{"id":1421,"date":"2020-03-26T09:36:13","date_gmt":"2020-03-26T14:36:13","guid":{"rendered":"https:\/\/www.zvhc.org\/?page_id=1421"},"modified":"2020-03-26T09:37:51","modified_gmt":"2020-03-26T14:37:51","slug":"adult-evaluation-form","status":"publish","type":"page","link":"https:\/\/www.zvhc.org\/adult-evaluation-form\/","title":{"rendered":"Adult Evaluation Form"},"content":{"rendered":"\n\t<script type=\"text\/javascript\">var gform;gform||(document.addEventListener(\"gform_main_scripts_loaded\",function(){gform.scriptsLoaded=!0}),window.addEventListener(\"DOMContentLoaded\",function(){gform.domLoaded=!0}),gform={domLoaded:!1,scriptsLoaded:!1,initializeOnLoaded:function(o){gform.domLoaded&&gform.scriptsLoaded?o():!gform.domLoaded&&gform.scriptsLoaded?window.addEventListener(\"DOMContentLoaded\",o):document.addEventListener(\"gform_main_scripts_loaded\",o)},hooks:{action:{},filter:{}},addAction:function(o,n,r,t){gform.addHook(\"action\",o,n,r,t)},addFilter:function(o,n,r,t){gform.addHook(\"filter\",o,n,r,t)},doAction:function(o){gform.doHook(\"action\",o,arguments)},applyFilters:function(o){return gform.doHook(\"filter\",o,arguments)},removeAction:function(o,n){gform.removeHook(\"action\",o,n)},removeFilter:function(o,n,r){gform.removeHook(\"filter\",o,n,r)},addHook:function(o,n,r,t,i){null==gform.hooks[o][n]&&(gform.hooks[o][n]=[]);var e=gform.hooks[o][n];null==i&&(i=n+\"_\"+e.length),gform.hooks[o][n].push({tag:i,callable:r,priority:t=null==t?10:t})},doHook:function(n,o,r){var t;if(r=Array.prototype.slice.call(r,1),null!=gform.hooks[n][o]&&((o=gform.hooks[n][o]).sort(function(o,n){return o.priority-n.priority}),o.forEach(function(o){\"function\"!=typeof(t=o.callable)&&(t=window[t]),\"action\"==n?t.apply(null,r):r[0]=t.apply(null,r)})),\"filter\"==n)return r[0]},removeHook:function(o,n,t,i){var r;null!=gform.hooks[o][n]&&(r=(r=gform.hooks[o][n]).filter(function(o,n,r){return!!(null!=i&&i!=o.tag||null!=t&&t!=o.priority)}),gform.hooks[o][n]=r)}});<\/script>\n                <div class='gf_browser_safari gform_wrapper gform_legacy_markup_wrapper gform-theme--no-framework' data-form-theme='legacy' data-form-index='0' id='gform_wrapper_15' style='display:none'><div id='gf_15' class='gform_anchor' tabindex='-1'><\/div><form method='post' enctype='multipart\/form-data' target='gform_ajax_frame_15' id='gform_15'  action='\/wp-json\/wp\/v2\/pages\/1421#gf_15' data-formid='15' novalidate>\n                        <div class='gform-body gform_body'><ul id='gform_fields_15' class='gform_fields top_label form_sublabel_below description_below'><li id=\"field_15_30\" class=\"gfield gfield--type-date gfield--input-type-datedropdown gfield_contains_required field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_15_30\" ><label class='gfield_label gform-field-label' >Date<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div id='input_15_30' class='ginput_container ginput_complex gform-grid-row'><div class=\"clear-multi\"><div class='gfield_date_dropdown_month ginput_container ginput_container_date gform-grid-col' id='input_15_30_1_container'><select name='input_30[]' id='input_15_30_1'   aria-required='true'  ><option value=''>Month<\/option><option value='1' >1<\/option><option value='2' >2<\/option><option value='3' >3<\/option><option value='4' >4<\/option><option value='5' >5<\/option><option value='6' >6<\/option><option value='7' >7<\/option><option value='8' >8<\/option><option value='9' >9<\/option><option value='10' >10<\/option><option value='11' >11<\/option><option value='12' >12<\/option><\/select><\/div><div class='gfield_date_dropdown_day ginput_container ginput_container_date gform-grid-col' id='input_15_30_2_container'><select name='input_30[]' id='input_15_30_2'   aria-required='true'  ><option value=''>Day<\/option><option value='1' >1<\/option><option value='2' >2<\/option><option value='3' >3<\/option><option value='4' >4<\/option><option value='5' >5<\/option><option value='6' >6<\/option><option value='7' >7<\/option><option value='8' >8<\/option><option value='9' >9<\/option><option value='10' >10<\/option><option value='11' >11<\/option><option value='12' >12<\/option><option value='13' >13<\/option><option value='14' >14<\/option><option value='15' >15<\/option><option value='16' >16<\/option><option value='17' >17<\/option><option value='18' >18<\/option><option value='19' >19<\/option><option value='20' >20<\/option><option value='21' >21<\/option><option value='22' >22<\/option><option value='23' >23<\/option><option value='24' >24<\/option><option value='25' >25<\/option><option value='26' >26<\/option><option value='27' >27<\/option><option value='28' >28<\/option><option value='29' >29<\/option><option value='30' >30<\/option><option value='31' >31<\/option><\/select><\/div><div class='gfield_date_dropdown_year ginput_container ginput_container_date gform-grid-col' id='input_15_30_3_container'><select name='input_30[]' id='input_15_30_3'   aria-required='true'  ><option value=''>Year<\/option><option value='2025' >2025<\/option><option value='2024' >2024<\/option><option value='2023' >2023<\/option><option value='2022' >2022<\/option><option value='2021' >2021<\/option><option value='2020' >2020<\/option><option value='2019' >2019<\/option><option value='2018' >2018<\/option><option value='2017' >2017<\/option><option value='2016' >2016<\/option><option value='2015' >2015<\/option><option value='2014' >2014<\/option><option value='2013' >2013<\/option><option value='2012' >2012<\/option><option value='2011' >2011<\/option><option value='2010' >2010<\/option><option value='2009' >2009<\/option><option value='2008' >2008<\/option><option value='2007' >2007<\/option><option value='2006' >2006<\/option><option value='2005' >2005<\/option><option value='2004' >2004<\/option><option value='2003' >2003<\/option><option value='2002' >2002<\/option><option value='2001' >2001<\/option><option value='2000' >2000<\/option><option value='1999' >1999<\/option><option value='1998' >1998<\/option><option value='1997' >1997<\/option><option value='1996' >1996<\/option><option value='1995' >1995<\/option><option value='1994' >1994<\/option><option value='1993' >1993<\/option><option value='1992' >1992<\/option><option value='1991' >1991<\/option><option value='1990' >1990<\/option><option value='1989' >1989<\/option><option value='1988' >1988<\/option><option value='1987' >1987<\/option><option value='1986' >1986<\/option><option value='1985' >1985<\/option><option value='1984' >1984<\/option><option value='1983' >1983<\/option><option value='1982' >1982<\/option><option value='1981' >1981<\/option><option value='1980' >1980<\/option><option value='1979' >1979<\/option><option value='1978' >1978<\/option><option value='1977' >1977<\/option><option value='1976' >1976<\/option><option value='1975' >1975<\/option><option value='1974' >1974<\/option><option value='1973' >1973<\/option><option value='1972' >1972<\/option><option value='1971' >1971<\/option><option value='1970' >1970<\/option><option value='1969' >1969<\/option><option value='1968' >1968<\/option><option value='1967' >1967<\/option><option value='1966' >1966<\/option><option value='1965' >1965<\/option><option value='1964' >1964<\/option><option value='1963' >1963<\/option><option value='1962' >1962<\/option><option value='1961' >1961<\/option><option value='1960' >1960<\/option><option value='1959' >1959<\/option><option value='1958' >1958<\/option><option value='1957' >1957<\/option><option value='1956' >1956<\/option><option value='1955' >1955<\/option><option value='1954' >1954<\/option><option value='1953' >1953<\/option><option value='1952' >1952<\/option><option value='1951' >1951<\/option><option value='1950' >1950<\/option><option value='1949' >1949<\/option><option value='1948' >1948<\/option><option value='1947' >1947<\/option><option value='1946' >1946<\/option><option value='1945' >1945<\/option><option value='1944' >1944<\/option><option value='1943' >1943<\/option><option value='1942' >1942<\/option><option value='1941' >1941<\/option><option value='1940' >1940<\/option><option value='1939' >1939<\/option><option value='1938' >1938<\/option><option value='1937' >1937<\/option><option value='1936' >1936<\/option><option value='1935' >1935<\/option><option value='1934' >1934<\/option><option value='1933' >1933<\/option><option value='1932' >1932<\/option><option value='1931' >1931<\/option><option value='1930' >1930<\/option><option value='1929' >1929<\/option><option value='1928' >1928<\/option><option value='1927' >1927<\/option><option value='1926' >1926<\/option><option value='1925' >1925<\/option><option value='1924' >1924<\/option><option value='1923' >1923<\/option><option value='1922' >1922<\/option><option value='1921' >1921<\/option><option value='1920' >1920<\/option><\/select><\/div><\/div><\/div><\/li><li id=\"field_15_1\" class=\"gfield gfield--type-name hipaa_forms_name gfield_contains_required field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_15_1\" ><label class='gfield_label gform-field-label gfield_label_before_complex' >Name<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_complex ginput_container ginput_container--name no_prefix has_first_name no_middle_name has_last_name no_suffix gf_name_has_2 ginput_container_name gform-grid-row' id='input_15_1'>\n                            \n                            <span id='input_15_1_3_container' class='name_first gform-grid-col gform-grid-col--size-auto' >\n                                                    <input type='text' name='input_1.3' id='input_15_1_3' value=''   aria-required='true'     \/>\n                                                    <label for='input_15_1_3' class='gform-field-label gform-field-label--type-sub '>First<\/label>\n                                                <\/span>\n                            \n                            <span id='input_15_1_6_container' class='name_last gform-grid-col gform-grid-col--size-auto' >\n                                                    <input type='text' name='input_1.6' id='input_15_1_6' value=''   aria-required='true'     \/>\n                                                    <label for='input_15_1_6' class='gform-field-label gform-field-label--type-sub '>Last<\/label>\n                                                <\/span>\n                            \n                        <\/div><\/li><li id=\"field_15_58\" class=\"gfield gfield--type-date gfield--input-type-datedropdown gfield_contains_required field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_15_58\" ><label class='gfield_label gform-field-label' >Date of Birth<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div id='input_15_58' class='ginput_container ginput_complex gform-grid-row'><div class=\"clear-multi\"><div class='gfield_date_dropdown_month ginput_container ginput_container_date gform-grid-col' id='input_15_58_1_container'><select name='input_58[]' id='input_15_58_1'   aria-required='true'  ><option value=''>Month<\/option><option value='1' >1<\/option><option value='2' >2<\/option><option value='3' >3<\/option><option value='4' >4<\/option><option value='5' >5<\/option><option value='6' >6<\/option><option value='7' >7<\/option><option value='8' >8<\/option><option value='9' >9<\/option><option value='10' >10<\/option><option value='11' >11<\/option><option value='12' >12<\/option><\/select><\/div><div class='gfield_date_dropdown_day ginput_container ginput_container_date gform-grid-col' id='input_15_58_2_container'><select name='input_58[]' id='input_15_58_2'   aria-required='true'  ><option value=''>Day<\/option><option value='1' >1<\/option><option value='2' >2<\/option><option value='3' >3<\/option><option value='4' >4<\/option><option value='5' >5<\/option><option value='6' >6<\/option><option value='7' >7<\/option><option value='8' >8<\/option><option value='9' >9<\/option><option value='10' >10<\/option><option value='11' >11<\/option><option value='12' >12<\/option><option value='13' >13<\/option><option value='14' >14<\/option><option value='15' >15<\/option><option value='16' >16<\/option><option value='17' >17<\/option><option value='18' >18<\/option><option value='19' >19<\/option><option value='20' >20<\/option><option value='21' >21<\/option><option value='22' >22<\/option><option value='23' >23<\/option><option value='24' >24<\/option><option value='25' >25<\/option><option value='26' >26<\/option><option value='27' >27<\/option><option value='28' >28<\/option><option value='29' >29<\/option><option value='30' >30<\/option><option value='31' >31<\/option><\/select><\/div><div class='gfield_date_dropdown_year ginput_container ginput_container_date gform-grid-col' id='input_15_58_3_container'><select name='input_58[]' id='input_15_58_3'   aria-required='true'  ><option value=''>Year<\/option><option value='2025' >2025<\/option><option value='2024' >2024<\/option><option value='2023' >2023<\/option><option value='2022' >2022<\/option><option value='2021' >2021<\/option><option value='2020' >2020<\/option><option value='2019' >2019<\/option><option value='2018' >2018<\/option><option value='2017' >2017<\/option><option value='2016' >2016<\/option><option value='2015' >2015<\/option><option value='2014' >2014<\/option><option value='2013' >2013<\/option><option value='2012' >2012<\/option><option value='2011' >2011<\/option><option value='2010' >2010<\/option><option value='2009' >2009<\/option><option value='2008' >2008<\/option><option value='2007' >2007<\/option><option value='2006' >2006<\/option><option value='2005' >2005<\/option><option value='2004' >2004<\/option><option value='2003' >2003<\/option><option value='2002' >2002<\/option><option value='2001' >2001<\/option><option value='2000' >2000<\/option><option value='1999' >1999<\/option><option value='1998' >1998<\/option><option value='1997' >1997<\/option><option value='1996' >1996<\/option><option value='1995' >1995<\/option><option value='1994' >1994<\/option><option value='1993' >1993<\/option><option value='1992' >1992<\/option><option value='1991' >1991<\/option><option value='1990' >1990<\/option><option value='1989' >1989<\/option><option value='1988' >1988<\/option><option value='1987' >1987<\/option><option value='1986' >1986<\/option><option value='1985' >1985<\/option><option value='1984' >1984<\/option><option value='1983' >1983<\/option><option value='1982' >1982<\/option><option value='1981' >1981<\/option><option value='1980' >1980<\/option><option value='1979' >1979<\/option><option value='1978' >1978<\/option><option value='1977' >1977<\/option><option value='1976' >1976<\/option><option value='1975' >1975<\/option><option value='1974' >1974<\/option><option value='1973' >1973<\/option><option value='1972' >1972<\/option><option value='1971' >1971<\/option><option value='1970' >1970<\/option><option value='1969' >1969<\/option><option value='1968' >1968<\/option><option value='1967' >1967<\/option><option value='1966' >1966<\/option><option value='1965' >1965<\/option><option value='1964' >1964<\/option><option value='1963' >1963<\/option><option value='1962' >1962<\/option><option value='1961' >1961<\/option><option value='1960' >1960<\/option><option value='1959' >1959<\/option><option value='1958' >1958<\/option><option value='1957' >1957<\/option><option value='1956' >1956<\/option><option value='1955' >1955<\/option><option value='1954' >1954<\/option><option value='1953' >1953<\/option><option