<div class="row">
<div class="col-md-9">
<p>[text* your-name placeholder "FULL NAME"] </p>
</div>
</div>

<div class="row">
<div class="col-md-9">
<p>[email* your-email placeholder "EMAIL"] </p>
</div>
</div>

<div class="row">
<div class="col-md-9">
<p>[tel* phone placeholder "PHONE"] </p>
</div>
</div>

Choose your preferred sextherapists or sexologist (more than one choice is possible)
<div class="row">
<div class="col-md-9">
</p>[checkbox selection-sexologue "Frank" "Catalina" "Claudia" "Saliha" "Gabriel-le"] </p>
</div>
</div>

What are your availabilities?
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<div class="col-md-9">
</p>[checkbox selection-dispo "Morning" "Afternoon" "Evening"] </p>
</div>
</div>

What type of consultation do you seek?
<div class="row">
<div class="col-md-9">
</p>[select* your-therapy include_blank "Individual psychotherapy" "Couple therapy" "Individual or couples Counseling" "Unsure"]</p>
</div>
</div>

Which format do you want therapy?
<div class="row">
<div class="col-md-9">
</p>[checkbox selection-format "Face to face" "Webcam" "No preference"] </p>
</div>
</div>

<div class="row">
<div class="col-md-9">
<p>[textarea your-message placeholder "Reasons for consultation"] </p>
</div>
<div class="col-md-3">
<p>[submit "Send"]</p>
</div>
</div>
[recaptcha]