Sample Form using CSS and PHP

By placing a “checkmark” in the boxes below, I agree that:
I have read the above informed consent and agree to all stipulations, terms, and guidelines.
I am 18 years of age or older.
Please check service:	Live Chat		Email Counseling
Please type in the following information:
Name
Address Line 1
Address Line 2
City
State		Zip
Phone
Email Address
The following are the names and license information of the therapists with whom you may choose to work:
Psychologist A
Psychologist B
Psychologist C
Psychologist D
No Preference
Name		Date

How did you hear about us?