{"id":3176,"date":"2021-01-02T19:41:03","date_gmt":"2021-01-02T19:41:03","guid":{"rendered":"https:\/\/screening.mhanational.org\/?post_type=screen&#038;p=3176"},"modified":"2025-11-18T16:02:45","modified_gmt":"2025-11-18T21:02:45","slug":"ptsd","status":"publish","type":"screen","link":"https:\/\/screening.mhanational.org\/es\/screening-tools\/ptsd\/","title":{"rendered":"Test de TEPT"},"content":{"rendered":"<script>\nvar gform;gform||(document.addEventListener(\"gform_main_scripts_loaded\",function(){gform.scriptsLoaded=!0}),document.addEventListener(\"gform\/theme\/scripts_loaded\",function(){gform.themeScriptsLoaded=!0}),window.addEventListener(\"DOMContentLoaded\",function(){gform.domLoaded=!0}),gform={domLoaded:!1,scriptsLoaded:!1,themeScriptsLoaded:!1,isFormEditor:()=>\"function\"==typeof InitializeEditor,callIfLoaded:function(o){return!(!gform.domLoaded||!gform.scriptsLoaded||!gform.themeScriptsLoaded&&!gform.isFormEditor()||(gform.isFormEditor()&&console.warn(\"The use of gform.initializeOnLoaded() is deprecated in the form editor context and will be removed in Gravity Forms 3.1.\"),o(),0))},initializeOnLoaded:function(o){gform.callIfLoaded(o)||(document.addEventListener(\"gform_main_scripts_loaded\",()=>{gform.scriptsLoaded=!0,gform.callIfLoaded(o)}),document.addEventListener(\"gform\/theme\/scripts_loaded\",()=>{gform.themeScriptsLoaded=!0,gform.callIfLoaded(o)}),window.addEventListener(\"DOMContentLoaded\",()=>{gform.domLoaded=!0,gform.callIfLoaded(o)}))},hooks:{action:{},filter:{}},addAction:function(o,r,e,t){gform.addHook(\"action\",o,r,e,t)},addFilter:function(o,r,e,t){gform.addHook(\"filter\",o,r,e,t)},doAction:function(o){gform.doHook(\"action\",o,arguments)},applyFilters:function(o){return gform.doHook(\"filter\",o,arguments)},removeAction:function(o,r){gform.removeHook(\"action\",o,r)},removeFilter:function(o,r,e){gform.removeHook(\"filter\",o,r,e)},addHook:function(o,r,e,t,n){null==gform.hooks[o][r]&&(gform.hooks[o][r]=[]);var d=gform.hooks[o][r];null==n&&(n=r+\"_\"+d.length),gform.hooks[o][r].push({tag:n,callable:e,priority:t=null==t?10:t})},doHook:function(r,o,e){var t;if(e=Array.prototype.slice.call(e,1),null!=gform.hooks[r][o]&&((o=gform.hooks[r][o]).sort(function(o,r){return o.priority-r.priority}),o.forEach(function(o){\"function\"!=typeof(t=o.callable)&&(t=window[t]),\"action\"==r?t.apply(null,e):e[0]=t.apply(null,e)})),\"filter\"==r)return e[0]},removeHook:function(o,r,t,n){var e;null!=gform.hooks[o][r]&&(e=(e=gform.hooks[o][r]).filter(function(o,r,e){return!!(null!=n&&n!=o.tag||null!=t&&t!=o.priority)}),gform.hooks[o][r]=e)}});\n<\/script>\n\n                <div class='gf_browser_gecko gform_wrapper gravity-theme gform-theme--no-framework' data-form-theme='gravity-theme' data-form-index='0' id='gform_wrapper_11' style='display:none'>\n                        <div class='gform_heading'>\n                            <h2 class=\"gform_title\">PTSD Test<\/h2>\n                            <p class='gform_description'><\/p>\n\t\t\t\t\t\t\t<p class='gform_required_legend'>&quot;<span class=\"gfield_required gfield_required_asterisk\">*<\/span>&quot; indicates required fields<\/p>\n                        <\/div><form method='post' enctype='multipart\/form-data'  id='gform_11'  class='clearfix' action='\/es\/wp-json\/wp\/v2\/screen\/3176' data-formid='11' novalidate><ol class=\"screen-progress-bar clearfix step-1-of-3\">\n\t\t\t\t\t<li class=\"step-1\"><span>Test<br \/>Questions<\/span><\/li>\n\t\t\t\t\t<li class=\"step-2\"><span>Optional<br \/>Questions<\/span><\/li>\n\t\t\t\t\t<li class=\"step-3\"><span>Your<br \/>Results<\/span><\/li>\n\t\t\t\t<\/ol>\n                        <div class='gform-body gform_body'><div id='gform_page_11_1' class='gform_page ' data-js='page-field-id-0' >\n\t\t\t\t\t<div class='gform_page_fields'><div id='gform_fields_11' class='gform_fields top_label form_sublabel_below description_above validation_below'><div id=\"field_11_145\" class=\"gfield gfield--type-honeypot gform_validation_container field_sublabel_below gfield--has-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_11_145'>Company<\/label><div class='gfield_description' id='gfield_description_11_145'>This field is for validation purposes and should be left unchanged.<\/div><div class='ginput_container'><input name='input_145' id='input_11_145' type='text' value='' autocomplete='new-password'\/><\/div><\/div><div id=\"field_11_38\" class=\"gfield gfield--type-hidden gfield--input-type-hidden gform_hidden field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><div class='ginput_container ginput_container_text'><input name='input_38' id='input_11_38' type='hidden' class='gform_hidden'  aria-invalid=\"false\" value='' \/><\/div><\/div><div id=\"field_11_39\" class=\"gfield gfield--type-hidden gfield--input-type-hidden gform_hidden field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><input name=\"input_39\" id=\"input_11_39\" type=\"hidden\" class=\"gform_hidden\" aria-invalid=\"false\" value=\"3176\"><\/div><div id=\"field_11_40\" class=\"gfield gfield--type-hidden gfield--input-type-hidden gform_hidden field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><input name=\"input_40\" id=\"input_11_40\" type=\"hidden\" class=\"gform_hidden\" aria-invalid=\"false\" value=\"f193bd523dbecb7ff45335fb32287682\"><\/div><div id=\"field_11_41\" class=\"gfield gfield--type-hidden gfield--input-type-hidden gform_hidden field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><div class='ginput_container ginput_container_text'><input name='input_41' id='input_11_41' type='hidden' class='gform_hidden'  aria-invalid=\"false\" value='' \/><\/div><\/div><div id=\"field_11_51\" class=\"gfield gfield--type-hidden gfield--input-type-hidden gform_hidden field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><div class='ginput_container ginput_container_text'><input name='input_51' id='input_11_51' type='hidden' class='gform_hidden'  aria-invalid=\"false\" value='' \/><\/div><\/div><div id=\"field_11_81\" class=\"gfield gfield--type-hidden gfield--input-type-hidden gform_hidden field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><div class='ginput_container ginput_container_text'><input name='input_81' id='input_11_81' type='hidden' class='gform_hidden'  aria-invalid=\"false\" value='' \/><\/div><\/div><div id=\"field_11_82\" class=\"gfield gfield--type-hidden gfield--input-type-hidden gform_hidden field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><div class='ginput_container ginput_container_text'><input name='input_82' id='input_11_82' type='hidden' class='gform_hidden'  aria-invalid=\"false\" value='' \/><\/div><\/div><div id=\"field_11_83\" class=\"gfield gfield--type-hidden gfield--input-type-hidden gform_hidden field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><div class='ginput_container ginput_container_text'><input name='input_83' id='input_11_83' type='hidden' class='gform_hidden'  aria-invalid=\"false\" value='' \/><\/div><\/div><div id=\"field_11_93\" class=\"gfield gfield--type-hidden gfield--input-type-hidden gfield--width-full gform_hidden field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><div class='ginput_container ginput_container_text'><input name='input_93' id='input_11_93' type='hidden' class='gform_hidden'  aria-invalid=\"false\" value='' \/><\/div><\/div><div id=\"field_11_94\" class=\"gfield gfield--type-hidden gfield--input-type-hidden gfield--width-full gform_hidden field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><div class='ginput_container ginput_container_text'><input name='input_94' id='input_11_94' type='hidden' class='gform_hidden'  aria-invalid=\"false\" value='https:\/\/screening.mhanational.org\/es\/wp-json\/wp\/v2\/screen\/3176' \/><\/div><\/div><div id=\"field_11_144\" class=\"gfield gfield--type-hidden gfield--input-type-hidden gfield--width-full gform_hidden field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><div class='ginput_container ginput_container_text'><input name='input_144' id='input_11_144' type='hidden' class='gform_hidden'  aria-invalid=\"false\" value='lang--es' \/><\/div><\/div><div id=\"field_11_136\" class=\"gfield gfield--type-html gfield--input-type-html gfield--width-full gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  >We're testing different ways to ask people about their PTSD symptoms.<\/div><fieldset id=\"field_11_137\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-full field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >Can you help us answer 9 extra questions about your experiences over different periods of time (1 month vs. 3 months)?<\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_11_137'>\n\t\t\t<div class='gchoice gchoice_11_137_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_137' type='radio' value='Yes'  id='choice_11_137_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_11_137_0' id='label_11_137_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_11_137_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_137' type='radio' value='No'  id='choice_11_137_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_11_137_1' id='label_11_137_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_11_138\" class=\"gfield gfield--type-html gfield--input-type-html gfield--width-full gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  >Thank you for your help!<\/div><div id=\"field_11_140\" class=\"gfield gfield--type-html gfield--input-type-html gfield--width-full gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  >Okay! You will only see the normal questions we always ask.<\/div><div id=\"field_11_139\" class=\"gfield gfield--type-html gfield--input-type-html gfield--width-full gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><hr \/><\/div><div id=\"field_11_131\" class=\"gfield gfield--type-html gfield--input-type-html gfield--width-full gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><p><strong>Note:<\/strong> We're testing different ways to ask people about their PTSD symptoms.<\/p>\n\n<p>You'll see some extra questions, which may seem repetitive. This could add about 5 minutes. You can opt out of the extra questions if you would like.<\/p><\/div><fieldset id=\"field_11_132\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield--input-type-checkbox gfield--width-full traditional field_sublabel_below gfield--no-description field_description_above hidden_label field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' >YC - opt out of extra questions<\/legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox ' id='input_11_132'><div class='gchoice gchoice_11_132_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_132.1' type='checkbox'  value='1'  id='choice_11_132_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_11_132_1' id='label_11_132_1' class='gform-field-label gform-field-label--type-inline'>Please don't ask me any extra questions.<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_11_134\" class=\"gfield gfield--type-html gfield--input-type-html gfield--width-full gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><strong>Okay! You will only see the normal questions we always ask.<\/strong><\/div><div id=\"field_11_133\" class=\"gfield gfield--type-html gfield--input-type-html gfield--width-full gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><hr \/><\/div><div id=\"field_11_97\" class=\"gfield gfield--type-html gfield--input-type-html gfield--width-full gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  >Sometimes things happen to people that are unusually or especially frightening, horrible, or traumatic.<\/div><fieldset id=\"field_11_95\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield--input-type-checkbox gfield--width-full traditional question gfield_contains_required field_sublabel_below gfield--has-description field_description_above field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Have you ever experienced any of the following?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class='gfield_description' id='gfield_description_11_95'>Select all that apply.