{"id":3188,"date":"2021-01-03T02:45:53","date_gmt":"2021-01-03T02:45:53","guid":{"rendered":"https:\/\/screening.mhanational.org\/?post_type=screen&#038;p=3188"},"modified":"2026-06-30T15:50:31","modified_gmt":"2026-06-30T19:50:31","slug":"youth","status":"publish","type":"screen","link":"https:\/\/screening.mhanational.org\/es\/screening-tools\/youth\/","title":{"rendered":"Test de salud mental para j\u00f3venes"},"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_14' style='display:none'>\n                        <div class='gform_heading'>\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_14'  class='clearfix' action='\/es\/wp-json\/wp\/v2\/screen\/3188' data-formid='14' 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_14_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_14' class='gform_fields top_label form_sublabel_below description_above validation_below'><div id=\"field_14_134\" 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_14_134'>Company<\/label><div class='gfield_description' id='gfield_description_14_134'>This field is for validation purposes and should be left unchanged.<\/div><div class='ginput_container'><input name='input_134' id='input_14_134' type='text' value='' autocomplete='new-password'\/><\/div><\/div><div id=\"field_14_4\" 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>Pediatric Symptom Checklist - Youth Report<br \/><br \/>\nThe questionnaire that follows can be used to see if you are having emotional, attentional, or behavioral difficulties. For each item please mark how often you:<\/p>\n<\/div><div id=\"field_14_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_14_38' type='hidden' class='gform_hidden'  aria-invalid=\"false\" value='' \/><\/div><\/div><div id=\"field_14_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_14_39\" type=\"hidden\" class=\"gform_hidden\" aria-invalid=\"false\" value=\"3188\"><\/div><div id=\"field_14_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_14_40\" type=\"hidden\" class=\"gform_hidden\" aria-invalid=\"false\" value=\"ede172135ec766ed8990c671404079fd\"><\/div><div id=\"field_14_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_14_41' type='hidden' class='gform_hidden'  aria-invalid=\"false\" value='' \/><\/div><\/div><div id=\"field_14_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_14_82' type='hidden' class='gform_hidden'  aria-invalid=\"false\" value='' \/><\/div><\/div><div id=\"field_14_112\" 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_112' id='input_14_112' type='hidden' class='gform_hidden'  aria-invalid=\"false\" value='' \/><\/div><\/div><div id=\"field_14_113\" 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_113' id='input_14_113' type='hidden' class='gform_hidden'  aria-invalid=\"false\" value='' \/><\/div><\/div><div id=\"field_14_133\" 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_133' id='input_14_133' type='hidden' class='gform_hidden'  aria-invalid=\"false\" value='lang--es' \/><\/div><\/div><div id=\"field_14_117\" 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_117' id='input_14_117' type='hidden' class='gform_hidden'  aria-invalid=\"false\" value='' \/><\/div><\/div><div id=\"field_14_114\" 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_114' id='input_14_114' type='hidden' class='gform_hidden'  aria-invalid=\"false\" value='' \/><\/div><\/div><div id=\"field_14_115\" 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_115' id='input_14_115' type='hidden' class='gform_hidden'  aria-invalid=\"false\" value='' \/><\/div><\/div><div id=\"field_14_116\" 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_116' id='input_14_116' type='hidden' class='gform_hidden'  aria-invalid=\"false\" value='' \/><\/div><\/div><div id=\"field_14_127\" 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_127' id='input_14_127' type='hidden' class='gform_hidden'  aria-invalid=\"false\" value='' \/><\/div><\/div><fieldset id=\"field_14_5\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio question 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' >Complain of aches or pains<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_14_5'>\n\t\t\t<div class='gchoice gchoice_14_5_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_5' type='radio' value='0'  id='choice_14_5_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_14_5_0' id='label_14_5_0' class='gform-field-label gform-field-label--type-inline'>Never<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_14_5_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_5' type='radio' value='1'  id='choice_14_5_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_14_5_1' id='label_14_5_1' class='gform-field-label gform-field-label--type-inline'>Sometimes<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_14_5_2'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_5' type='radio' value='2'  id='choice_14_5_2' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_14_5_2' id='label_14_5_2' class='gform-field-label gform-field-label--type-inline'>Often<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_14_47\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio question 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' >Spend more time alone<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_14_47'>\n\t\t\t<div class='gchoice gchoice_14_47_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_47' type='radio' value='0'  id='choice_14_47_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_14_47_0' id='label_14_47_0' class='gform-field-label gform-field-label--type-inline'>Never<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_14_47_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_47' type='radio' value='1'  id='choice_14_47_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_14_47_1' id='label_14_47_1' class='gform-field-label gform-field-label--type-inline'>Sometimes<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_14_47_2'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_47' type='radio' value='2'  id='choice_14_47_2' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_14_47_2' id='label_14_47_2' class='gform-field-label gform-field-label--type-inline'>Often<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_14_48\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio question 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' >Tire easily, little energy<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_14_48'>\n\t\t\t<div class='gchoice gchoice_14_48_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_48' type='radio' value='0'  id='choice_14_48_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_14_48_0' id='label_14_48_0' class='gform-field-label gform-field-label--type-inline'>Never<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_14_48_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_48' type='radio' value='1'  id='choice_14_48_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_14_48_1' id='label_14_48_1' class='gform-field-label gform-field-label--type-inline'>Sometimes<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_14_48_2'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_48' type='radio' value='2'  id='choice_14_48_2' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_14_48_2' id='label_14_48_2' class='gform-field-label gform-field-label--type-inline'>Often<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_14_49\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio question 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' >Fidgety, unable to sit still<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_14_49'>\n\t\t\t<div class='gchoice gchoice_14_49_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_49' type='radio' value='0'  id='choice_14_49_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_14_49_0' id='label_14_49_0' class='gform-field-label gform-field-label--type-inline'>Never<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_14_49_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_49' type='radio' value='1'  id='choice_14_49_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_14_49_1' id='label_14_49_1' class='gform-field-label gform-field-label--type-inline'>Sometimes<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_14_49_2'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_49' type='radio' value='2'  id='choice_14_49_2' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_14_49_2' id='label_14_49_2' class='gform-field-label gform-field-label--type-inline'>Often<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_14_50\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio question 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' >Have trouble with teacher<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_14_50'>\n\t\t\t<div class='gchoice gchoice_14_50_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_50' type='radio' value='0'  id='choice_14_50_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_14_50_0' id='label_14_50_0' class='gform-field-label gform-field-label--type-inline'>Never<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_14_50_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_50' type='radio' value='1'  id='choice_14_50_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_14_50_1' id='label_14_50_1' class='gform-field-label gform-field-label--type-inline'>Sometimes<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_14_50_2'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_50' type='radio' value='2'  