{"id":1116,"date":"2019-04-29T09:41:21","date_gmt":"2019-04-29T09:41:21","guid":{"rendered":"http:\/\/www.reachoutmyanmar.com\/client-registration\/"},"modified":"2020-02-07T05:29:17","modified_gmt":"2020-02-07T05:29:17","slug":"client-registration","status":"publish","type":"page","link":"https:\/\/www.reachoutmyanmar.com\/my\/client-registration\/","title":{"rendered":"\u1006\u103d\u1031\u1038\u1014\u103d\u1031\u1038\u1019\u103e\u102f\u1021\u1010\u103d\u1000\u103a \u1005\u102c\u101b\u1004\u103a\u1038\u1015\u1031\u1038\u101e\u103d\u1004\u103a\u1038\u1001\u103c\u1004\u103a\u1038"},"content":{"rendered":"\n                <div class='gf_browser_gecko gform_wrapper' id='gform_wrapper_4' style='display:none'><form method='post' enctype='multipart\/form-data'  id='gform_4'  action='\/my\/wp-json\/wp\/v2\/pages\/1116'>\n                        <div class='gform_heading'>\n                            <h3 class='gform_title'>\u1031\u1006\u103c\u1038\u1031\u108f\u103c\u1038\u1000\u102f\u101e\u1019\u1088\u1001\u1036\u101a\u1030\u101e\u1030\u104f \u1000\u102d\u102f\u101a\u1039\u1031\u101b\u1038\u101e\u1010\u1004\u1039\u1038\u1021\u1001\u103a\u1000\u1039\u1021\u101c\u1000\u1039<\/h3>\n                            <span class='gform_description'><\/span>\n                        <\/div>\n                        <div class='gform_body'><ul id='gform_fields_4' class='gform_fields top_label form_sublabel_below description_below'><li id='field_4_1'  class='gfield gfield_contains_required field_sublabel_below field_description_below gfield_visibility_visible' ><label class='gfield_label' for='input_4_1' >\u1021\u1019\u100a\u1039<span class='gfield_required'>*<\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_1' id='input_4_1' type='text' value='' class='medium'     aria-required=\"true\" aria-invalid=\"false\" \/><\/div><\/li><li id='field_4_2'  class='gfield gfield_contains_required field_sublabel_below field_description_below gfield_visibility_visible' ><label class='gfield_label' for='input_4_2' >\u1031\u1019\u103c\u1038\u101e\u1000\u1060\u101b\u102c\u1007\u1039 (\u101e\u102d\u102f\u1094) \u1021\u101e\u1000\u1039<span class='gfield_required'>*<\/span><\/label><div class='ginput_container ginput_container_date'>\n                            <input name='input_2' id='input_4_2' type='text' value='' class='datepicker medium mdy datepicker_with_icon'    aria-describedby='input_4_2_date_format' \/>\n                            <span id='input_4_2_date_format' class='screen-reader-text'>Date Format: MM slash DD slash YYYY<\/span>\n                        <\/div>\n                        <input type='hidden' id='gforms_calendar_icon_input_4_2' class='gform_hidden' value='https:\/\/www.reachoutmyanmar.com\/wp-content\/plugins\/gravityforms\/images\/calendar.png'\/><\/li><li id='field_4_3'  class='gfield gfield_contains_required field_sublabel_below field_description_below gfield_visibility_visible' ><label class='gfield_label' for='input_4_3' >\u1014\u102d\u102f\u1004\u1039\u1004\u1036\u101e\u102c\u1038\u1021\u103b\u1016\u1005\u1039\u1001\u1036\u101a\u1030\u1011\u102c\u1038\u1031\u101e\u102c\u1010\u102d\u102f\u1004\u1039\u1038\u103b\u1015\u100a\u1039<span class='gfield_required'>*<\/span><\/label><div class='ginput_container ginput_container_select'><select name='input_3' id='input_4_3' class='medium gfield_select'   aria-required=\"true\" aria-invalid=\"false\"><option value='Afghanistan' >Afghanistan<\/option><option value='Albania' >Albania<\/option><option value='Algeria' >Algeria<\/option><option value='American Samoa' >American Samoa<\/option><option value='Andorra' >Andorra<\/option><option value='Angola' >Angola<\/option><option value='Anguilla' >Anguilla<\/option><option value='Antarctica' >Antarctica<\/option><option value='Antigua and Barbuda' >Antigua and Barbuda<\/option><option value='Argentina' >Argentina<\/option><option value='Armenia' >Armenia<\/option><option value='Aruba' >Aruba<\/option><option value='Australia' >Australia<\/option><option value='Austria' >Austria<\/option><option value='Azerbaijan' >Azerbaijan<\/option><option value='Bahamas' >Bahamas<\/option><option value='Bahrain' >Bahrain<\/option><option value='Bangladesh' >Bangladesh<\/option><option value='Barbados' >Barbados<\/option><option value='Belarus' >Belarus<\/option><option value='Belgium' >Belgium<\/option><option value='Belize' >Belize<\/option><option value='Benin' >Benin<\/option><option value='Bermuda' >Bermuda<\/option><option value='Bhutan' >Bhutan<\/option><option value='Bolivia' >Bolivia<\/option><option value='Bonaire, Sint Eustatius and Saba' >Bonaire, Sint Eustatius and Saba<\/option><option value='Bosnia and Herzegovina' >Bosnia and Herzegovina<\/option><option value='Botswana' >Botswana<\/option><option value='Bouvet Island' >Bouvet Island<\/option><option value='Brazil' >Brazil<\/option><option value='British Indian Ocean Territory' >British Indian Ocean Territory<\/option><option value='Brunei Darrussalam' >Brunei Darrussalam<\/option><option value='Bulgaria' >Bulgaria<\/option><option value='Burkina Faso' >Burkina Faso<\/option><option value='Burundi' >Burundi<\/option><option value='Cambodia' >Cambodia<\/option><option value='Cameroon' >Cameroon<\/option><option value='Canada' >Canada<\/option><option value='Cape Verde' >Cape Verde<\/option><option value='Cayman Islands' >Cayman Islands<\/option><option value='Central African Republic' >Central African Republic<\/option><option value='Chad' >Chad<\/option><option value='Chile' >Chile<\/option><option