{"id":794,"date":"2011-06-27T03:58:41","date_gmt":"2011-06-27T03:58:41","guid":{"rendered":"http:\/\/tonkonogy.com\/marina\/contact-me\/"},"modified":"2025-07-23T19:20:07","modified_gmt":"2025-07-23T19:20:07","slug":"informed-consent","status":"publish","type":"page","link":"https:\/\/tonkonogy.com\/marina\/forms\/informed-consent\/","title":{"rendered":"Informed Consent"},"content":{"rendered":"<div class=\"forminator-ui forminator-custom-form forminator-custom-form-1088 forminator-design--material  forminator_ajax\" data-forminator-render=\"0\" data-form=\"forminator-module-1088\" data-uid=\"6a13413f30d9b\"><br\/><\/div><form\n\t\t\t\tid=\"forminator-module-1088\"\n\t\t\t\tclass=\"forminator-ui forminator-custom-form forminator-custom-form-1088 forminator-design--material  forminator_ajax\"\n\t\t\t\tmethod=\"post\"\n\t\t\t\tdata-forminator-render=\"0\"\n\t\t\t\tdata-form-id=\"1088\"\n\t\t\t\tenctype=\"multipart\/form-data\" data-color-option=\"default\" data-design=\"material\" data-grid=\"open\" style=\"display: none;\"\n\t\t\t\tdata-uid=\"6a13413f30d9b\"\n\t\t\t><div role=\"alert\" aria-live=\"polite\" class=\"forminator-response-message forminator-error\" aria-hidden=\"true\"><\/div><div class=\"forminator-row\"><div id=\"html-1\" class=\"forminator-field-html forminator-col forminator-col-12 \"><div class=\"forminator-field forminator-merge-tags\" data-field=\"html-1\"><label class=\"forminator-label\">For therapy sessions with Marina Tonkonogy, LMFT (California License 48252)<\/label><div data-removefontsize=\"true\" data-originalcomputedfontsize=\"16\">&nbsp;<\/div>\n<div data-removefontsize=\"true\" data-originalcomputedfontsize=\"16\">I, {name-1} {name-2}, hereby consent to engage in telehealth mental health counseling services with Marina Tonkonogy, LMFT (further referred to as Psychotherapist).<\/div>\n<div data-removefontsize=\"true\" data-originalcomputedfontsize=\"16\">\n<div>&nbsp;<\/div>\n<div>\n<h2>Definition<\/h2>\n<p>I understand that the term \"telehealth\" refers to mental health consultations, psychotherapy, or psychological education delivered via interactive audio, video, or data communications over the internet or phone.<\/p>\n<hr>\n<h2>Rights &amp; Responsibilities<\/h2>\n<p>I understand that I have the following rights and responsibilities in receiving telehealth services:<\/p>\n<ul>\n<li>I am required to provide my full name, address, and phone number before the first telehealth session. I understand that I must be physically located in the State of California to receive telehealth services. I agree to confirm the address from which I receive telehealth services before the beginning of every session and to notify Psychotherapist in advance if I plan to be out of state for any scheduled session. I also agree to upload a copy of my picture ID as proof of identity.<\/li>\n<li>I understand that I have the right to access my psychotherapy records and that Psychotherapist has the right to determine how such access is provided.<\/li>\n<li>I have the right to ask questions and express concerns related to my treatment, as well as to receive information about alternative treatment options.<\/li>\n<li>I have the right to seek a second opinion. However, once a second opinion is obtained, I understand that I must commit to working with one mental health professional only. I may not work concurrently with another mental health provider while continuing therapy with Psychotherapist unless agreed upon by both professionals. I understand that engaging in concurrent therapy without such agreement may result in termination of services.<\/li>\n<li>I agree not to appear for psychotherapy sessions with any third party without prior discussion and agreement with Psychotherapist. I understand that if I appear with another individual without prior agreement, the session will be ended immediately and the full session fee will apply.<\/li>\n<li>I understand that telehealth psychotherapy is not appropriate for crisis or emergencies. If I am in crisis or a life-threatening or dangerous situation, I agree to immediately call 911, go to the nearest emergency room or crisis facility, or contact the National Suicide Hotline at 1-800-784-2433.<\/li>\n<li>I am responsible for securing my computer, internet connection, and access points, and for ensuring a private, secure location for each session. If I do not provide privacy, Psychotherapist will terminate the session and the session fee will apply.