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Tell Us About Your Family
1
How soon are you hoping to begin therapy services?
*
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🚨ASAP – We’re actively looking for something this week
🗓️Soon – Within the next few weeks is ideal
🌿Flexible – We’re still exploring and open to later start dates
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2
How Many Kids are Ready for Therapy?
*
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1 Kid
2 Kids
3 Kids
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3
Child's
First Name
*
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4
Second Child's
First Name
*
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5
Third Child's
First Name
*
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6
How Old
is {childsFirst}
*
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Under 1 Year Old
1 Year Old
2 Years Old
3 Years Old
4 Years Old
5 Years Old
6 Years Old
7 Years Old
8 Years Old
9 Years Old
10 Years Old
11 Years Old
12 Years Old
13 Years Old
14 Years Old
15 Years Old
16 Years Old
17 Years Old
18 Years Old
19 Years Old
20 Years Old
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7
How Old
is {secondChilds}
*
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Under 1 Year Old
1 Year Old
2 Years Old
3 Years Old
4 Years Old
5 Years Old
6 Years Old
7 Years Old
8 Years Old
9 Years Old
10 Years Old
11 Years Old
12 Years Old
13 Years Old
14 Years Old
15 Years Old
16 Years Old
17 Years Old
18 Years Old
19 Years Old
20 Years Old
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8
How Old
is {thirdChilds}
*
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Under 1 Year Old
1 Year Old
2 Years Old
3 Years Old
4 Years Old
5 Years Old
6 Years Old
7 Years Old
8 Years Old
9 Years Old
10 Years Old
11 Years Old
12 Years Old
13 Years Old
14 Years Old
15 Years Old
16 Years Old
17 Years Old
18 Years Old
19 Years Old
20 Years Old
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9
Which Therapies Does {childsFirst} Need?
*
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select all that apply
Occupational Therapy
Speech Therapy
ABA Therapy
Physical Therapy
Psychotherapy and Counseling
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10
Which Therapies Does {secondChilds} Need?
*
This field is required.
select all that apply
Occupational Therapy
Speech Therapy
ABA Therapy
Physical Therapy
Psychotherapy and Counseling
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11
Which Therapies Does {thirdChilds} Need?
*
This field is required.
select all that apply
Occupational Therapy
Speech Therapy
ABA Therapy
Physical Therapy
Psychotherapy and Counseling
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12
Does {childsFirst} have a diagnosis?
*
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YES
NO
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13
Does {secondChilds} have a diagnosis?
*
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YES
NO
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14
Does {thirdChilds} have a diagnosis?
*
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YES
NO
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15
What diagnosis does {childsFirst} have?
*
This field is required.
select all that apply
ADHD
Autism
Apraxia
Developmental Delays
Speech and Language Disorders
Other
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16
What diagnosis does {secondChilds} have?
*
This field is required.
select all that apply
ADHD
Autism
Apraxia
Developmental Delays
Speech and Language Disorders
Other
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17
What diagnosis does {thirdChilds} have?
*
This field is required.
select all that apply
ADHD
Autism
Apraxia
Developmental Delays
Speech and Language Disorders
Other
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18
{childsFirst} needs support to grow in these areas:
*
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Communication and Language
Social Skills
Sensory Processing
Feeding and Eating
Fine Motor
Gross Motor
Emotional Regulation
Cognition and Learning
Self-Care and Independence
Attention and Executive Functioning
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19
{secondChilds} needs support to grow in these areas:
*
This field is required.
Communication and Language
Social Skills
Sensory Processing
Feeding and Eating
Fine Motor
Gross Motor
Emotional Regulation
Cognition and Learning
Self-Care and Independence
Attention and Executive Functioning
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20
{thirdChilds} needs support to grow in these areas:
*
This field is required.
Communication and Language
Social Skills
Sensory Processing
Feeding and Eating
Fine Motor
Gross Motor
Emotional Regulation
Cognition and Learning
Self-Care and Independence
Attention and Executive Functioning
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21
Where would you prefer {childsFirst}'s therapy to take place?
*
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Choose all the places that work for you
At Home
In a Therapy Clinic
At an ABA Clinic
At Daycare
At a Private School
Online / Virtual Sessions
Other Location NOT Home
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22
Where would you prefer {secondChilds}'s therapy to take place?
