wpforms-one-fourth\" data-field-id=\"69\"><label class=\"wpforms-field-label\" for=\"wpforms-6401-field_69\">Num\u00e9ro de la sonnette<\/label><input type=\"text\" id=\"wpforms-6401-field_69\" class=\"wpforms-field-medium\" name=\"wpforms[fields][69]\" ><\/div><div id=\"wpforms-6401-field_70-container\" class=\"wpforms-field wpforms-field-number wpforms-one-third wpforms-first\" data-field-id=\"70\"><label class=\"wpforms-field-label\" for=\"wpforms-6401-field_70\">Code postal <span class=\"wpforms-required-label\">*<\/span><\/label><input type=\"number\" pattern=\"[0-9]*\" id=\"wpforms-6401-field_70\" class=\"wpforms-field-large wpforms-field-required\" name=\"wpforms[fields][70]\" required><\/div><div id=\"wpforms-6401-field_71-container\" class=\"wpforms-field wpforms-field-text wpforms-two-thirds\" data-field-id=\"71\"><label class=\"wpforms-field-label\" for=\"wpforms-6401-field_71\">Localit\u00e9 <span class=\"wpforms-required-label\">*<\/span><\/label><input type=\"text\" id=\"wpforms-6401-field_71\" class=\"wpforms-field-medium wpforms-field-required\" name=\"wpforms[fields][71]\" required><\/div><div id=\"wpforms-6401-field_74-container\" class=\"wpforms-field wpforms-field-date-time wpf_6pct\" data-field-id=\"74\"><label class=\"wpforms-field-label\" for=\"wpforms-6401-field_74\">Heure du rendez-vous ou de la permanence \u00e0 laquelle le b\u00e9n\u00e9ficiaire doit se rendre (HH:MM) <span class=\"wpforms-required-label\">*<\/span><\/label><input type=\"text\" id=\"wpforms-6401-field_74-time\" class=\"wpforms-field-date-time-time\" data-rule-time24h=\"true\" data-time-format=\"H:i\" data-step=\"30\" name=\"wpforms[fields][74][time]\" placeholder=\"HH:MM\" required><\/div><div id=\"wpforms-6401-field_51-container\" class=\"wpforms-field wpforms-field-text\" data-field-id=\"51\"><label class=\"wpforms-field-label\" for=\"wpforms-6401-field_51\">Nom de la personne que le b\u00e9n\u00e9ficiaire doit rencontrer <span class=\"wpforms-required-label\">*<\/span><\/label><input type=\"text\" id=\"wpforms-6401-field_51\" class=\"wpforms-field-medium wpforms-field-required\" name=\"wpforms[fields][51]\" required><\/div><div id=\"wpforms-6401-field_80-container\" class=\"wpforms-field wpforms-field-text\" data-field-id=\"80\"><label class=\"wpforms-field-label\" for=\"wpforms-6401-field_80\">Num\u00e9ro de t\u00e9l\u00e9phone de la personne que le b\u00e9n\u00e9ficiaire doit rencontrer <span class=\"wpforms-required-label\">*<\/span><\/label><input type=\"text\" id=\"wpforms-6401-field_80\" class=\"wpforms-field-small wpforms-field-required\" name=\"wpforms[fields][80]\" required><div class=\"wpforms-field-description\">Num\u00e9ro de t\u00e9l\u00e9phone belge Fixe ou Gsm.