<\/li>\n<li>I agree not to consume alcohol or any mind-altering substances, including recreational drugs, during or within 12 hours before each session. I understand that failure to comply will result in termination of the session, and the session fee will not be reimbursed.<\/li>\n<\/ul>\n<hr>\n<h2>Confidentiality of Services<\/h2>\n<p>The laws that protect the confidentiality of medical and mental health information apply to telehealth psychotherapy services. I understand that information disclosed during therapy is generally confidential. However, there are mandatory and permissive exceptions to confidentiality, including but not limited to: reporting child, elder, or dependent adult abuse; expressed threats of violence toward an identifiable victim; and situations in which my mental or emotional condition is made an issue in a legal proceeding.<\/p>\n<p>I understand that no recording or dissemination of any personally identifiable images or information from telehealth sessions will happen without written consent from both Psychotherapist and me.<\/p>\n<p>The telehealth software used by Psychotherapist is HIPAA-compliant and uses encryption and other safeguards to protect confidentiality. However, I acknowledge that electronic transmission of information cannot be guaranteed to be completely secure.<\/p>\n<hr>\n<h2>Internet Service &amp; Transmission of Information<\/h2>\n<p>I understand that despite reasonable efforts by Psychotherapist, telehealth services carry inherent risks, including possible disruptions, distortions, or unauthorized access due to technical failures.<\/p>\n<p>In the event of a disruption during a session, Psychotherapist will attempt to contact me using the phone number I have provided to discuss appropriate next steps.<\/p>\n<hr>\n<h2>Medical Insurance<\/h2>\n<p>Psychotherapist is not an in-network provider for any insurance plans, including Medi-Cal or Medicare. However, Psychotherapist may provide services through third-party, insurance-affiliated platforms that allow clients to use insurance benefits.<\/p>\n<p>If I choose to use insurance to pay for services, I understand that insurance coverage is a contract between myself and my insurance carrier, not between the insurance carrier and Psychotherapist. I understand that insurance coverage does not guarantee reimbursement for services rendered.<\/p>\n<p>I understand and agree that I am fully financially responsible for all fees associated with therapy sessions if my insurance company denies coverage, delays payment, determines services are not medically necessary, or otherwise does not reimburse Psychotherapist for any reason.<\/p>\n<p>When working through insurance-affiliated platforms, I agree to follow the billing, payment, and cancellation policies established by those platforms.<\/p>\n<hr>\n<h2>Session Frequency<\/h2>\n<p>If I choose to use insurance benefits to pay for services, I agree to commit to attending weekly appointments.<\/p>\n<p>If I prefer more flexibility in scheduling frequency, I understand that I may do so under the private pay system.<\/p>\n<hr>\n<h2>Payments<\/h2>\n<p>The following applies only when I work directly with Psychotherapist and do not use insurance-affiliated platforms.<\/p>\n<ul>\n<li>The fee for telehealth psychotherapy is $175 per 50-minute session, unless otherwise negotiated.<\/li>\n<li>I understand that payment must be made online through the payment form on&nbsp;<a data-saferedirecturl=\"https:\/\/www.google.com\/url?q=http:\/\/www.mtmft.com&amp;source=gmail&amp;ust=1767627144088000&amp;usg=AOvVaw1gMsgsl4nyxgaXC63CH50S\" rel=\"noopener\" target=\"_blank\" href=\"http:\/\/www.mtmft.com\/\">www.mtmft.com<\/a>&nbsp;at least 24 hours prior to the scheduled session.<\/li>\n<li>A session is considered confirmed only after payment has been received.<\/li>\n<li>Payments are securely processed via Stripe (all major credit cards accepted).<\/li>\n<li>Session fees are subject to annual adjustment based on current market conditions. I understand that I will be notified in advance of any fee changes.<\/li>\n<\/ul>\n<hr>\n<h2>Canceling a Session<\/h2>\n<p>The following applies only when I work directly with Psychotherapist and do not use insurance-affiliated platforms:<\/p>\n<ul>\n<li>A minimum of 24-hour notice is required to reschedule or cancel a session.<\/li>\n<li>Sessions canceled with at least 24 hours' notice will have the prepaid amount credited toward a future session.<\/li>\n<li>Failure to provide timely notice will be considered a no-show, and the session fee will be forfeited.