value='China' >China<\/option><option value='Christmas Island' >Christmas Island<\/option><option value='Cocos Islands' >Cocos Islands<\/option><option value='Colombia' >Colombia<\/option><option value='Comoros' >Comoros<\/option><option value='Congo, Democratic Republic of the' >Congo, Democratic Republic of the<\/option><option value='Congo, Republic of the' >Congo, Republic of the<\/option><option value='Cook Islands' >Cook Islands<\/option><option value='Costa Rica' >Costa Rica<\/option><option value='Croatia' >Croatia<\/option><option value='Cuba' >Cuba<\/option><option value='Cura\u00e7ao' >Cura\u00e7ao<\/option><option value='Cyprus' >Cyprus<\/option><option value='Czech Republic' >Czech Republic<\/option><option value='C\u00f4te d&#039;Ivoire' >C\u00f4te d&#039;Ivoire<\/option><option value='Denmark' >Denmark<\/option><option value='Djibouti' >Djibouti<\/option><option value='Dominica' >Dominica<\/option><option value='Dominican Republic' >Dominican Republic<\/option><option value='Ecuador' >Ecuador<\/option><option value='Egypt' >Egypt<\/option><option value='El Salvador' >El Salvador<\/option><option value='Equatorial Guinea' >Equatorial Guinea<\/option><option value='Eritrea' >Eritrea<\/option><option value='Estonia' >Estonia<\/option><option value='Eswatini (Swaziland)' >Eswatini (Swaziland)<\/option><option value='Ethiopia' >Ethiopia<\/option><option value='Falkland Islands' >Falkland Islands<\/option><option value='Faroe Islands' >Faroe Islands<\/option><option value='Fiji' >Fiji<\/option><option value='Finland' >Finland<\/option><option value='France' >France<\/option><option value='French Guiana' >French Guiana<\/option><option value='French Polynesia' >French Polynesia<\/option><option value='French Southern Territories' >French Southern Territories<\/option><option value='Gabon' >Gabon<\/option><option value='Gambia' >Gambia<\/option><option value='Georgia' >Georgia<\/option><option value='Germany' >Germany<\/option><option value='Ghana' >Ghana<\/option><option value='Gibraltar' >Gibraltar<\/option><option value='Greece' >Greece<\/option><option value='Greenland' >Greenland<\/option><option value='Grenada' >Grenada<\/option><option value='Guadeloupe' >Guadeloupe<\/option><option value='Guam' >Guam<\/option><option value='Guatemala' >Guatemala<\/option><option value='Guernsey' >Guernsey<\/option><option value='Guinea' >Guinea<\/option><option value='Guinea-Bissau' >Guinea-Bissau<\/option><option value='Guyana' >Guyana<\/option><option value='Haiti' >Haiti<\/option><option value='Heard and McDonald Islands' >Heard and McDonald Islands<\/option><option value='Holy See' >Holy See<\/option><option value='Honduras' >Honduras<\/option><option value='Hong Kong' >Hong Kong<\/option><option value='Hungary' >Hungary<\/option><option value='Iceland' >Iceland<\/option><option value='India' >India<\/option><option value='Indonesia' >Indonesia<\/option><option value='Iran' >Iran<\/option><option value='Iraq' >Iraq<\/option><option value='Ireland' >Ireland<\/option><option value='Isle of Man' >Isle of Man<\/option><option value='Israel' >Israel<\/option><option value='Italy' >Italy<\/option><option value='Jamaica' >Jamaica<\/option><option value='Japan' >Japan<\/option><option value='Jersey' >Jersey<\/option><option value='Jordan' >Jordan<\/option><option value='Kazakhstan' >Kazakhstan<\/option><option value='Kenya' >Kenya<\/option><option value='Kiribati' >Kiribati<\/option><option value='Kuwait' >Kuwait<\/option><option value='Kyrgyzstan' >Kyrgyzstan<\/option><option value='Lao People&#039;s Democratic Republic' >Lao People&#039;s Democratic Republic<\/option><option value='Latvia' >Latvia<\/option><option value='Lebanon' >Lebanon<\/option><option value='Lesotho' >Lesotho<\/option><option value='Liberia' >Liberia<\/option><option value='Libya' >Libya<\/option><option value='Liechtenstein' >Liechtenstein<\/option><option value='Lithuania' >Lithuania<\/option><option value='Luxembourg' >Luxembourg<\/option><option value='Macau' >Macau<\/option><option value='Macedonia' >Macedonia<\/option><option value='Madagascar' >Madagascar<\/option><option value='Malawi' >Malawi<\/option><option value='Malaysia' >Malaysia<\/option><option value='Maldives' >Maldives<\/option><option value='Mali' >Mali<\/option><option value='Malta' >Malta<\/option><option value='Marshall Islands' >Marshall Islands<\/option><option value='Martinique' >Martinique<\/option><option value='Mauritania' >Mauritania<\/option><option value='Mauritius' >Mauritius<\/option><option value='Mayotte' >Mayotte<\/option><option value='Mexico' >Mexico<\/option><option value='Micronesia' >Micronesia<\/option><option value='Moldova' >Moldova<\/option><option value='Monaco' >Monaco<\/option><option value='Mongolia' >Mongolia<\/option><option value='Montenegro' >Montenegro<\/option><option value='Montserrat' >Montserrat<\/option><option value='Morocco' >Morocco<\/option><option value='Mozambique' >Mozambique<\/option><option value='Myanmar' >Myanmar<\/option><option value='Namibia' >Namibia<\/option><option value='Nauru' >Nauru<\/option><option value='Nepal' >Nepal<\/option><option value='Netherlands' >Netherlands<\/option><option value='New Caledonia' >New Caledonia<\/option><option value='New Zealand' >New Zealand<\/option><option value='Nicaragua' >Nicaragua<\/option><option value='Niger' >Niger<\/option><option value='Nigeria' >Nigeria<\/option><option value='Niue' >Niue<\/option><option value='Norfolk Island' >Norfolk Island<\/option><option value='North Korea' >North Korea<\/option><option value='Northern Mariana