<\/div><\/div><div id=\"wpforms-6401-field_53-container\" class=\"wpforms-field wpforms-field-textarea\" data-field-id=\"53\"><label class=\"wpforms-field-label\" for=\"wpforms-6401-field_53\">Raison pour laquelle votre b\u00e9n\u00e9ficiaire a besoin d&#039;\u00eatre accompagn\u00e9 <span class=\"wpforms-required-label\">*<\/span><\/label><textarea id=\"wpforms-6401-field_53\" class=\"wpforms-field-medium wpforms-field-required\" name=\"wpforms[fields][53]\" placeholder=\"Exemples: traduction, besoin de soutien moral, besoin d\u2019aide \u00e0 la compr\u00e9hension, besoin d\u2019aide pour s\u2019orienter, besoin de soutien physique\u2026 - Attention, nos volontaires ne sont pas habilit\u00e9s \u00e0 transporter des bagages, ni \u00e0 pousser une chaise roulante, ni \u00e0 faire des accompagnements avec leur v\u00e9hicule. - Attention, nous ne sommes pas un service sp\u00e9cialis\u00e9 dans la traduction.\" required><\/textarea><\/div><div id=\"wpforms-6401-field_54-container\" class=\"wpforms-field wpforms-field-radio\" data-field-id=\"54\"><label class=\"wpforms-field-label\" for=\"wpforms-6401-field_54\">Besoin de traduction <span class=\"wpforms-required-label\">*<\/span><\/label><ul id=\"wpforms-6401-field_54\" class=\"wpforms-field-required\"><li class=\"choice-1 depth-1\"><input type=\"radio\" id=\"wpforms-6401-field_54_1\" name=\"wpforms[fields][54]\" value=\"oui\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-6401-field_54_1\">oui<\/label><\/li><li class=\"choice-2 depth-1\"><input type=\"radio\" id=\"wpforms-6401-field_54_2\" name=\"wpforms[fields][54]\" value=\"non\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-6401-field_54_2\">non<\/label><\/li><li class=\"choice-3 depth-1\"><input type=\"radio\" id=\"wpforms-6401-field_54_3\" name=\"wpforms[fields][54]\" value=\"oui mais pas indispensable. Le b\u00e9n\u00e9ficiare ma\u00eetrise un peu la langue.\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-6401-field_54_3\">oui mais pas indispensable. Le b\u00e9n\u00e9ficiare ma\u00eetrise un peu la langue.<\/label><\/li><\/ul><\/div><div id=\"wpforms-6401-field_55-container\" class=\"wpforms-field wpforms-field-text\" data-field-id=\"55\"><label class=\"wpforms-field-label\" for=\"wpforms-6401-field_55\">Langue parl\u00e9e par le b\u00e9n\u00e9ficiaire<\/label><input type=\"text\" id=\"wpforms-6401-field_55\" class=\"wpforms-field-small\" name=\"wpforms[fields][55]\" placeholder=\"A remplir si traduction d\u00e9sir\u00e9e\" ><\/div><div id=\"wpforms-6401-field_57-container\" class=\"wpforms-field wpforms-field-textarea\" data-field-id=\"57\"><label class=\"wpforms-field-label\" for=\"wpforms-6401-field_57\">D\u00e9marche \u00e0 r\u00e9aliser <span class=\"wpforms-required-label\">*<\/span><\/label><textarea id=\"wpforms-6401-field_57\" class=\"wpforms-field-medium wpforms-field-required\" name=\"wpforms[fields][57]\" placeholder=\"D\u00e9tailler la d\u00e9marche que le b\u00e9n\u00e9ficiaire voudrait r\u00e9aliser avec l\u2019aide du b\u00e9n\u00e9vole. Ex.: Rencontrer son m\u00e9decin, obtenir tel ou tel document, apprendre l&#039;itin\u00e9raire jusqu&#039;\u00e0 son nouveau centre de jour,... Description de la situation, du but \u00e0 atteindre, des documents \u00e0 obtenir,...