<\/li>\n<\/ul>\n<hr>\n<h2>Termination of Telehealth Services<\/h2>\n<p>I may terminate therapy at any time and for any reason.<\/p>\n<p>Psychotherapist may terminate services for reasons including, but not limited to: lack of therapeutic benefit, scope-of-practice limitations, non-payment, threats or abusive behavior, completion of therapy goals, or circumstances in which continued treatment is inappropriate, contraindicated, or unnecessary.<\/p>\n<p>If services are terminated by Psychotherapist, appropriate referrals will be provided when clinically indicated. If services are terminated by me, Psychotherapist is not obligated to provide referrals.<\/p>\n<hr>\n<h2>Risks and Benefits of Psychotherapy<\/h2>\n<p>I understand that psychotherapy:<\/p>\n<ul>\n<li>Does not guarantee favorable outcomes<\/li>\n<li>Can be unpredictable, with goals and focus evolving over time<\/li>\n<li>May involve emotional discomfort or temporary worsening of symptoms<\/li>\n<li>Has no predefined timeline for resolution<\/li>\n<li>Does not operate with the same predictability as other medical fields<\/li>\n<\/ul>\n<p>Accordingly, no specific results can be guaranteed.<\/p>\n<hr>\n<h2>Scope of Competence &amp; Limitations<\/h2>\n<p>I understand that Psychotherapist has training and experience in the assessment and treatment of conditions including depression, anxiety, stress, relational difficulties, life transitions, self-esteem issues, and symptoms of complex trauma (C-PTSD), among others.<\/p>\n<p>I understand that Psychotherapist does not provide evaluations, reports, or documentation for legal proceedings, disability or workers' compensation claims, custody matters, employer accommodations, or Emotional Support Animal letters.<\/p>\n<hr>\n<h2>Involvement in Legal Proceedings<\/h2>\n<p>If I choose to involve Psychotherapist in any legal process, I agree to compensate Psychotherapist at a rate of $300 per hour for all time spent, including but not limited to testimony, record review, report writing, travel, and attorney communication.<\/p>\n<\/div>\n<\/div><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"address-1\" class=\"forminator-field-address forminator-col forminator-col-12 \"><div class=\"forminator-row\"><div id=\"address-1-street_address\" class=\"forminator-col\"><div class=\"forminator-field\"><label for=\"forminator-field-address-1-street_address_6a13413f30d9b\" id=\"forminator-field-address-1-street_address_6a13413f30d9b-label\" class=\"forminator-label\">Street Address <span class=\"forminator-required\">*<\/span><\/label><input type=\"text\" name=\"address-1-street_address\" placeholder=\"E.g. 42 Wallaby Way\" id=\"forminator-field-address-1-street_address_6a13413f30d9b\" class=\"forminator-input\" data-required=\"1\" aria-required=\"true\" autocomplete=\"address-line1\" value=\"\" \/><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"address-1-address_line\" class=\"forminator-col\"><div class=\"forminator-field\"><label for=\"forminator-field-address-1-address_line_6a13413f30d9b\" id=\"forminator-field-address-1-address_line_6a13413f30d9b-label\" class=\"forminator-label\">Apartment, suite, etc<\/label><input type=\"text\" name=\"address-1-address_line\" placeholder=\"\" id=\"forminator-field-address-1-address_line_6a13413f30d9b\" class=\"forminator-input\" data-required=\"\" aria-required=\"false\" autocomplete=\"address-line2\" value=\"\" \/><\/div><\/div><\/div><div class=\"forminator-row\" data-multiple=\"true\"><div id=\"address-1-city\" class=\"forminator-col forminator-col-6\"><div class=\"forminator-field\"><label for=\"forminator-field-address-1-city_6a13413f30d9b\" id=\"forminator-field-address-1-city_6a13413f30d9b-label\" class=\"forminator-label\">City <span class=\"forminator-required\">*<\/span><\/label><input type=\"text\" name=\"address-1-city\" placeholder=\"E.g. Sydney\" id=\"forminator-field-address-1-city_6a13413f30d9b\" class=\"forminator-input\" data-required=\"1\" aria-required=\"true\" autocomplete=\"address-level2\" value=\"\" \/><\/div><\/div><div id=\"address-1-state\" class=\"forminator-col forminator-col-6\"><div class=\"forminator-field\"><label for=\"forminator-field-address-1-state_6a13413f30d9b\" id=\"forminator-field-address-1-state_6a13413f30d9b-label\" class=\"forminator-label\">State\/Province <span class=\"forminator-required\">*<\/span><\/label><input type=\"text\" name=\"address-1-state\" placeholder=\"E.g. New South