value='1952' >1952<\/option><option value='1951' >1951<\/option><option value='1950' >1950<\/option><option value='1949' >1949<\/option><option value='1948' >1948<\/option><option value='1947' >1947<\/option><option value='1946' >1946<\/option><option value='1945' >1945<\/option><option value='1944' >1944<\/option><option value='1943' >1943<\/option><option value='1942' >1942<\/option><option value='1941' >1941<\/option><option value='1940' >1940<\/option><option value='1939' >1939<\/option><option value='1938' >1938<\/option><option value='1937' >1937<\/option><option value='1936' >1936<\/option><option value='1935' >1935<\/option><option value='1934' >1934<\/option><option value='1933' >1933<\/option><option value='1932' >1932<\/option><option value='1931' >1931<\/option><option value='1930' >1930<\/option><option value='1929' >1929<\/option><option value='1928' >1928<\/option><option value='1927' >1927<\/option><option value='1926' >1926<\/option><option value='1925' >1925<\/option><option value='1924' >1924<\/option><option value='1923' >1923<\/option><option value='1922' >1922<\/option><option value='1921' >1921<\/option><option value='1920' >1920<\/option><\/select><\/div><\/div><\/div><\/li><li id=\"field_15_2\" class=\"gfield gfield--type-email hipaa_forms_email gfield_contains_required field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_15_2\" ><label class='gfield_label gform-field-label gfield_label_before_complex' >Email<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_complex ginput_container ginput_container_email gform-grid-row' id='input_15_2_container'>\n                                <span id='input_15_2_1_container' class='ginput_left gform-grid-col gform-grid-col--size-auto'>\n                                    <input class='' type='email' name='input_2' id='input_15_2' value=''    aria-required=\"true\" aria-invalid=\"false\"  \/>\n                                    <label for='input_15_2' class='gform-field-label gform-field-label--type-sub '>Enter Email<\/label>\n                                <\/span>\n                                <span id='input_15_2_2_container' class='ginput_right gform-grid-col gform-grid-col--size-auto'>\n                                    <input class='' type='email' name='input_2_2' id='input_15_2_2' value=''    aria-required=\"true\" aria-invalid=\"false\"  \/>\n                                    <label for='input_15_2_2' class='gform-field-label gform-field-label--type-sub '>Confirm Email<\/label>\n                                <\/span>\n                                <div class='gf_clear gf_clear_complex'><\/div>\n                            <\/div><\/li><li id=\"field_15_3\" class=\"gfield gfield--type-section gsection field_sublabel_below gfield--has-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_15_3\" ><h2 class=\"gsection_title\">Patient Health Questionnaire  PHQ-9<\/h2><div class='gsection_description' id='gfield_description_15_3'>Over the last 2 weeks, how often have you been bothered by any of the following problems? Read each item carefully and mark your response.<\/div><\/li><li id=\"field_15_4\" class=\"gfield gfield--type-checkbox gfield--type-choice field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_15_4\" ><label class='gfield_label gform-field-label gfield_label_before_complex' >Little interest or pleasure in doing things<\/label><div class='ginput_container ginput_container_checkbox'><ul class='gfield_checkbox' id='input_15_4'><li class='gchoice gchoice_15_4_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_4.1' type='checkbox'  value='Not at all'  id='choice_15_4_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_15_4_1' id='label_15_4_1' class='gform-field-label gform-field-label--type-inline'>Not at all<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_15_4_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_4.2' type='checkbox'  value='Several days'  id='choice_15_4_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_15_4_2' id='label_15_4_2' class='gform-field-label gform-field-label--type-inline'>Several days<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_15_4_3'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_4.3' type='checkbox'  value='More than half the days'  id='choice_15_4_3'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_15_4_3' id='label_15_4_3' class='gform-field-label gform-field-label--type-inline'>More than half the days<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_15_4_4'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_4.4' type='checkbox'  value='Nearly every day'  id='choice_15_4_4'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_15_4_4' id='label_15_4_4' class='gform-field-label gform-field-label--type-inline'>Nearly every day<\/label>\n\t\t\t\t\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_15_5\" class=\"gfield gfield--type-checkbox gfield--type-choice field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_15_5\" ><label class='gfield_label gform-field-label gfield_label_before_complex' >Feeling down, depressed, or hopeless<\/label><div class='ginput_container ginput_container_checkbox'><ul class='gfield_checkbox' id='input_15_5'><li class='gchoice gchoice_15_5_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_5.1' type='checkbox'  value='Not at all'  id='choice_15_5_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_15_5_1' id='label_15_5_1' class='gform-field-label gform-field-label--type-inline'>Not at all<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_15_5_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_5.2' type='checkbox'  value='Several days'  id='choice_15_5_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_15_5_2' id='label_15_5_2' class='gform-field-label gform-field-label--type-inline'>Several days<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_15_5_3'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_5.3' type='checkbox'  value='More than half the days'  id='choice_15_5_3'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_15_5_3' id='label_15_5_3' class='gform-field-label gform-field-label--type-inline'>More than half the days<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_15_5_4'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_5.4' type='checkbox'  value='Nearly every day'  id='choice_15_5_4'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_15_5_4' id='label_15_5_4' class='gform-field-label gform-field-label--type-inline'>Nearly every day<\/label>\n\t\t\t\t\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_15_6\" class=\"gfield gfield--type-checkbox gfield--type-choice field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_15_6\" ><label class='gfield_label gform-field-label gfield_label_before_complex' >Trouble falling asleep, staying asleep, or sleeping too much<\/label><div class='ginput_container ginput_container_checkbox'><ul class='gfield_checkbox' id='input_15_6'><li class='gchoice gchoice_15_6_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_6.1' type='checkbox'  value='Not at all'  id='choice_15_6_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_15_6_1' id='label_15_6_1' class='gform-field-label gform-field-label--type-inline'>Not at all<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_15_6_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_6.2' type='checkbox'  value='Several days'  id='choice_15_6_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_15_6_2' id='label_15_6_2' class='gform-field-label gform-field-label--type-inline'>Several days<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_15_6_3'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_6.3' type='checkbox'  value='More than half the days'  id='choice_15_6_3'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_15_6_3' id='label_15_6_3' class='gform-field-label gform-field-label--type-inline'>More than half the days<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_15_6_4'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_6.4' type='checkbox'  value='Nearly every day'  id='choice_15_6_4'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_15_6_4' id='label_15_6_4' class='gform-field-label gform-field-label--type-inline'>Nearly every day<\/label>\n\t\t\t\t\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_15_7\" class=\"gfield gfield--type-checkbox gfield--type-choice field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_15_7\" ><label class='gfield_label gform-field-label gfield_label_before_complex' >Feeling tired or having little energy<\/label><div class='ginput_container ginput_container_checkbox'><ul class='gfield_checkbox' id='input_15_7'><li class='gchoice gchoice_15_7_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_7.1' type='checkbox'  value='Not at all'  id='choice_15_7_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_15_7_1' id='label_15_7_1' class='gform-field-label gform-field-label--type-inline'>Not at all<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_15_7_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_7.2' type='checkbox'  value='Several days'  id='choice_15_7_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_15_7_2' id='label_15_7_2' class='gform-field-label gform-field-label--type-inline'>Several days<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_15_7_3'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_7.3' type='checkbox'  value='More than half the days'  id='choice_15_7_3'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_15_7_3' id='label_15_7_3' class='gform-field-label gform-field-label--type-inline'>More than half the days<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_15_7_4'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_7.4' type='checkbox'  value='Nearly every day'  id='choice_15_7_4'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_15_7_4' id='label_15_7_4' class='gform-field-label gform-field-label--type-inline'>Nearly every day<\/label>\n\t\t\t\t\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_15_8\" class=\"gfield gfield--type-checkbox gfield--type-choice field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_15_8\" ><label class='gfield_label gform-field-label gfield_label_before_complex' >Poor appetite or over eating<\/label><div class='ginput_container ginput_container_checkbox'><ul class='gfield_checkbox' id='input_15_8'><li class='gchoice gchoice_15_8_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_8.1' type='checkbox'  value='Not at all'  id='choice_15_8_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_15_8_1' id='label_15_8_1' class='gform-field-label gform-field-label--type-inline'>Not at all<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_15_8_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_8.2' type='checkbox'  value='Several days'  id='choice_15_8_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_15_8_2' id='label_15_8_2' class='gform-field-label gform-field-label--type-inline'>Several days<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_15_8_3'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_8.3' type='checkbox'  value='More than half the days'  id='choice_15_8_3'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_15_8_3' id='label_15_8_3' class='gform-field-label gform-field-label--type-inline'>More than half the days<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_15_8_4'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_8.4' type='checkbox'  value='Nearly every day'  id='choice_15_8_4'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_15_8_4' id='label_15_8_4' class='gform-field-label gform-field-label--type-inline'>Nearly every day<\/label>\n\t\t\t\t\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_15_9\" class=\"gfield gfield--type-checkbox gfield--type-choice field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_15_9\" ><label class='gfield_label gform-field-label gfield_label_before_complex' >Feeling bad about yourself - or that you are a failure or have let yourself or your family down<\/label><div class='ginput_container ginput_container_checkbox'><ul class='gfield_checkbox' id='input_15_9'><li class='gchoice gchoice_15_9_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_9.1' type='checkbox'  value='Not at all'  id='choice_15_9_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_15_9_1' id='label_15_9_1' class='gform-field-label gform-field-label--type-inline'>Not at all<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_15_9_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_9.2' type='checkbox'  value='Several days'  id='choice_15_9_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_15_9_2' id='label_15_9_2' class='gform-field-label gform-field-label--type-inline'>Several days<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_15_9_3'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_9.3' type='checkbox'  value='More than half the days'  id='choice_15_9_3'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_15_9_3' id='label_15_9_3' class='gform-field-label gform-field-label--type-inline'>More than half the days<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_15_9_4'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_9.4' type='checkbox'  value='Nearly every day'  id='choice_15_9_4'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_15_9_4' id='label_15_9_4' class='gform-field-label gform-field-label--type-inline'>Nearly every day<\/label>\n\t\t\t\t\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_15_10\" class=\"gfield gfield--type-checkbox gfield--type-choice field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_15_10\" ><label class='gfield_label gform-field-label gfield_label_before_complex' >Trouble concentrating on things such as reading the newspaper or watching television<\/label><div class='ginput_container ginput_container_checkbox'><ul class='gfield_checkbox' id='input_15_10'><li class='gchoice gchoice_15_10_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_10.1' type='checkbox'  value='Not at all'  id='choice_15_10_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_15_10_1' id='label_15_10_1' class='gform-field-label gform-field-label--type-inline'>Not at all<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_15_10_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_10.2' type='checkbox'  value='Several days'  id='choice_15_10_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_15_10_2' id='label_15_10_2' class='gform-field-label gform-field-label--type-inline'>Several days<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_15_10_3'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_10.3' type='checkbox'  value='More than half the days'  id='choice_15_10_3'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_15_10_3' id='label_15_10_3' class='gform-field-label gform-field-label--type-inline'>More than half the days<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_15_10_4'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_10.4' type='checkbox'  value='Nearly every day'  id='choice_15_10_4'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_15_10_4' id='label_15_10_4' class='gform-field-label gform-field-label--type-inline'>Nearly every day<\/label>\n\t\t\t\t\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_15_11\" class=\"gfield gfield--type-checkbox gfield--type-choice field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_15_11\" ><label class='gfield_label gform-field-label