id='choice_14_50_2' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_14_50_2' id='label_14_50_2' class='gform-field-label gform-field-label--type-inline'>Often<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_14_51\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio question 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' >Less interested in school<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_14_51'>\n\t\t\t<div class='gchoice gchoice_14_51_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_51' type='radio' value='0'  id='choice_14_51_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_14_51_0' id='label_14_51_0' class='gform-field-label gform-field-label--type-inline'>Never<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_14_51_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_51' type='radio' value='1'  id='choice_14_51_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_14_51_1' id='label_14_51_1' class='gform-field-label gform-field-label--type-inline'>Sometimes<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_14_51_2'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_51' type='radio' value='2'  id='choice_14_51_2' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_14_51_2' id='label_14_51_2' class='gform-field-label gform-field-label--type-inline'>Often<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_14_52\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio question 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' >Act as if driven by motor<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_14_52'>\n\t\t\t<div class='gchoice gchoice_14_52_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_52' type='radio' value='0'  id='choice_14_52_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_14_52_0' id='label_14_52_0' class='gform-field-label gform-field-label--type-inline'>Never<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_14_52_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_52' type='radio' value='1'  id='choice_14_52_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_14_52_1' id='label_14_52_1' class='gform-field-label gform-field-label--type-inline'>Sometimes<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_14_52_2'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_52' type='radio' value='2'  id='choice_14_52_2' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_14_52_2' id='label_14_52_2' class='gform-field-label gform-field-label--type-inline'>Often<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_14_53\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio question 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' >Daydream too much<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_14_53'>\n\t\t\t<div class='gchoice gchoice_14_53_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_53' type='radio' value='0'  id='choice_14_53_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_14_53_0' id='label_14_53_0' class='gform-field-label gform-field-label--type-inline'>Never<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_14_53_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_53' type='radio' value='1'  id='choice_14_53_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_14_53_1' id='label_14_53_1' class='gform-field-label gform-field-label--type-inline'>Sometimes<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_14_53_2'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_53' type='radio' value='2'  id='choice_14_53_2' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_14_53_2' id='label_14_53_2' class='gform-field-label gform-field-label--type-inline'>Often<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_14_54\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio question 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' >Distract easily<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_14_54'>\n\t\t\t<div class='gchoice gchoice_14_54_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_54' type='radio' value='0'  id='choice_14_54_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_14_54_0' id='label_14_54_0' class='gform-field-label gform-field-label--type-inline'>Never<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_14_54_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_54' type='radio' value='1'  id='choice_14_54_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_14_54_1' id='label_14_54_1' class='gform-field-label gform-field-label--type-inline'>Sometimes<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_14_54_2'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_54' type='radio' value='2'  id='choice_14_54_2' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_14_54_2' id='label_14_54_2' class='gform-field-label gform-field-label--type-inline'>Often<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_14_55\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio question 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' >Are afraid of new situations<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_14_55'>\n\t\t\t<div class='gchoice gchoice_14_55_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_55' type='radio' value='0'  id='choice_14_55_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_14_55_0' id='label_14_55_0' class='gform-field-label gform-field-label--type-inline'>Never<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_14_55_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_55' type='radio' value='1'  id='choice_14_55_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_14_55_1' id='label_14_55_1' class='gform-field-label gform-field-label--type-inline'>Sometimes<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_14_55_2'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_55' type='radio' value='2'  id='choice_14_55_2' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_14_55_2' id='label_14_55_2' class='gform-field-label gform-field-label--type-inline'>Often<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_14_56\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio question 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' >Feel sad, unhappy<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_14_56'>\n\t\t\t<div class='gchoice gchoice_14_56_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_56' type='radio' value='0'  id='choice_14_56_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_14_56_0' id='label_14_56_0' class='gform-field-label gform-field-label--type-inline'>Never<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_14_56_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_56' type='radio' value='1'  id='choice_14_56_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_14_56_1' id='label_14_56_1' class='gform-field-label gform-field-label--type-inline'>Sometimes<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_14_56_2'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_56' type='radio' value='2'  id='choice_14_56_2' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_14_56_2' id='label_14_56_2' class='gform-field-label gform-field-label--type-inline'>Often<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_14_57\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio question 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' >Are irritable, angry<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_14_57'>\n\t\t\t<div class='gchoice gchoice_14_57_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_57' type='radio' value='0'  id='choice_14_57_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_14_57_0' id='label_14_57_0' class='gform-field-label gform-field-label--type-inline'>Never<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_14_57_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_57' type='radio' value='1'  id='choice_14_57_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_14_57_1' id='label_14_57_1' class='gform-field-label gform-field-label--type-inline'>Sometimes<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_14_57_2'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_57' type='radio' value='2'  id='choice_14_57_2' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_14_57_2' id='label_14_57_2' class='gform-field-label gform-field-label--type-inline'>Often<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_14_58\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio question 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' >Feel hopeless<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_14_58'>\n\t\t\t<div class='gchoice gchoice_14_58_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_58' type='radio' value='0'  id='choice_14_58_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_14_58_0' id='label_14_58_0' class='gform-field-label gform-field-label--type-inline'>Never<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_14_58_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_58' type='radio' value='1'  id='choice_14_58_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_14_58_1' id='label_14_58_1' class='gform-field-label gform-field-label--type-inline'>Sometimes<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_14_58_2'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_58' type='radio' value='2'  id='choice_14_58_2' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_14_58_2' id='label_14_58_2' class='gform-field-label