<\/div><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox ' id='input_11_95'><div class='gchoice gchoice_11_95_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_95.1' type='checkbox'  value='Been in a national disaster where you thought you were going to die or be seriously injured ... like a flood ... or a tornado ... or an earthquake ... or a hurricane?'  id='choice_11_95_1'   aria-describedby=\"gfield_description_11_95\"\/>\n\t\t\t\t\t\t\t\t<label for='choice_11_95_1' id='label_11_95_1' class='gform-field-label gform-field-label--type-inline'>Been in a national disaster where you thought you were going to die or be seriously injured ... like a flood ... or a tornado ... or an earthquake ... or a hurricane?<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_11_95_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_95.2' type='checkbox'  value='Been attacked or hurt very badly'  id='choice_11_95_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_11_95_2' id='label_11_95_2' class='gform-field-label gform-field-label--type-inline'>Been attacked or hurt very badly<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_11_95_3'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_95.3' type='checkbox'  value='Any type of unwanted or uncomfortable sexual encounter'  id='choice_11_95_3'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_11_95_3' id='label_11_95_3' class='gform-field-label gform-field-label--type-inline'>Any type of unwanted or uncomfortable sexual encounter<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_11_95_4'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_95.4' type='checkbox'  value='Been in a situation when you thought you were going to die'  id='choice_11_95_4'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_11_95_4' id='label_11_95_4' class='gform-field-label gform-field-label--type-inline'>Been in a situation when you thought you were going to die<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_11_95_5'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_95.5' type='checkbox'  value='Had someone you were close be attacked or hurt very badly'  id='choice_11_95_5'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_11_95_5' id='label_11_95_5' class='gform-field-label gform-field-label--type-inline'>Had someone you were close be attacked or hurt very badly<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_11_95_6'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_95.6' type='checkbox'  value='Had someone close to you die very suddenly'  id='choice_11_95_6'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_11_95_6' id='label_11_95_6' class='gform-field-label gform-field-label--type-inline'>Had someone close to you die very suddenly<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_11_95_7'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_95.7' type='checkbox'  value='Seen anyone be killed or die suddenly in front of you (not on TV or in the movies)'  id='choice_11_95_7'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_11_95_7' id='label_11_95_7' class='gform-field-label gform-field-label--type-inline'>Seen anyone be killed or die suddenly in front of you (not on TV or in the movies)<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_11_95_8'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_95.8' type='checkbox'  value='Other...'  id='choice_11_95_8'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_11_95_8' id='label_11_95_8' class='gform-field-label gform-field-label--type-inline'>Other...<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_11_95_9'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_95.9' type='checkbox'  value='None of the above'  id='choice_11_95_9'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_11_95_9' id='label_11_95_9' class='gform-field-label gform-field-label--type-inline'>None of the above<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_11_96\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield--input-type-checkbox gfield--width-full traditional question gfield_contains_required field_sublabel_below gfield--has-description field_description_above field_validation_below gfield_visibility_hidden\"  ><div class=\"admin-hidden-markup\"><i class=\"gform-icon gform-icon--hidden\" aria-hidden=\"true\" title=\"This field is hidden when viewing the form\"><\/i><span>This field is hidden when viewing the form<\/span><\/div><legend class='gfield_label gform-field-label gfield_label_before_complex' >Have you ever experienced any of the following?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class='gfield_description' id='gfield_description_11_96'>Select all that apply.<\/div><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox ' id='input_11_96'><div class='gchoice gchoice_11_96_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_96.1' type='checkbox'  value='A serious accident or fire'  id='choice_11_96_1'   aria-describedby=\"gfield_description_11_96\"\/>\n\t\t\t\t\t\t\t\t<label for='choice_11_96_1' id='label_11_96_1' class='gform-field-label gform-field-label--type-inline'>A serious accident or fire<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_11_96_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_96.2' type='checkbox'  value='A physical or sexual assault or abuse'  id='choice_11_96_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_11_96_2' id='label_11_96_2' class='gform-field-label gform-field-label--type-inline'>A physical or sexual assault or abuse<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_11_96_3'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_96.3' type='checkbox'  value='An earthquake or flood'  id='choice_11_96_3'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_11_96_3' id='label_11_96_3' class='gform-field-label gform-field-label--type-inline'>An earthquake or flood<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_11_96_4'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_96.4' type='checkbox'  value='A war'  id='choice_11_96_4'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_11_96_4' id='label_11_96_4' class='gform-field-label gform-field-label--type-inline'>A war<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_11_96_5'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_96.5' type='checkbox'  value='Seeing someone be killed or seriously injured'  id='choice_11_96_5'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_11_96_5' id='label_11_96_5' class='gform-field-label gform-field-label--type-inline'>Seeing someone be killed or seriously injured<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_11_96_6'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_96.6' type='checkbox'  value='Having a loved one die through homicide or suicide'  id='choice_11_96_6'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_11_96_6' id='label_11_96_6' class='gform-field-label gform-field-label--type-inline'>Having a loved one die through homicide or suicide<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_11_96_7'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_96.7' type='checkbox'  value='Other...'  id='choice_11_96_7'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_11_96_7' id='label_11_96_7' class='gform-field-label gform-field-label--type-inline'>Other...<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_11_96_8'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_96.8' type='checkbox'  value='None of the above'  id='choice_11_96_8'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_11_96_8' id='label_11_96_8' class='gform-field-label gform-field-label--type-inline'>None of the above<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_11_98\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-full field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_11_98'>What else have you experienced that was especially frightening, horrible, or traumatic?<\/label><div class='ginput_container ginput_container_text'><input name='input_98' id='input_11_98' type='text' value='' class='large'    placeholder='Tell us more...'  aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_11_99\" class=\"gfield gfield--type-html gfield--input-type-html gfield--width-full gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  >\n<p>If YES - please answer the questions below.<\/p>\n\n<p style=\"display:none;\"><strong>In the past month, have you...<\/strong><\/p><\/div><div id=\"field_11_101\" class=\"gfield gfield--type-section gfield--input-type-section gsection field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><h3 class=\"gsection_title\">In the last 3 months...<\/h3><\/div><fieldset id=\"field_11_102\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' ><strong>In the last three months<\/strong>, have you often thought about any of these events?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_11_102'>\n\t\t\t<div class='gchoice gchoice_11_102_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_102' type='radio' value='Yes'  id='choice_11_102_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_11_102_0' id='label_11_102_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_11_102_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_102' type='radio' value='No'  id='choice_11_102_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_11_102_1' id='label_11_102_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_11_104\" class=\"gfield gfield--type-html gfield--input-type-html gfield--width-full gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  >These next questions are about how you have been acting and feeling in the last three months, because of the upsetting event that you said happened to you.<\/div><fieldset id=\"field_11_103\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' ><strong>In the last three months<\/strong>, have you had problems falling asleep or staying asleep?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_11_103'>\n\t\t\t<div class='gchoice gchoice_11_103_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_103' type='radio' value='Yes'  id='choice_11_103_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_11_103_0' id='label_11_103_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_11_103_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_103' type='radio' value='No'  id='choice_11_103_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_11_103_1' id='label_11_103_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_11_105\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' ><strong>In the last three months<\/strong>, have you had a lot of nightmares about what happened?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_11_105'>\n\t\t\t<div class='gchoice gchoice_11_105_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_105' type='radio' value='Yes'  id='choice_11_105_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_11_105_0' id='label_11_105_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_11_105_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_105' type='radio' value='No'  id='choice_11_105_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_11_105_1' id='label_11_105_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_11_106\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' ><strong>In the last three months<\/strong>, have you tried very hard not to think about what happened and not to hear about it or talk about it?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_11_106'>\n\t\t\t<div class='gchoice gchoice_11_106_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_106' type='radio' value='Yes'  id='choice_11_106_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_11_106_0' id='label_11_106_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_11_106_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_106' type='radio' value='No'  id='choice_11_106_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_11_106_1' id='label_11_106_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_11_107\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' ><strong>In the last three months<\/strong>, have you stopped going places or doing things that might make you think about what happened?