gfield_label_before_complex' >Moving or speaking so slowly that other people could notice. Or the opposite - being so fidgety or restless that you are moving around a lot more than usual<\/label><div class='ginput_container ginput_container_checkbox'><ul class='gfield_checkbox' id='input_15_11'><li class='gchoice gchoice_15_11_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_11.1' type='checkbox'  value='Not at all'  id='choice_15_11_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_15_11_1' id='label_15_11_1' class='gform-field-label gform-field-label--type-inline'>Not at all<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_15_11_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_11.2' type='checkbox'  value='Several days'  id='choice_15_11_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_15_11_2' id='label_15_11_2' class='gform-field-label gform-field-label--type-inline'>Several days<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_15_11_3'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_11.3' type='checkbox'  value='More than half the days'  id='choice_15_11_3'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_15_11_3' id='label_15_11_3' class='gform-field-label gform-field-label--type-inline'>More than half the days<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_15_11_4'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_11.4' type='checkbox'  value='Nearly every day'  id='choice_15_11_4'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_15_11_4' id='label_15_11_4' class='gform-field-label gform-field-label--type-inline'>Nearly every day<\/label>\n\t\t\t\t\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_15_12\" class=\"gfield gfield--type-checkbox gfield--type-choice field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_15_12\" ><label class='gfield_label gform-field-label gfield_label_before_complex' >Thoughts that you would be better off dead, or of hurting yourself in some way<\/label><div class='ginput_container ginput_container_checkbox'><ul class='gfield_checkbox' id='input_15_12'><li class='gchoice gchoice_15_12_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_12.1' type='checkbox'  value='Not at all'  id='choice_15_12_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_15_12_1' id='label_15_12_1' class='gform-field-label gform-field-label--type-inline'>Not at all<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_15_12_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_12.2' type='checkbox'  value='Several days'  id='choice_15_12_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_15_12_2' id='label_15_12_2' class='gform-field-label gform-field-label--type-inline'>Several days<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_15_12_3'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_12.3' type='checkbox'  value='More than half the days'  id='choice_15_12_3'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_15_12_3' id='label_15_12_3' class='gform-field-label gform-field-label--type-inline'>More than half the days<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_15_12_4'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_12.4' type='checkbox'  value='Nearly every day'  id='choice_15_12_4'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_15_12_4' id='label_15_12_4' class='gform-field-label gform-field-label--type-inline'>Nearly every day<\/label>\n\t\t\t\t\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_15_13\" class=\"gfield gfield--type-checkbox gfield--type-choice field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_15_13\" ><label class='gfield_label gform-field-label gfield_label_before_complex' >How difficult have these problems made it for you at work, home, or getting along with others?<\/label><div class='ginput_container ginput_container_checkbox'><ul class='gfield_checkbox' id='input_15_13'><li class='gchoice gchoice_15_13_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_13.1' type='checkbox'  value='Not difficult at all'  id='choice_15_13_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_15_13_1' id='label_15_13_1' class='gform-field-label gform-field-label--type-inline'>Not difficult at all<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_15_13_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_13.2' type='checkbox'  value='Somewhat difficult'  id='choice_15_13_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_15_13_2' id='label_15_13_2' class='gform-field-label gform-field-label--type-inline'>Somewhat difficult<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_15_13_3'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_13.3' type='checkbox'  value='Very difficult'  id='choice_15_13_3'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_15_13_3' id='label_15_13_3' class='gform-field-label gform-field-label--type-inline'>Very difficult<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_15_13_4'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_13.4' type='checkbox'  value='Extremely difficult'  id='choice_15_13_4'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_15_13_4' id='label_15_13_4' class='gform-field-label gform-field-label--type-inline'>Extremely difficult<\/label>\n\t\t\t\t\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_15_14\" class=\"gfield gfield--type-section gsection field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_15_14\" ><h2 class=\"gsection_title\">AUDIT-C Questionnaire<\/h2><\/li><li id=\"field_15_15\" class=\"gfield gfield--type-checkbox gfield--type-choice field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_15_15\" ><label class='gfield_label gform-field-label gfield_label_before_complex' >How often do you have a drink containing alcohol?<\/label><div class='ginput_container ginput_container_checkbox'><ul class='gfield_checkbox' id='input_15_15'><li class='gchoice gchoice_15_15_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_15.1' type='checkbox'  value='Never'  id='choice_15_15_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_15_15_1' id='label_15_15_1' class='gform-field-label gform-field-label--type-inline'>Never<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_15_15_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_15.2' type='checkbox'  value='Monthly or less'  id='choice_15_15_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_15_15_2' id='label_15_15_2' class='gform-field-label gform-field-label--type-inline'>Monthly or less<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_15_15_3'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_15.3' type='checkbox'  value='2 - 4 times a month'  id='choice_15_15_3'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_15_15_3' id='label_15_15_3' class='gform-field-label gform-field-label--type-inline'>2 - 4 times a month<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_15_15_4'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_15.4' type='checkbox'  value='2 - 3 times a week'  id='choice_15_15_4'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_15_15_4' id='label_15_15_4' class='gform-field-label gform-field-label--type-inline'>2 - 3 times a week<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_15_15_5'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_15.5' type='checkbox'  value='4 or more times a week'  id='choice_15_15_5'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_15_15_5' id='label_15_15_5' class='gform-field-label gform-field-label--type-inline'>4 or more times a week<\/label>\n\t\t\t\t\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_15_16\" class=\"gfield gfield--type-checkbox gfield--type-choice field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_15_16\" ><label class='gfield_label gform-field-label gfield_label_before_complex' >When you do drink, how many standard drinks containing alcohol do you have on a typical day?<\/label><div class='ginput_container ginput_container_checkbox'><ul class='gfield_checkbox' id='input_15_16'><li class='gchoice gchoice_15_16_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_16.1' type='checkbox'  value='1 or 2'  id='choice_15_16_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_15_16_1' id='label_15_16_1' class='gform-field-label gform-field-label--type-inline'>1 or 2<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_15_16_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_16.2' type='checkbox'  value='3 or 4'  id='choice_15_16_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_15_16_2' id='label_15_16_2' class='gform-field-label gform-field-label--type-inline'>3 or 4<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_15_16_3'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_16.3' type='checkbox'  value='5 or 6'  id='choice_15_16_3'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_15_16_3' id='label_15_16_3' class='gform-field-label gform-field-label--type-inline'>5 or 6<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_15_16_4'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_16.4' type='checkbox'  value='7 to 9'  id='choice_15_16_4'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_15_16_4' id='label_15_16_4' class='gform-field-label gform-field-label--type-inline'>7 to 9<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_15_16_5'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_16.5' type='checkbox'  value='10 or more'  id='choice_15_16_5'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_15_16_5' id='label_15_16_5' class='gform-field-label gform-field-label--type-inline'>10 or more<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_15_16_6'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_16.6' type='checkbox'  value='N\/A'  id='choice_15_16_6'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_15_16_6' id='label_15_16_6' class='gform-field-label gform-field-label--type-inline'>N\/A<\/label>\n\t\t\t\t\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_15_17\" class=\"gfield gfield--type-checkbox gfield--type-choice field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_15_17\" ><label class='gfield_label gform-field-label gfield_label_before_complex' >When you do drink, how often do you have six or more drinks on one occasion?<\/label><div class='ginput_container ginput_container_checkbox'><ul class='gfield_checkbox' id='input_15_17'><li class='gchoice gchoice_15_17_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_17.1' type='checkbox'  value='Never'  id='choice_15_17_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_15_17_1' id='label_15_17_1' class='gform-field-label gform-field-label--type-inline'>Never<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_15_17_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_17.2' type='checkbox'  value='Less than monthly'  id='choice_15_17_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_15_17_2' id='label_15_17_2' class='gform-field-label gform-field-label--type-inline'>Less than monthly<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_15_17_3'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_17.3' type='checkbox'  value='Monthly'  id='choice_15_17_3'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_15_17_3' id='label_15_17_3' class='gform-field-label gform-field-label--type-inline'>Monthly<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_15_17_4'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_17.4' type='checkbox'  value='Weekly'  id='choice_15_17_4'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_15_17_4' id='label_15_17_4' class='gform-field-label gform-field-label--type-inline'>Weekly<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_15_17_5'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_17.5' type='checkbox'  value='Daily or almost daily'  id='choice_15_17_5'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_15_17_5' id='label_15_17_5' class='gform-field-label gform-field-label--type-inline'>Daily or almost daily<\/label>\n\t\t\t\t\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_15_18\" class=\"gfield gfield--type-section gsection field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_15_18\" ><h2 class=\"gsection_title\">Columbia-Suicide Severity Rating Scale<\/h2><\/li><li id=\"field_15_19\" class=\"gfield gfield--type-checkbox gfield--type-choice field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_15_19\" ><label class='gfield_label gform-field-label gfield_label_before_complex' >In the past month, have you wished you were dead or wished you could go to sleep and not wake up?<\/label><div class='ginput_container ginput_container_checkbox'><ul class='gfield_checkbox' id='input_15_19'><li class='gchoice gchoice_15_19_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_19.1' type='checkbox'  value='Yes'  id='choice_15_19_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_15_19_1' id='label_15_19_1' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_15_19_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_19.2' type='checkbox'  value='No'  id='choice_15_19_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_15_19_2' id='label_15_19_2' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t\t\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_15_20\" class=\"gfield gfield--type-checkbox gfield--type-choice field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_15_20\" ><label class='gfield_label gform-field-label gfield_label_before_complex' >In the past month, have you actually had any thoughts about killing yourself?<\/label><div class='ginput_container ginput_container_checkbox'><ul class='gfield_checkbox' id='input_15_20'><li class='gchoice gchoice_15_20_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_20.1' type='checkbox'  value='Yes'  id='choice_15_20_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_15_20_1' id='label_15_20_1' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_15_20_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_20.2' type='checkbox'  value='No'  id='choice_15_20_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_15_20_2' id='label_15_20_2' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t\t\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_15_21\" class=\"gfield gfield--type-checkbox gfield--type-choice field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_15_21\" ><label class='gfield_label gform-field-label gfield_label_before_complex' >Have you thought about how you might do this?<\/label><div class='ginput_container ginput_container_checkbox'><ul class='gfield_checkbox' id='input_15_21'><li class='gchoice gchoice_15_21_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_21.1' type='checkbox'  value='Yes'  id='choice_15_21_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_15_21_1' id='label_15_21_1' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_15_21_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_21.2' type='checkbox'  value='No'  id='choice_15_21_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_15_21_2' id='label_15_21_2' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t\t\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_15_22\" class=\"gfield gfield--type-checkbox gfield--type-choice field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_15_22\" ><label class='gfield_label gform-field-label gfield_label_before_complex' >Have you had any intention on acting on these thoughts of killing yourself, as opposed to you have the thoughts but you definitely would not act on them?