gform-field-label--type-inline'>Often<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_14_59\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio question 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' >Have trouble concentrating<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_14_59'>\n\t\t\t<div class='gchoice gchoice_14_59_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_59' type='radio' value='0'  id='choice_14_59_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_14_59_0' id='label_14_59_0' class='gform-field-label gform-field-label--type-inline'>Never<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_14_59_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_59' type='radio' value='1'  id='choice_14_59_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_14_59_1' id='label_14_59_1' class='gform-field-label gform-field-label--type-inline'>Sometimes<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_14_59_2'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_59' type='radio' value='2'  id='choice_14_59_2' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_14_59_2' id='label_14_59_2' class='gform-field-label gform-field-label--type-inline'>Often<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_14_60\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio question 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' >Less interested in friends<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_14_60'>\n\t\t\t<div class='gchoice gchoice_14_60_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_60' type='radio' value='0'  id='choice_14_60_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_14_60_0' id='label_14_60_0' class='gform-field-label gform-field-label--type-inline'>Never<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_14_60_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_60' type='radio' value='1'  id='choice_14_60_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_14_60_1' id='label_14_60_1' class='gform-field-label gform-field-label--type-inline'>Sometimes<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_14_60_2'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_60' type='radio' value='2'  id='choice_14_60_2' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_14_60_2' id='label_14_60_2' class='gform-field-label gform-field-label--type-inline'>Often<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_14_61\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio question 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' >Fight with other children<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_14_61'>\n\t\t\t<div class='gchoice gchoice_14_61_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_61' type='radio' value='0'  id='choice_14_61_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_14_61_0' id='label_14_61_0' class='gform-field-label gform-field-label--type-inline'>Never<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_14_61_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_61' type='radio' value='1'  id='choice_14_61_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_14_61_1' id='label_14_61_1' class='gform-field-label gform-field-label--type-inline'>Sometimes<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_14_61_2'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_61' type='radio' value='2'  id='choice_14_61_2' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_14_61_2' id='label_14_61_2' class='gform-field-label gform-field-label--type-inline'>Often<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_14_62\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio question 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' >Absent from school<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_14_62'>\n\t\t\t<div class='gchoice gchoice_14_62_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_62' type='radio' value='0'  id='choice_14_62_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_14_62_0' id='label_14_62_0' class='gform-field-label gform-field-label--type-inline'>Never<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_14_62_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_62' type='radio' value='1'  id='choice_14_62_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_14_62_1' id='label_14_62_1' class='gform-field-label gform-field-label--type-inline'>Sometimes<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_14_62_2'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_62' type='radio' value='2'  id='choice_14_62_2' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_14_62_2' id='label_14_62_2' class='gform-field-label gform-field-label--type-inline'>Often<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_14_63\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio question 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' >School grades dropping<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_14_63'>\n\t\t\t<div class='gchoice gchoice_14_63_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_63' type='radio' value='0'  id='choice_14_63_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_14_63_0' id='label_14_63_0' class='gform-field-label gform-field-label--type-inline'>Never<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_14_63_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_63' type='radio' value='1'  id='choice_14_63_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_14_63_1' id='label_14_63_1' class='gform-field-label gform-field-label--type-inline'>Sometimes<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_14_63_2'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_63' type='radio' value='2'  id='choice_14_63_2' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_14_63_2' id='label_14_63_2' class='gform-field-label gform-field-label--type-inline'>Often<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_14_64\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio question 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' >Down on yourself<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_14_64'>\n\t\t\t<div class='gchoice gchoice_14_64_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_64' type='radio' value='0'  id='choice_14_64_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_14_64_0' id='label_14_64_0' class='gform-field-label gform-field-label--type-inline'>Never<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_14_64_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_64' type='radio' value='1'  id='choice_14_64_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_14_64_1' id='label_14_64_1' class='gform-field-label gform-field-label--type-inline'>Sometimes<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_14_64_2'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_64' type='radio' value='2'  id='choice_14_64_2' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_14_64_2' id='label_14_64_2' class='gform-field-label gform-field-label--type-inline'>Often<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_14_65\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio question 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' >Visit doctor with doctor finding nothing wrong<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_14_65'>\n\t\t\t<div class='gchoice gchoice_14_65_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_65' type='radio' value='0'  id='choice_14_65_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_14_65_0' id='label_14_65_0' class='gform-field-label gform-field-label--type-inline'>Never<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_14_65_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_65' type='radio' value='1'  id='choice_14_65_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_14_65_1' id='label_14_65_1' class='gform-field-label gform-field-label--type-inline'>Sometimes<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_14_65_2'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_65' type='radio' value='2'  id='choice_14_65_2' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_14_65_2' id='label_14_65_2' class='gform-field-label gform-field-label--type-inline'>Often<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_14_66\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio question 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' >Have trouble sleeping<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_14_66'>\n\t\t\t<div class='gchoice gchoice_14_66_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_66' type='radio' value='0'  id='choice_14_66_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_14_66_0' id='label_14_66_0' class='gform-field-label gform-field-label--type-inline'>Never<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_14_66_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_66' type='radio' value='1'  id='choice_14_66_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_14_66_1' id='label_14_66_1' class='gform-field-label gform-field-label--type-inline'>Sometimes<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_14_66_2'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_66' type='radio' value='2'  id='choice_14_66_2' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_14_66_2' id='label_14_66_2' class='gform-field-label gform-field-label--type-inline'>Often<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_14_67\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio question 