Islands' >Northern Mariana Islands<\/option><option value='Norway' >Norway<\/option><option value='Oman' >Oman<\/option><option value='Pakistan' >Pakistan<\/option><option value='Palau' >Palau<\/option><option value='Palestine, State of' >Palestine, State of<\/option><option value='Panama' >Panama<\/option><option value='Papua New Guinea' >Papua New Guinea<\/option><option value='Paraguay' >Paraguay<\/option><option value='Peru' >Peru<\/option><option value='Philippines' >Philippines<\/option><option value='Pitcairn' >Pitcairn<\/option><option value='Poland' >Poland<\/option><option value='Portugal' >Portugal<\/option><option value='Puerto Rico' >Puerto Rico<\/option><option value='Qatar' >Qatar<\/option><option value='Romania' >Romania<\/option><option value='Russia' >Russia<\/option><option value='Rwanda' >Rwanda<\/option><option value='R\u00e9union' >R\u00e9union<\/option><option value='Saint Barth\u00e9lemy' >Saint Barth\u00e9lemy<\/option><option value='Saint Helena' >Saint Helena<\/option><option value='Saint Kitts and Nevis' >Saint Kitts and Nevis<\/option><option value='Saint Lucia' >Saint Lucia<\/option><option value='Saint Martin' >Saint Martin<\/option><option value='Saint Pierre and Miquelon' >Saint Pierre and Miquelon<\/option><option value='Saint Vincent and the Grenadines' >Saint Vincent and the Grenadines<\/option><option value='Samoa' >Samoa<\/option><option value='San Marino' >San Marino<\/option><option value='Sao Tome and Principe' >Sao Tome and Principe<\/option><option value='Saudi Arabia' >Saudi Arabia<\/option><option value='Senegal' >Senegal<\/option><option value='Serbia' >Serbia<\/option><option value='Seychelles' >Seychelles<\/option><option value='Sierra Leone' >Sierra Leone<\/option><option value='Singapore' >Singapore<\/option><option value='Sint Maarten' >Sint Maarten<\/option><option value='Slovakia' >Slovakia<\/option><option value='Slovenia' >Slovenia<\/option><option value='Solomon Islands' >Solomon Islands<\/option><option value='Somalia' >Somalia<\/option><option value='South Africa' >South Africa<\/option><option value='South Georgia' >South Georgia<\/option><option value='South Korea' >South Korea<\/option><option value='South Sudan' >South Sudan<\/option><option value='Spain' >Spain<\/option><option value='Sri Lanka' >Sri Lanka<\/option><option value='Sudan' >Sudan<\/option><option value='Suriname' >Suriname<\/option><option value='Svalbard and Jan Mayen Islands' >Svalbard and Jan Mayen Islands<\/option><option value='Sweden' >Sweden<\/option><option value='Switzerland' >Switzerland<\/option><option value='Syria' >Syria<\/option><option value='Taiwan' >Taiwan<\/option><option value='Tajikistan' >Tajikistan<\/option><option value='Tanzania' >Tanzania<\/option><option value='Thailand' >Thailand<\/option><option value='Timor-Leste' >Timor-Leste<\/option><option value='Togo' >Togo<\/option><option value='Tokelau' >Tokelau<\/option><option value='Tonga' >Tonga<\/option><option value='Trinidad and Tobago' >Trinidad and Tobago<\/option><option value='Tunisia' >Tunisia<\/option><option value='Turkey' >Turkey<\/option><option value='Turkmenistan' >Turkmenistan<\/option><option value='Turks and Caicos Islands' >Turks and Caicos Islands<\/option><option value='Tuvalu' >Tuvalu<\/option><option value='US Minor Outlying Islands' >US Minor Outlying Islands<\/option><option value='Uganda' >Uganda<\/option><option value='Ukraine' >Ukraine<\/option><option value='United Arab Emirates' >United Arab Emirates<\/option><option value='United Kingdom' >United Kingdom<\/option><option value='United States' >United States<\/option><option value='Uruguay' >Uruguay<\/option><option value='Uzbekistan' >Uzbekistan<\/option><option value='Vanuatu' >Vanuatu<\/option><option value='Venezuela' >Venezuela<\/option><option value='Vietnam' >Vietnam<\/option><option value='Virgin Islands, British' >Virgin Islands, British<\/option><option value='Virgin Islands, U.S.' >Virgin Islands, U.S.<\/option><option value='Wallis and Futuna' >Wallis and Futuna<\/option><option value='Western Sahara' >Western Sahara<\/option><option value='Yemen' >Yemen<\/option><option value='Zambia' >Zambia<\/option><option value='Zimbabwe' >Zimbabwe<\/option><option value='\u00c5land Islands' >\u00c5land Islands<\/option><\/select><\/div><\/li><li id='field_4_4'  class='gfield gfield_contains_required field_sublabel_below field_description_below gfield_visibility_visible' ><label class='gfield_label' for='input_4_4' >\u101c\u1000\u1039\u101b\u102d\u103d\u1031\u1014\u1011\u102d\u102f\u1004\u1039\u101b\u102c\u1010\u102d\u102f\u1004\u1039\u1038\u103b\u1015\u100a\u1039\t<span class='gfield_required'>*<\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_4' id='input_4_4' type='text' value='' class='medium'     aria-required=\"true\" aria-invalid=\"false\" \/><\/div><\/li><li id='field_4_5'  class='gfield gfield_contains_required field_sublabel_below field_description_below gfield_visibility_visible' ><label class='gfield_label' for='input_4_5' >\u1021\u101c\u102f\u1015\u1039\u1021\u1000\u102d\u102f\u1004\u1039<span class='gfield_required'>*<\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_5' id='input_4_5' type='text' value='' class='medium'     aria-required=\"true\" aria-invalid=\"false\" \/><\/div><\/li><li id='field_4_6'  class='gfield gfield_contains_required field_sublabel_below field_description_below gfield_visibility_visible' ><label class='gfield_label'  >\u1021\u102d\u1019\u1039\u1031\u1011\u102c\u1004\u1039\u1031\u101b\u1038\u1021\u1031\u103b\u1001\u1021\u1031\u1014\t<span