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_11_107'>\n\t\t\t<div class='gchoice gchoice_11_107_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_107' type='radio' value='Yes'  id='choice_11_107_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_11_107_0' id='label_11_107_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_11_107_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_107' type='radio' value='No'  id='choice_11_107_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_11_107_1' id='label_11_107_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_11_108\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' ><strong>In the last three months<\/strong>, have you tried to keep away from people who might remind you of what happened?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_11_108'>\n\t\t\t<div class='gchoice gchoice_11_108_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_108' type='radio' value='Yes'  id='choice_11_108_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_11_108_0' id='label_11_108_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_11_108_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_108' type='radio' value='No'  id='choice_11_108_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_11_108_1' id='label_11_108_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_11_109\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' ><strong>In the last three months<\/strong>, have you stopped thinking about the future or about things that you might do when you are older?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_11_109'>\n\t\t\t<div class='gchoice gchoice_11_109_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_109' type='radio' value='Yes'  id='choice_11_109_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_11_109_0' id='label_11_109_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_11_109_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_109' type='radio' value='No'  id='choice_11_109_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_11_109_1' id='label_11_109_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_11_110\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' ><strong>In the last three months<\/strong>, has it been harder to keep your mind on things or to concentrate?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_11_110'>\n\t\t\t<div class='gchoice gchoice_11_110_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_110' type='radio' value='Yes'  id='choice_11_110_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_11_110_0' id='label_11_110_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_11_110_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_110' type='radio' value='No'  id='choice_11_110_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_11_110_1' id='label_11_110_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_11_111\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' ><strong>In the last three months<\/strong>, have you been very upset, afraid or sad when something has made you think about what happened?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_11_111'>\n\t\t\t<div class='gchoice gchoice_11_111_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_111' type='radio' value='Yes'  id='choice_11_111_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_11_111_0' id='label_11_111_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_11_111_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_111' type='radio' value='No'  id='choice_11_111_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_11_111_1' id='label_11_111_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_11_112\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' ><strong>In the last three months<\/strong>, have you had trouble remembering important parts of what happened?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_11_112'>\n\t\t\t<div class='gchoice gchoice_11_112_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_112' type='radio' value='Yes'  id='choice_11_112_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_11_112_0' id='label_11_112_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_11_112_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_112' type='radio' value='No'  id='choice_11_112_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_11_112_1' id='label_11_112_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_11_113\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' ><strong>In the last three months<\/strong>, have you had upsetting thoughts or pictures of what happened come into your mind, when you didn't want them to?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_11_113'>\n\t\t\t<div class='gchoice gchoice_11_113_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_113' type='radio' value='Yes'  id='choice_11_113_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_11_113_0' id='label_11_113_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_11_113_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_113' type='radio' value='No'  id='choice_11_113_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_11_113_1' id='label_11_113_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_11_100\" class=\"gfield gfield--type-section gfield--input-type-section gsection field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><h3 class=\"gsection_title\">In the past month, have you...<\/h3><\/div><fieldset id=\"field_11_5\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio question short gfield_contains_required field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >1. had nightmares about the event(s) or thought about the event(s) when you did not want to?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_11_5'>\n\t\t\t<div class='gchoice gchoice_11_5_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_5' type='radio' value='0'  id='choice_11_5_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_11_5_0' id='label_11_5_0' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_11_5_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_5' type='radio' value='1'  id='choice_11_5_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_11_5_1' id='label_11_5_1' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_11_47\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio question short gfield_contains_required field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >2. tried hard not to think about the event(s) or went out of your way to avoid situations that reminded you of the event(s)?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_11_47'>\n\t\t\t<div class='gchoice gchoice_11_47_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_47' type='radio' value='0'  id='choice_11_47_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_11_47_0' id='label_11_47_0' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_11_47_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_47' type='radio' value='1'  id='choice_11_47_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_11_47_1' id='label_11_47_1' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_11_48\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio question short gfield_contains_required field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >3. been constantly on guard, watchful, or easily startled?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_11_48'>\n\t\t\t<div class='gchoice gchoice_11_48_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_48' type='radio' value='0'  id='choice_11_48_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_11_48_0' id='label_11_48_0' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_11_48_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_48' type='radio' value='1'  id='choice_11_48_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_11_48_1' id='label_11_48_1' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_11_49\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio question short gfield_contains_required field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >4. felt numb or detached from people, activities, or your surroundings?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_11_49'>\n\t\t\t<div class='gchoice gchoice_11_49_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_49' type='radio' value='0'  id='choice_11_49_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_11_49_0' id='label_11_49_0' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_11_49_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_49' type='radio' value='1'  id='choice_11_49_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_11_49_1' id='label_11_49_1' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_11_50\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio question short gfield_contains_required field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >5. felt guilty or unable to stop blaming yourself or others for the event(s) or any problems the event(s) may have caused?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_11_50'>\n\t\t\t<div class='gchoice gchoice_11_50_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_50' type='radio' value='0'  id='choice_11_50_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_11_50_0' id='label_11_50_0' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_11_50_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_50' type='radio' value='1'  id='choice_11_50_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_11_50_1' id='label_11_50_1' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_11_115\" class=\"gfield gfield--type-section gfield--input-type-section gsection field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><h3 class=\"gsection_title\">In the last 3 months...<\/h3><\/div><fieldset id=\"field_11_114\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' ><strong>In the last three months<\/strong>, have you often thought about any of these events?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_11_114'>\n\t\t\t<div class='gchoice gchoice_11_114_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_114' type='radio' value='Yes'  id='choice_11_114_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_11_114_0' id='label_11_114_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_11_114_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_114' type='radio' value='No'  id='choice_11_114_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_11_114_1' id='label_11_114_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_11_116\" class=\"gfield gfield--type-html gfield--input-type-html gfield--width-full gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  >These next questions are about how you have been acting and feeling in the last three months, because of the upsetting event that you said happened to you.<\/div><fieldset id=\"field_11_117\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' ><strong>In the last three months<\/strong>, have you had problems falling asleep or staying asleep?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_11_117'>\n\t\t\t<div class='gchoice gchoice_11_117_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_117' type='radio' value='Yes'  id='choice_11_117_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_11_117_0' id='label_11_117_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_11_117_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_117' type='radio' value='No'  id='choice_11_117_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_11_117_1' id='label_11_117_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_11_118\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' ><strong>In the last three months<\/strong>, have you had a lot of nightmares about what happened?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_11_118'>\n\t\t\t<div class='gchoice gchoice_11_118_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_118' type='radio' value='Yes'  id='choice_11_118_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_11_118_0' id='label_11_118_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_11_118_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_118' type='radio' value='No'  id='choice_11_118_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_11_118_1' id='label_11_118_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_11_119\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' ><strong>In the last three months<\/strong>, have you tried very hard not to think about what happened and not to hear about it or talk about it?