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' >Worry a lot<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_14_67'>\n\t\t\t<div class='gchoice gchoice_14_67_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_67' type='radio' value='0'  id='choice_14_67_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_14_67_0' id='label_14_67_0' class='gform-field-label gform-field-label--type-inline'>Never<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_14_67_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_67' type='radio' value='1'  id='choice_14_67_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_14_67_1' id='label_14_67_1' class='gform-field-label gform-field-label--type-inline'>Sometimes<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_14_67_2'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_67' type='radio' value='2'  id='choice_14_67_2' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_14_67_2' id='label_14_67_2' class='gform-field-label gform-field-label--type-inline'>Often<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_14_68\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio question 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' >Want to be with parent more than before<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_14_68'>\n\t\t\t<div class='gchoice gchoice_14_68_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_68' type='radio' value='0'  id='choice_14_68_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_14_68_0' id='label_14_68_0' class='gform-field-label gform-field-label--type-inline'>Never<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_14_68_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_68' type='radio' value='1'  id='choice_14_68_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_14_68_1' id='label_14_68_1' class='gform-field-label gform-field-label--type-inline'>Sometimes<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_14_68_2'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_68' type='radio' value='2'  id='choice_14_68_2' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_14_68_2' id='label_14_68_2' class='gform-field-label gform-field-label--type-inline'>Often<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_14_69\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio question 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' >Feel that you are bad<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_14_69'>\n\t\t\t<div class='gchoice gchoice_14_69_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_69' type='radio' value='0'  id='choice_14_69_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_14_69_0' id='label_14_69_0' class='gform-field-label gform-field-label--type-inline'>Never<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_14_69_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_69' type='radio' value='1'  id='choice_14_69_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_14_69_1' id='label_14_69_1' class='gform-field-label gform-field-label--type-inline'>Sometimes<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_14_69_2'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_69' type='radio' value='2'  id='choice_14_69_2' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_14_69_2' id='label_14_69_2' class='gform-field-label gform-field-label--type-inline'>Often<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_14_70\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio question 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' >Take unnecessary risks<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_14_70'>\n\t\t\t<div class='gchoice gchoice_14_70_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_70' type='radio' value='0'  id='choice_14_70_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_14_70_0' id='label_14_70_0' class='gform-field-label gform-field-label--type-inline'>Never<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_14_70_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_70' type='radio' value='1'  id='choice_14_70_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_14_70_1' id='label_14_70_1' class='gform-field-label gform-field-label--type-inline'>Sometimes<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_14_70_2'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_70' type='radio' value='2'  id='choice_14_70_2' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_14_70_2' id='label_14_70_2' class='gform-field-label gform-field-label--type-inline'>Often<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_14_71\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio question 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' >Get hurt frequently<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_14_71'>\n\t\t\t<div class='gchoice gchoice_14_71_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_71' type='radio' value='0'  id='choice_14_71_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_14_71_0' id='label_14_71_0' class='gform-field-label gform-field-label--type-inline'>Never<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_14_71_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_71' type='radio' value='1'  id='choice_14_71_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_14_71_1' id='label_14_71_1' class='gform-field-label gform-field-label--type-inline'>Sometimes<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_14_71_2'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_71' type='radio' value='2'  id='choice_14_71_2' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_14_71_2' id='label_14_71_2' class='gform-field-label gform-field-label--type-inline'>Often<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_14_72\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio question 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' >Seem to be having less fun<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_14_72'>\n\t\t\t<div class='gchoice gchoice_14_72_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_72' type='radio' value='0'  id='choice_14_72_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_14_72_0' id='label_14_72_0' class='gform-field-label gform-field-label--type-inline'>Never<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_14_72_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_72' type='radio' value='1'  id='choice_14_72_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_14_72_1' id='label_14_72_1' class='gform-field-label gform-field-label--type-inline'>Sometimes<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_14_72_2'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_72' type='radio' value='2'  id='choice_14_72_2' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_14_72_2' id='label_14_72_2' class='gform-field-label gform-field-label--type-inline'>Often<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_14_73\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio question 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' >Act younger than children your age<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_14_73'>\n\t\t\t<div class='gchoice gchoice_14_73_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_73' type='radio' value='0'  id='choice_14_73_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_14_73_0' id='label_14_73_0' class='gform-field-label gform-field-label--type-inline'>Never<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_14_73_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_73' type='radio' value='1'  id='choice_14_73_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_14_73_1' id='label_14_73_1' class='gform-field-label gform-field-label--type-inline'>Sometimes<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_14_73_2'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_73' type='radio' value='2'  id='choice_14_73_2' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_14_73_2' id='label_14_73_2' class='gform-field-label gform-field-label--type-inline'>Often<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_14_74\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio question 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' >Do not listen to rules<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_14_74'>\n\t\t\t<div class='gchoice gchoice_14_74_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_74' type='radio' value='0'  id='choice_14_74_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_14_74_0' id='label_14_74_0' class='gform-field-label gform-field-label--type-inline'>Never<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_14_74_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_74' type='radio' value='1'  id='choice_14_74_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_14_74_1' id='label_14_74_1' class='gform-field-label gform-field-label--type-inline'>Sometimes<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_14_74_2'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_74' type='radio' value='2'  id='choice_14_74_2' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_14_74_2' id='label_14_74_2' class='gform-field-label gform-field-label--type-inline'>Often<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_14_75\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio question 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' >Do not show feelings<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_14_75'>\n\t\t\t<div class='gchoice