class='gfield_required'>*<\/span><\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_4_6'><li class='gchoice_4_6_0'><input name='input_6' type='radio' value='Single'  id='choice_4_6_0'    \/><label for='choice_4_6_0' id='label_4_6_0'>\u1021\u1015\u103a\u102d\u1033\/\u101c\u1030\u1015\u103a\u102d\u1033<\/label><\/li><li class='gchoice_4_6_1'><input name='input_6' type='radio' value='Married'  id='choice_4_6_1'    \/><label for='choice_4_6_1' id='label_4_6_1'>Married<\/label><\/li><li class='gchoice_4_6_2'><input name='input_6' type='radio' value='Divorced'  id='choice_4_6_2'    \/><label for='choice_4_6_2' id='label_4_6_2'>\u1010\u1001\u102f\u101c\u1015\u1039<\/label><\/li><li class='gchoice_4_6_3'><input name='input_6' type='radio' value='Widow\/er'  id='choice_4_6_3'    \/><label for='choice_4_6_3' id='label_4_6_3'>\u1019\u102f\u1006\u102d\u102f\u1038\u1019\/\u1016\u102d\u102f<\/label><\/li><\/ul><\/div><\/li><li id='field_4_7'  class='gfield field_sublabel_below field_description_below gfield_visibility_visible' ><label class='gfield_label' for='input_4_7' >\u101e\u102c\u1038\u101e\u1019\u102e\u1038 <\/label><div class='ginput_container ginput_container_text'><input name='input_7' id='input_4_7' type='text' value='' class='medium'      aria-invalid=\"false\" \/><\/div><\/li><li id='field_4_8'  class='gfield field_sublabel_below field_description_below gfield_visibility_visible' ><label class='gfield_label' for='input_4_8' >\u1006\u1000\u1039\u101e\u103c\u101a\u1039\u101b\u1014\u1039 \u101c\u102d\u1015\u1039\u1005\u102c <\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_8' id='input_4_8' class='textarea medium'      aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/li><li id='field_4_9'  class='gfield gfield_contains_required field_sublabel_below field_description_below gfield_visibility_visible' ><label class='gfield_label' for='input_4_9' >\u1016\u102f\u1014\u1039\u1038\u1014\u1036\u1015\u102b\u1010\u1039<span class='gfield_required'>*<\/span><\/label><div class='ginput_container ginput_container_phone'><input name='input_9' id='input_4_9' type='text' value='' class='medium'   aria-required=\"true\" aria-invalid=\"false\"  \/><\/div><\/li><li id='field_4_10'  class='gfield gfield_contains_required field_sublabel_below field_description_below gfield_visibility_visible' ><label class='gfield_label' for='input_4_10' >Email<span class='gfield_required'>*<\/span><\/label><div class='ginput_container ginput_container_email'>\n                            <input name='input_10' id='input_4_10' type='text' value='' class='medium'    aria-required=\"true\" aria-invalid=\"false\" \/>\n                        <\/div><\/li><li id='field_4_11'  class='gfield gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below field_description_below gfield_visibility_visible' >\u1021\u1031\u101b\u1038\u1031\u1015\u105a\u1006\u1000\u1039\u101e\u103c\u101a\u1039\u101b\u1014\u1039 \u1015\u102f\u1002\u1062\u102d\u1033\u101c\u1039<\/li><li id='field_4_12'  class='gfield gfield_contains_required field_sublabel_below field_description_below gfield_visibility_visible' ><label class='gfield_label' for='input_4_12' >\u1021\u1019\u100a\u1039<span class='gfield_required'>*<\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_12' id='input_4_12' type='text' value='' class='medium'     aria-required=\"true\" aria-invalid=\"false\" \/><\/div><\/li><li id='field_4_15'  class='gfield field_sublabel_below field_description_below gfield_visibility_visible' ><label class='gfield_label' for='input_4_15' >\u1031\u1010\u102c\u1039\u1005\u1015\u1039\u1015\u1036\u102f\t<\/label><div class='ginput_container ginput_container_text'><input name='input_15' id='input_4_15' type='text' value='' class='medium'      aria-invalid=\"false\" \/><\/div><\/li><li id='field_4_16'  class='gfield gfield_contains_required field_sublabel_below field_description_below gfield_visibility_visible' ><label class='gfield_label gfield_label_before_complex'  >\u101c\u102d\u1015\u1039\u1005\u102c<span class='gfield_required'>*<\/span><\/label>    \n                    <div class='ginput_complex ginput_container has_street has_street2 has_city has_country ginput_container_address' id='input_4_16' >\n                         <span class='ginput_full address_line_1' id='input_4_16_1_container' >\n                                        <input type='text' name='input_16.1' id='input_4_16_1' value=''    aria-required=\"true\"\/>\n                                        <label for='input_4_16_1' id='input_4_16_1_label' >Street Address<\/label>\n                                    <\/span><span class='ginput_full address_line_2' id='input_4_16_2_container' >\n                                        <input type='text' name='input_16.2' id='input_4_16_2' value=''   \/>\n                                        <label for='input_4_16_2' id='input_4_16_2_label' >Address Line 2<\/label>\n                                    <\/span><span class='ginput_left address_city' id='input_4_16_3_container' >\n                                    <input type='text' name='input_16.3' id='input_4_16_3' value=''    aria-required=\"true\"\/>\n                                    <label for='input_4_16_3' id='input_4_16_3_label' >City<\/label>\n                                 <\/span><input type='hidden' class='gform_hidden' name='input_16.4' id='input_4_16_4' value=''\/><span class='ginput_left address_country' id='input_4_16_6_container' >\n                                        <select name='input_16.6' id='input_4_16_6'   