				<!-- Dashboard Panel -->
				<div class="dashboard-panel">
					<form action="#" method="post" name="chekout" class="comment-form dark-fields">
						<div class="row">
							<div class="col-sm-6 ">
								<div class="input-group ">
									<label>Category:</label>
									<div class="dark-picker dark-picker-bright">
										<select class="select-picker ">
											<option selected="" disabled="" value="">Select Category</option>
											<option value="AL1">Mediation1</option>
											<option value="AL2">Mediation2</option>
											<option value="AL3">Mediation3</option>
											<option value="AL4">Mediation4</option>
										</select>
									</div>
								</div>
							</div>
						</div>
						<div class="row">
							<div class="col-sm-12">
								<div class="input-group ">
									<label>Please Enter a message below to save responses</label>
									<textarea rows="6"></textarea>
									<div class="textarea-tag">Hint: Provide as much information as you can. <span>2000 characters remaining</span></div>
								</div>
								<button class="btn-link-dark dash-btn" name="Submit" type="Submit">SAVE RESPONSES</button>
							</div>
						</div>
					</form>

				</div>