gchoice_14_75_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_75' type='radio' value='0'  id='choice_14_75_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_14_75_0' id='label_14_75_0' class='gform-field-label gform-field-label--type-inline'>Never<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_14_75_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_75' type='radio' value='1'  id='choice_14_75_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_14_75_1' id='label_14_75_1' class='gform-field-label gform-field-label--type-inline'>Sometimes<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_14_75_2'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_75' type='radio' value='2'  id='choice_14_75_2' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_14_75_2' id='label_14_75_2' class='gform-field-label gform-field-label--type-inline'>Often<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_14_76\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio question 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' >Do not understand other people&#039;s feelings<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_14_76'>\n\t\t\t<div class='gchoice gchoice_14_76_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_76' type='radio' value='0'  id='choice_14_76_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_14_76_0' id='label_14_76_0' class='gform-field-label gform-field-label--type-inline'>Never<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_14_76_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_76' type='radio' value='1'  id='choice_14_76_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_14_76_1' id='label_14_76_1' class='gform-field-label gform-field-label--type-inline'>Sometimes<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_14_76_2'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_76' type='radio' value='2'  id='choice_14_76_2' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_14_76_2' id='label_14_76_2' class='gform-field-label gform-field-label--type-inline'>Often<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_14_77\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio question 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' >Tease others<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_14_77'>\n\t\t\t<div class='gchoice gchoice_14_77_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_77' type='radio' value='0'  id='choice_14_77_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_14_77_0' id='label_14_77_0' class='gform-field-label gform-field-label--type-inline'>Never<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_14_77_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_77' type='radio' value='1'  id='choice_14_77_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_14_77_1' id='label_14_77_1' class='gform-field-label gform-field-label--type-inline'>Sometimes<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_14_77_2'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_77' type='radio' value='2'  id='choice_14_77_2' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_14_77_2' id='label_14_77_2' class='gform-field-label gform-field-label--type-inline'>Often<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_14_78\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio question 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' >Blame others for your troubles<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_14_78'>\n\t\t\t<div class='gchoice gchoice_14_78_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_78' type='radio' value='0'  id='choice_14_78_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_14_78_0' id='label_14_78_0' class='gform-field-label gform-field-label--type-inline'>Never<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_14_78_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_78' type='radio' value='1'  id='choice_14_78_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_14_78_1' id='label_14_78_1' class='gform-field-label gform-field-label--type-inline'>Sometimes<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_14_78_2'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_78' type='radio' value='2'  id='choice_14_78_2' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_14_78_2' id='label_14_78_2' class='gform-field-label gform-field-label--type-inline'>Often<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_14_79\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio question 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' >Take things that do not belong to you<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_14_79'>\n\t\t\t<div class='gchoice gchoice_14_79_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_79' type='radio' value='0'  id='choice_14_79_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_14_79_0' id='label_14_79_0' class='gform-field-label gform-field-label--type-inline'>Never<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_14_79_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_79' type='radio' value='1'  id='choice_14_79_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_14_79_1' id='label_14_79_1' class='gform-field-label gform-field-label--type-inline'>Sometimes<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_14_79_2'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_79' type='radio' value='2'  id='choice_14_79_2' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_14_79_2' id='label_14_79_2' class='gform-field-label gform-field-label--type-inline'>Often<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_14_80\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio question 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' >Refuse to share<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_14_80'>\n\t\t\t<div class='gchoice gchoice_14_80_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_80' type='radio' value='0'  id='choice_14_80_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_14_80_0' id='label_14_80_0' class='gform-field-label gform-field-label--type-inline'>Never<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_14_80_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_80' type='radio' value='1'  id='choice_14_80_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_14_80_1' id='label_14_80_1' class='gform-field-label gform-field-label--type-inline'>Sometimes<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_14_80_2'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_80' type='radio' value='2'  id='choice_14_80_2' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_14_80_2' id='label_14_80_2' class='gform-field-label gform-field-label--type-inline'>Often<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_14_81\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio question short exclude 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' >Do you have any emotional or behavioral problems for which you need help?<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_14_81'>\n\t\t\t<div class='gchoice gchoice_14_81_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_81' type='radio' value='0'  id='choice_14_81_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_14_81_0' id='label_14_81_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_14_81_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_81' type='radio' value='1'  id='choice_14_81_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_14_81_1' id='label_14_81_1' class='gform-field-label gform-field-label--type-inline'>Yes<\/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_14_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_14_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_14_2' class='gform_fields top_label form_sublabel_below description_above validation_below'><div id=\"field_14_83\" 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_14_118\" 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_14_119\" 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_14_119'>\n\t\t\t<div class='gchoice gchoice_14_119_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_119' type='radio' value='For myself'  id='choice_14_119_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_14_119_0' id='label_14_119_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_14_119_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_119' type='radio' value='For someone else'  id='choice_14_119_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_14_119_1' id='label_14_119_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_14_120\" 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_14_84\" 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_14_85\" 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_14_85'>Age Range<\/label><div class='ginput_container ginput_container_select'><select name='input_85' id='input_14_85' class='medium gfield_select'     aria-invalid=\"false\" ><option value='' ><\/option><option value='4-5' >4-5<\/option><option value='6-7' >6-7<\/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+' >18+<\/option><\/select><\/div><\/div><fieldset id=\"field_14_86\" 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_14_86'>\n\t\t\t<div class='gchoice gchoice_14_86_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_86' type='radio' value='Female'  id='choice_14_86_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_14_86_0' id='label_14_86_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_14_86_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_86' type='radio' value='Male'  id='choice_14_86_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_14_86_1' id='label_14_86_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_14_86_2'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_86' type='radio' value='Non-Binary'  id='choice_14_86_2' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_14_86_2' id='label_14_86_2' class='gform-field-label gform-field-label--type-inline'>Non-Binary<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_14_130\" 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_14_130'>\n\t\t\t<div class='gchoice gchoice_14_130_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_130' type='radio' value='Yes'  id='choice_14_130_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_14_130_0' id='label_14_130_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_14_130_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_130' type='radio' value='No'  id='choice_14_130_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_14_130_1' id='label_14_130_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_14_87\" 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_14_87'>How would you describe your gender?