Wales\" id=\"forminator-field-address-1-state_6a13413f30d9b\" class=\"forminator-input\" data-required=\"1\" aria-required=\"true\" autocomplete=\"address-level1\" value=\"\" \/><\/div><\/div><\/div><div class=\"forminator-row\" data-multiple=\"true\"><div id=\"address-1-zip\" class=\"forminator-col forminator-col-6\"><div class=\"forminator-field\"><label for=\"forminator-field-address-1-zip_6a13413f30d9b\" id=\"forminator-field-address-1-zip_6a13413f30d9b-label\" class=\"forminator-label\">ZIP \/ Postal Code <span class=\"forminator-required\">*<\/span><\/label><input type=\"text\" name=\"address-1-zip\" placeholder=\"E.g. 2000\" id=\"forminator-field-address-1-zip_6a13413f30d9b\" class=\"forminator-input\" autocomplete=\"postal-code\" value=\"\" \/><\/div><\/div><div id=\"address-1-country\" class=\"forminator-col forminator-col-6\"><div class=\"forminator-field\"><label for=\"forminator-field-1088__field--address-1-country_6a13413f30d9b\" id=\"forminator-field-1088__field--address-1-country_6a13413f30d9b-label\" class=\"forminator-label\">Country<\/label><select name=\"address-1-country\" id=\"forminator-field-1088__field--address-1-country_6a13413f30d9b\" class=\"forminator-select2\" data-search=\"true\" data-placeholder=\"Select country\" autocomplete=\"country-name country\" data-default-value=\"United States of America (USA)\"><option value=\"\" data-country-code=\"\" selected=\"selected\"><\/option><option value=\"Afghanistan\" data-country-code=\"AF\" >Afghanistan<\/option><option value=\"Albania\" data-country-code=\"AL\" >Albania<\/option><option value=\"Algeria\" data-country-code=\"DZ\" >Algeria<\/option><option value=\"American Samoa\" data-country-code=\"AS\" >American Samoa<\/option><option value=\"Andorra\" data-country-code=\"AD\" >Andorra<\/option><option value=\"Angola\" data-country-code=\"AO\" >Angola<\/option><option value=\"Anguilla\" data-country-code=\"AI\" >Anguilla<\/option><option value=\"Antarctica\" data-country-code=\"AQ\" >Antarctica<\/option><option value=\"Antigua and Barbuda\" data-country-code=\"AG\" >Antigua and Barbuda<\/option><option value=\"Argentina\" data-country-code=\"AR\" >Argentina<\/option><option value=\"Armenia\" data-country-code=\"AM\" >Armenia<\/option><option value=\"Aruba\" data-country-code=\"AW\" >Aruba<\/option><option value=\"Australia\" data-country-code=\"AU\" >Australia<\/option><option value=\"Austria\" data-country-code=\"AT\" >Austria<\/option><option value=\"Azerbaijan\" data-country-code=\"AZ\" >Azerbaijan<\/option><option value=\"Bahamas\" data-country-code=\"BS\" >Bahamas<\/option><option value=\"Bahrain\" data-country-code=\"BH\" >Bahrain<\/option><option value=\"Bangladesh\" data-country-code=\"BD\" >Bangladesh<\/option><option value=\"Barbados\" data-country-code=\"BB\" >Barbados<\/option><option value=\"Belarus\" data-country-code=\"BY\" >Belarus<\/option><option value=\"Belgium\" data-country-code=\"BE\" >Belgium<\/option><option value=\"Belize\" data-country-code=\"BZ\" >Belize<\/option><option value=\"Benin\" data-country-code=\"BJ\" >Benin<\/option><option value=\"Bermuda\" data-country-code=\"BM\" >Bermuda<\/option><option value=\"Bhutan\" data-country-code=\"BT\" >Bhutan<\/option><option value=\"Bolivia\" data-country-code=\"BO\" >Bolivia<\/option><option value=\"Bosnia and Herzegovina\" data-country-code=\"BA\" >Bosnia and Herzegovina<\/option><option value=\"Botswana\" data-country-code=\"BW\" >Botswana<\/option><option value=\"Bouvet Island\" data-country-code=\"BV\" >Bouvet Island<\/option><option value=\"Brazil\" data-country-code=\"BR\" >Brazil<\/option><option value=\"British Indian Ocean Territory\" data-country-code=\"IO\" >British Indian Ocean Territory<\/option><option value=\"Brunei\" data-country-code=\"BN\" >Brunei<\/option><option value=\"Bulgaria\" data-country-code=\"BG\" >Bulgaria<\/option><option value=\"Burkina Faso\" data-country-code=\"BF\" >Burkina Faso<\/option><option value=\"Burundi\" data-country-code=\"BI\" >Burundi<\/option><option value=\"Cabo Verde\" data-country-code=\"CV\" >Cabo Verde<\/option><option value=\"Cambodia\" data-country-code=\"KH\" >Cambodia<\/option><option value=\"Cameroon\" data-country-code=\"CM\" >Cameroon<\/option><option value=\"Canada\" data-country-code=\"CA\" >Canada<\/option><option value=\"Cayman Islands\" data-country-code=\"KY\" >Cayman Islands<\/option><option value=\"Central African Republic\" data-country-code=\"CF\" >Central African Republic<\/option><option value=\"Chad\" data-country-code=\"TD\" >Chad<\/option><option value=\"Chile\" data-country-code=\"CL\" >Chile<\/option><option