<div class="brz-forms__fields css-10cwydl">
<div class="fw-col-sm-6" style="padding-bottom: 20px;"><label class="contactform">Email address *</label>[email* email]</div>

<div class="fw-col-sm-6" style="padding-bottom: 20px;"><label class="contactform">Name of the Therapist *</label>[text* name-therapist]</div>

<div class="fw-col-sm-6" style="padding-bottom: 20px;"><label class="contactform">Contact Number *</label>[tel* contact-number minlength:10 maxlength:12]</div>

<div class="fw-col-sm-6" style="padding-bottom: 20px;"><label class="contactform">Your Country / City / State *</label>[text* country-city-state]</div>

<div class="fw-col-sm-6" style="padding-bottom: 20px;"><label class="contactform">You practice independently? *</label>[radio practice-independently default:0 "Yes" "No"]</div>

<div class="fw-col-sm-6" style="padding-bottom: 20px;"><label class="contactform">If you are a part of an organization, please mention name of your organization /center/hospital/clinic. *</label>[text* organization]</div>

<div class="fw-col-sm-6" style="padding-bottom: 20px;"><label class="contactform">How many children on your caseload?*</label>[number* children min:1 max:1000]</div>

<div class="fw-col-sm-12">
[submit class:vconnect-submit "Send"]</div></div>