\" required><\/textarea><\/div><div id=\"wpforms-6401-field_58-container\" class=\"wpforms-field wpforms-field-textarea\" data-field-id=\"58\"><label class=\"wpforms-field-label\" for=\"wpforms-6401-field_58\">Informations compl\u00e9mentaires<\/label><textarea id=\"wpforms-6401-field_58\" class=\"wpforms-field-medium\" name=\"wpforms[fields][58]\" placeholder=\"Le cas \u00e9ch\u00e9ant, indiquer les sp\u00e9cificit\u00e9s du b\u00e9n\u00e9ficiaire si celles-ci risquent d\u2019influencer le d\u00e9roulement de l\u2019accompagnement. Ex.: chaise roulante, poussette, difficult\u00e9s \u00e0 la marche, assu\u00e9tude, \u00e9pilepsie, phobie\u2026\" ><\/textarea><\/div><div id=\"wpforms-6401-field_61-container\" class=\"wpforms-field wpforms-field-radio\" data-field-id=\"61\"><label class=\"wpforms-field-label\" for=\"wpforms-6401-field_61\">Retour n\u00e9cessaire avec l&#039;accompagnateur vers le lieu de d\u00e9part de l&#039;accompagnement <span class=\"wpforms-required-label\">*<\/span><\/label><ul id=\"wpforms-6401-field_61\" class=\"wpforms-field-required\"><li class=\"choice-1 depth-1\"><input type=\"radio\" id=\"wpforms-6401-field_61_1\" name=\"wpforms[fields][61]\" value=\"oui\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-6401-field_61_1\">oui<\/label><\/li><li class=\"choice-2 depth-1\"><input type=\"radio\" id=\"wpforms-6401-field_61_2\" name=\"wpforms[fields][61]\" value=\"non\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-6401-field_61_2\">non<\/label><\/li><\/ul><\/div><div id=\"wpforms-6401-field_91-container\" class=\"wpforms-field wpforms-field-gdpr-checkbox\" data-field-id=\"91\"><label class=\"wpforms-field-label\" for=\"wpforms-6401-field_91\">Accord RGPD <span class=\"wpforms-required-label\">*<\/span><\/label><ul id=\"wpforms-6401-field_91\" class=\"wpforms-field-required\"><li class=\"choice-1\"><input type=\"checkbox\" id=\"wpforms-6401-field_91_1\" name=\"wpforms[fields][91][]\" value=\"Je consens \u00e0 ce que Les Amis d&#039;Accompagner stocke mes informations envoy\u00e9es afin qu\u2019il puisse r\u00e9pondre \u00e0 ma requ\u00eate.\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-6401-field_91_1\">Je consens \u00e0 ce que Les Amis d'Accompagner stocke mes informations envoy\u00e9es afin qu\u2019il puisse r\u00e9pondre \u00e0 ma requ\u00eate.<\/label><\/li><\/ul><\/div><div id=\"wpforms-6401-field_90-container\" class=\"wpforms-field wpforms-field-checkbox\" data-field-id=\"90\"><label class=\"wpforms-field-label\" for=\"wpforms-6401-field_90\">En soumettant ce formulaire, j&#039;accepte que l&#039;ASBL Les Amis d&#039;Accompagner<\/label><ul id=\"wpforms-6401-field_90\"><li class=\"choice-1 depth-1\"><input type=\"checkbox\" id=\"wpforms-6401-field_90_1\" name=\"wpforms[fields][90][]\" value=\"me contacte pour me transmettre des informations la concernant\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-6401-field_90_1\">me contacte pour me transmettre des informations la concernant<\/label><\/li><li class=\"choice-2 depth-1\"><input type=\"checkbox\" id=\"wpforms-6401-field_90_2\" name=\"wpforms[fields][90][]\" value=\"m\u2019envoie la