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_11_119'>\n\t\t\t<div class='gchoice gchoice_11_119_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_119' type='radio' value='Yes'  id='choice_11_119_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_11_119_0' id='label_11_119_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_11_119_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_119' type='radio' value='No'  id='choice_11_119_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_11_119_1' id='label_11_119_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_11_120\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' ><strong>In the last three months<\/strong>, have you stopped going places or doing things that might make you think about what happened?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_11_120'>\n\t\t\t<div class='gchoice gchoice_11_120_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_120' type='radio' value='Yes'  id='choice_11_120_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_11_120_0' id='label_11_120_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_11_120_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_120' type='radio' value='No'  id='choice_11_120_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_11_120_1' id='label_11_120_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_11_121\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' ><strong>In the last three months<\/strong>, have you tried to keep away from people who might remind you of what happened?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_11_121'>\n\t\t\t<div class='gchoice gchoice_11_121_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_121' type='radio' value='Yes'  id='choice_11_121_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_11_121_0' id='label_11_121_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_11_121_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_121' type='radio' value='No'  id='choice_11_121_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_11_121_1' id='label_11_121_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_11_122\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' ><strong>In the last three months<\/strong>, have you stopped thinking about the future or about things that you might do when you are older?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_11_122'>\n\t\t\t<div class='gchoice gchoice_11_122_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_122' type='radio' value='Yes'  id='choice_11_122_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_11_122_0' id='label_11_122_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_11_122_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_122' type='radio' value='No'  id='choice_11_122_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_11_122_1' id='label_11_122_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_11_123\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' ><strong>In the last three months<\/strong>, has it been harder to keep your mind on things or to concentrate?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_11_123'>\n\t\t\t<div class='gchoice gchoice_11_123_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_123' type='radio' value='Yes'  id='choice_11_123_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_11_123_0' id='label_11_123_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_11_123_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_123' type='radio' value='No'  id='choice_11_123_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_11_123_1' id='label_11_123_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_11_124\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' ><strong>In the last three months<\/strong>, have you been very upset, afraid or sad when something has made you think about what happened?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_11_124'>\n\t\t\t<div class='gchoice gchoice_11_124_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_124' type='radio' value='Yes'  id='choice_11_124_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_11_124_0' id='label_11_124_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_11_124_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_124' type='radio' value='No'  id='choice_11_124_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_11_124_1' id='label_11_124_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_11_125\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' ><strong>In the last three months<\/strong>, have you had trouble remembering important parts of what happened?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_11_125'>\n\t\t\t<div class='gchoice gchoice_11_125_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_125' type='radio' value='Yes'  id='choice_11_125_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_11_125_0' id='label_11_125_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_11_125_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_125' type='radio' value='No'  id='choice_11_125_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_11_125_1' id='label_11_125_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_11_126\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' ><strong>In the last three months<\/strong>, have you had upsetting thoughts or pictures of what happened come into your mind, when you didn't want them to?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_11_126'>\n\t\t\t<div class='gchoice gchoice_11_126_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_126' type='radio' value='Yes'  id='choice_11_126_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_11_126_0' id='label_11_126_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_11_126_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_126' type='radio' value='No'  id='choice_11_126_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_11_126_1' id='label_11_126_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><\/div>\n                    <\/div>\n                    <div class='gform-page-footer gform_page_footer top_label'>\n                         <input type='button' id='gform_next_button_11_17' class='gform_next_button gform-theme-button button' onclick='gform.submission.handleButtonClick(this);' data-submission-type='next' value='Next'  \/> \n                    <\/div>\n                <\/div>\n                <div id='gform_page_11_2' class='gform_page demographics' data-js='page-field-id-17' style='display:none;'>\n                    <div class='gform_page_fields'>\n                        <div id='gform_fields_11_2' class='gform_fields top_label form_sublabel_below description_above validation_below'><div id=\"field_11_52\" class=\"gfield gfield--type-html gfield--input-type-html gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><p>Please take a moment to answer the following <strong>optional<\/strong> questions. Your answers are totally anonymous\u2014we won't be able to identify you based on this information. Your answers help us provide better information and support for people like you.<\/p>\n\n<p>You can answer as many or as few questions as you would like. When you are done, scroll to the bottom of the survey and click \"submit\" to receive your screening results.<\/p><\/div><div id=\"field_11_84\" class=\"gfield gfield--type-html gfield--input-type-html gfield--width-full gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><hr \/><\/div><fieldset id=\"field_11_85\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-full field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >Are you taking this test for yourself or for someone else?<\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_11_85'>\n\t\t\t<div class='gchoice gchoice_11_85_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_85' type='radio' value='For myself'  id='choice_11_85_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_11_85_0' id='label_11_85_0' class='gform-field-label gform-field-label--type-inline'>For myself<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_11_85_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_85' type='radio' value='For someone else'  id='choice_11_85_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_11_85_1' id='label_11_85_1' class='gform-field-label gform-field-label--type-inline'>For someone else<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_11_86\" class=\"gfield gfield--type-html gfield--input-type-html gfield--width-full gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  >If you are taking this test for someone else, <strong>please use that person's information<\/strong> for the questions below, or leave them blank if you don't know the answer. Remember, <em>these questions are optional<\/em>.<\/div><div id=\"field_11_53\" class=\"gfield gfield--type-html gfield--input-type-html section-title gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><h2>About You<\/h2><\/div><div id=\"field_11_54\" class=\"gfield gfield--type-select gfield--input-type-select optional taxonomy field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_11_54'>Age Range<\/label><div class='ginput_container ginput_container_select'><select name='input_54' id='input_11_54' class='medium gfield_select'     aria-invalid=\"false\" ><option value='' ><\/option><option value='8-10' >8-10<\/option><option value='11-13' >11-13<\/option><option value='14-15' >14-15<\/option><option value='16-17' >16-17<\/option><option value='18-24' >18-24<\/option><option value='25-34' >25-34<\/option><option value='35-44' >35-44<\/option><option value='45-54' >45-54<\/option><option value='55-64' >55-64<\/option><option value='65+' >65+<\/option><\/select><\/div><\/div><fieldset id=\"field_11_55\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio optional field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >Gender<\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_11_55'>\n\t\t\t<div class='gchoice gchoice_11_55_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_55' type='radio' value='Female'  id='choice_11_55_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_11_55_0' id='label_11_55_0' class='gform-field-label gform-field-label--type-inline'>Female<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_11_55_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_55' type='radio' value='Male'  id='choice_11_55_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_11_55_1' id='label_11_55_1' class='gform-field-label gform-field-label--type-inline'>Male<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_11_55_2'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_55' type='radio' value='Non-Binary'  id='choice_11_55_2' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_11_55_2' id='label_11_55_2' class='gform-field-label gform-field-label--type-inline'>Non-Binary<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_11_141\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-full field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >Do you identify as transgender?<\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_11_141'>\n\t\t\t<div class='gchoice gchoice_11_141_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_141' type='radio' value='Yes'  id='choice_11_141_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_11_141_0' id='label_11_141_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_11_141_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_141' type='radio' value='No'  id='choice_11_141_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_11_141_1' id='label_11_141_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_11_56\" class=\"gfield gfield--type-text gfield--input-type-text optional field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_11_56'>How would you describe your gender?