<div class="contact-register">
<div class="contact-register-header">
<p>Enter here your</p>
<h4>Appointment request</h4>
<span class="arrow">&nbsp;</span>
</div>
<div class="contact-register-content">
<p>[text* your-name placeholder "Name"]</p>
<p>[tel* phone placeholder "Phone"] </p>
<p>[email* your-email placeholder "EMAIL"] </p>
Choose your sextherapists of preference
</p>[checkbox selection-sexologue "Frank" "Catalina" "Claudia" "Saliha" "Gabriel-le"] </p>
What are your availabilities?
</p>[checkbox selection-dispo "Morning" "Afternoon" "Evening"] </p>
Which format do you want therapy?
</p>[checkbox selection-format "Face to Face" "Webcam" "No preference"] </p>
What type of therapy do you seek?
</p>[select* your-therapy include_blank "Individual psychotherapy" "Couple therapy" "Individual or couples Counseling" "Unsure"]</p>
<p>[textarea* your-message placeholder "Reason for consultation"]</p>
[recaptcha]
</div>
<p>[submit "Send"]</p>
</div>