newsletter\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-6401-field_90_2\">m\u2019envoie la newsletter<\/label><\/li><\/ul><\/div><\/div><div class=\"wpforms-field wpforms-field-hp\"><label for=\"wpforms-6401-field-hp\" class=\"wpforms-field-label\">Name<\/label><input type=\"text\" name=\"wpforms[hp]\" id=\"wpforms-6401-field-hp\" class=\"wpforms-field-medium\"><\/div><div class=\"wpforms-submit-container\" ><input type=\"hidden\" name=\"wpforms[id]\" value=\"6401\"><input type=\"hidden\" name=\"wpforms[author]\" value=\"8\"><button type=\"submit\" name=\"wpforms[submit]\" class=\"wpforms-submit \" id=\"wpforms-submit-6401\" value=\"wpforms-submit\" aria-live=\"assertive\" data-alt-text=\"Envoi en cours...\" data-submit-text=\"Envoyer\">Envoyer<\/button><\/div><\/form><\/div>  <!-- .wpforms-container -->\n\n\n\n<p><\/p>\n","protected":false},"excerpt":{"rendered":"<p>U kunt dit formulier ininvullen. Les zones obligatoires marqu\u00e9es d&rsquo;un * contiennent des donn\u00e9es indispensables \u00e0 l&rsquo;ouverture du dossier et au bon d\u00e9roulement de l&rsquo;accompagnement.&nbsp;Introduire la demande au moins 3-4 jours avant la date de l&rsquo;accompagnement. De pr\u00e9f\u00e9rence, pr\u00e9voyez des accompagnements \u00e0 partir de 8h30. Nous sommes tenus au secret professionnel.&nbsp;Si vous d\u00e9sirez gagner du [&hellip;]<\/p>\n","protected":false},"author":8,"featured_media":0,"parent":0,"menu_order":0,"comment_status":"closed","ping_status":"closed","template":"","meta":{"advgb_blocks_editor_width":"","advgb_blocks_columns_visual_guide":""},"yoast_head":"<!-- This site is optimized with the Yoast SEO plugin v16.3 - https:\/\/yoast.com\/wordpress\/plugins\/seo\/ -->\n<title>Formulaire de demande d&#039;accompagnement ambulatoire - Les Amis d\u2019Accompagner<\/title>\n<meta name=\"robots\" content=\"index, follow, max-snippet:-1, max-image-preview:large, max-video-preview:-1\" \/>\n<link rel=\"canonical\" href=\"https:\/\/bxl.accompagner.be\/fr\/demander-un-accompagnement\/\" \/>\n<meta property=\"og:locale\" content=\"fr_FR\" \/>\n<meta property=\"og:type\" content=\"article\" \/>\n<meta property=\"og:title\" content=\"Formulaire de demande d&#039;accompagnement ambulatoire - Les Amis d\u2019Accompagner\" \/>\n<meta property=\"og:description\" content=\"U kunt dit formulier ininvullen. Les zones obligatoires marqu\u00e9es d&rsquo;un * contiennent des donn\u00e9es indispensables \u00e0 l&rsquo;ouverture du dossier et au bon d\u00e9roulement de l&rsquo;accompagnement.&nbsp;Introduire la demande au moins 3-4 jours avant la date de l&rsquo;accompagnement. De pr\u00e9f\u00e9rence, pr\u00e9voyez des accompagnements \u00e0 partir de 8h30. Nous sommes tenus au secret professionnel.&nbsp;Si vous d\u00e9sirez gagner du [&hellip;]\" \/>\n<meta property=\"og:url\" content=\"https:\/\/bxl.accompagner.be\/fr\/demander-un-accompagnement\/\" \/>\n<meta property=\"og:site_name\" content=\"Les Amis d\u2019Accompagner\" \/>\n<meta property=\"article:modified_time\" content=\"2021-09-23T14:03:22+00:00\" \/>\n<meta name=\"twitter:card\" content=\"summary_large_image\" \/>\n<meta name=\"twitter:label1\" content=\"Dur\u00e9e de lecture est.