*
This field is required.
Choose all the places that work for you
At Home
In a Therapy Clinic
At an ABA Clinic
At Daycare
At a Private School
Online / Virtual Sessions
Other Location NOT Home
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23
Where would you prefer {thirdChilds}'s therapy to take place?
*
This field is required.
Choose all the places that work for you
At Home
In a Therapy Clinic
At an ABA Clinic
At Daycare
At a Private School
Online / Virtual Sessions
Other Location NOT Home
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24
Place's Name and Address
*
This field is required.
Name of location (ABA/School)
Address Line 1
City
State / Province
Postal / Zip Code
Please Select
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
The Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bosnia and Herzegovina
Botswana
Brazil
Brunei
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos (Keeling) Islands
Colombia
Comoros
Congo
Cook Islands
Costa Rica
Cote d'Ivoire
Croatia
Cuba
Curaçao
Cyprus
Czech Republic
Democratic Republic of the Congo
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Polynesia
Gabon
The Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
North Korea
South Korea
Kosovo
Kuwait
Kyrgyzstan
Laos
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macau
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Nagorno-Karabakh
Namibia
Nauru
Nepal
Netherlands
Netherlands Antilles
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
Turkish Republic of Northern Cyprus
Northern Mariana
Norway
Oman
Pakistan
Palau
Palestine
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn Islands
Poland
Portugal
Puerto Rico
Qatar
Republic of the Congo
Romania
Russia
Rwanda
Saint Barthelemy
Saint Helena
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Slovakia
Slovenia
Solomon Islands
Somalia
Somaliland
South Africa
South Ossetia
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard
eSwatini
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Transnistria Pridnestrovie
Trinidad and Tobago
Tristan da Cunha
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
Uganda
Ukraine
United Arab Emirates
United Kingdom
United States
Uruguay
Uzbekistan
Vanuatu
Vatican City
Venezuela
Vietnam
British Virgin Islands
Isle of Man
US Virgin Islands
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Other
Please Select
Please Select
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
The Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bosnia and Herzegovina
Botswana
Brazil
Brunei
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos (Keeling) Islands
Colombia
Comoros
Congo
Cook Islands
Costa Rica
Cote d'Ivoire
Croatia
Cuba
Curaçao
Cyprus
Czech Republic
Democratic Republic of the Congo
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Polynesia
Gabon
The Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
North Korea
South Korea
Kosovo
Kuwait
Kyrgyzstan
Laos
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macau
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Nagorno-Karabakh
Namibia
Nauru
Nepal
Netherlands
Netherlands Antilles
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
Turkish Republic of Northern Cyprus
Northern Mariana
Norway
Oman
Pakistan
Palau
Palestine
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn Islands
Poland
Portugal
Puerto Rico
Qatar
Republic of the Congo
Romania
Russia
Rwanda
Saint Barthelemy
Saint Helena
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Slovakia
Slovenia
Solomon Islands
Somalia
Somaliland
South Africa
South Ossetia
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard
eSwatini
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Transnistria Pridnestrovie
Trinidad and Tobago
Tristan da Cunha
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
Uganda
Ukraine
United Arab Emirates
United Kingdom
United States
Uruguay
Uzbekistan
Vanuatu
Vatican City
Venezuela
Vietnam
British Virgin Islands
Isle of Man
US Virgin Islands
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Other
Country
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25
Which days are best for {childsFirst}'s therapy?
*
This field is required.
Monday
Tuesday
Wednesday
Thursday
Friday
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26
Which days are best for {childsFirst}'s and {secondChilds}'s therapy?
*
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Monday
Tuesday
Wednesday
Thursday
Friday
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27
Which days are best for {childsFirst}'s, {secondChilds}'s and {thirdChilds}'s therapy?
*
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Monday
Tuesday
Wednesday
Thursday
Friday
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28
Which times are most convenient for therapy?
*
This field is required.
Select all that apply
8:00 AM - 9:00 AM
9:00 AM - 10:00 AM
10:00 AM - 11:00 AM
11:00 AM - 12:00 PM
12:00 PM - 1:00 PM
1:00 PM - 2:00 PM
2:00 PM - 3:00 PM
3:00 PM - 4:00 PM
4:00 PM - 5:00 PM
5:00 PM - 6:00 PM
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29
Would copays, deductibles, or recommended therapy tools create a financial burden for your family?