value=\"China, People's Republic of\" data-country-code=\"CN\" >China, People's Republic of<\/option><option value=\"Christmas Island\" data-country-code=\"CX\" >Christmas Island<\/option><option value=\"Cocos Islands\" data-country-code=\"CC\" >Cocos Islands<\/option><option value=\"Colombia\" data-country-code=\"CO\" >Colombia<\/option><option value=\"Comoros\" data-country-code=\"KM\" >Comoros<\/option><option value=\"Congo, Democratic Republic of the\" data-country-code=\"CD\" >Congo, Democratic Republic of the<\/option><option value=\"Congo, Republic of the\" data-country-code=\"CG\" >Congo, Republic of the<\/option><option value=\"Cook Islands\" data-country-code=\"CK\" >Cook Islands<\/option><option value=\"Costa Rica\" data-country-code=\"CR\" >Costa Rica<\/option><option value=\"Croatia\" data-country-code=\"HR\" >Croatia<\/option><option value=\"Cuba\" data-country-code=\"CU\" >Cuba<\/option><option value=\"Cura\u00e7ao\" data-country-code=\"CW\" >Cura\u00e7ao<\/option><option value=\"Cyprus\" data-country-code=\"CY\" >Cyprus<\/option><option value=\"Czech Republic\" data-country-code=\"CZ\" >Czech Republic<\/option><option value=\"C\u00f4te d'Ivoire\" data-country-code=\"CI\" >C\u00f4te d'Ivoire<\/option><option value=\"Denmark\" data-country-code=\"DK\" >Denmark<\/option><option value=\"Djibouti\" data-country-code=\"DJ\" >Djibouti<\/option><option value=\"Dominica\" data-country-code=\"DM\" >Dominica<\/option><option value=\"Dominican Republic\" data-country-code=\"DO\" >Dominican Republic<\/option><option value=\"East Timor\" data-country-code=\"TL\" >East Timor<\/option><option value=\"Ecuador\" data-country-code=\"EC\" >Ecuador<\/option><option value=\"Egypt\" data-country-code=\"EG\" >Egypt<\/option><option value=\"El Salvador\" data-country-code=\"SV\" >El Salvador<\/option><option value=\"Equatorial Guinea\" data-country-code=\"GQ\" >Equatorial Guinea<\/option><option value=\"Eritrea\" data-country-code=\"ER\" >Eritrea<\/option><option value=\"Estonia\" data-country-code=\"EE\" >Estonia<\/option><option value=\"Ethiopia\" data-country-code=\"ET\" >Ethiopia<\/option><option value=\"Falkland Islands\" data-country-code=\"FK\" >Falkland Islands<\/option><option value=\"Faroe Islands\" data-country-code=\"FO\" >Faroe Islands<\/option><option value=\"Fiji\" data-country-code=\"FJ\" >Fiji<\/option><option value=\"Finland\" data-country-code=\"FI\" >Finland<\/option><option value=\"France\" data-country-code=\"FR\" >France<\/option><option value=\"France, Metropolitan\" data-country-code=\"FX\" >France, Metropolitan<\/option><option value=\"French Guiana\" data-country-code=\"GF\" >French Guiana<\/option><option value=\"French Polynesia\" data-country-code=\"PF\" >French Polynesia<\/option><option value=\"French South Territories\" data-country-code=\"TF\" >French South Territories<\/option><option value=\"Gabon\" data-country-code=\"GA\" >Gabon<\/option><option value=\"Gambia\" data-country-code=\"GM\" >Gambia<\/option><option value=\"Georgia\" data-country-code=\"GE\" >Georgia<\/option><option value=\"Germany\" data-country-code=\"DE\" >Germany<\/option><option value=\"Ghana\" data-country-code=\"GH\" >Ghana<\/option><option value=\"Gibraltar\" data-country-code=\"GI\" >Gibraltar<\/option><option value=\"Greece\" data-country-code=\"GR\" >Greece<\/option><option value=\"Greenland\" data-country-code=\"GL\" >Greenland<\/option><option value=\"Grenada\" data-country-code=\"GD\" >Grenada<\/option><option value=\"Guadeloupe\" data-country-code=\"GP\" >Guadeloupe<\/option><option value=\"Guam\" data-country-code=\"GU\" >Guam<\/option><option value=\"Guatemala\" data-country-code=\"GT\" >Guatemala<\/option><option value=\"Guernsey\" data-country-code=\"GG\" >Guernsey<\/option><option value=\"Guinea\" data-country-code=\"GN\" >Guinea<\/option><option value=\"Guinea-Bissau\" data-country-code=\"GW\" >Guinea-Bissau<\/option><option value=\"Guyana\" data-country-code=\"GY\" >Guyana<\/option><option value=\"Haiti\" data-country-code=\"HT\" >Haiti<\/option><option value=\"Heard Island And Mcdonald Island\" data-country-code=\"HM\" >Heard Island And Mcdonald Island<\/option><option value=\"Honduras\" data-country-code=\"HN\" >Honduras<\/option><option value=\"Hong Kong\" data-country-code=\"HK\" >Hong Kong<\/option><option value=\"Hungary\" data-country-code=\"HU\" >Hungary<\/option><option value=\"Iceland\" data-country-code=\"IS\" >Iceland<\/option><option value=\"India\" data-country-code=\"IN\" >India<\/option><option