<p>[text* your-name placeholder "Name"]</p>
<p>[tel* phone placeholder "Phone"] </p>
<p>[email* your-email placeholder "Email"]</p>
Choose your sextherapist 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 of therapy are you seeking?
</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 "Message"]</p>
[recaptcha theme:dark]
<p>[submit "Send"]</p>