*
This field is required.
No – We could manage these expenses.
Yes – These costs would be a challenge.
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30
What's your
primary
insurance
provider
?
*
This field is required.
Aetna
Anthem - Blue Cross Blue Shield
Blue Cross Blue Shield-Texas
Cigna
Oscar
TriWest
United Healthcare
Health Care Sharing Ministries (HCSMs)
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31
What's your
primary
insurance
plan type
?
*
This field is required.
PPO (Preferred Provider Organization)
HMO (Health Maintenance Organization)
EPO (Exclusive Provider Organization)
POS (Point of Service)
I'm not sure
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32
I have a
secondary
insurance
YES
NO
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33
What's your
secondary
insurance
provider
?
Aetna
Anthem - Blue Cross Blue Shield
Blue Cross Blue Shield - Texas
Cigna
Oscar
TriWest
United Healthcare
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34
What's your
secondary
insurance
plan type
?
PPO (Preferred Provider Organization)
HMO (Health Maintenance Organization)
EPO (Exclusive Provider Organization)
POS (Point of Service)
I'm not sure
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35
Caregiver's Name
*
This field is required.
First Name
Last Name
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36
Email
*
This field is required.
example@example.com
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37
Phone Number
*
This field is required.
Please enter a valid phone number.
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38
What’s your current zip code?
*
This field is required.
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Please Select
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
The Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bosnia and Herzegovina
Botswana
Brazil
Brunei
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos (Keeling) Islands
Colombia
Comoros
Congo
Cook Islands
Costa Rica
Cote d'Ivoire
Croatia
Cuba
Curaçao
Cyprus
Czech Republic
Democratic Republic of the Congo
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Polynesia
Gabon
The Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
North Korea
South Korea
Kosovo
Kuwait
Kyrgyzstan
Laos
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macau
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Nagorno-Karabakh
Namibia
Nauru
Nepal
Netherlands
Netherlands Antilles
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
Turkish Republic of Northern Cyprus
Northern Mariana
Norway
Oman
Pakistan
Palau
Palestine
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn Islands
Poland
Portugal
Puerto Rico
Qatar
Republic of the Congo
Romania
Russia
Rwanda
Saint Barthelemy
Saint Helena
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Slovakia
Slovenia
Solomon Islands
Somalia
Somaliland
South Africa
South Ossetia
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard
eSwatini
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Transnistria Pridnestrovie
Trinidad and Tobago
Tristan da Cunha
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
Uganda
Ukraine
United Arab Emirates
United Kingdom
United States
Uruguay
Uzbekistan
Vanuatu
Vatican City
Venezuela
Vietnam
British Virgin Islands
Isle of Man
US Virgin Islands
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Other
Please Select
Please Select
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
The Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bosnia and Herzegovina
Botswana
Brazil
Brunei
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos (Keeling) Islands
Colombia
Comoros
Congo
Cook Islands
Costa Rica
Cote d'Ivoire
Croatia
Cuba
Curaçao
Cyprus
Czech Republic
Democratic Republic of the Congo
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Polynesia
Gabon
The Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
North Korea
South Korea
Kosovo
Kuwait
Kyrgyzstan
Laos
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macau
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Nagorno-Karabakh
Namibia
Nauru
Nepal
Netherlands
Netherlands Antilles
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
Turkish Republic of Northern Cyprus
Northern Mariana
Norway
Oman
Pakistan
Palau
Palestine
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn Islands
Poland
Portugal
Puerto Rico
Qatar
Republic of the Congo
Romania
Russia
Rwanda
Saint Barthelemy
Saint Helena
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Slovakia
Slovenia
Solomon Islands
Somalia
Somaliland
South Africa
South Ossetia
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard
eSwatini
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Transnistria Pridnestrovie
Trinidad and Tobago
Tristan da Cunha
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
Uganda
Ukraine
United Arab Emirates
United Kingdom
United States
Uruguay
Uzbekistan
Vanuatu
Vatican City
Venezuela
Vietnam
British Virgin Islands
Isle of Man
US Virgin Islands
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Other
Country
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