aria-required=\"true\"><option value='' selected='selected'><\/option><option value='Afghanistan' >Afghanistan<\/option><option value='Albania' >Albania<\/option><option value='Algeria' >Algeria<\/option><option value='American Samoa' >American Samoa<\/option><option value='Andorra' >Andorra<\/option><option value='Angola' >Angola<\/option><option value='Anguilla' >Anguilla<\/option><option value='Antarctica' >Antarctica<\/option><option value='Antigua and Barbuda' >Antigua and Barbuda<\/option><option value='Argentina' >Argentina<\/option><option value='Armenia' >Armenia<\/option><option value='Aruba' >Aruba<\/option><option value='Australia' >Australia<\/option><option value='Austria' >Austria<\/option><option value='Azerbaijan' >Azerbaijan<\/option><option value='Bahamas' >Bahamas<\/option><option value='Bahrain' >Bahrain<\/option><option value='Bangladesh' >Bangladesh<\/option><option value='Barbados' >Barbados<\/option><option value='Belarus' >Belarus<\/option><option value='Belgium' >Belgium<\/option><option value='Belize' >Belize<\/option><option value='Benin' >Benin<\/option><option value='Bermuda' >Bermuda<\/option><option value='Bhutan' >Bhutan<\/option><option value='Bolivia' >Bolivia<\/option><option value='Bonaire, Sint Eustatius and Saba' >Bonaire, Sint Eustatius and Saba<\/option><option value='Bosnia and Herzegovina' >Bosnia and Herzegovina<\/option><option value='Botswana' >Botswana<\/option><option value='Bouvet Island' >Bouvet Island<\/option><option value='Brazil' >Brazil<\/option><option value='British Indian Ocean Territory' >British Indian Ocean Territory<\/option><option value='Brunei Darussalam' >Brunei Darussalam<\/option><option value='Bulgaria' >Bulgaria<\/option><option value='Burkina Faso' >Burkina Faso<\/option><option value='Burundi' >Burundi<\/option><option value='Cambodia' >Cambodia<\/option><option value='Cameroon' >Cameroon<\/option><option value='Canada' >Canada<\/option><option value='Cape Verde' >Cape Verde<\/option><option value='Cayman Islands' >Cayman Islands<\/option><option value='Central African Republic' >Central African Republic<\/option><option value='Chad' >Chad<\/option><option value='Chile' >Chile<\/option><option value='China' >China<\/option><option value='Christmas Island' >Christmas Island<\/option><option value='Cocos Islands' >Cocos Islands<\/option><option value='Colombia' >Colombia<\/option><option value='Comoros' >Comoros<\/option><option value='Congo, Democratic Republic of the' >Congo, Democratic Republic of the<\/option><option value='Congo, Republic of the' >Congo, Republic of the<\/option><option value='Cook Islands' >Cook Islands<\/option><option value='Costa Rica' >Costa Rica<\/option><option value='Croatia' >Croatia<\/option><option value='Cuba' >Cuba<\/option><option value='Cura\u00e7ao' >Cura\u00e7ao<\/option><option value='Cyprus' >Cyprus<\/option><option value='Czech Republic' >Czech Republic<\/option><option value='C\u00f4te d&#039;Ivoire' >C\u00f4te d&#039;Ivoire<\/option><option value='Denmark' >Denmark<\/option><option value='Djibouti' >Djibouti<\/option><option value='Dominica' >Dominica<\/option><option value='Dominican Republic' >Dominican Republic<\/option><option value='Ecuador' >Ecuador<\/option><option value='Egypt' >Egypt<\/option><option value='El Salvador' >El Salvador<\/option><option value='Equatorial Guinea' >Equatorial Guinea<\/option><option value='Eritrea' >Eritrea<\/option><option value='Estonia' >Estonia<\/option><option value='Eswatini (Swaziland)' >Eswatini (Swaziland)<\/option><option value='Ethiopia' >Ethiopia<\/option><option value='Falkland Islands' >Falkland Islands<\/option><option value='Faroe Islands' >Faroe Islands<\/option><option value='Fiji' >Fiji<\/option><option value='Finland' >Finland<\/option><option value='France' >France<\/option><option value='French Guiana' >French Guiana<\/option><option value='French Polynesia' >French Polynesia<\/option><option value='French Southern Territories' >French Southern Territories<\/option><option value='Gabon' >Gabon<\/option><option value='Gambia' >Gambia<\/option><option value='Georgia' >Georgia<\/option><option value='Germany' >Germany<\/option><option value='Ghana' >Ghana<\/option><option value='Gibraltar' >Gibraltar<\/option><option value='Greece' >Greece<\/option><option value='Greenland' >Greenland<\/option><option value='Grenada' >Grenada<\/option><option value='Guadeloupe' >Guadeloupe<\/option><option value='Guam' >Guam<\/option><option value='Guatemala' >Guatemala<\/option><option value='Guernsey' >Guernsey<\/option><option value='Guinea' >Guinea<\/option><option value='Guinea-Bissau' >Guinea-Bissau<\/option><option value='Guyana' >Guyana<\/option><option value='Haiti' >Haiti<\/option><option value='Heard and McDonald Islands' >Heard and McDonald Islands<\/option><option value='Holy See' >Holy See<\/option><option value='Honduras' >Honduras<\/option><option value='Hong Kong' >Hong Kong<\/option><option value='Hungary' >Hungary<\/option><option value='Iceland' >Iceland<\/option><option value='India' >India<\/option><option value='Indonesia' >Indonesia<\/option><option value='Iran' >Iran<\/option><option value='Iraq' >Iraq<\/option><option value='Ireland' >Ireland<\/option><option value='Isle of Man' >Isle of Man<\/option><option value='Israel' >Israel<\/option><option value='Italy' >Italy<\/option><option value='Jamaica' >Jamaica<\/option><option value='Japan' >Japan<\/option><option value='Jersey' >Jersey<\/option><option value='Jordan' >Jordan<\/option><option value='Kazakhstan' >Kazakhstan<\/option><option