Cannot submit form getting form error

Getting the following error when I try to submit the form:

https://cdn.livechat-static.com/api/file/v2/lc/att-old/8801096/d5d2571e67bbe71b83c6cbd7e3e9a0e1/Screen%20Shot%202019-02-23%20at%2011.03.28%20PM.png

Please advise what needs to be done to correct this.