<\/label><div class='ginput_container ginput_container_text'><input name='input_56' id='input_11_56' type='text' value='' class='small'    placeholder='Enter gender...'  aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_11_58\" class=\"gfield gfield--type-select gfield--input-type-select optional field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_11_58'>Race\/Ethnicity<\/label><div class='ginput_container ginput_container_select'><select name='input_58' id='input_11_58' class='medium gfield_select'     aria-invalid=\"false\" ><option value='' ><\/option><option value='American Indian or Alaska Native' >American Indian or Alaska Native<\/option><option value='Asian' >Asian<\/option><option value='Black or African American (non-Hispanic)' >Black or African American (non-Hispanic)<\/option><option value='Hispanic or Latino' >Hispanic or Latino<\/option><option value='Middle Eastern or North African' >Middle Eastern or North African<\/option><option value='Native Hawaiian or other Pacific Islander' >Native Hawaiian or other Pacific Islander<\/option><option value='White (non-Hispanic)' >White (non-Hispanic)<\/option><option value='More than one of the above' >More than one of the above<\/option><option value='Other' >Other<\/option><\/select><\/div><\/div><div id=\"field_11_59\" class=\"gfield gfield--type-select gfield--input-type-select optional field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_11_59'>Household Income<\/label><div class='ginput_container ginput_container_select'><select name='input_59' id='input_11_59' class='medium gfield_select'     aria-invalid=\"false\" ><option value='' ><\/option><option value='Less than $20,000' >Less than $20,000<\/option><option value='$20,000 - $39,999' >$20,000 - $39,999<\/option><option value='$40,000 - $59,999' >$40,000 - $59,999<\/option><option value='$60,000 - $79,999' >$60,000 - $79,999<\/option><option value='$80,000 - $99,999' >$80,000 - $99,999<\/option><option value='$100,000 - $149,999' >$100,000 - $149,999<\/option><option value='$150,000+' >$150,000+<\/option><\/select><\/div><\/div><fieldset id=\"field_11_87\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-full field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >Do you live in the United States or another country?<\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_11_87'>\n\t\t\t<div class='gchoice gchoice_11_87_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_87' type='radio' value='I live in the United States'  id='choice_11_87_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_11_87_0' id='label_11_87_0' class='gform-field-label gform-field-label--type-inline'>I live in the United States<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_11_87_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_87' type='radio' value='I live in another country'  id='choice_11_87_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_11_87_1' id='label_11_87_1' class='gform-field-label gform-field-label--type-inline'>I live in another country<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_11_78\" class=\"gfield gfield--type-select gfield--input-type-select gfield--width-full optional field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_11_78'>State<\/label><div class='ginput_container ginput_container_select'><select name='input_78' id='input_11_78' class='medium gfield_select'     aria-invalid=\"false\" ><option value='' ><\/option><option value='Alabama' >Alabama<\/option><option value='Alaska' >Alaska<\/option><option value='Arizona' >Arizona<\/option><option value='Arkansas' >Arkansas<\/option><option value='California' >California<\/option><option value='Colorado' >Colorado<\/option><option value='Connecticut' >Connecticut<\/option><option value='Delaware' >Delaware<\/option><option value='District of Columbia' >District of Columbia<\/option><option value='Florida' >Florida<\/option><option value='Georgia' >Georgia<\/option><option value='Hawaii' >Hawaii<\/option><option value='Idaho' >Idaho<\/option><option value='Illinois' >Illinois<\/option><option value='Indiana' >Indiana<\/option><option value='Iowa' >Iowa<\/option><option value='Kansas' >Kansas<\/option><option value='Kentucky' >Kentucky<\/option><option value='Louisiana' >Louisiana<\/option><option value='Maine' >Maine<\/option><option value='Maryland' >Maryland<\/option><option value='Massachusetts' >Massachusetts<\/option><option value='Michigan' >Michigan<\/option><option value='Minnesota' >Minnesota<\/option><option value='Mississippi' >Mississippi<\/option><option value='Missouri' >Missouri<\/option><option value='Montana' >Montana<\/option><option value='Nebraska' >Nebraska<\/option><option value='Nevada' >Nevada<\/option><option value='New Hampshire' >New Hampshire<\/option><option value='New Jersey' >New Jersey<\/option><option value='New Mexico' >New Mexico<\/option><option value='New York' >New York<\/option><option value='North Carolina' >North Carolina<\/option><option value='North Dakota' >North Dakota<\/option><option value='Ohio' >Ohio<\/option><option value='Oklahoma' >Oklahoma<\/option><option value='Oregon' >Oregon<\/option><option value='Pennsylvania' >Pennsylvania<\/option><option value='Rhode Island' >Rhode Island<\/option><option value='South Carolina' >South Carolina<\/option><option value='South Dakota' >South Dakota<\/option><option value='Tennessee' >Tennessee<\/option><option value='Texas' >Texas<\/option><option value='Utah' >Utah<\/option><option value='Vermont' >Vermont<\/option><option value='Virginia' >Virginia<\/option><option value='Washington' >Washington<\/option><option value='West Virginia' >West Virginia<\/option><option value='Wisconsin' >Wisconsin<\/option><option value='Wyoming' >Wyoming<\/option><option value='I live in a U.S. Territory' >I live in a U.S. Territory<\/option><\/select><\/div><\/div><div id=\"field_11_80\" class=\"gfield gfield--type-select gfield--input-type-select gfield--width-full optional field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_11_80'>What country do you live in?<\/label><div class='ginput_container ginput_container_select'><select name='input_80' id='input_11_80' class='medium gfield_select'     aria-invalid=\"false\" ><option value='' ><\/option><option value='Afghanistan' >Afghanistan<\/option><option value='Albania' >Albania<\/option><option value='Algeria' >Algeria<\/option><option value='American Samoa' >American Samoa<\/option><option value='Andorra' >Andorra<\/option><option value='Angola' >Angola<\/option><option value='Anguilla' >Anguilla<\/option><option value='Antarctica' >Antarctica<\/option><option value='Antigua and Barbuda' >Antigua and Barbuda<\/option><option value='Argentina' >Argentina<\/option><option value='Armenia' >Armenia<\/option><option value='Aruba' >Aruba<\/option><option value='Australia' >Australia<\/option><option value='Austria' >Austria<\/option><option value='Azerbaijan' >Azerbaijan<\/option><option value='Bahamas' >Bahamas<\/option><option value='Bahrain' >Bahrain<\/option><option value='Bangladesh' >Bangladesh<\/option><option value='Barbados' >Barbados<\/option><option value='Belarus' >Belarus<\/option><option value='Belgium' >Belgium<\/option><option value='Belize' >Belize<\/option><option value='Benin' >Benin<\/option><option value='Bermuda' >Bermuda<\/option><option value='Bhutan' >Bhutan<\/option><option value='Bolivia' >Bolivia<\/option><option value='Bonaire, Sint Eustatius and Saba' >Bonaire, Sint Eustatius and Saba<\/option><option value='Bosnia and Herzegovina' >Bosnia and Herzegovina<\/option><option value='Botswana' >Botswana<\/option><option value='Bouvet Island' >Bouvet Island<\/option><option value='Brazil' >Brazil<\/option><option value='British Indian Ocean Territory' >British Indian Ocean Territory<\/option><option value='Brunei Darussalam' >Brunei Darussalam<\/option><option value='Bulgaria' >Bulgaria<\/option><option value='Burkina Faso' >Burkina Faso<\/option><option value='Burundi' >Burundi<\/option><option value='Cambodia' >Cambodia<\/option><option value='Cameroon' >Cameroon<\/option><option value='Canada' >Canada<\/option><option value='Cape Verde' >Cape Verde<\/option><option value='Cayman Islands' >Cayman Islands<\/option><option value='Central African Republic' >Central African Republic<\/option><option value='Chad' >Chad<\/option><option value='Chile' >Chile<\/option><option value='China' >China<\/option><option value='Christmas Island' >Christmas Island<\/option><option value='Cocos Islands' >Cocos Islands<\/option><option value='Colombia' >Colombia<\/option><option value='Comoros' >Comoros<\/option><option value='Congo, Democratic Republic of the' >Congo, Democratic Republic of the<\/option><option value='Congo, Republic of the' >Congo, Republic of the<\/option><option value='Cook Islands' >Cook Islands<\/option><option value='Costa Rica' >Costa Rica<\/option><option value='Croatia' >Croatia<\/option><option value='Cuba' >Cuba<\/option><option value='Cura\u00e7ao' >Cura\u00e7ao<\/option><option value='Cyprus' >Cyprus<\/option><option value='Czech Republic' >Czech Republic<\/option><option value='C\u00f4te d&#039;Ivoire' >C\u00f4te d&#039;Ivoire<\/option><option value='Denmark' >Denmark<\/option><option value='Djibouti' >Djibouti<\/option><option value='Dominica' >Dominica<\/option><option value='Dominican Republic' >Dominican Republic<\/option><option value='Ecuador' >Ecuador<\/option><option value='Egypt' >Egypt<\/option><option value='El Salvador' >El Salvador<\/option><option value='Equatorial Guinea' >Equatorial Guinea<\/option><option value='Eritrea' >Eritrea<\/option><option value='Estonia' >Estonia<\/option><option value='Eswatini (Swaziland)' >Eswatini (Swaziland)<\/option><option value='Ethiopia' >Ethiopia<\/option><option value='Falkland Islands' >Falkland Islands<\/option><option value='Faroe Islands' >Faroe Islands<\/option><option value='Fiji' >Fiji<\/option><option value='Finland' >Finland<\/option><option value='France' >France<\/option><option value='French Guiana' >French Guiana<\/option><option value='French Polynesia' >French Polynesia<\/option><option value='French Southern Territories' >French Southern Territories<\/option><option value='Gabon' >Gabon<\/option><option value='Gambia' >Gambia<\/option><option value='Georgia' >Georgia<\/option><option value='Germany' >Germany<\/option><option value='Ghana' >Ghana<\/option><option value='Gibraltar' >Gibraltar<\/option><option value='Greece' >Greece<\/option><option value='Greenland' >Greenland<\/option><option value='Grenada' >Grenada<\/option><option value='Guadeloupe' >Guadeloupe<\/option><option value='Guam' >Guam<\/option><option value='Guatemala' >Guatemala<\/option><option value='Guernsey' >Guernsey<\/option><option value='Guinea' >Guinea<\/option><option value='Guinea-Bissau' >Guinea-Bissau<\/option><option value='Guyana' >Guyana<\/option><option value='Haiti' >Haiti<\/option><option value='Heard and McDonald Islands' >Heard and McDonald Islands<\/option><option value='Holy See' >Holy See<\/option><option value='Honduras' >Honduras<\/option><option value='Hong Kong' >Hong Kong<\/option><option value='Hungary' >Hungary<\/option><option value='Iceland' >Iceland<\/option><option value='India' >India<\/option><option value='Indonesia' >Indonesia<\/option><option value='Iran' >Iran<\/option><option value='Iraq' >Iraq<\/option><option value='Ireland' >Ireland<\/option><option value='Isle of Man' >Isle of Man<\/option><option value='Israel' >Israel<\/option><option value='Italy' >Italy<\/option><option value='Jamaica' >Jamaica<\/option><option value='Japan' >Japan<\/option><option value='Jersey' >Jersey<\/option><option value='Jordan' >Jordan<\/option><option value='Kazakhstan' >Kazakhstan<\/option><option value='Kenya' >Kenya<\/option><option value='Kiribati' >Kiribati<\/option><option value='Kuwait' >Kuwait<\/option><option value='Kyrgyzstan' >Kyrgyzstan<\/option><option value='Lao People&#039;s Democratic Republic' >Lao People&#039;s Democratic Republic<\/option><option value='Latvia' >Latvia<\/option><option value='Lebanon' >Lebanon<\/option><option value='Lesotho' >Lesotho<\/option><option