<\/label><div class='ginput_container ginput_container_text'><input name='input_87' id='input_14_87' type='text' value='' class='small'    placeholder='Enter gender...'  aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_14_89\" 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_14_89'>Race\/Ethnicity<\/label><div class='ginput_container ginput_container_select'><select name='input_89' id='input_14_89' 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_14_90\" 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_14_90'>Household Income<\/label><div class='ginput_container ginput_container_select'><select name='input_90' id='input_14_90' 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_14_121\" 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_14_121'>\n\t\t\t<div class='gchoice gchoice_14_121_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_121' type='radio' value='I live in the United States'  id='choice_14_121_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_14_121_0' id='label_14_121_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_14_121_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_121' type='radio' value='I live in another country'  id='choice_14_121_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_14_121_1' id='label_14_121_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_14_109\" 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_14_109'>State<\/label><div class='ginput_container ginput_container_select'><select name='input_109' id='input_14_109' 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_14_111\" 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_14_111'>What country do you live in?<\/label><div class='ginput_container ginput_container_select'><select name='input_111' id='input_14_111' 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_14_110\" 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_14_110'>Zip\/Postal Code<\/label><div class='ginput_container ginput_container_text'><input name='input_110' id='input_14_110' type='text' value='' class='small'      aria-invalid=\"false\"   \/><\/div><\/div><fieldset id=\"field_14_91\" 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_14_91'>Select all that apply.<\/div><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox ' id='input_14_91'><div class='gchoice gchoice_14_91_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_91.1' type='checkbox'  value='Child of veteran or active-duty military'  id='choice_14_91_1'   aria-describedby=\"gfield_description_14_91\"\/>\n\t\t\t\t\t\t\t\t<label for='choice_14_91_1' id='label_14_91_1' class='gform-field-label gform-field-label--type-inline'>Child of veteran or active-duty military<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_14_91_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_91.2' type='checkbox'  value='Caregiver of someone living with emotional or physical illness'  id='choice_14_91_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_14_91_2' id='label_14_91_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_14_91_3'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_91.3' type='checkbox'  value='LGBTQ+'  id='choice_14_91_3'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_14_91_3' id='label_14_91_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_14_91_4'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_91.4' type='checkbox'  value='Student'  id='choice_14_91_4'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_14_91_4' id='label_14_91_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_14_91_5'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_91.5' type='checkbox'  value='Trauma survivor'  id='choice_14_91_5'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_14_91_5' id='label_14_91_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_14_91_6'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_91.6' type='checkbox'  value='New or expecting parent'  id='choice_14_91_6'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_14_91_6' id='label_14_91_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_14_91_7'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_91.7' type='checkbox'  value='Healthcare worker'  id='choice_14_91_7'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_14_91_7' id='label_14_91_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_14_122\" 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_14_122'>\n\t\t\t<div class='gchoice gchoice_14_122_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_122' type='radio' value='Mental health condition'  id='choice_14_122_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_14_122_0' id='label_14_122_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_14_122_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_122' type='radio' value='Physical health condition'  id='choice_14_122_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_14_122_1' id='label_14_122_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_14_122_2'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_122' type='radio' value='Both mental and physical health conditions'  id='choice_14_122_2' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_14_122_2' id='label_14_122_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_14_123\" 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_14_123'>Which of the following best describes your sexual orientation?<\/label><div class='ginput_container ginput_container_select'><select name='input_123' id='input_14_123' 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_14_97\" 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_14_97'>What is your sexual orientation?<\/label><div class='ginput_container ginput_container_text'><input name='input_97' id='input_14_97' type='text' value='' class='small'    placeholder='Enter sexual orientation...'  aria-invalid=\"false\"   \/><\/div><\/div><fieldset id=\"field_14_124\" 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' >Which of the following describe your experience of trauma?<\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_14_124'>\n\t\t\t<div class='gchoice gchoice_14_124_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_124' type='radio' value='Child abuse\/violence'  id='choice_14_124_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_14_124_0' id='label_14_124_0' class='gform-field-label gform-field-label--type-inline'>Child abuse\/violence<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_14_124_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_124' type='radio' value='Intimate partner violence'  id='choice_14_124_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_14_124_1' id='label_14_124_1' class='gform-field-label gform-field-label--type-inline'>Intimate partner violence<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_14_124_2'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_124' type='radio' value='Sexual assault\/violence'  id='choice_14_124_2' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_14_124_2' id='label_14_124_2' class='gform-field-label gform-field-label--type-inline'>Sexual assault\/violence<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_14_124_3'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_124' type='radio' value='Serious illness\/injury\/assault'  id='choice_14_124_3' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_14_124_3' id='label_14_124_3' class='gform-field-label gform-field-label--type-inline'>Serious illness\/injury\/assault<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_14_124_4'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_124' type='radio' value='Family conflict (identity acceptance\/separation\/divorce)'  id='choice_14_124_4' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_14_124_4' id='label_14_124_4' class='gform-field-label gform-field-label--type-inline'>Family conflict (identity acceptance\/separation\/divorce)<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_14_124_5'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_124' type='radio' value='Traumatic event (natural disaster, accident, witnessing violence, etc.)'  id='choice_14_124_5' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_14_124_5' id='label_14_124_5' class='gform-field-label gform-field-label--type-inline'>Traumatic event (natural disaster, accident, witnessing violence, etc.)