<\/label><div class='ginput_container ginput_container_checkbox'><ul class='gfield_checkbox' id='input_15_22'><li class='gchoice gchoice_15_22_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_22.1' type='checkbox'  value='Yes'  id='choice_15_22_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_15_22_1' id='label_15_22_1' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_15_22_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_22.2' type='checkbox'  value='No'  id='choice_15_22_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_15_22_2' id='label_15_22_2' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t\t\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_15_23\" class=\"gfield gfield--type-checkbox gfield--type-choice field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_15_23\" ><label class='gfield_label gform-field-label gfield_label_before_complex' >Have you started to work out or worked out the details of how to kill yourself?<\/label><div class='ginput_container ginput_container_checkbox'><ul class='gfield_checkbox' id='input_15_23'><li class='gchoice gchoice_15_23_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_23.1' type='checkbox'  value='Yes'  id='choice_15_23_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_15_23_1' id='label_15_23_1' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_15_23_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_23.2' type='checkbox'  value='No'  id='choice_15_23_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_15_23_2' id='label_15_23_2' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t\t\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_15_24\" class=\"gfield gfield--type-checkbox gfield--type-choice field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_15_24\" ><label class='gfield_label gform-field-label gfield_label_before_complex' >Did you intend to carry out this plan?<\/label><div class='ginput_container ginput_container_checkbox'><ul class='gfield_checkbox' id='input_15_24'><li class='gchoice gchoice_15_24_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_24.1' type='checkbox'  value='Yes'  id='choice_15_24_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_15_24_1' id='label_15_24_1' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_15_24_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_24.2' type='checkbox'  value='No'  id='choice_15_24_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_15_24_2' id='label_15_24_2' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t\t\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_15_26\" class=\"gfield gfield--type-checkbox gfield--type-choice field_sublabel_below gfield--has-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_15_26\" ><label class='gfield_label gform-field-label gfield_label_before_complex' >In the past 3 months, have you done any of the following?<\/label><div class='ginput_container ginput_container_checkbox'><ul class='gfield_checkbox' id='input_15_26'><li class='gchoice gchoice_15_26_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_26.1' type='checkbox'  value='Attempted to kill yourself even if ending your life was only part of your motivation'  id='choice_15_26_1'   aria-describedby=\"gfield_description_15_26\"\/>\n\t\t\t\t\t\t\t\t<label for='choice_15_26_1' id='label_15_26_1' class='gform-field-label gform-field-label--type-inline'>Attempted to kill yourself even if ending your life was only part of your motivation<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_15_26_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_26.2' type='checkbox'  value='Started to do something to end your life but someone or something stopped you before you actually did anything'  id='choice_15_26_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_15_26_2' id='label_15_26_2' class='gform-field-label gform-field-label--type-inline'>Started to do something to end your life but someone or something stopped you before you actually did anything<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_15_26_3'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_26.3' type='checkbox'  value='Started to do something to end your life but you stopped yourself before you actually did anything'  id='choice_15_26_3'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_15_26_3' id='label_15_26_3' class='gform-field-label gform-field-label--type-inline'>Started to do something to end your life but you stopped yourself before you actually did anything<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_15_26_4'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_26.4' type='checkbox'  value='Taken any steps towards making a suicide attempt or preparing to kill yourself'  id='choice_15_26_4'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_15_26_4' id='label_15_26_4' class='gform-field-label gform-field-label--type-inline'>Taken any steps towards making a suicide attempt or preparing to kill yourself<\/label>\n\t\t\t\t\t\t\t<\/li><\/ul><\/div><div class='gfield_description' id='gfield_description_15_26'>Examples: Collected pills, obtained a gun, gave away valuables, wrote a will or suicide note, took out pills but didn't swallow any, held a gun but changed your mind or it was grabbed from your hand, wend to the roof but didn't jump; or actually took pills, tried to shoot yourself, tried to hang yourself, etc.<\/div><\/li><li id=\"field_15_28\" class=\"gfield gfield--type-text field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_15_28\" ><label class='gfield_label gform-field-label' for='input_15_28'>In your entire lifetime, how many times have you done any of these things?<\/label><div class='ginput_container ginput_container_text'><input name='input_28' id='input_15_28' type='text' value='' class='medium'      aria-invalid=\"false\"   \/> <\/div><\/li><li id=\"field_15_29\" class=\"gfield gfield--type-section gsection field_sublabel_below gfield--has-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_15_29\" ><h2 class=\"gsection_title\">GAIN-Short Screener (GAIN-SS)<\/h2><div class='gsection_description' id='gfield_description_15_29'>The following questions are about common psychological, behavioral, and personal problems. These problems are considered significant when you have them for two or more weeks, when they keep coming back, when they keep you from meeting your responsibilities, or when they make you feel like you can't go on.<\/div><\/li><li id=\"field_15_31\" class=\"gfield gfield--type-checkbox gfield--type-choice field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_15_31\" ><label class='gfield_label gform-field-label gfield_label_before_complex' >When was the last time that you had significant problems with feeling very trapped, lonely, sad, blue, depressed, or hopeless?<\/label><div class='ginput_container ginput_container_checkbox'><ul class='gfield_checkbox' id='input_15_31'><li class='gchoice gchoice_15_31_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_31.1' type='checkbox'  value='Past month'  id='choice_15_31_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_15_31_1' id='label_15_31_1' class='gform-field-label gform-field-label--type-inline'>Past month<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_15_31_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_31.2' type='checkbox'  value='2 to 12 months ago'  id='choice_15_31_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_15_31_2' id='label_15_31_2' class='gform-field-label gform-field-label--type-inline'>2 to 12 months ago<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_15_31_3'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_31.3' type='checkbox'  value='1+ years ago'  id='choice_15_31_3'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_15_31_3' id='label_15_31_3' class='gform-field-label gform-field-label--type-inline'>1+ years ago<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_15_31_4'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_31.4' type='checkbox'  value='Never'  id='choice_15_31_4'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_15_31_4' id='label_15_31_4' class='gform-field-label gform-field-label--type-inline'>Never<\/label>\n\t\t\t\t\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_15_32\" class=\"gfield gfield--type-checkbox gfield--type-choice field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_15_32\" ><label class='gfield_label gform-field-label gfield_label_before_complex' >When was the last time that you had significant problems with sleep trouble, such as bad dreams, sleeping restlessly, or falling asleep during the day?<\/label><div class='ginput_container ginput_container_checkbox'><ul class='gfield_checkbox' id='input_15_32'><li class='gchoice gchoice_15_32_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_32.1' type='checkbox'  value='Past month'  id='choice_15_32_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_15_32_1' id='label_15_32_1' class='gform-field-label gform-field-label--type-inline'>Past month<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_15_32_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_32.2' type='checkbox'  value='2 to 12 months ago'  id='choice_15_32_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_15_32_2' id='label_15_32_2' class='gform-field-label gform-field-label--type-inline'>2 to 12 months ago<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_15_32_3'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_32.3' type='checkbox'  value='1+ years ago'  id='choice_15_32_3'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_15_32_3' id='label_15_32_3' class='gform-field-label gform-field-label--type-inline'>1+ years ago<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_15_32_4'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_32.4' type='checkbox'  value='Never'  id='choice_15_32_4'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_15_32_4' id='label_15_32_4' class='gform-field-label gform-field-label--type-inline'>Never<\/label>\n\t\t\t\t\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_15_33\" class=\"gfield gfield--type-checkbox gfield--type-choice field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_15_33\" ><label class='gfield_label gform-field-label gfield_label_before_complex' >When was the last time that you had significant problems with feeling very anxious, nervous, tense, scared, panicked, or like something bad was going to happen?<\/label><div class='ginput_container ginput_container_checkbox'><ul class='gfield_checkbox' id='input_15_33'><li class='gchoice gchoice_15_33_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_33.1' type='checkbox'  value='Past month'  id='choice_15_33_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_15_33_1' id='label_15_33_1' class='gform-field-label gform-field-label--type-inline'>Past month<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_15_33_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_33.2' type='checkbox'  value='2 to 12 months ago'  id='choice_15_33_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_15_33_2' id='label_15_33_2' class='gform-field-label gform-field-label--type-inline'>2 to 12 months ago<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_15_33_3'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_33.3' type='checkbox'  value='1+ years ago'  id='choice_15_33_3'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_15_33_3' id='label_15_33_3' class='gform-field-label gform-field-label--type-inline'>1+ years ago<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_15_33_4'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_33.4' type='checkbox'  value='Never'  id='choice_15_33_4'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_15_33_4' id='label_15_33_4' class='gform-field-label gform-field-label--type-inline'>Never<\/label>\n\t\t\t\t\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_15_34\" class=\"gfield gfield--type-checkbox gfield--type-choice field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_15_34\" ><label class='gfield_label gform-field-label gfield_label_before_complex' >When was the last time that you had significant problems with becoming very distressed and upset when something reminded you of the past?<\/label><div class='ginput_container ginput_container_checkbox'><ul class='gfield_checkbox' id='input_15_34'><li class='gchoice gchoice_15_34_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_34.1' type='checkbox'  value='Past month'  id='choice_15_34_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_15_34_1' id='label_15_34_1' class='gform-field-label gform-field-label--type-inline'>Past month<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_15_34_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_34.2' type='checkbox'  value='2 to 12 months ago'  id='choice_15_34_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_15_34_2' id='label_15_34_2' class='gform-field-label gform-field-label--type-inline'>2 to 12 months ago<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_15_34_3'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_34.3' type='checkbox'  value='1+ years ago'  id='choice_15_34_3'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_15_34_3' id='label_15_34_3' class='gform-field-label gform-field-label--type-inline'>1+ years ago<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_15_34_4'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_34.4' type='checkbox'  value='Never'  id='choice_15_34_4'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_15_34_4' id='label_15_34_4' class='gform-field-label gform-field-label--type-inline'>Never<\/label>\n\t\t\t\t\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_15_35\" class=\"gfield gfield--type-checkbox gfield--type-choice field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_15_35\" ><label class='gfield_label gform-field-label gfield_label_before_complex' >When was the last time that you had significant problems with thinking about ending your life or committing suicide?<\/label><div class='ginput_container ginput_container_checkbox'><ul class='gfield_checkbox' id='input_15_35'><li class='gchoice gchoice_15_35_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_35.1' type='checkbox'  value='Past month'  id='choice_15_35_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_15_35_1' id='label_15_35_1' class='gform-field-label gform-field-label--type-inline'>Past month<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_15_35_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_35.2' type='checkbox'  value='2 to 12 months ago'  id='choice_15_35_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_15_35_2' id='label_15_35_2' class='gform-field-label gform-field-label--type-inline'>2 to 12 months ago<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_15_35_3'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_35.3' type='checkbox'  value='1+ years ago'  id='choice_15_35_3'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_15_35_3' id='label_15_35_3' class='gform-field-label gform-field-label--type-inline'>1+ years ago<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_15_35_4'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_35.4' type='checkbox'  value='Never'  id='choice_15_35_4'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_15_35_4' id='label_15_35_4' class='gform-field-label gform-field-label--type-inline'>Never<\/label>\n\t\t\t\t\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_15_36\" class=\"gfield gfield--type-checkbox gfield--type-choice field_sublabel_below gfield--has-description field_description_above gfield_visibility_visible\"  data-js-reload=\"field_15_36\" ><label class='gfield_label gform-field-label gfield_label_before_complex' >When was the last time that you did the following thing two or more times?