value=\"Indonesia\" data-country-code=\"ID\" >Indonesia<\/option><option value=\"Iran\" data-country-code=\"IR\" >Iran<\/option><option value=\"Iraq\" data-country-code=\"IQ\" >Iraq<\/option><option value=\"Ireland\" data-country-code=\"IE\" >Ireland<\/option><option value=\"Israel\" data-country-code=\"IL\" >Israel<\/option><option value=\"Italy\" data-country-code=\"IT\" >Italy<\/option><option value=\"Jamaica\" data-country-code=\"JM\" >Jamaica<\/option><option value=\"Japan\" data-country-code=\"JP\" >Japan<\/option><option value=\"Jersey\" data-country-code=\"JE\" >Jersey<\/option><option value=\"Johnston Island\" data-country-code=\"JT\" >Johnston Island<\/option><option value=\"Jordan\" data-country-code=\"JO\" >Jordan<\/option><option value=\"Kazakhstan\" data-country-code=\"KZ\" >Kazakhstan<\/option><option value=\"Kenya\" data-country-code=\"KE\" >Kenya<\/option><option value=\"Kiribati\" data-country-code=\"KI\" >Kiribati<\/option><option value=\"Korea, Democratic People's Republic of\" data-country-code=\"KP\" >Korea, Democratic People's Republic of<\/option><option value=\"Korea, Republic of\" data-country-code=\"KR\" >Korea, Republic of<\/option><option value=\"Kosovo\" data-country-code=\"XK\" >Kosovo<\/option><option value=\"Kuwait\" data-country-code=\"KW\" >Kuwait<\/option><option value=\"Kyrgyzstan\" data-country-code=\"KG\" >Kyrgyzstan<\/option><option value=\"Lao People's Democratic Republic\" data-country-code=\"LA\" >Lao People's Democratic Republic<\/option><option value=\"Latvia\" data-country-code=\"LV\" >Latvia<\/option><option value=\"Lebanon\" data-country-code=\"LB\" >Lebanon<\/option><option value=\"Lesotho\" data-country-code=\"LS\" >Lesotho<\/option><option value=\"Liberia\" data-country-code=\"LR\" >Liberia<\/option><option value=\"Libya\" data-country-code=\"LY\" >Libya<\/option><option value=\"Liechtenstein\" data-country-code=\"LI\" >Liechtenstein<\/option><option value=\"Lithuania\" data-country-code=\"LT\" >Lithuania<\/option><option value=\"Luxembourg\" data-country-code=\"LU\" >Luxembourg<\/option><option value=\"Macau\" data-country-code=\"MO\" >Macau<\/option><option value=\"Madagascar\" data-country-code=\"MG\" >Madagascar<\/option><option value=\"Malawi\" data-country-code=\"MW\" >Malawi<\/option><option value=\"Malaysia\" data-country-code=\"MY\" >Malaysia<\/option><option value=\"Maldives\" data-country-code=\"MV\" >Maldives<\/option><option value=\"Mali\" data-country-code=\"ML\" >Mali<\/option><option value=\"Malta\" data-country-code=\"MT\" >Malta<\/option><option value=\"Marshall Islands\" data-country-code=\"MH\" >Marshall Islands<\/option><option value=\"Martinique\" data-country-code=\"MQ\" >Martinique<\/option><option value=\"Mauritania\" data-country-code=\"MR\" >Mauritania<\/option><option value=\"Mauritius\" data-country-code=\"MU\" >Mauritius<\/option><option value=\"Mayotte\" data-country-code=\"YT\" >Mayotte<\/option><option value=\"Mexico\" data-country-code=\"MX\" >Mexico<\/option><option value=\"Micronesia\" data-country-code=\"FM\" >Micronesia<\/option><option value=\"Moldova\" data-country-code=\"MD\" >Moldova<\/option><option value=\"Monaco\" data-country-code=\"MC\" >Monaco<\/option><option value=\"Mongolia\" data-country-code=\"MN\" >Mongolia<\/option><option value=\"Montenegro\" data-country-code=\"ME\" >Montenegro<\/option><option value=\"Montserrat\" data-country-code=\"MS\" >Montserrat<\/option><option value=\"Morocco\" data-country-code=\"MA\" >Morocco<\/option><option value=\"Mozambique\" data-country-code=\"MZ\" >Mozambique<\/option><option value=\"Myanmar\" data-country-code=\"MM\" >Myanmar<\/option><option value=\"Namibia\" data-country-code=\"NA\" >Namibia<\/option><option value=\"Nauru\" data-country-code=\"NR\" >Nauru<\/option><option value=\"Nepal\" data-country-code=\"NP\" >Nepal<\/option><option value=\"Netherlands\" data-country-code=\"NL\" >Netherlands<\/option><option value=\"Netherlands Antilles\" data-country-code=\"AN\" >Netherlands Antilles<\/option><option value=\"New Caledonia\" data-country-code=\"NC\" >New Caledonia<\/option><option value=\"New Zealand\" data-country-code=\"NZ\" >New Zealand<\/option><option value=\"Nicaragua\" data-country-code=\"NI\" >Nicaragua<\/option><option value=\"Niger\" data-country-code=\"NE\" >Niger<\/option><option value=\"Nigeria\" data-country-code=\"NG\" >Nigeria<\/option><option value=\"Niue\" data-country-code=\"NU\" >Niue<\/option><option value=\"Norfolk Island\" data-country-code=\"NF\" >Norfolk Island<\/option><option value=\"North