<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_14_124_6'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_124' type='radio' value='Death of a loved one'  id='choice_14_124_6' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_14_124_6' id='label_14_124_6' class='gform-field-label gform-field-label--type-inline'>Death of a loved one<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_14_124_7'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_124' type='radio' value='Other and\/or tell us more about your trauma'  id='choice_14_124_7' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_14_124_7' id='label_14_124_7' class='gform-field-label gform-field-label--type-inline'>Other and\/or tell us more about your trauma<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_14_125\" 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_14_125'>Please tell us more about your experience of trauma:<\/label><div class='ginput_container ginput_container_text'><input name='input_125' id='input_14_125' type='text' value='' class='medium'    placeholder='Tell us more...'  aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_14_98\" 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_14_100\" 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_14_100'>\n\t\t\t<div class='gchoice gchoice_14_100_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_100' type='radio' value='Yes'  id='choice_14_100_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_14_100_0' id='label_14_100_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_14_100_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_100' type='radio' value='No'  id='choice_14_100_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_14_100_1' id='label_14_100_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_14_101\" 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_14_101'>\n\t\t\t<div class='gchoice gchoice_14_101_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_101' type='radio' value='Yes'  id='choice_14_101_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_14_101_0' id='label_14_101_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_14_101_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_101' type='radio' value='No'  id='choice_14_101_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_14_101_1' id='label_14_101_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_14_131\" 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_14_131'>Choose up to 3.<\/div><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox ' id='input_14_131'><div class='gchoice gchoice_14_131_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_131.1' type='checkbox'  value='I wanted to handle my mental health on my own'  id='choice_14_131_1'   aria-describedby=\"gfield_description_14_131\"\/>\n\t\t\t\t\t\t\t\t<label for='choice_14_131_1' id='label_14_131_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_14_131_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_131.2' type='checkbox'  value='I didn\u2019t know how or where to start'  id='choice_14_131_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_14_131_2' id='label_14_131_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_14_131_3'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_131.3' type='checkbox'  value='I thought it would cost too much'  id='choice_14_131_3'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_14_131_3' id='label_14_131_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_14_131_4'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_131.4' type='checkbox'  value='I didn\u2019t have time'  id='choice_14_131_4'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_14_131_4' id='label_14_131_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_14_131_5'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_131.5' type='checkbox'  value='I didn\u2019t think it would help me'  id='choice_14_131_5'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_14_131_5' id='label_14_131_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_14_131_6'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_131.6' type='checkbox'  value='I didn&#039;t feel ready to start treatment'  id='choice_14_131_6'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_14_131_6' id='label_14_131_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_14_131_7'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_131.7' type='checkbox'  value='I was worried about what people would think or say if I got treatment'  id='choice_14_131_7'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_14_131_7' id='label_14_131_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_14_131_8'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_131.8' type='checkbox'  value='I was afraid of being forced into a hospital or forced to take medication'  id='choice_14_131_8'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_14_131_8' id='label_14_131_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_14_131_9'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_131.9' type='checkbox'  value='I tried, but couldn\u2019t find available treatment (no openings, wouldn\u2019t take insurance, etc.)'  id='choice_14_131_9'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_14_131_9' id='label_14_131_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_14_131_11'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_131.11' type='checkbox'  value='My parent(s) or guardian wouldn&#039;t let me, or I didn&#039;t want to ask'  id='choice_14_131_11'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_14_131_11' id='label_14_131_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_14_131_12'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_131.12' type='checkbox'  value='Other...'  id='choice_14_131_12'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_14_131_12' id='label_14_131_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_14_132\" 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_14_132'>What else has prevented you from seeking treatment in the past?<\/label><div class='ginput_container ginput_container_text'><input name='input_132' id='input_14_132' type='text' value='' class='medium'    placeholder='Tell us more...'  aria-invalid=\"false\"   \/><\/div><\/div><fieldset id=\"field_14_102\" 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_14_102'>Choose up to 3.<\/div><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox ' id='input_14_102'><div class='gchoice gchoice_14_102_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_102.1' type='checkbox'  value='Abuse or violence'  id='choice_14_102_1'   aria-describedby=\"gfield_description_14_102\"\/>\n\t\t\t\t\t\t\t\t<label for='choice_14_102_1' id='label_14_102_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_14_102_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_102.2' type='checkbox'  value='Relationship problems (friends, family, or significant other)'  id='choice_14_102_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_14_102_2' id='label_14_102_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_14_102_3'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_102.3' type='checkbox'  value='Body image'  id='choice_14_102_3'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_14_102_3' id='label_14_102_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_14_102_4'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_102.4' type='checkbox'  value='Low self-esteem or self-image'  id='choice_14_102_4'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_14_102_4' id='label_14_102_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_14_102_5'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_102.5' type='checkbox'  value='School or work problems'  id='choice_14_102_5'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_14_102_5' id='label_14_102_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_14_102_6'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_102.6' type='checkbox'  value='Financial problems'  id='choice_14_102_6'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_14_102_6' id='label_14_102_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_14_102_7'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_102.7' type='checkbox'  value='Loneliness or isolation'  id='choice_14_102_7'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_14_102_7' id='label_14_102_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_14_102_8'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_102.8' type='checkbox'  value='Grief or loss of someone or something'  id='choice_14_102_8'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_14_102_8' id='label_14_102_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_14_102_9'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_102.9' type='checkbox'  value='Experiencing hate\/bullying (including racism, homophobia, transphobia, or discrimination)'  id='choice_14_102_9'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_14_102_9' id='label_14_102_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_14_102_11'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_102.11' type='checkbox'  value='State of the world (war, climate, politics, immigration)'  id='choice_14_102_11'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_14_102_11' id='label_14_102_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_14_102_12'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_102.12' type='checkbox'  value='I don\u2019t know (something just feels wrong)'  id='choice_14_102_12'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_14_102_12' id='label_14_102_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_14_102_13'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_102.13' type='checkbox'  value='Other...'  