<\/label><div class='gfield_description' id='gfield_description_15_36'>Lied or conned to get things you wanted to avoid having to do something<\/div><div class='ginput_container ginput_container_checkbox'><ul class='gfield_checkbox' id='input_15_36'><li class='gchoice gchoice_15_36_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_36.1' type='checkbox'  value='Past month'  id='choice_15_36_1'   aria-describedby=\"gfield_description_15_36\"\/>\n\t\t\t\t\t\t\t\t<label for='choice_15_36_1' id='label_15_36_1' class='gform-field-label gform-field-label--type-inline'>Past month<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_15_36_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_36.2' type='checkbox'  value='2 to 12 months ago'  id='choice_15_36_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_15_36_2' id='label_15_36_2' class='gform-field-label gform-field-label--type-inline'>2 to 12 months ago<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_15_36_3'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_36.3' type='checkbox'  value='1+ years ago'  id='choice_15_36_3'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_15_36_3' id='label_15_36_3' class='gform-field-label gform-field-label--type-inline'>1+ years ago<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_15_36_4'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_36.4' type='checkbox'  value='Never'  id='choice_15_36_4'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_15_36_4' id='label_15_36_4' class='gform-field-label gform-field-label--type-inline'>Never<\/label>\n\t\t\t\t\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_15_37\" class=\"gfield gfield--type-checkbox gfield--type-choice field_sublabel_below gfield--has-description field_description_above gfield_visibility_visible\"  data-js-reload=\"field_15_37\" ><label class='gfield_label gform-field-label gfield_label_before_complex' >When was the last time that you did the following thing two or more times?<\/label><div class='gfield_description' id='gfield_description_15_37'>Had a hard time paying attention at school, work, or home<\/div><div class='ginput_container ginput_container_checkbox'><ul class='gfield_checkbox' id='input_15_37'><li class='gchoice gchoice_15_37_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_37.1' type='checkbox'  value='Past month'  id='choice_15_37_1'   aria-describedby=\"gfield_description_15_37\"\/>\n\t\t\t\t\t\t\t\t<label for='choice_15_37_1' id='label_15_37_1' class='gform-field-label gform-field-label--type-inline'>Past month<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_15_37_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_37.2' type='checkbox'  value='2 to 12 months ago'  id='choice_15_37_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_15_37_2' id='label_15_37_2' class='gform-field-label gform-field-label--type-inline'>2 to 12 months ago<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_15_37_3'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_37.3' type='checkbox'  value='1+ years ago'  id='choice_15_37_3'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_15_37_3' id='label_15_37_3' class='gform-field-label gform-field-label--type-inline'>1+ years ago<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_15_37_4'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_37.4' type='checkbox'  value='Never'  id='choice_15_37_4'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_15_37_4' id='label_15_37_4' class='gform-field-label gform-field-label--type-inline'>Never<\/label>\n\t\t\t\t\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_15_38\" class=\"gfield gfield--type-checkbox gfield--type-choice field_sublabel_below gfield--has-description field_description_above gfield_visibility_visible\"  data-js-reload=\"field_15_38\" ><label class='gfield_label gform-field-label gfield_label_before_complex' >When was the last time that you did the following thing two or more times?<\/label><div class='gfield_description' id='gfield_description_15_38'>Had a hard time listening to instructions at school, work, or home<\/div><div class='ginput_container ginput_container_checkbox'><ul class='gfield_checkbox' id='input_15_38'><li class='gchoice gchoice_15_38_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_38.1' type='checkbox'  value='Past month'  id='choice_15_38_1'   aria-describedby=\"gfield_description_15_38\"\/>\n\t\t\t\t\t\t\t\t<label for='choice_15_38_1' id='label_15_38_1' class='gform-field-label gform-field-label--type-inline'>Past month<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_15_38_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_38.2' type='checkbox'  value='2 to 12 months ago'  id='choice_15_38_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_15_38_2' id='label_15_38_2' class='gform-field-label gform-field-label--type-inline'>2 to 12 months ago<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_15_38_3'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_38.3' type='checkbox'  value='1+ years ago'  id='choice_15_38_3'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_15_38_3' id='label_15_38_3' class='gform-field-label gform-field-label--type-inline'>1+ years ago<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_15_38_4'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_38.4' type='checkbox'  value='Never'  id='choice_15_38_4'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_15_38_4' id='label_15_38_4' class='gform-field-label gform-field-label--type-inline'>Never<\/label>\n\t\t\t\t\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_15_39\" class=\"gfield gfield--type-checkbox gfield--type-choice field_sublabel_below gfield--has-description field_description_above gfield_visibility_visible\"  data-js-reload=\"field_15_39\" ><label class='gfield_label gform-field-label gfield_label_before_complex' >When was the last time that you did the following thing two or more times?<\/label><div class='gfield_description' id='gfield_description_15_39'>Were a bully or threatened other people<\/div><div class='ginput_container ginput_container_checkbox'><ul class='gfield_checkbox' id='input_15_39'><li class='gchoice gchoice_15_39_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_39.1' type='checkbox'  value='Past month'  id='choice_15_39_1'   aria-describedby=\"gfield_description_15_39\"\/>\n\t\t\t\t\t\t\t\t<label for='choice_15_39_1' id='label_15_39_1' class='gform-field-label gform-field-label--type-inline'>Past month<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_15_39_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_39.2' type='checkbox'  value='2 to 12 months ago'  id='choice_15_39_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_15_39_2' id='label_15_39_2' class='gform-field-label gform-field-label--type-inline'>2 to 12 months ago<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_15_39_3'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_39.3' type='checkbox'  value='1+ years ago'  id='choice_15_39_3'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_15_39_3' id='label_15_39_3' class='gform-field-label gform-field-label--type-inline'>1+ years ago<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_15_39_4'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_39.4' type='checkbox'  value='Never'  id='choice_15_39_4'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_15_39_4' id='label_15_39_4' class='gform-field-label gform-field-label--type-inline'>Never<\/label>\n\t\t\t\t\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_15_40\" class=\"gfield gfield--type-checkbox gfield--type-choice field_sublabel_below gfield--has-description field_description_above gfield_visibility_visible\"  data-js-reload=\"field_15_40\" ><label class='gfield_label gform-field-label gfield_label_before_complex' >When was the last time that you did the following thing two or more times?<\/label><div class='gfield_description' id='gfield_description_15_40'>Started physical fights with other people<\/div><div class='ginput_container ginput_container_checkbox'><ul class='gfield_checkbox' id='input_15_40'><li class='gchoice gchoice_15_40_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_40.1' type='checkbox'  value='Past month'  id='choice_15_40_1'   aria-describedby=\"gfield_description_15_40\"\/>\n\t\t\t\t\t\t\t\t<label for='choice_15_40_1' id='label_15_40_1' class='gform-field-label gform-field-label--type-inline'>Past month<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_15_40_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_40.2' type='checkbox'  value='2 to 12 months ago'  id='choice_15_40_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_15_40_2' id='label_15_40_2' class='gform-field-label gform-field-label--type-inline'>2 to 12 months ago<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_15_40_3'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_40.3' type='checkbox'  value='1+ years ago'  id='choice_15_40_3'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_15_40_3' id='label_15_40_3' class='gform-field-label gform-field-label--type-inline'>1+ years ago<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_15_40_4'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_40.4' type='checkbox'  value='Never'  id='choice_15_40_4'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_15_40_4' id='label_15_40_4' class='gform-field-label gform-field-label--type-inline'>Never<\/label>\n\t\t\t\t\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_15_41\" class=\"gfield gfield--type-checkbox gfield--type-choice field_sublabel_below gfield--no-description field_description_above gfield_visibility_visible\"  data-js-reload=\"field_15_41\" ><label class='gfield_label gform-field-label gfield_label_before_complex' >When was the last time that you used alcohol or other drugs weekly or more often?<\/label><div class='ginput_container ginput_container_checkbox'><ul class='gfield_checkbox' id='input_15_41'><li class='gchoice gchoice_15_41_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_41.1' type='checkbox'  value='Past month'  id='choice_15_41_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_15_41_1' id='label_15_41_1' class='gform-field-label gform-field-label--type-inline'>Past month<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_15_41_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_41.2' type='checkbox'  value='2 to 12 months ago'  id='choice_15_41_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_15_41_2' id='label_15_41_2' class='gform-field-label gform-field-label--type-inline'>2 to 12 months ago<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_15_41_3'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_41.3' type='checkbox'  value='1+ years ago'  id='choice_15_41_3'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_15_41_3' id='label_15_41_3' class='gform-field-label gform-field-label--type-inline'>1+ years ago<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_15_41_4'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_41.4' type='checkbox'  value='Never'  id='choice_15_41_4'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_15_41_4' id='label_15_41_4' class='gform-field-label gform-field-label--type-inline'>Never<\/label>\n\t\t\t\t\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_15_42\" class=\"gfield gfield--type-checkbox gfield--type-choice field_sublabel_below gfield--no-description field_description_above gfield_visibility_visible\"  data-js-reload=\"field_15_42\" ><label class='gfield_label gform-field-label gfield_label_before_complex' >When was the last time that you spent a lot of time either getting alcohol or other drugs, using alcohol or other drugs, or feeling the effects of alcohol or other drugs?<\/label><div class='ginput_container ginput_container_checkbox'><ul class='gfield_checkbox' id='input_15_42'><li class='gchoice gchoice_15_42_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_42.1' type='checkbox'  value='Past month'  id='choice_15_42_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_15_42_1' id='label_15_42_1' class='gform-field-label gform-field-label--type-inline'>Past month<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_15_42_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_42.2' type='checkbox'  value='2 to 12 months ago'  id='choice_15_42_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_15_42_2' id='label_15_42_2' class='gform-field-label gform-field-label--type-inline'>2 to 12 months ago<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_15_42_3'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_42.3' type='checkbox'  value='1+ years ago'  id='choice_15_42_3'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_15_42_3' id='label_15_42_3' class='gform-field-label gform-field-label--type-inline'>1+ years ago<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_15_42_4'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_42.4' type='checkbox'  value='Never'  id='choice_15_42_4'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_15_42_4' id='label_15_42_4' class='gform-field-label gform-field-label--type-inline'>Never<\/label>\n\t\t\t\t\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_15_43\" class=\"gfield gfield--type-checkbox gfield--type-choice field_sublabel_below gfield--no-description field_description_above gfield_visibility_visible\"  data-js-reload=\"field_15_43\" ><label class='gfield_label gform-field-label gfield_label_before_complex' >When was the last time that you kept using alcohol or other drugs even though it was causing social problems, leading to fights, or getting you into trouble with other people?<\/label><div class='ginput_container ginput_container_checkbox'><ul class='gfield_checkbox' id='input_15_43'><li class='gchoice gchoice_15_43_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_43.1' type='checkbox'  value='Past month'  id='choice_15_43_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_15_43_1' id='label_15_43_1' class='gform-field-label gform-field-label--type-inline'>Past month<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_15_43_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_43.2' type='checkbox'  value='2 to 12 months ago'  id='choice_15_43_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_15_43_2' id='label_15_43_2' class='gform-field-label gform-field-label--type-inline'>2 to 12 months ago<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_15_43_3'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_43.3' type='checkbox'  value='1+ years ago'  id='choice_15_43_3'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_15_43_3' id='label_15_43_3' class='gform-field-label gform-field-label--type-inline'>1+ years ago<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_15_43_4'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_43.4' type='checkbox'  value='Never'  id='choice_15_43_4'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_15_43_4' id='label_15_43_4' class='gform-field-label gform-field-label--type-inline'>Never<\/label>\n\t\t\t\t\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_15_44\" class=\"gfield gfield--type-checkbox gfield--type-choice field_sublabel_below gfield--no-description field_description_above gfield_visibility_visible\"  data-js-reload=\"field_15_44\" ><label class='gfield_label gform-field-label gfield_label_before_complex' >When was the last time that your use of alcohol or other drugs caused you to give up, reduce or have problems at important activities at work, school, home, or social events?