Macedonia\" data-country-code=\"MK\" >North Macedonia<\/option><option value=\"Northern Mariana Islands\" data-country-code=\"MP\" >Northern Mariana Islands<\/option><option value=\"Norway\" data-country-code=\"NO\" >Norway<\/option><option value=\"Oman\" data-country-code=\"OM\" >Oman<\/option><option value=\"Pakistan\" data-country-code=\"PK\" >Pakistan<\/option><option value=\"Palau\" data-country-code=\"PW\" >Palau<\/option><option value=\"Palestine, State of\" data-country-code=\"PS\" >Palestine, State of<\/option><option value=\"Panama\" data-country-code=\"PA\" >Panama<\/option><option value=\"Papua New Guinea\" data-country-code=\"PG\" >Papua New Guinea<\/option><option value=\"Paraguay\" data-country-code=\"PY\" >Paraguay<\/option><option value=\"Peru\" data-country-code=\"PE\" >Peru<\/option><option value=\"Philippines\" data-country-code=\"PH\" >Philippines<\/option><option value=\"Pitcairn Islands\" data-country-code=\"PN\" >Pitcairn Islands<\/option><option value=\"Poland\" data-country-code=\"PL\" >Poland<\/option><option value=\"Portugal\" data-country-code=\"PT\" >Portugal<\/option><option value=\"Puerto Rico\" data-country-code=\"PR\" >Puerto Rico<\/option><option value=\"Qatar\" data-country-code=\"QA\" >Qatar<\/option><option value=\"Reunion Island\" data-country-code=\"RE\" >Reunion Island<\/option><option value=\"Romania\" data-country-code=\"RO\" >Romania<\/option><option value=\"Russia\" data-country-code=\"RU\" >Russia<\/option><option value=\"Rwanda\" data-country-code=\"RW\" >Rwanda<\/option><option value=\"Saint Helena\" data-country-code=\"SH\" >Saint Helena<\/option><option value=\"Saint Kitts and Nevis\" data-country-code=\"KN\" >Saint Kitts and Nevis<\/option><option value=\"Saint Lucia\" data-country-code=\"LC\" >Saint Lucia<\/option><option value=\"Saint Pierre & Miquelon\" data-country-code=\"PM\" >Saint Pierre & Miquelon<\/option><option value=\"Saint Vincent and the Grenadines\" data-country-code=\"VC\" >Saint Vincent and the Grenadines<\/option><option value=\"Samoa\" data-country-code=\"WS\" >Samoa<\/option><option value=\"San Marino\" data-country-code=\"SM\" >San Marino<\/option><option value=\"Sao Tome and Principe\" data-country-code=\"ST\" >Sao Tome and Principe<\/option><option value=\"Saudi Arabia\" data-country-code=\"SA\" >Saudi Arabia<\/option><option value=\"Senegal\" data-country-code=\"SN\" >Senegal<\/option><option value=\"Serbia\" data-country-code=\"RS\" >Serbia<\/option><option value=\"Seychelles\" data-country-code=\"SC\" >Seychelles<\/option><option value=\"Sierra Leone\" data-country-code=\"SL\" >Sierra Leone<\/option><option value=\"Singapore\" data-country-code=\"SG\" >Singapore<\/option><option value=\"Sint Maarten\" data-country-code=\"MF\" >Sint Maarten<\/option><option value=\"Slovakia\" data-country-code=\"SK\" >Slovakia<\/option><option value=\"Slovenia\" data-country-code=\"SI\" >Slovenia<\/option><option value=\"Solomon Islands\" data-country-code=\"SB\" >Solomon Islands<\/option><option value=\"Somalia\" data-country-code=\"SO\" >Somalia<\/option><option value=\"South Africa\" data-country-code=\"ZA\" >South Africa<\/option><option value=\"South Georgia and South Sandwich\" data-country-code=\"GS\" >South Georgia and South Sandwich<\/option><option value=\"Spain\" data-country-code=\"ES\" >Spain<\/option><option value=\"Sri Lanka\" data-country-code=\"LK\" >Sri Lanka<\/option><option value=\"Stateless Persons\" data-country-code=\"XX\" >Stateless Persons<\/option><option value=\"Sudan\" data-country-code=\"SD\" >Sudan<\/option><option value=\"Sudan, South\" data-country-code=\"SS\" >Sudan, South<\/option><option value=\"Suriname\" data-country-code=\"SR\" >Suriname<\/option><option value=\"Svalbard and Jan Mayen\" data-country-code=\"SJ\" >Svalbard and Jan Mayen<\/option><option value=\"Swaziland\" data-country-code=\"SZ\" >Swaziland<\/option><option value=\"Sweden\" data-country-code=\"SE\" >Sweden<\/option><option value=\"Switzerland\" data-country-code=\"CH\" >Switzerland<\/option><option value=\"Syria\" data-country-code=\"SY\" >Syria<\/option><option value=\"Taiwan, Republic of China\" data-country-code=\"TW\" >Taiwan, Republic of China<\/option><option value=\"Tajikistan\" data-country-code=\"TJ\" >Tajikistan<\/option><option value=\"Tanzania\" data-country-code=\"TZ\" >Tanzania<\/option><option value=\"Thailand\" data-country-code=\"TH\" >Thailand<\/option><option value=\"Togo\" data-country-code=\"TG\" >Togo<\/option><option value=\"Tokelau\" data-country-code=\"TK\" >Tokelau<\/option><option