value='Kenya' >Kenya<\/option><option value='Kiribati' >Kiribati<\/option><option value='Kuwait' >Kuwait<\/option><option value='Kyrgyzstan' >Kyrgyzstan<\/option><option value='Lao People&#039;s Democratic Republic' >Lao People&#039;s Democratic Republic<\/option><option value='Latvia' >Latvia<\/option><option value='Lebanon' >Lebanon<\/option><option value='Lesotho' >Lesotho<\/option><option value='Liberia' >Liberia<\/option><option value='Libya' >Libya<\/option><option value='Liechtenstein' >Liechtenstein<\/option><option value='Lithuania' >Lithuania<\/option><option value='Luxembourg' >Luxembourg<\/option><option value='Macau' >Macau<\/option><option value='Macedonia' >Macedonia<\/option><option value='Madagascar' >Madagascar<\/option><option value='Malawi' >Malawi<\/option><option value='Malaysia' >Malaysia<\/option><option value='Maldives' >Maldives<\/option><option value='Mali' >Mali<\/option><option value='Malta' >Malta<\/option><option value='Marshall Islands' >Marshall Islands<\/option><option value='Martinique' >Martinique<\/option><option value='Mauritania' >Mauritania<\/option><option value='Mauritius' >Mauritius<\/option><option value='Mayotte' >Mayotte<\/option><option value='Mexico' >Mexico<\/option><option value='Micronesia' >Micronesia<\/option><option value='Moldova' >Moldova<\/option><option value='Monaco' >Monaco<\/option><option value='Mongolia' >Mongolia<\/option><option value='Montenegro' >Montenegro<\/option><option value='Montserrat' >Montserrat<\/option><option value='Morocco' >Morocco<\/option><option value='Mozambique' >Mozambique<\/option><option value='Myanmar' >Myanmar<\/option><option value='Namibia' >Namibia<\/option><option value='Nauru' >Nauru<\/option><option value='Nepal' >Nepal<\/option><option value='Netherlands' >Netherlands<\/option><option value='New Caledonia' >New Caledonia<\/option><option value='New Zealand' >New Zealand<\/option><option value='Nicaragua' >Nicaragua<\/option><option value='Niger' >Niger<\/option><option value='Nigeria' >Nigeria<\/option><option value='Niue' >Niue<\/option><option value='Norfolk Island' >Norfolk Island<\/option><option value='North Korea' >North Korea<\/option><option value='Northern Mariana Islands' >Northern Mariana Islands<\/option><option value='Norway' >Norway<\/option><option value='Oman' >Oman<\/option><option value='Pakistan' >Pakistan<\/option><option value='Palau' >Palau<\/option><option value='Palestine, State of' >Palestine, State of<\/option><option value='Panama' >Panama<\/option><option value='Papua New Guinea' >Papua New Guinea<\/option><option value='Paraguay' >Paraguay<\/option><option value='Peru' >Peru<\/option><option value='Philippines' >Philippines<\/option><option value='Pitcairn' >Pitcairn<\/option><option value='Poland' >Poland<\/option><option value='Portugal' >Portugal<\/option><option value='Puerto Rico' >Puerto Rico<\/option><option value='Qatar' >Qatar<\/option><option value='Romania' >Romania<\/option><option value='Russia' >Russia<\/option><option value='Rwanda' >Rwanda<\/option><option value='R\u00e9union' >R\u00e9union<\/option><option value='Saint Barth\u00e9lemy' >Saint Barth\u00e9lemy<\/option><option value='Saint Helena' >Saint Helena<\/option><option value='Saint Kitts and Nevis' >Saint Kitts and Nevis<\/option><option value='Saint Lucia' >Saint Lucia<\/option><option value='Saint Martin' >Saint Martin<\/option><option value='Saint Pierre and Miquelon' >Saint Pierre and Miquelon<\/option><option value='Saint Vincent and the Grenadines' >Saint Vincent and the Grenadines<\/option><option value='Samoa' >Samoa<\/option><option value='San Marino' >San Marino<\/option><option value='Sao Tome and Principe' >Sao Tome and Principe<\/option><option value='Saudi Arabia' >Saudi Arabia<\/option><option value='Senegal' >Senegal<\/option><option value='Serbia' >Serbia<\/option><option value='Seychelles' >Seychelles<\/option><option value='Sierra Leone' >Sierra Leone<\/option><option value='Singapore' >Singapore<\/option><option value='Sint Maarten' >Sint Maarten<\/option><option value='Slovakia' >Slovakia<\/option><option value='Slovenia' >Slovenia<\/option><option value='Solomon Islands' >Solomon Islands<\/option><option value='Somalia' >Somalia<\/option><option value='South Africa' >South Africa<\/option><option value='South Georgia' >South Georgia<\/option><option value='South Korea' >South Korea<\/option><option value='South Sudan' >South Sudan<\/option><option value='Spain' >Spain<\/option><option value='Sri Lanka' >Sri Lanka<\/option><option value='Sudan' >Sudan<\/option><option value='Suriname' >Suriname<\/option><option value='Svalbard and Jan Mayen Islands' >Svalbard and Jan Mayen Islands<\/option><option value='Sweden' >Sweden<\/option><option value='Switzerland' >Switzerland<\/option><option value='Syria' >Syria<\/option><option value='Taiwan' >Taiwan<\/option><option value='Tajikistan' >Tajikistan<\/option><option value='Tanzania' >Tanzania<\/option><option value='Thailand' >Thailand<\/option><option value='Timor-Leste' >Timor-Leste<\/option><option value='Togo' >Togo<\/option><option value='Tokelau' >Tokelau<\/option><option value='Tonga' >Tonga<\/option><option value='Trinidad and Tobago' >Trinidad and Tobago<\/option><option value='Tunisia' >Tunisia<\/option><option value='Turkey' >Turkey<\/option><option value='Turkmenistan' >Turkmenistan<\/option><option value='Turks and Caicos Islands' >Turks and Caicos Islands<\/option><option value='Tuvalu' >Tuvalu<\/option><option value='US Minor Outlying Islands' >US Minor Outlying Islands<\/option><option value='Uganda' >Uganda<\/option><option value='Ukraine' >Ukraine<\/option><option value='United Arab Emirates' >United Arab Emirates<\/option><option value='United Kingdom' >United Kingdom<\/option><option value='United States' >United States<\/option><option value='Uruguay' >Uruguay<\/option><option value='Uzbekistan' >Uzbekistan<\/option><option value='Vanuatu' >Vanuatu<\/option><option value='Venezuela' >Venezuela<\/option><option value='Vietnam' >Vietnam<\/option><option value='Virgin Islands, British' >Virgin Islands, British<\/option><option value='Virgin Islands, U.S.' >Virgin Islands, U.S.