<\/label><div class='ginput_container ginput_container_checkbox'><ul class='gfield_checkbox' id='input_15_44'><li class='gchoice gchoice_15_44_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_44.1' type='checkbox'  value='Past month'  id='choice_15_44_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_15_44_1' id='label_15_44_1' class='gform-field-label gform-field-label--type-inline'>Past month<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_15_44_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_44.2' type='checkbox'  value='2 to 12 months ago'  id='choice_15_44_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_15_44_2' id='label_15_44_2' class='gform-field-label gform-field-label--type-inline'>2 to 12 months ago<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_15_44_3'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_44.3' type='checkbox'  value='1+ years ago'  id='choice_15_44_3'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_15_44_3' id='label_15_44_3' class='gform-field-label gform-field-label--type-inline'>1+ years ago<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_15_44_4'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_44.4' type='checkbox'  value='Never'  id='choice_15_44_4'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_15_44_4' id='label_15_44_4' class='gform-field-label gform-field-label--type-inline'>Never<\/label>\n\t\t\t\t\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_15_45\" class=\"gfield gfield--type-checkbox gfield--type-choice field_sublabel_below gfield--no-description field_description_above gfield_visibility_visible\"  data-js-reload=\"field_15_45\" ><label class='gfield_label gform-field-label gfield_label_before_complex' >When was the last time that you had withdrawal problems from alcohol or other drugs like shaky hands, throwing up, having trouble sitting still or sleeping, or that you used any alcohol or other drugs to stop being sick or avoid withdrawal problems?<\/label><div class='ginput_container ginput_container_checkbox'><ul class='gfield_checkbox' id='input_15_45'><li class='gchoice gchoice_15_45_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_45.1' type='checkbox'  value='Past month'  id='choice_15_45_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_15_45_1' id='label_15_45_1' class='gform-field-label gform-field-label--type-inline'>Past month<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_15_45_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_45.2' type='checkbox'  value='2 to 12 months ago'  id='choice_15_45_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_15_45_2' id='label_15_45_2' class='gform-field-label gform-field-label--type-inline'>2 to 12 months ago<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_15_45_3'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_45.3' type='checkbox'  value='1+ years ago'  id='choice_15_45_3'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_15_45_3' id='label_15_45_3' class='gform-field-label gform-field-label--type-inline'>1+ years ago<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_15_45_4'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_45.4' type='checkbox'  value='Never'  id='choice_15_45_4'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_15_45_4' id='label_15_45_4' class='gform-field-label gform-field-label--type-inline'>Never<\/label>\n\t\t\t\t\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_15_46\" class=\"gfield gfield--type-checkbox gfield--type-choice field_sublabel_below gfield--no-description field_description_above gfield_visibility_visible\"  data-js-reload=\"field_15_46\" ><label class='gfield_label gform-field-label gfield_label_before_complex' >When was the last time that you had a disagreement in which you pushed, grabbed, or shoved someone?<\/label><div class='ginput_container ginput_container_checkbox'><ul class='gfield_checkbox' id='input_15_46'><li class='gchoice gchoice_15_46_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_46.1' type='checkbox'  value='Past month'  id='choice_15_46_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_15_46_1' id='label_15_46_1' class='gform-field-label gform-field-label--type-inline'>Past month<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_15_46_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_46.2' type='checkbox'  value='2 to 12 months ago'  id='choice_15_46_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_15_46_2' id='label_15_46_2' class='gform-field-label gform-field-label--type-inline'>2 to 12 months ago<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_15_46_3'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_46.3' type='checkbox'  value='1+ years ago'  id='choice_15_46_3'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_15_46_3' id='label_15_46_3' class='gform-field-label gform-field-label--type-inline'>1+ years ago<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_15_46_4'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_46.4' type='checkbox'  value='Never'  id='choice_15_46_4'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_15_46_4' id='label_15_46_4' class='gform-field-label gform-field-label--type-inline'>Never<\/label>\n\t\t\t\t\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_15_47\" class=\"gfield gfield--type-checkbox gfield--type-choice field_sublabel_below gfield--no-description field_description_above gfield_visibility_visible\"  data-js-reload=\"field_15_47\" ><label class='gfield_label gform-field-label gfield_label_before_complex' >When was the last time that you took something from a store without paying for it?<\/label><div class='ginput_container ginput_container_checkbox'><ul class='gfield_checkbox' id='input_15_47'><li class='gchoice gchoice_15_47_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_47.1' type='checkbox'  value='Past month'  id='choice_15_47_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_15_47_1' id='label_15_47_1' class='gform-field-label gform-field-label--type-inline'>Past month<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_15_47_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_47.2' type='checkbox'  value='2 to 12 months ago'  id='choice_15_47_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_15_47_2' id='label_15_47_2' class='gform-field-label gform-field-label--type-inline'>2 to 12 months ago<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_15_47_3'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_47.3' type='checkbox'  value='1+ years ago'  id='choice_15_47_3'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_15_47_3' id='label_15_47_3' class='gform-field-label gform-field-label--type-inline'>1+ years ago<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_15_47_4'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_47.4' type='checkbox'  value='Never'  id='choice_15_47_4'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_15_47_4' id='label_15_47_4' class='gform-field-label gform-field-label--type-inline'>Never<\/label>\n\t\t\t\t\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_15_48\" class=\"gfield gfield--type-checkbox gfield--type-choice field_sublabel_below gfield--no-description field_description_above gfield_visibility_visible\"  data-js-reload=\"field_15_48\" ><label class='gfield_label gform-field-label gfield_label_before_complex' >When was the last time that you sold, distributed, or helped to make illegal drugs?<\/label><div class='ginput_container ginput_container_checkbox'><ul class='gfield_checkbox' id='input_15_48'><li class='gchoice gchoice_15_48_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_48.1' type='checkbox'  value='Past month'  id='choice_15_48_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_15_48_1' id='label_15_48_1' class='gform-field-label gform-field-label--type-inline'>Past month<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_15_48_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_48.2' type='checkbox'  value='2 to 12 months ago'  id='choice_15_48_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_15_48_2' id='label_15_48_2' class='gform-field-label gform-field-label--type-inline'>2 to 12 months ago<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_15_48_3'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_48.3' type='checkbox'  value='1+ years ago'  id='choice_15_48_3'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_15_48_3' id='label_15_48_3' class='gform-field-label gform-field-label--type-inline'>1+ years ago<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_15_48_4'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_48.4' type='checkbox'  value='Never'  id='choice_15_48_4'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_15_48_4' id='label_15_48_4' class='gform-field-label gform-field-label--type-inline'>Never<\/label>\n\t\t\t\t\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_15_49\" class=\"gfield gfield--type-checkbox gfield--type-choice field_sublabel_below gfield--no-description field_description_above gfield_visibility_visible\"  data-js-reload=\"field_15_49\" ><label class='gfield_label gform-field-label gfield_label_before_complex' >When was the last time that you drove a vehicle while under the influence of alcohol or illegal drugs?<\/label><div class='ginput_container ginput_container_checkbox'><ul class='gfield_checkbox' id='input_15_49'><li class='gchoice gchoice_15_49_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_49.1' type='checkbox'  value='Past month'  id='choice_15_49_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_15_49_1' id='label_15_49_1' class='gform-field-label gform-field-label--type-inline'>Past month<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_15_49_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_49.2' type='checkbox'  value='2 to 12 months ago'  id='choice_15_49_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_15_49_2' id='label_15_49_2' class='gform-field-label gform-field-label--type-inline'>2 to 12 months ago<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_15_49_3'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_49.3' type='checkbox'  value='1+ years ago'  id='choice_15_49_3'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_15_49_3' id='label_15_49_3' class='gform-field-label gform-field-label--type-inline'>1+ years ago<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_15_49_4'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_49.4' type='checkbox'  value='Never'  id='choice_15_49_4'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_15_49_4' id='label_15_49_4' class='gform-field-label gform-field-label--type-inline'>Never<\/label>\n\t\t\t\t\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_15_50\" class=\"gfield gfield--type-checkbox gfield--type-choice field_sublabel_below gfield--no-description field_description_above gfield_visibility_visible\"  data-js-reload=\"field_15_50\" ><label class='gfield_label gform-field-label gfield_label_before_complex' >When was the last time that you purposely damaged or destroyed property that did not belong to you?<\/label><div class='ginput_container ginput_container_checkbox'><ul class='gfield_checkbox' id='input_15_50'><li class='gchoice gchoice_15_50_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_50.1' type='checkbox'  value='Past month'  id='choice_15_50_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_15_50_1' id='label_15_50_1' class='gform-field-label gform-field-label--type-inline'>Past month<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_15_50_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_50.2' type='checkbox'  value='2 to 12 months ago'  id='choice_15_50_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_15_50_2' id='label_15_50_2' class='gform-field-label gform-field-label--type-inline'>2 to 12 months ago<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_15_50_3'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_50.3' type='checkbox'  value='1+ years ago'  id='choice_15_50_3'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_15_50_3' id='label_15_50_3' class='gform-field-label gform-field-label--type-inline'>1+ years ago<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_15_50_4'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_50.4' type='checkbox'  value='Never'  id='choice_15_50_4'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_15_50_4' id='label_15_50_4' class='gform-field-label gform-field-label--type-inline'>Never<\/label>\n\t\t\t\t\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_15_51\" class=\"gfield gfield--type-checkbox gfield--type-choice field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_15_51\" ><label class='gfield_label gform-field-label gfield_label_before_complex' >Do you have other significant psychological, behavioral, or personal problems that you want treatment for or help with?<\/label><div class='ginput_container ginput_container_checkbox'><ul class='gfield_checkbox' id='input_15_51'><li class='gchoice gchoice_15_51_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_51.1' type='checkbox'  value='Yes'  id='choice_15_51_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_15_51_1' id='label_15_51_1' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_15_51_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_51.2' type='checkbox'  value='No'  id='choice_15_51_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_15_51_2' id='label_15_51_2' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t\t\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_15_52\" class=\"gfield gfield--type-textarea field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_15_52\" ><label class='gfield_label gform-field-label' for='input_15_52'>If yes, please describe below<\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_52' id='input_15_52' class='textarea medium'      aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/li><li id=\"field_15_53\" class=\"gfield gfield--type-checkbox gfield--type-choice field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_15_53\" ><label class='gfield_label gform-field-label gfield_label_before_complex' >What is your gender?<\/label><div class='ginput_container ginput_container_checkbox'><ul class='gfield_checkbox' id='input_15_53'><li class='gchoice gchoice_select_all'>\n\t\t\t\t\t\t<input class='gfield-choice-input' type='checkbox' id='choice_53_select_all'   onclick='gformToggleCheckboxes( this )' onkeypress='gformToggleCheckboxes( this )' \/>\n\t\t\t\t\t\t<label for='choice_53_select_all' id='label_53_select_all' class='gform-field-label  gform-field-label--type-inline' data-label-select='Select All' data-label-deselect='Deselect All'>Select All<\/label>\n\t\t\t\t\t<\/li><li class='gchoice gchoice_15_53_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_53.1' type='checkbox'  value='Male'  id='choice_15_53_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_15_53_1' id='label_15_53_1' class='gform-field-label gform-field-label--type-inline'>Male<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_15_53_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_53.2' type='checkbox'  value='Female'  id='choice_15_53_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_15_53_2' id='label_15_53_2' class='gform-field-label gform-field-label--type-inline'>Female<\/label>\n\t\t\t\t\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_15_54\" class=\"gfield gfield--type-text field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_15_54\" ><label class='gfield_label gform-field-label' for='input_15_54'>How old are you today?