value='Liberia' >Liberia<\/option><option value='Libya' >Libya<\/option><option value='Liechtenstein' >Liechtenstein<\/option><option value='Lithuania' >Lithuania<\/option><option value='Luxembourg' >Luxembourg<\/option><option value='Macau' >Macau<\/option><option value='Macedonia' >Macedonia<\/option><option value='Madagascar' >Madagascar<\/option><option value='Malawi' >Malawi<\/option><option value='Malaysia' >Malaysia<\/option><option value='Maldives' >Maldives<\/option><option value='Mali' >Mali<\/option><option value='Malta' >Malta<\/option><option value='Marshall Islands' >Marshall Islands<\/option><option value='Martinique' >Martinique<\/option><option value='Mauritania' >Mauritania<\/option><option value='Mauritius' >Mauritius<\/option><option value='Mayotte' >Mayotte<\/option><option value='Mexico' >Mexico<\/option><option value='Micronesia' >Micronesia<\/option><option value='Moldova' >Moldova<\/option><option value='Monaco' >Monaco<\/option><option value='Mongolia' >Mongolia<\/option><option value='Montenegro' >Montenegro<\/option><option value='Montserrat' >Montserrat<\/option><option value='Morocco' >Morocco<\/option><option value='Mozambique' >Mozambique<\/option><option value='Myanmar' >Myanmar<\/option><option value='Namibia' >Namibia<\/option><option value='Nauru' >Nauru<\/option><option value='Nepal' >Nepal<\/option><option value='Netherlands' >Netherlands<\/option><option value='New Caledonia' >New Caledonia<\/option><option value='New Zealand' >New Zealand<\/option><option value='Nicaragua' >Nicaragua<\/option><option value='Niger' >Niger<\/option><option value='Nigeria' >Nigeria<\/option><option value='Niue' >Niue<\/option><option value='Norfolk Island' >Norfolk Island<\/option><option value='North Korea' >North Korea<\/option><option value='Northern Mariana Islands' >Northern Mariana Islands<\/option><option value='Norway' >Norway<\/option><option value='Oman' >Oman<\/option><option value='Pakistan' >Pakistan<\/option><option value='Palau' >Palau<\/option><option value='Palestine, State of' >Palestine, State of<\/option><option value='Panama' >Panama<\/option><option value='Papua New Guinea' >Papua New Guinea<\/option><option value='Paraguay' >Paraguay<\/option><option value='Peru' >Peru<\/option><option value='Philippines' >Philippines<\/option><option value='Pitcairn' >Pitcairn<\/option><option value='Poland' >Poland<\/option><option value='Portugal' >Portugal<\/option><option value='Puerto Rico' >Puerto Rico<\/option><option value='Qatar' >Qatar<\/option><option value='Romania' >Romania<\/option><option value='Russia' >Russia<\/option><option value='Rwanda' >Rwanda<\/option><option value='R\u00e9union' >R\u00e9union<\/option><option value='Saint Barth\u00e9lemy' >Saint Barth\u00e9lemy<\/option><option value='Saint Helena' >Saint Helena<\/option><option value='Saint Kitts and Nevis' >Saint Kitts and Nevis<\/option><option value='Saint Lucia' >Saint Lucia<\/option><option value='Saint Martin' >Saint Martin<\/option><option value='Saint Pierre and Miquelon' >Saint Pierre and Miquelon<\/option><option value='Saint Vincent and the Grenadines' >Saint Vincent and the Grenadines<\/option><option value='Samoa' >Samoa<\/option><option value='San Marino' >San Marino<\/option><option value='Sao Tome and Principe' >Sao Tome and Principe<\/option><option value='Saudi Arabia' >Saudi Arabia<\/option><option value='Senegal' >Senegal<\/option><option value='Serbia' >Serbia<\/option><option value='Seychelles' >Seychelles<\/option><option value='Sierra Leone' >Sierra Leone<\/option><option value='Singapore' >Singapore<\/option><option value='Sint Maarten' >Sint Maarten<\/option><option value='Slovakia' >Slovakia<\/option><option value='Slovenia' >Slovenia<\/option><option value='Solomon Islands' >Solomon Islands<\/option><option value='Somalia' >Somalia<\/option><option value='South Africa' >South Africa<\/option><option value='South Georgia' >South Georgia<\/option><option value='South Korea' >South Korea<\/option><option value='South Sudan' >South Sudan<\/option><option value='Spain' >Spain<\/option><option value='Sri Lanka' >Sri Lanka<\/option><option value='Sudan' >Sudan<\/option><option value='Suriname' >Suriname<\/option><option value='Svalbard and Jan Mayen Islands' >Svalbard and Jan Mayen Islands<\/option><option value='Sweden' >Sweden<\/option><option value='Switzerland' >Switzerland<\/option><option value='Syria' >Syria<\/option><option value='Taiwan' >Taiwan<\/option><option value='Tajikistan' >Tajikistan<\/option><option value='Tanzania' >Tanzania<\/option><option value='Thailand' >Thailand<\/option><option value='Timor-Leste' >Timor-Leste<\/option><option value='Togo' >Togo<\/option><option value='Tokelau' >Tokelau<\/option><option value='Tonga' >Tonga<\/option><option value='Trinidad and Tobago' >Trinidad and Tobago<\/option><option value='Tunisia' >Tunisia<\/option><option value='Turkey' >Turkey<\/option><option value='Turkmenistan' >Turkmenistan<\/option><option value='Turks and Caicos Islands' >Turks and Caicos Islands<\/option><option value='Tuvalu' >Tuvalu<\/option><option value='US Minor Outlying Islands' >US Minor Outlying Islands<\/option><option value='Uganda' >Uganda<\/option><option value='Ukraine' >Ukraine<\/option><option value='United Arab Emirates' >United Arab Emirates<\/option><option value='United Kingdom' >United Kingdom<\/option><option value='Uruguay' >Uruguay<\/option><option value='Uzbekistan' >Uzbekistan<\/option><option value='Vanuatu' >Vanuatu<\/option><option value='Venezuela' >Venezuela<\/option><option value='Vietnam' >Vietnam<\/option><option value='Virgin Islands, British' >Virgin Islands, British<\/option><option value='Virgin Islands, U.S.' >Virgin Islands, U.S.<\/option><option value='Wallis and Futuna' >Wallis and Futuna<\/option><option value='Western Sahara' >Western Sahara<\/option><option value='Yemen' >Yemen<\/option><option value='Zambia' >Zambia<\/option><option value='Zimbabwe' >Zimbabwe<\/option><option value='\u00c5land Islands' >\u00c5land Islands<\/option><\/select><\/div><\/div><div id=\"field_11_79\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-full optional field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_11_79'>Zip\/Postal Code<\/label><div class='ginput_container ginput_container_text'><input name='input_79' id='input_11_79' type='text' value='' class='small'      aria-invalid=\"false\"   \/><\/div><\/div><fieldset id=\"field_11_60\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield--input-type-checkbox optional traditional field_sublabel_below gfield--has-description field_description_above field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Which of the following populations describes you?<\/legend><div class='gfield_description' id='gfield_description_11_60'>Select all that apply.<\/div><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox ' id='input_11_60'><div class='gchoice gchoice_11_60_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_60.1' type='checkbox'  value='Veteran or active-duty military'  id='choice_11_60_1'   aria-describedby=\"gfield_description_11_60\"\/>\n\t\t\t\t\t\t\t\t<label for='choice_11_60_1' id='label_11_60_1' class='gform-field-label gform-field-label--type-inline'>Veteran or active-duty military<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_11_60_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_60.2' type='checkbox'  value='Caregiver of someone living with emotional or physical illness'  id='choice_11_60_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_11_60_2' id='label_11_60_2' class='gform-field-label gform-field-label--type-inline'>Caregiver of someone living with emotional or physical illness<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_11_60_3'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_60.3' type='checkbox'  value='LGBTQ+'  id='choice_11_60_3'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_11_60_3' id='label_11_60_3' class='gform-field-label gform-field-label--type-inline'>LGBTQ+<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_11_60_4'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_60.4' type='checkbox'  value='Student'  id='choice_11_60_4'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_11_60_4' id='label_11_60_4' class='gform-field-label gform-field-label--type-inline'>Student<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_11_60_5'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_60.5' type='checkbox'  value='Trauma survivor'  id='choice_11_60_5'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_11_60_5' id='label_11_60_5' class='gform-field-label gform-field-label--type-inline'>Trauma survivor<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_11_60_6'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_60.6' type='checkbox'  value='New or expecting parent'  id='choice_11_60_6'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_11_60_6' id='label_11_60_6' class='gform-field-label gform-field-label--type-inline'>New or expecting parent<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_11_60_7'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_60.7' type='checkbox'  value='Healthcare worker'  id='choice_11_60_7'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_11_60_7' id='label_11_60_7' class='gform-field-label gform-field-label--type-inline'>Healthcare worker<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_11_88\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-full traditional field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >Are you caring for someone with a mental or physical health condition?<\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_11_88'>\n\t\t\t<div class='gchoice gchoice_11_88_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_88' type='radio' value='Mental health condition'  id='choice_11_88_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_11_88_0' id='label_11_88_0' class='gform-field-label gform-field-label--type-inline'>Mental health condition<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_11_88_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_88' type='radio' value='Physical health condition'  id='choice_11_88_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_11_88_1' id='label_11_88_1' class='gform-field-label gform-field-label--type-inline'>Physical health condition<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_11_88_2'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_88' type='radio' value='Both mental and physical health conditions'  id='choice_11_88_2' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_11_88_2' id='label_11_88_2' class='gform-field-label gform-field-label--type-inline'>Both mental and physical health conditions<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_11_89\" class=\"gfield gfield--type-select gfield--input-type-select gfield--width-full field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_11_89'>Which of the following best describes your sexual orientation?<\/label><div class='ginput_container ginput_container_select'><select name='input_89' id='input_11_89' class='medium gfield_select'     aria-invalid=\"false\" ><option value='' ><\/option><option value='Lesbian or Gay' >Lesbian or Gay<\/option><option value='Bisexual' >Bisexual<\/option><option value='Queer' >Queer<\/option><option value='Pansexual' >Pansexual<\/option><option value='Asexual' >Asexual<\/option><option value='Straight' >Straight<\/option><option value='Other...' >Other...<\/option><\/select><\/div><\/div><div id=\"field_11_66\" class=\"gfield gfield--type-text gfield--input-type-text optional field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_11_66'>What is your sexual orientation?<\/label><div class='ginput_container ginput_container_text'><input name='input_66' id='input_11_66' type='text' value='' class='small'    placeholder='Enter sexual orientation...'  aria-invalid=\"false\"   \/><\/div><\/div><fieldset id=\"field_11_90\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield--input-type-checkbox gfield--width-full traditional field_sublabel_below gfield--has-description field_description_above field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Which of the following describe your experience of trauma?