<\/option><option value='Wallis and Futuna' >Wallis and Futuna<\/option><option value='Western Sahara' >Western Sahara<\/option><option value='Yemen' >Yemen<\/option><option value='Zambia' >Zambia<\/option><option value='Zimbabwe' >Zimbabwe<\/option><option value='\u00c5land Islands' >\u00c5land Islands<\/option><\/select>\n                                        <label for='input_4_16_6' id='input_4_16_6_label' >Country<\/label>\n                                    <\/span>\n                    <div class='gf_clear gf_clear_complex'><\/div>\n                <\/div><\/li><li id='field_4_17'  class='gfield gfield_contains_required field_sublabel_below field_description_below gfield_visibility_visible' ><label class='gfield_label' for='input_4_17' >\u1016\u102f\u1014\u1039\u1038\u1014\u1036\u1015\u102b\u1010\u1039<span class='gfield_required'>*<\/span><\/label><div class='ginput_container ginput_container_phone'><input name='input_17' id='input_4_17' type='text' value='' class='medium'   aria-required=\"true\" aria-invalid=\"false\"  \/><\/div><\/li><li id='field_4_18'  class='gfield gfield_contains_required field_sublabel_below field_description_below gfield_visibility_visible' ><label class='gfield_label' for='input_4_18' >Email<span class='gfield_required'>*<\/span><\/label><div class='ginput_container ginput_container_email'>\n                            <input name='input_18' id='input_4_18' type='text' value='' class='medium'    aria-required=\"true\" aria-invalid=\"false\" \/>\n                        <\/div><\/li><li id='field_4_19'  class='gfield field_sublabel_below field_description_below gfield_visibility_visible' ><label class='gfield_label'  >\u101c\u1030\u1010\u102d\u102f\u1004\u1039\u1038\u1021\u1010\u103c\u1000\u1039 \u1005\u102d\u1010\u1039\u1015\u100a\u102c\u104f \u1031\u1006\u103c\u1038\u1031\u108f\u103c\u1038\u1000\u102f\u101e\u103b\u1001\u1004\u1039\u1038 \u1040\u1014\u1039\u1031\u1006\u102c\u1004\u1039\u1019\u1088\u1021\u1031\u107e\u1000\u102c\u1004\u1039\u1038\u1019\u100a\u1039\u101e\u102d\u102f\u1094\u101e\u102d\u101b\u102d\u103d\u101e\u1014\u100a\u1039\u1038\u104b <\/label><div class='ginput_container ginput_container_checkbox'><ul class='gfield_checkbox' id='input_4_19'><li class='gchoice_4_19_1'>\n\t\t\t\t\t\t\t\t<input name='input_19.1' type='checkbox'  value='Facebook \u2013 Reach Out Myanmar (\u101c\u1030\u1010\u102f\u102d\u1004\u1039\u1038\u1021\u1010\u103c\u1000\u1039 \u1005\u102d\u1010\u1039\u1015\u100a\u102c)'  id='choice_4_19_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_4_19_1' id='label_4_19_1'>Facebook \u2013 Reach Out Myanmar (\u101c\u1030\u1010\u102f\u102d\u1004\u1039\u1038\u1021\u1010\u103c\u1000\u1039 \u1005\u102d\u1010\u1039\u1015\u100a\u102c)<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice_4_19_2'>\n\t\t\t\t\t\t\t\t<input name='input_19.2' type='checkbox'  value='Website \u2013 Reach Out Myanmar (\u101c\u1030\u1010\u102f\u102d\u1004\u1039\u1038\u1021\u1010\u103c\u1000\u1039 \u1005\u102d\u1010\u1039\u1015\u100a\u102c)'  id='choice_4_19_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_4_19_2' id='label_4_19_2'>Website \u2013 Reach Out Myanmar (\u101c\u1030\u1010\u102f\u102d\u1004\u1039\u1038\u1021\u1010\u103c\u1000\u1039 \u1005\u102d\u1010\u1039\u1015\u100a\u102c)<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice_4_19_3'>\n\t\t\t\t\t\t\t\t<input name='input_19.3' type='checkbox'  value='Psychological Matter Asia'  id='choice_4_19_3'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_4_19_3' id='label_4_19_3'>Psychological Matter Asia<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice_4_19_4'>\n\t\t\t\t\t\t\t\t<input name='input_19.4' type='checkbox'  value='Google'  id='choice_4_19_4'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_4_19_4' id='label_4_19_4'>Google<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice_4_19_5'>\n\t\t\t\t\t\t\t\t<input name='input_19.5' type='checkbox'  value='Friends'  id='choice_4_19_5'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_4_19_5' id='label_4_19_5'>\u101e\u1030\u1004\u101a\u1039\u1001\u103a\u1004\u1039\u1038<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice_4_19_6'>\n\t\t\t\t\t\t\t\t<input name='input_19.6' type='checkbox'  value='Family'  id='choice_4_19_6'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_4_19_6' id='label_4_19_6'>\u1019\u102d\u101e\u102c\u1038\u1005\u102f<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice_4_19_7'>\n\t\t\t\t\t\t\t\t<input name='input_19.7' type='checkbox'  value='Others'  id='choice_4_19_7'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_4_19_7' id='label_4_19_7'>\u1021\u103b\u1001\u102c\u1038 <\/label>\n\t\t\t\t\t\t\t<\/li><\/ul><\/div><\/li><li id='field_4_22'  class='gfield gfield_contains_required field_sublabel_below field_description_below gfield_visibility_visible' ><label class='gfield_label'  ><span class='gfield_required'>*<\/span><\/label><div