<\/label><div class='ginput_container ginput_container_text'><input name='input_54' id='input_15_54' type='text' value='' class='medium'      aria-invalid=\"false\"   \/> <\/div><\/li><li id=\"field_15_56\" class=\"gfield gfield--type-section gsection field_sublabel_below gfield--has-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_15_56\" ><h2 class=\"gsection_title\">Current Symptoms<\/h2><div class='gsection_description' id='gfield_description_15_56'>Please check symptoms you currently experiencing<\/div><\/li><li id=\"field_15_55\" class=\"gfield gfield--type-checkbox gfield--type-choice field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_15_55\" ><label class='gfield_label gform-field-label screen-reader-text gfield_label_before_complex' ><\/label><div class='ginput_container ginput_container_checkbox'><ul class='gfield_checkbox' id='input_15_55'><li class='gchoice gchoice_15_55_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_55.1' type='checkbox'  value='Aches\/pains'  id='choice_15_55_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_15_55_1' id='label_15_55_1' class='gform-field-label gform-field-label--type-inline'>Aches\/pains<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_15_55_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_55.2' type='checkbox'  value='Anxious\/nervous'  id='choice_15_55_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_15_55_2' id='label_15_55_2' class='gform-field-label gform-field-label--type-inline'>Anxious\/nervous<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_15_55_3'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_55.3' type='checkbox'  value='Ashamed'  id='choice_15_55_3'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_15_55_3' id='label_15_55_3' class='gform-field-label gform-field-label--type-inline'>Ashamed<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_15_55_4'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_55.4' type='checkbox'  value='Blames others'  id='choice_15_55_4'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_15_55_4' id='label_15_55_4' class='gform-field-label gform-field-label--type-inline'>Blames others<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_15_55_5'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_55.5' type='checkbox'  value='Body image concerns'  id='choice_15_55_5'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_15_55_5' id='label_15_55_5' class='gform-field-label gform-field-label--type-inline'>Body image concerns<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_15_55_6'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_55.6' type='checkbox'  value='Can&#039;t enjoy myself'  id='choice_15_55_6'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_15_55_6' id='label_15_55_6' class='gform-field-label gform-field-label--type-inline'>Can't enjoy myself<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_15_55_7'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_55.7' type='checkbox'  value='Choking feeling'  id='choice_15_55_7'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_15_55_7' id='label_15_55_7' class='gform-field-label gform-field-label--type-inline'>Choking feeling<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_15_55_8'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_55.8' type='checkbox'  value='Cry easily\/often'  id='choice_15_55_8'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_15_55_8' id='label_15_55_8' class='gform-field-label gform-field-label--type-inline'>Cry easily\/often<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_15_55_9'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_55.9' type='checkbox'  value='Depressed\/sad'  id='choice_15_55_9'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_15_55_9' id='label_15_55_9' class='gform-field-label gform-field-label--type-inline'>Depressed\/sad<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_15_55_11'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_55.11' type='checkbox'  value='Destroys property\/fires'  id='choice_15_55_11'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_15_55_11' id='label_15_55_11' class='gform-field-label gform-field-label--type-inline'>Destroys property\/fires<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_15_55_12'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_55.12' type='checkbox'  value='Difficulty breathing'  id='choice_15_55_12'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_15_55_12' id='label_15_55_12' class='gform-field-label gform-field-label--type-inline'>Difficulty breathing<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_15_55_13'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_55.13' type='checkbox'  value='Distressing memories'  id='choice_15_55_13'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_15_55_13' id='label_15_55_13' class='gform-field-label gform-field-label--type-inline'>Distressing memories<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_15_55_14'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_55.14' type='checkbox'  value='Disturbing thoughts'  id='choice_15_55_14'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_15_55_14' id='label_15_55_14' class='gform-field-label gform-field-label--type-inline'>Disturbing thoughts<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_15_55_15'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_55.15' type='checkbox'  value='Dizziness'  id='choice_15_55_15'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_15_55_15' id='label_15_55_15' class='gform-field-label gform-field-label--type-inline'>Dizziness<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_15_55_16'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_55.16' type='checkbox'  value='Eating\/appetite concerns'  id='choice_15_55_16'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_15_55_16' id='label_15_55_16' class='gform-field-label gform-field-label--type-inline'>Eating\/appetite concerns<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_15_55_17'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_55.17' type='checkbox'  value='Elevated mood'  id='choice_15_55_17'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_15_55_17' id='label_15_55_17' class='gform-field-label gform-field-label--type-inline'>Elevated mood<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_15_55_18'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_55.18' type='checkbox'  value='Excessive worry'  id='choice_15_55_18'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_15_55_18' id='label_15_55_18' class='gform-field-label gform-field-label--type-inline'>Excessive worry<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_15_55_19'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_55.19' type='checkbox'  value='Feel inferior'  id='choice_15_55_19'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_15_55_19' id='label_15_55_19' class='gform-field-label gform-field-label--type-inline'>Feel inferior<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_15_55_21'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_55.21' type='checkbox'  value='Feel unworthy'  id='choice_15_55_21'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_15_55_21' id='label_15_55_21' class='gform-field-label gform-field-label--type-inline'>Feel unworthy<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_15_55_22'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_55.22' type='checkbox'  value='Feeling paranoid\/suspicious'  id='choice_15_55_22'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_15_55_22' id='label_15_55_22' class='gform-field-label gform-field-label--type-inline'>Feeling paranoid\/suspicious<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_15_55_23'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_55.23' type='checkbox'  value='Forgetful'  id='choice_15_55_23'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_15_55_23' id='label_15_55_23' class='gform-field-label gform-field-label--type-inline'>Forgetful<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_15_55_24'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_55.24' type='checkbox'  value='Frequent mood swings'  id='choice_15_55_24'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_15_55_24' id='label_15_55_24' class='gform-field-label gform-field-label--type-inline'>Frequent mood swings<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_15_55_25'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_55.25' type='checkbox'  value='Frustration'  id='choice_15_55_25'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_15_55_25' id='label_15_55_25' class='gform-field-label gform-field-label--type-inline'>Frustration<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_15_55_26'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_55.26' type='checkbox'  value='Guilt feelings'  id='choice_15_55_26'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_15_55_26' id='label_15_55_26' class='gform-field-label gform-field-label--type-inline'>Guilt feelings<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_15_55_27'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_55.27' type='checkbox'  value='Headaches'  id='choice_15_55_27'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_15_55_27' id='label_15_55_27' class='gform-field-label gform-field-label--type-inline'>Headaches<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_15_55_28'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_55.28' type='checkbox'  value='Hear voices'  id='choice_15_55_28'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_15_55_28' id='label_15_55_28' class='gform-field-label gform-field-label--type-inline'>Hear voices<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_15_55_29'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_55.29' type='checkbox'  value='Heart racing'  id='choice_15_55_29'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_15_55_29' id='label_15_55_29' class='gform-field-label gform-field-label--type-inline'>Heart racing<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_15_55_31'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_55.31' type='checkbox'  value='Heavy feeling'  id='choice_15_55_31'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_15_55_31' id='label_15_55_31' class='gform-field-label gform-field-label--type-inline'>Heavy feeling<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_15_55_32'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_55.32' type='checkbox'  value='Hoarding'  id='choice_15_55_32'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_15_55_32' id='label_15_55_32' class='gform-field-label gform-field-label--type-inline'>Hoarding<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_15_55_33'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_55.33' type='checkbox'  value='Hopelessness'  id='choice_15_55_33'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_15_55_33' id='label_15_55_33' class='gform-field-label gform-field-label--type-inline'>Hopelessness<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_15_55_34'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_55.34' type='checkbox'  value='Hyperactivity'  id='choice_15_55_34'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_15_55_34' id='label_15_55_34' class='gform-field-label gform-field-label--type-inline'>Hyperactivity<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_15_55_35'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_55.35' type='checkbox'  value='Impulsive'  id='choice_15_55_35'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_15_55_35' id='label_15_55_35' class='gform-field-label gform-field-label--type-inline'>Impulsive<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_15_55_36'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_55.36' type='checkbox'  value='Irritable\/angry'  id='choice_15_55_36'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_15_55_36' id='label_15_55_36' class='gform-field-label gform-field-label--type-inline'>Irritable\/angry<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_15_55_37'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_55.37' type='checkbox'  value='Lack of motivation'  id='choice_15_55_37'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_15_55_37' id='label_15_55_37' class='gform-field-label gform-field-label--type-inline'>Lack of motivation<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_15_55_38'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_55.38' type='checkbox'  value='Lies\/steals'  id='choice_15_55_38'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_15_55_38' id='label_15_55_38' class='gform-field-label gform-field-label--type-inline'>Lies\/steals<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_15_55_39'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_55.39' type='checkbox'  value='Lonliness'  id='choice_15_55_39'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_15_55_39' id='label_15_55_39' class='gform-field-label gform-field-label--type-inline'>Lonliness<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_15_55_41'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_55.41' type='checkbox'  value='Lose temper'  id='choice_15_55_41'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_15_55_41' id='label_15_55_41' class='gform-field-label gform-field-label--type-inline'>Lose temper<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_15_55_42'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_55.42' type='checkbox'  value='Low energy\/tired'  id='choice_15_55_42'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_15_55_42' id='label_15_55_42' class='gform-field-label gform-field-label--type-inline'>Low energy\/tired<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_15_55_43'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_55.43' type='checkbox'  value='Low self-esteem'  id='choice_15_55_43'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_15_55_43' id='label_15_55_43' class='gform-field-label gform-field-label--type-inline'>Low self-esteem<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_15_55_44'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_55.44' type='checkbox'  value='Motor or verbal tics'  id='choice_15_55_44'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_15_55_44' id='label_15_55_44' class='gform-field-label gform-field-label--type-inline'>Motor or verbal tics<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_15_55_45'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_55.45' type='checkbox'  value='Nightmares'  id='choice_15_55_45'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_15_55_45' id='label_15_55_45' class='gform-field-label