<\/legend><div class='gfield_description' id='gfield_description_11_90'>Select all that apply.<\/div><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox ' id='input_11_90'><div class='gchoice gchoice_11_90_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_90.1' type='checkbox'  value='Child abuse\/violence'  id='choice_11_90_1'   aria-describedby=\"gfield_description_11_90\"\/>\n\t\t\t\t\t\t\t\t<label for='choice_11_90_1' id='label_11_90_1' class='gform-field-label gform-field-label--type-inline'>Child abuse\/violence<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_11_90_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_90.2' type='checkbox'  value='Intimate partner violence'  id='choice_11_90_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_11_90_2' id='label_11_90_2' class='gform-field-label gform-field-label--type-inline'>Intimate partner violence<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_11_90_3'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_90.3' type='checkbox'  value='Sexual assault\/violence'  id='choice_11_90_3'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_11_90_3' id='label_11_90_3' class='gform-field-label gform-field-label--type-inline'>Sexual assault\/violence<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_11_90_4'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_90.4' type='checkbox'  value='Serious illness\/injury\/assault'  id='choice_11_90_4'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_11_90_4' id='label_11_90_4' class='gform-field-label gform-field-label--type-inline'>Serious illness\/injury\/assault<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_11_90_5'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_90.5' type='checkbox'  value='Family conflict (identity acceptance\/separation\/divorce)'  id='choice_11_90_5'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_11_90_5' id='label_11_90_5' class='gform-field-label gform-field-label--type-inline'>Family conflict (identity acceptance\/separation\/divorce)<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_11_90_6'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_90.6' type='checkbox'  value='Traumatic event (natural disaster, accident, witnessing violence, etc.)'  id='choice_11_90_6'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_11_90_6' id='label_11_90_6' class='gform-field-label gform-field-label--type-inline'>Traumatic event (natural disaster, accident, witnessing violence, etc.)<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_11_90_7'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_90.7' type='checkbox'  value='Death of a loved one'  id='choice_11_90_7'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_11_90_7' id='label_11_90_7' class='gform-field-label gform-field-label--type-inline'>Death of a loved one<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_11_90_8'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_90.8' type='checkbox'  value='Other and\/or tell us more about your trauma'  id='choice_11_90_8'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_11_90_8' id='label_11_90_8' class='gform-field-label gform-field-label--type-inline'>Other and\/or tell us more about your trauma<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_11_91\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-full field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_11_91'>Please tell us more about your experience of trauma:<\/label><div class='ginput_container ginput_container_text'><input name='input_91' id='input_11_91' type='text' value='' class='medium'    placeholder='Tell us more...'  aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_11_67\" class=\"gfield gfield--type-html gfield--input-type-html section-title gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><h2>About Your Mental Health<\/h2><\/div><fieldset id=\"field_11_69\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio optional short field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >Have you ever received treatment\/support for a mental health problem?<\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_11_69'>\n\t\t\t<div class='gchoice gchoice_11_69_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_69' type='radio' value='Yes'  id='choice_11_69_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_11_69_0' id='label_11_69_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_11_69_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_69' type='radio' value='No'  id='choice_11_69_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_11_69_1' id='label_11_69_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_11_70\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio optional short field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >Are you receiving treatment\/support now?<\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_11_70'>\n\t\t\t<div class='gchoice gchoice_11_70_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_70' type='radio' value='Yes'  id='choice_11_70_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_11_70_0' id='label_11_70_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_11_70_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_70' type='radio' value='No'  id='choice_11_70_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_11_70_1' id='label_11_70_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_11_142\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield--input-type-checkbox gfield--width-full optional traditional limit-3 field_sublabel_below gfield--has-description field_description_above field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' >What has prevented you from seeking treatment in the past?<\/legend><div class='gfield_description' id='gfield_description_11_142'>Choose up to 3.<\/div><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox ' id='input_11_142'><div class='gchoice gchoice_11_142_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_142.1' type='checkbox'  value='I wanted to handle my mental health on my own'  id='choice_11_142_1'   aria-describedby=\"gfield_description_11_142\"\/>\n\t\t\t\t\t\t\t\t<label for='choice_11_142_1' id='label_11_142_1' class='gform-field-label gform-field-label--type-inline'>I wanted to handle my mental health on my own<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_11_142_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_142.2' type='checkbox'  value='I didn\u2019t know how or where to start'  id='choice_11_142_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_11_142_2' id='label_11_142_2' class='gform-field-label gform-field-label--type-inline'>I didn\u2019t know how or where to start<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_11_142_3'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_142.3' type='checkbox'  value='I thought it would cost too much'  id='choice_11_142_3'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_11_142_3' id='label_11_142_3' class='gform-field-label gform-field-label--type-inline'>I thought it would cost too much<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_11_142_4'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_142.4' type='checkbox'  value='I didn\u2019t have time'  id='choice_11_142_4'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_11_142_4' id='label_11_142_4' class='gform-field-label gform-field-label--type-inline'>I didn\u2019t have time<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_11_142_5'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_142.5' type='checkbox'  value='I didn\u2019t think it would help me'  id='choice_11_142_5'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_11_142_5' id='label_11_142_5' class='gform-field-label gform-field-label--type-inline'>I didn\u2019t think it would help me<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_11_142_6'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_142.6' type='checkbox'  value='I didn&#039;t feel ready to start treatment'  id='choice_11_142_6'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_11_142_6' id='label_11_142_6' class='gform-field-label gform-field-label--type-inline'>I didn't feel ready to start treatment<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_11_142_7'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_142.7' type='checkbox'  value='I was worried about what people would think or say if I got treatment'  id='choice_11_142_7'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_11_142_7' id='label_11_142_7' class='gform-field-label gform-field-label--type-inline'>I was worried about what people would think or say if I got treatment<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_11_142_8'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_142.8' type='checkbox'  value='I was afraid of being forced into a hospital or forced to take medication'  id='choice_11_142_8'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_11_142_8' id='label_11_142_8' class='gform-field-label gform-field-label--type-inline'>I was afraid of being forced into a hospital or forced to take medication<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_11_142_9'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_142.9' type='checkbox'  value='I tried, but couldn\u2019t find available treatment (no openings, wouldn\u2019t take insurance, etc.)'  id='choice_11_142_9'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_11_142_9' id='label_11_142_9' class='gform-field-label gform-field-label--type-inline'>I tried, but couldn\u2019t find available treatment (no openings, wouldn\u2019t take insurance, etc.)<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_11_142_11'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_142.11' type='checkbox'  value='My parent(s) or guardian wouldn&#039;t let me, or I didn&#039;t want to ask'  id='choice_11_142_11'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_11_142_11' id='label_11_142_11' class='gform-field-label gform-field-label--type-inline'>My parent(s) or guardian wouldn't let me, or I didn't want to ask<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_11_142_12'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_142.12' type='checkbox'  value='Other...'  id='choice_11_142_12'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_11_142_12' id='label_11_142_12' class='gform-field-label gform-field-label--type-inline'>Other...<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_11_143\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-full optional field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_11_143'>What else has prevented you from seeking treatment in the past?<\/label><div class='ginput_container ginput_container_text'><input name='input_143' id='input_11_143' type='text' value='' class='medium'    placeholder='Tell us more...'  aria-invalid=\"false\"   \/><\/div><\/div><fieldset id=\"field_11_71\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield--input-type-checkbox optional traditional limit-3 field_sublabel_below gfield--has-description field_description_above field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Think about your mental health test. What are the main things contributing to your mental health problems right now?<\/legend><div class='gfield_description' id='gfield_description_11_71'>Choose up to 3.