class='ginput_container ginput_container_checkbox'><ul class='gfield_checkbox' id='input_4_22'><li class='gchoice_4_22_1'>\n\t\t\t\t\t\t\t\t<input name='input_22.1' type='checkbox'  value='I have read the &lt;a href=&quot;http:\/\/www.reachoutmyanmar.com\/service-agreement\/&quot; target=&quot;_blank&quot;&gt;Terms and Conditions&lt;\/a&gt;'  id='choice_4_22_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_4_22_1' id='label_4_22_1'>I have read the <a href=\"http:\/\/www.reachoutmyanmar.com\/my\/service-agreement\/\" target=\"_blank\">Terms and Conditions<\/a><\/label>\n\t\t\t\t\t\t\t<\/li><\/ul><\/div><\/li><li id='field_4_23'  class='gfield gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below field_description_below gfield_visibility_visible' >Welcome to Reach Out Myanmar- Psychological and Consultancy Services. Our psychologists and therapists are helping clients to live their lives to the fullness through mental health services. Kindly read the following items thoroughly and feel free to clarify if necessary.\n<h3><strong>Confidentiality<\/strong><\/h3>\nIn general, all communications between a client and psychologist or therapist are confidential. We can\u00a0 release your information to other only with your permission. Moreover, we will not be revealing others that you are seeking help from me or from our organization unless permission granted by you. But there are exceptions to this\n<ul>\n \t<li>If there are situations when you are threatening to harm yourself, the psychologist or therapist is obliged to inform the person of emergency contact, family members or any other who can protect your safety.<\/li>\n \t<li>If you are threatening to harm other or someone who is vulnerable, the psychologist or therapist will be taking necessary protective actions, such as notifying the potential victim, contacting proper authorities, or seeking hospitalization for you.<\/li>\n \t<li>In some legal proceedings, the psychologist may be required by Myanmar law to provide information about your treatment. For example, a judge may order my testimony if he\/she wishes. Please consult your legal professional and consider this before involving me in legal proceedings.<\/li>\n<\/ul>\nThe psychologist or therapist may occasionally consult with other mental health professionals in order to provide most effective treatment for you. In such situation, the psychologist will make all the effort to avoid revealing your identity in accordance with the ethical standards of the mental health professionals.\n<h3><strong>Treatment Record <\/strong><\/h3>\nThe standards of mental health profession requires the psychologist to keep treatment records. You are entitled to receive a copy of your records, or\u00a0 a summary of it.\n<h3><strong>Payment <\/strong><\/h3>\nAll modes of counseling services (except messaging) are charged 60,000 kyats per session (45 mins to 60 mins). However, we do have a sliding scale in Reach Out Myanmar for those who cannot afford to pay the standard fees. You may discuss about it with the psychologist or therapist at the end of the first session if interested.\n\nIn addition to appointments, we charge this amount for other professional services and uses of our time.\n\nThe services might include report writing, telephone conversations lasting longer than 10 minutes,\n\nattendance at meetings with other professionals you have authorized, preparation of records or\n\ntreatment summaries, or other appropriate services you request.\n<h3><strong>Cancellation Policy<\/strong><\/h3>\nOnce we schedule an appointment hour, you will be expected to pay for it unless you provide 24\n\nhours advance notice of cancellation [unless we both agree that you were unable to attend due\n\nto circumstances beyond your control]. We only accept cancellations by phone call at +959767128927 or on viber account of the same number if you happens to be in other country during the office hour. For late cancellation, you will be charged 50% of the fees and will have to make a new appointment.\n<h3><strong>Communication<\/strong><\/h3>\nFor inquiry and making appointments, you may contact us at +959767128927 or <a href=\"https:\/\/www.facebook.com\/ReachOutMyanmar\/\">https:\/\/www.facebook.com\/ReachOutMyanmar\/<\/a> or <a href=\"mailto:contact@reachoutmyanmar.com\">contact@reachoutmyanmar.com<\/a>.\n\nGenerally, the psychologist will not discuss about your treatments on the phone or via internet. The emails you sent to the psychologist might not be replied but the issues you mentioned in the email will be discussed in the next session. However, in case of emergency, the psychologist will try his or her best to reach you back on the phone or reply your email within two or three days during office hour.\n<h3><strong>Understanding about Treatment Process<\/strong><\/h3>\nI commit myself to participate in the whole treatment process and understand that the treatment will not be lesser than five sessions and differs according to my condition.\n\nI understand and agree to do the homework given by the psychologist or therapist, for example, reading, praying, change of behaviors and other necessary activities that will be helpful for me wellbeing. I also understand and acknowledge that I am fully responsible for my actions and I have to make my own decision, if there are things to decide within the process.\n\nI understand that I need to put afford to overcome my difficulties and my progress is largely depends on my sincerity and eagerness. 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