id='choice_14_102_13'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_14_102_13' id='label_14_102_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_14_103\" 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_14_103'>What else is contributing to your mental health problems right now?<\/label><div class='ginput_container ginput_container_text'><input name='input_103' id='input_14_103' type='text' value='' class='medium'    placeholder='Tell us more...'  aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_14_126\" 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_14_126'>What about the state of the world is affecting you the most?<\/label><div class='ginput_container ginput_container_text'><input name='input_126' id='input_14_126' type='text' value='' class='large'    placeholder='Tell us more...'  aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_14_104\" 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_14_105\" 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_14_105'>\n\t\t\t<div class='gchoice gchoice_14_105_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_105' type='radio' value='Yes'  id='choice_14_105_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_14_105_0' id='label_14_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_14_105_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_105' type='radio' value='No'  id='choice_14_105_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_14_105_1' id='label_14_105_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_14_105_2'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_105' type='radio' value='I don&#039;t know'  id='choice_14_105_2' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_14_105_2' id='label_14_105_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_14_106\" 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_14_106'>Select all that apply.<\/div><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox ' id='input_14_106'><div class='gchoice gchoice_14_106_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_106.1' type='checkbox'  value='Heart disease'  id='choice_14_106_1'   aria-describedby=\"gfield_description_14_106\"\/>\n\t\t\t\t\t\t\t\t<label for='choice_14_106_1' id='label_14_106_1' 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value='Cancer'  id='choice_14_106_4'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_14_106_4' id='label_14_106_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_14_106_5'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_106.5' type='checkbox'  value='Arthritis or other chronic pain'  id='choice_14_106_5'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_14_106_5' id='label_14_106_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_14_106_6'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_106.6' type='checkbox'  value='Asthma, COPD or other lung conditions'  id='choice_14_106_6'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_14_106_6' id='label_14_106_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 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conditions (epilepsy, etc.) or traumatic brain injury (TBI)'  id='choice_14_106_9'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_14_106_9' id='label_14_106_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_14_106_11'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_106.11' type='checkbox'  value='Other...'  id='choice_14_106_11'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_14_106_11' id='label_14_106_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_14_107\" 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_14_107'>What other physical health conditions do you have?<\/label><div class='ginput_container ginput_container_text'><input name='input_107' id='input_14_107' type='text' value='' class='medium'    placeholder='Tell us more...'  aria-invalid=\"false\"   \/><\/div><\/div><fieldset id=\"field_14_128\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-full 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 have a pet that supports your mental health?<\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_14_128'>\n\t\t\t<div class='gchoice gchoice_14_128_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_128' type='radio' value='Yes'  id='choice_14_128_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_14_128_0' id='label_14_128_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_14_128_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_128' type='radio' value='No'  id='choice_14_128_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_14_128_1' id='label_14_128_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_14_129\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-full 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 interested in having a pet that supports your mental health?<\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_14_129'>\n\t\t\t<div class='gchoice gchoice_14_129_0'>\n\t\t\t\t\t<input 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attributeFilter: [ 'style', 'class' ],            });        } else {            triggerPostRender();        }    } );} );\n<\/script>\n\n<p>&nbsp;<\/p>\n<hr \/>\n<h2 class=\"smaller\">Source:<\/h2>\n<div class=\"references\">\n<p>Pediatric Symptom Checklist &#8211; Youth Self-Report (PSC-Y)<\/p>\n<p>Jellinek, Murphy, et al. (1988). Pediatric Symptom Checklist: Screening school-age children for psychosocial dysfunction. <em>The Journal of Pediatrics, 112<\/em>(2), pp. 201-209. Retrieved from <a href=\"https:\/\/doi.org\/10.1016\/S0022-3476(88)80056-8\">https:\/\/doi.org\/10.1016\/S0022-3476(88)80056-8<\/a><\/p>\n<p>For more information, visit the Pediatric Symptom Checklist page at Massachusetts General Hospital Psychiatry: <a href=\"https:\/\/www.massgeneral.org\/psychiatry\/treatments-and-services\/pediatric-symptom-checklist\">https:\/\/www.massgeneral.org\/psychiatry\/treatments-and-services\/pediatric-symptom-checklist<\/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><em><strong>Please note:<\/strong> 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, of the use and application of these screens.<\/em><\/p>\n<\/div>\n","protected":false},"excerpt":{"rendered":"<p>Para j\u00f3venes (de 11 a 17 a\u00f1os) que est\u00e1n preocupados porque sus emociones, atenci\u00f3n o comportamientos podr\u00edan ser signos de un problema.<\/p>","protected":false},"template":"","tags":[103],"age_group":[],"condition":[],"class_list":["post-3188","screen","type-screen","status-publish","hentry","tag-youth"],"acf":[],"yoast_head":"<title>Youth Mental Health Test &#8211; Mental Health America<\/title>\n<meta name=\"description\" content=\"For children and teenagers worried about their emotions, attention, or behaviors\u2014the Youth Mental Health Test is free, quick, &amp; confidential.\" \/>\n<meta name=\"robots\" content=\"index, follow, max-snippet:-1, max-image-preview:large, max-video-preview:-1\" \/>\n<link rel=\"canonical\" href=\"https:\/\/screening.mhanational.org\/es\/screening-tools\/youth\/\" \/>\n<meta property=\"og:locale\" content=\"es_MX\" \/>\n<meta property=\"og:type\" content=\"article\" \/>\n<meta property=\"og:title\" content=\"Youth Test\" \/>\n<meta property=\"og:description\" content=\"The Youth Test is for young people (age 11-17) who are concerned that their emotions, attention, or behaviors might be signs of a problem.\" \/>\n<meta property=\"og:url\" content=\"https:\/\/screening.mhanational.org\/es\/screening-tools\/youth\/\" \/>\n<meta property=\"og:site_name\" content=\"Mental Health America\" \/>\n<meta property=\"article:publisher\" content=\"https:\/\/www.facebook.com\/mentalhealthamerica\" \/>\n<meta property=\"article:modified_time\" content=\"2026-06-30T19:50:31+00:00\" \/>\n<meta property=\"og:image\" content=\"https:\/\/screening.mhanational.org\/wp-content\/uploads\/2022\/04\/Social-media-share-preview.png\" \/>\n\t<meta property=\"og:image:width\" content=\"1200\" \/>\n\t<meta property=\"og:image:height\" content=\"631\" \/>\n\t<meta property=\"og:image:type\" content=\"image\/png\" \/>\n<meta name=\"twitter:card\" content=\"summary_large_image\" \/>\n<meta name=\"twitter:title\" content=\"Youth Test\" \/>\n<meta name=\"twitter:description\" content=\"The Youth Test is for young people (age 11-17) who are concerned that their emotions, attention, or behaviors might be signs of a problem.\" \/>\n<meta name=\"twitter:site\" content=\"@mentalhealtham\" \/>\n<meta name=\"twitter:label1\" content=\"Est. reading time\" \/>\n\t<meta name=\"twitter:data1\" content=\"3 minutos\" \/>\n<script type=\"application\/ld+json\" class=\"yoast-schema-graph\">{\"@context\":\"https:\\\/\\\/schema.org\",\"@graph\":[{\"@type\":\"WebPage\",\"@id\":\"https:\\\/\\\/screening.mhanational.org\\\/screening-tools\\\/youth\\\/\",\"url\":\"https:\\\/\\\/screening.mhanational.org\\\/screening-tools\\\/youth\\\/\",\"name\":\"Youth Mental Health Test &#8211; 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