value=\"Tonga\" data-country-code=\"TO\" >Tonga<\/option><option value=\"Trinidad and Tobago\" data-country-code=\"TT\" >Trinidad and Tobago<\/option><option value=\"Tunisia\" data-country-code=\"TN\" >Tunisia<\/option><option value=\"Turkey\" data-country-code=\"TR\" >Turkey<\/option><option value=\"Turkmenistan\" data-country-code=\"TM\" >Turkmenistan<\/option><option value=\"Turks And Caicos Islands\" data-country-code=\"TC\" >Turks And Caicos Islands<\/option><option value=\"Tuvalu\" data-country-code=\"TV\" >Tuvalu<\/option><option value=\"US Minor Outlying Islands\" data-country-code=\"UM\" >US Minor Outlying Islands<\/option><option value=\"Uganda\" data-country-code=\"UG\" >Uganda<\/option><option value=\"Ukraine\" data-country-code=\"UA\" >Ukraine<\/option><option value=\"United Arab Emirates\" data-country-code=\"AE\" >United Arab Emirates<\/option><option value=\"United Kingdom\" data-country-code=\"GB\" >United Kingdom<\/option><option value=\"United States of America (USA)\" data-country-code=\"US\" selected=\"selected\">United States of America (USA)<\/option><option value=\"Uruguay\" data-country-code=\"UY\" >Uruguay<\/option><option value=\"Uzbekistan\" data-country-code=\"UZ\" >Uzbekistan<\/option><option value=\"Vanuatu\" data-country-code=\"VU\" >Vanuatu<\/option><option value=\"Vatican City\" data-country-code=\"VA\" >Vatican City<\/option><option value=\"Venezuela\" data-country-code=\"VE\" >Venezuela<\/option><option value=\"Vietnam\" data-country-code=\"VN\" >Vietnam<\/option><option value=\"Virgin Islands, British\" data-country-code=\"VG\" >Virgin Islands, British<\/option><option value=\"Virgin Islands, U.S.\" data-country-code=\"VI\" >Virgin Islands, U.S.<\/option><option value=\"Wallis And Futuna Islands\" data-country-code=\"WF\" >Wallis And Futuna Islands<\/option><option value=\"Western Sahara\" data-country-code=\"EH\" >Western Sahara<\/option><option value=\"Yemen\" data-country-code=\"YE\" >Yemen<\/option><option value=\"Zambia\" data-country-code=\"ZM\" >Zambia<\/option><option value=\"Zimbabwe\" data-country-code=\"ZW\" >Zimbabwe<\/option><\/select><\/div><\/div><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"name-1\" class=\"forminator-field-name forminator-col forminator-col-6 \"><div class=\"forminator-field\"><label for=\"forminator-field-name-1_6a13413f30d9b\" id=\"forminator-field-name-1_6a13413f30d9b-label\" class=\"forminator-label\">First Name <span class=\"forminator-required\">*<\/span><\/label><input type=\"text\" name=\"name-1\" value=\"\" placeholder=\"E.g. John\" id=\"forminator-field-name-1_6a13413f30d9b\" class=\"forminator-input forminator-name--field\" aria-required=\"true\" autocomplete=\"name\" \/><\/div><\/div><div id=\"name-2\" class=\"forminator-field-name forminator-col forminator-col-6 \"><div class=\"forminator-field\"><label for=\"forminator-field-name-2_6a13413f30d9b\" id=\"forminator-field-name-2_6a13413f30d9b-label\" class=\"forminator-label\">Last Name <span class=\"forminator-required\">*<\/span><\/label><input type=\"text\" name=\"name-2\" value=\"\" placeholder=\"E.g. 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value=\"forminator_submit_form_custom-forms\"><\/form>\n","protected":false},"excerpt":{"rendered":"","protected":false},"author":1,"featured_media":0,"parent":901,"menu_order":7,"comment_status":"closed","ping_status":"closed","template":"","meta":{"footnotes":""},"class_list":["post-794","page","type-page","status-publish","hentry"],"_links":{"self":[{"href":"https:\/\/tonkonogy.com\/marina\/wp-json\/wp\/v2\/pages\/794","targetHints":{"allow":["GET"]}}],"collection":[{"href":"https:\/\/tonkonogy.com\/marina\/wp-json\/wp\/v2\/pages"}],"about":[{"href":"https:\/\/tonkonogy.com\/marina\/wp-json\/wp\/v2\/types\/page"}],"author":[{"embeddable":true,"href":"https:\/\/tonkonogy.com\/marina\/wp-json\/wp\/v2\/users\/1"}],"replies":[{"embeddable":true,"href":"https:\/\/tonkonogy.com\/marina\/wp-json\/wp\/v2\/comments?post=794"}],"version-history":[{"count":5,"href":"https:\/\/tonkonogy.com\/marina\/wp-json\/wp\/v2\/pages\/794\/revisions"}],"predecessor-version":[{"id":1453,"href":"https:\/\/tonkonogy.com\/marina\/wp-json\/wp\/v2\/pages\/794\/revisions\/1453"}],"up":[{"embeddable":true,"href":"https:\/\/tonkonogy.com\/marina\/wp-json\/wp\/v2\/pages\/901"}],"wp:attachment":[{"href":"https:\/\/tonkonogy.com\/marina\/wp-json\/wp\/v2\/media?parent=794"}],"curies":[{"name":"wp","href":"https:\/\/api.w.org\/{rel}","templated":true}]}}