gform-field-label--type-inline'>Nightmares<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_15_55_46'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_55.46' type='checkbox'  value='Numbness\/tingling'  id='choice_15_55_46'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_15_55_46' id='label_15_55_46' class='gform-field-label gform-field-label--type-inline'>Numbness\/tingling<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_15_55_47'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_55.47' type='checkbox'  value='Physical aggression\/cruelty to animals'  id='choice_15_55_47'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_15_55_47' id='label_15_55_47' class='gform-field-label gform-field-label--type-inline'>Physical aggression\/cruelty to animals<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_15_55_48'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_55.48' type='checkbox'  value='Poor concentration'  id='choice_15_55_48'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_15_55_48' id='label_15_55_48' class='gform-field-label gform-field-label--type-inline'>Poor concentration<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_15_55_49'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_55.49' type='checkbox'  value='Poor memory'  id='choice_15_55_49'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_15_55_49' id='label_15_55_49' class='gform-field-label gform-field-label--type-inline'>Poor memory<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_15_55_51'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_55.51' type='checkbox'  value='Racing thoughts'  id='choice_15_55_51'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_15_55_51' id='label_15_55_51' class='gform-field-label gform-field-label--type-inline'>Racing thoughts<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_15_55_52'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_55.52' type='checkbox'  value='Repetitive actions'  id='choice_15_55_52'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_15_55_52' id='label_15_55_52' class='gform-field-label gform-field-label--type-inline'>Repetitive actions<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_15_55_53'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_55.53' type='checkbox'  value='Restless\/fidgety'  id='choice_15_55_53'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_15_55_53' id='label_15_55_53' class='gform-field-label gform-field-label--type-inline'>Restless\/fidgety<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_15_55_54'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_55.54' type='checkbox'  value='See images or objects'  id='choice_15_55_54'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_15_55_54' id='label_15_55_54' class='gform-field-label gform-field-label--type-inline'>See images or objects<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_15_55_55'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_55.55' type='checkbox'  value='Self-harming behaviors\/urges'  id='choice_15_55_55'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_15_55_55' id='label_15_55_55' class='gform-field-label gform-field-label--type-inline'>Self-harming behaviors\/urges<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_15_55_56'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_55.56' type='checkbox'  value='Sexual issues\/concerns'  id='choice_15_55_56'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_15_55_56' id='label_15_55_56' class='gform-field-label gform-field-label--type-inline'>Sexual issues\/concerns<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_15_55_57'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_55.57' type='checkbox'  value='Shaking'  id='choice_15_55_57'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_15_55_57' id='label_15_55_57' class='gform-field-label gform-field-label--type-inline'>Shaking<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_15_55_58'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_55.58' type='checkbox'  value='Sleep problems'  id='choice_15_55_58'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_15_55_58' id='label_15_55_58' class='gform-field-label gform-field-label--type-inline'>Sleep problems<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_15_55_59'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_55.59' type='checkbox'  value='Social discomfort'  id='choice_15_55_59'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_15_55_59' id='label_15_55_59' class='gform-field-label gform-field-label--type-inline'>Social discomfort<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_15_55_61'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_55.61' type='checkbox'  value='Tense feelings'  id='choice_15_55_61'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_15_55_61' id='label_15_55_61' class='gform-field-label gform-field-label--type-inline'>Tense feelings<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_15_55_62'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_55.62' type='checkbox'  value='Thoughts of wanting to die'  id='choice_15_55_62'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_15_55_62' id='label_15_55_62' class='gform-field-label gform-field-label--type-inline'>Thoughts of wanting to die<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_15_55_63'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_55.63' type='checkbox'  value='Thoughts of wanting to hurt others'  id='choice_15_55_63'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_15_55_63' id='label_15_55_63' class='gform-field-label gform-field-label--type-inline'>Thoughts of wanting to hurt others<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_15_55_64'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_55.64' type='checkbox'  value='Wound up'  id='choice_15_55_64'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_15_55_64' id='label_15_55_64' class='gform-field-label gform-field-label--type-inline'>Wound up<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_15_55_65'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_55.65' type='checkbox'  value='None reported'  id='choice_15_55_65'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_15_55_65' id='label_15_55_65' class='gform-field-label gform-field-label--type-inline'>None reported<\/label>\n\t\t\t\t\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_15_57\" class=\"gfield gfield--type-textarea field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_15_57\" ><label class='gfield_label gform-field-label' for='input_15_57'>Please list any other symptoms<\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_57' id='input_15_57' class='textarea medium'      aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/li><li id=\"field_15_59\" class=\"gfield gfield--type-section gsection field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_15_59\" ><h2 class=\"gsection_title\">Finding Your ACE Score<\/h2><\/li><li id=\"field_15_60\" class=\"gfield gfield--type-radio gfield--type-choice field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_15_60\" ><label class='gfield_label gform-field-label' >1. Did a parent or other adult in the household often \u2026  Swear at you, insult you, put you down, or humiliate you?  or  Act in a way that made you afraid that you might be physically hurt?<\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_15_60'>\n\t\t\t<li class='gchoice gchoice_15_60_0'>\n\t\t\t\t<input name='input_60' type='radio' value='1'  id='choice_15_60_0'    \/>\n\t\t\t\t<label for='choice_15_60_0' id='label_15_60_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_15_60_1'>\n\t\t\t\t<input name='input_60' type='radio' value='0'  id='choice_15_60_1'    \/>\n\t\t\t\t<label for='choice_15_60_1' id='label_15_60_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_15_61\" class=\"gfield gfield--type-radio gfield--type-choice field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_15_61\" ><label class='gfield_label gform-field-label' >2. Did a parent or other adult in the household often \u2026  Push, grab, slap, or throw something at you?  or Ever hit you so hard that you had marks or were injured?<\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_15_61'>\n\t\t\t<li class='gchoice gchoice_15_61_0'>\n\t\t\t\t<input name='input_61' type='radio' value='1'  id='choice_15_61_0'    \/>\n\t\t\t\t<label for='choice_15_61_0' id='label_15_61_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_15_61_1'>\n\t\t\t\t<input name='input_61' type='radio' value='0'  id='choice_15_61_1'    \/>\n\t\t\t\t<label for='choice_15_61_1' id='label_15_61_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_15_62\" class=\"gfield gfield--type-radio gfield--type-choice field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_15_62\" ><label class='gfield_label gform-field-label' >3. Did an adult or person at least 5 years older than you ever\u2026  Touch or fondle you or have you touch their body in a sexual way?  or  Try to or actually have oral, anal, or vaginal sex with you?<\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_15_62'>\n\t\t\t<li class='gchoice gchoice_15_62_0'>\n\t\t\t\t<input name='input_62' type='radio' value='1'  id='choice_15_62_0'    \/>\n\t\t\t\t<label for='choice_15_62_0' id='label_15_62_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_15_62_1'>\n\t\t\t\t<input name='input_62' type='radio' value='0'  id='choice_15_62_1'    \/>\n\t\t\t\t<label for='choice_15_62_1' id='label_15_62_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_15_64\" class=\"gfield gfield--type-radio gfield--type-choice field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_15_64\" ><label class='gfield_label gform-field-label' >4. Did you often feel that \u2026  No one in your family loved you or thought you were important or special?  or  Your family didn\u2019t look out for each other, feel close to each other, or support each other?<\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_15_64'>\n\t\t\t<li class='gchoice gchoice_15_64_0'>\n\t\t\t\t<input name='input_64' type='radio' value='1'  id='choice_15_64_0'    \/>\n\t\t\t\t<label for='choice_15_64_0' id='label_15_64_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_15_64_1'>\n\t\t\t\t<input name='input_64' type='radio' value='0'  id='choice_15_64_1'    \/>\n\t\t\t\t<label for='choice_15_64_1' id='label_15_64_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_15_65\" class=\"gfield gfield--type-radio gfield--type-choice field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_15_65\" ><label class='gfield_label gform-field-label' >5.  Did you often feel that \u2026  You didn\u2019t have enough to eat, had to wear dirty clothes, and had no one to protect you?  or  Your parents were too drunk or high to take care of you or take you to the doctor if you needed it?<\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_15_65'>\n\t\t\t<li class='gchoice gchoice_15_65_0'>\n\t\t\t\t<input name='input_65' type='radio' value='1'  id='choice_15_65_0'    \/>\n\t\t\t\t<label for='choice_15_65_0' id='label_15_65_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_15_65_1'>\n\t\t\t\t<input name='input_65' type='radio' value='0'  id='choice_15_65_1'    \/>\n\t\t\t\t<label for='choice_15_65_1' id='label_15_65_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_15_66\" class=\"gfield gfield--type-radio gfield--type-choice field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_15_66\" ><label class='gfield_label gform-field-label' >6.  Were your parents ever separated or divorced?<\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_15_66'>\n\t\t\t<li class='gchoice gchoice_15_66_0'>\n\t\t\t\t<input name='input_66' type='radio' value='1'  id='choice_15_66_0'    \/>\n\t\t\t\t<label for='choice_15_66_0' id='label_15_66_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_15_66_1'>\n\t\t\t\t<input name='input_66' type='radio' value='0'  id='choice_15_66_1'    \/>\n\t\t\t\t<label for='choice_15_66_1' id='label_15_66_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_15_67\" class=\"gfield gfield--type-radio gfield--type-choice field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_15_67\" ><label class='gfield_label gform-field-label' >7.  Was your mother or stepmother often pushed, grabbed, slapped, or had something thrown at her? Sometimes or often kicked, bitten, hit with a fist, or hit with something hard? Ever repeatedly hit over at least a few minutes or threatened with a gun or knife?<\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_15_67'>\n\t\t\t<li class='gchoice gchoice_15_67_0'>\n\t\t\t\t<input name='input_67' type='radio' value='1'  id='choice_15_67_0'    \/>\n\t\t\t\t<label for='choice_15_67_0' id='label_15_67_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_15_67_1'>\n\t\t\t\t<input name='input_67' type='radio' value='0'  id='choice_15_67_1'    \/>\n\t\t\t\t<label for='choice_15_67_1' id='label_15_67_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_15_68\" class=\"gfield gfield--type-radio gfield--type-choice field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_15_68\" ><label class='gfield_label gform-field-label' >8. Did you live with anyone who was a problem drinker or alcoholic or who used street drugs?<\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_15_68'>\n\t\t\t<li class='gchoice gchoice_15_68_0'>\n\t\t\t\t<input name='input_68' type='radio' value='1'  id='choice_15_68_0'    \/>\n\t\t\t\t<label for='choice_15_68_0' id='label_15_68_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_15_68_1'>\n\t\t\t\t<input name='input_68' type='radio' value='0'  id='choice_15_68_1'    \/>\n\t\t\t\t<label for='choice_15_68_1' id='label_15_68_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_15_69\" class=\"gfield gfield--type-radio gfield--type-choice field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_15_69\" ><label class='gfield_label gform-field-label' >9. Was a household member depressed or mentally ill or did a household member attempt suicide?<\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_15_69'>\n\t\t\t<li class='gchoice gchoice_15_69_0'>\n\t\t\t\t<input name='input_69' type='radio' value='1'  id='choice_15_69_0'    \/>\n\t\t\t\t<label for='choice_15_69_0' id='label_15_69_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_15_69_1'>\n\t\t\t\t<input name='input_69' type='radio' value='0'  id='choice_15_69_1'    \/>\n\t\t\t\t<label for='choice_15_69_1' id='label_15_69_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_15_70\" class=\"gfield gfield--type-radio gfield--type-choice field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_15_70\" ><label class='gfield_label gform-field-label' >10. Did a household member go to prison?<\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_15_70'>\n\t\t\t<li class='gchoice gchoice_15_70_0'>\n\t\t\t\t<input name='input_70' type='radio' value='1'  id='choice_15_70_0'    \/>\n\t\t\t\t<label for='choice_15_70_0' id='label_15_70_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_15_70_1'>\n\t\t\t\t<input name='input_70' type='radio' value='0'  id='choice_15_70_1'    \/>\n\t\t\t\t<label for='choice_15_70_1' id='label_15_70_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_15_71\" class=\"gfield gfield--type-text field_sublabel_below gfield--has-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_15_71\" ><label class='gfield_label gform-field-label' for='input_15_71'>Add up your YES answers.  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