\">\n\t<meta name=\"twitter:data1\" content=\"1 minute\">\n<script type=\"application\/ld+json\" class=\"yoast-schema-graph\">{\"@context\":\"https:\/\/schema.org\",\"@graph\":[{\"@type\":\"WebSite\",\"@id\":\"https:\/\/bxl.accompagner.be\/fr\/#website\",\"url\":\"https:\/\/bxl.accompagner.be\/fr\/\",\"name\":\"Les Amis d\\u2019Accompagner\",\"description\":\"Ensemble, pas \\u00e0 pas!\",\"potentialAction\":[{\"@type\":\"SearchAction\",\"target\":\"https:\/\/bxl.accompagner.be\/fr\/?s={search_term_string}\",\"query-input\":\"required name=search_term_string\"}],\"inLanguage\":\"fr-FR\"},{\"@type\":\"WebPage\",\"@id\":\"https:\/\/bxl.accompagner.be\/fr\/demander-un-accompagnement\/#webpage\",\"url\":\"https:\/\/bxl.accompagner.be\/fr\/demander-un-accompagnement\/\",\"name\":\"Formulaire de demande d'accompagnement ambulatoire - Les Amis d\\u2019Accompagner\",\"isPartOf\":{\"@id\":\"https:\/\/bxl.accompagner.be\/fr\/#website\"},\"datePublished\":\"2020-06-23T21:34:52+00:00\",\"dateModified\":\"2021-09-23T14:03:22+00:00\",\"breadcrumb\":{\"@id\":\"https:\/\/bxl.accompagner.be\/fr\/demander-un-accompagnement\/#breadcrumb\"},\"inLanguage\":\"fr-FR\",\"potentialAction\":[{\"@type\":\"ReadAction\",\"target\":[\"https:\/\/bxl.accompagner.be\/fr\/demander-un-accompagnement\/\"]}]},{\"@type\":\"BreadcrumbList\",\"@id\":\"https:\/\/bxl.accompagner.be\/fr\/demander-un-accompagnement\/#breadcrumb\",\"itemListElement\":[{\"@type\":\"ListItem\",\"position\":1,\"item\":{\"@type\":\"WebPage\",\"@id\":\"https:\/\/bxl.accompagner.be\/fr\/\",\"url\":\"https:\/\/bxl.accompagner.be\/fr\/\",\"name\":\"Accueil\"}},{\"@type\":\"ListItem\",\"position\":2,\"item\":{\"@id\":\"https:\/\/bxl.accompagner.be\/fr\/demander-un-accompagnement\/#webpage\"}}]}]}<\/script>\n<!-- \/ Yoast SEO plugin. -->","coauthors":[],"author_meta":{"author_link":"https:\/\/bxl.accompagner.be\/fr\/author\/phd2019\/","display_name":"PhD2019"},"relative_dates":{"created":"Posted 6 ans ago","modified":"Updated 5 ans ago"},"featured_img_caption":"","_links":{"self":[{"href":"https:\/\/bxl.accompagner.be\/fr\/wp-json\/wp\/v2\/pages\/8860"}],"collection":[{"href":"https:\/\/bxl.accompagner.be\/fr\/wp-json\/wp\/v2\/pages"}],"about":[{"href":"https:\/\/bxl.accompagner.be\/fr\/wp-json\/wp\/v2\/types\/page"}],"author":[{"embeddable":true,"href":"https:\/\/bxl.accompagner.be\/fr\/wp-json\/wp\/v2\/users\/8"}],"replies":[{"embeddable":true,"href":"https:\/\/bxl.accompagner.be\/fr\/wp-json\/wp\/v2\/comments?post=8860"}],"version-history":[{"count":11,"href":"https:\/\/bxl.accompagner.be\/fr\/wp-json\/wp\/v2\/pages\/8860\/revisions"}],"predecessor-version":[{"id":10537,"href":"https:\/\/bxl.accompagner.be\/fr\/wp-json\/wp\/v2\/pages\/8860\/revisions\/10537"}],"wp:attachment":[{"href":"https:\/\/bxl.accompagner.be\/fr\/wp-json\/wp\/v2\/media?parent=8860"}],"curies":[{"name":"wp","href":"https:\/\/api.w.org\/{rel}","templated":true}]}}