<\/div><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox ' id='input_11_71'><div class='gchoice gchoice_11_71_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_71.1' type='checkbox'  value='Abuse or violence'  id='choice_11_71_1'   aria-describedby=\"gfield_description_11_71\"\/>\n\t\t\t\t\t\t\t\t<label for='choice_11_71_1' id='label_11_71_1' class='gform-field-label gform-field-label--type-inline'>Abuse or violence<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_11_71_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_71.2' type='checkbox'  value='Relationship problems (friends, family, or significant other)'  id='choice_11_71_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_11_71_2' id='label_11_71_2' class='gform-field-label gform-field-label--type-inline'>Relationship problems (friends, family, or significant other)<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_11_71_3'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_71.3' type='checkbox'  value='Body image'  id='choice_11_71_3'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_11_71_3' id='label_11_71_3' class='gform-field-label gform-field-label--type-inline'>Body image<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_11_71_4'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_71.4' type='checkbox'  value='Low self-esteem or self-image'  id='choice_11_71_4'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_11_71_4' id='label_11_71_4' class='gform-field-label gform-field-label--type-inline'>Low self-esteem or self-image<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_11_71_5'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_71.5' type='checkbox'  value='School or work problems'  id='choice_11_71_5'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_11_71_5' id='label_11_71_5' class='gform-field-label gform-field-label--type-inline'>School or work problems<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_11_71_6'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_71.6' type='checkbox'  value='Financial problems'  id='choice_11_71_6'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_11_71_6' id='label_11_71_6' class='gform-field-label gform-field-label--type-inline'>Financial problems<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_11_71_7'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_71.7' type='checkbox'  value='Loneliness or isolation'  id='choice_11_71_7'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_11_71_7' id='label_11_71_7' class='gform-field-label gform-field-label--type-inline'>Loneliness or isolation<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_11_71_8'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_71.8' type='checkbox'  value='Grief or loss of someone or something'  id='choice_11_71_8'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_11_71_8' id='label_11_71_8' class='gform-field-label gform-field-label--type-inline'>Grief or loss of someone or something<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_11_71_9'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_71.9' type='checkbox'  value='Experiencing hate\/bullying (including racism, homophobia, transphobia, or discrimination)'  id='choice_11_71_9'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_11_71_9' id='label_11_71_9' class='gform-field-label gform-field-label--type-inline'>Experiencing hate\/bullying (including racism, homophobia, transphobia, or discrimination)<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_11_71_11'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_71.11' type='checkbox'  value='State of the world (war, climate, politics, immigration)'  id='choice_11_71_11'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_11_71_11' id='label_11_71_11' class='gform-field-label gform-field-label--type-inline'>State of the world (war, climate, politics, immigration)<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_11_71_12'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_71.12' type='checkbox'  value='I don\u2019t know (something just feels wrong)'  id='choice_11_71_12'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_11_71_12' id='label_11_71_12' class='gform-field-label gform-field-label--type-inline'>I don\u2019t know (something just feels wrong)<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_11_71_13'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_71.13' type='checkbox'  value='Other...'  id='choice_11_71_13'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_11_71_13' id='label_11_71_13' class='gform-field-label gform-field-label--type-inline'>Other...<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_11_72\" class=\"gfield gfield--type-text gfield--input-type-text optional field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_11_72'>What else is contributing to your mental health problems right now?<\/label><div class='ginput_container ginput_container_text'><input name='input_72' id='input_11_72' type='text' value='' class='medium'    placeholder='Tell us more...'  aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_11_92\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-full field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_11_92'>What about the state of the world is affecting you the most?<\/label><div class='ginput_container ginput_container_text'><input name='input_92' id='input_11_92' type='text' value='' class='large'    placeholder='Tell us more...'  aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_11_73\" class=\"gfield gfield--type-html gfield--input-type-html section-title gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><h2>About Your Health<\/h2><\/div><fieldset id=\"field_11_74\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio optional short field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >Do you currently have health insurance?<\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_11_74'>\n\t\t\t<div class='gchoice gchoice_11_74_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_74' type='radio' value='Yes'  id='choice_11_74_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_11_74_0' id='label_11_74_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_11_74_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_74' type='radio' value='No'  id='choice_11_74_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_11_74_1' id='label_11_74_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_11_74_2'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_74' type='radio' value='I don&#039;t know'  id='choice_11_74_2' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_11_74_2' id='label_11_74_2' class='gform-field-label gform-field-label--type-inline'>I don't know<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_11_75\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield--input-type-checkbox optional traditional field_sublabel_below gfield--has-description field_description_above field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Do you have any of the following physical health conditions?<\/legend><div class='gfield_description' id='gfield_description_11_75'>Select all that apply.<\/div><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox ' id='input_11_75'><div class='gchoice gchoice_11_75_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_75.1' type='checkbox'  value='Heart disease'  id='choice_11_75_1'   aria-describedby=\"gfield_description_11_75\"\/>\n\t\t\t\t\t\t\t\t<label for='choice_11_75_1' id='label_11_75_1' class='gform-field-label gform-field-label--type-inline'>Heart disease<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_11_75_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_75.2' type='checkbox'  value='Reproductive health concerns (PCOS, endometriosis, infertility, etc.)'  id='choice_11_75_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_11_75_2' id='label_11_75_2' class='gform-field-label gform-field-label--type-inline'>Reproductive health concerns (PCOS, endometriosis, infertility, etc.)<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_11_75_3'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_75.3' type='checkbox'  value='Diabetes'  id='choice_11_75_3'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_11_75_3' id='label_11_75_3' class='gform-field-label gform-field-label--type-inline'>Diabetes<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_11_75_4'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_75.4' type='checkbox'  value='Cancer'  id='choice_11_75_4'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_11_75_4' id='label_11_75_4' class='gform-field-label gform-field-label--type-inline'>Cancer<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_11_75_5'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_75.5' type='checkbox'  value='Arthritis or other chronic pain'  id='choice_11_75_5'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_11_75_5' id='label_11_75_5' class='gform-field-label gform-field-label--type-inline'>Arthritis or other chronic pain<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_11_75_6'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_75.6' type='checkbox'  value='Asthma, COPD or other lung conditions'  id='choice_11_75_6'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_11_75_6' id='label_11_75_6' class='gform-field-label gform-field-label--type-inline'>Asthma, COPD or other lung conditions<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_11_75_7'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_75.7' type='checkbox'  value='Movement Disorders (involuntary tics, tardive dyskinesia, etc.)'  id='choice_11_75_7'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_11_75_7' id='label_11_75_7' class='gform-field-label gform-field-label--type-inline'>Movement Disorders (involuntary tics, tardive dyskinesia, etc.)<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_11_75_8'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_75.8' type='checkbox'  value='Digestive problems (Crohn\u2019s, colitis, IBS, etc.)'  id='choice_11_75_8'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_11_75_8' id='label_11_75_8' class='gform-field-label gform-field-label--type-inline'>Digestive problems (Crohn\u2019s, colitis, IBS, etc.)<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_11_75_9'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_75.9' type='checkbox'  value='Neurological conditions (epilepsy, etc.) or traumatic brain injury (TBI)'  id='choice_11_75_9'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_11_75_9' id='label_11_75_9' class='gform-field-label gform-field-label--type-inline'>Neurological conditions (epilepsy, etc.) or traumatic brain injury (TBI)<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_11_75_11'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_75.11' type='checkbox'  value='Other...'  id='choice_11_75_11'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_11_75_11' id='label_11_75_11' class='gform-field-label gform-field-label--type-inline'>Other...<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_11_76\" class=\"gfield gfield--type-text gfield--input-type-text optional field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_11_76'>What other physical health conditions do you have?<\/label><div class='ginput_container 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(2004). The primary care PTSD screen (PC-PTSD): Corrigendum. <em>Primary Care Psychiatry 9<\/em>(151).<\/p>\n<p>PC-PTSSD is in the Public Domain and available at <a href=\"https:\/\/www.ptsd.va.gov\/professional\/assessment\/screens\/pc-ptsd.asp\">https:\/\/www.ptsd.va.gov\/professional\/assessment\/screens\/pc-ptsd.asp<\/a>.<\/p>\n<p><a href=\"https:\/\/screening.mhanational.org\/about-our-mental-health-tests\/\" target=\"_blank\" rel=\"noopener\">For more information about our screening tools, please click here.<\/a><\/p>\n<p><strong><em>Please note:<\/em><\/strong><em> Online screening tools are not diagnostic instruments. You are encouraged to share your results with a physician or healthcare provider. Mental Health America Inc., sponsors, partners, and advertisers disclaim any liability, loss, or risk incurred as a consequence, directly or indirectly, from the use and application of these screens.<\/em><\/p>\n<\/div>\n","protected":false},"excerpt":{"rendered":"<p>Para personas que experimentan angustia continua despu\u00e9s de un evento traum\u00e1tico en su vida.<\/p>","protected":false},"template":"","tags":[],"age_group":[],"condition":[119],"class_list":["post-3176","screen","type-screen","status-publish","hentry","condition-trauma-ptsd"],"acf":[],"yoast_head":"<title>PTSD Test &#8211; Post-Traumatic Stress Disorder &#8211; Mental Health America<\/title>\n<meta name=\"description\" content=\"Trauma can have long-lasting effects on your well-being. 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