{"id":788,"date":"2020-12-28T17:11:01","date_gmt":"2020-12-28T17:11:01","guid":{"rendered":"https:\/\/screening.mhanational.org\/?post_type=screen&#038;p=788"},"modified":"2025-08-01T12:23:01","modified_gmt":"2025-08-01T16:23:01","slug":"postpartum-depression","status":"publish","type":"screen","link":"https:\/\/screening.mhanational.org\/es\/screening-tools\/postpartum-depression\/","title":{"rendered":"Prueba de depresi\u00f3n posparto (padres primerizos y futuros padres)"},"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 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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_77' style='display:none'>\n                        <div class='gform_heading'>\n                            <h2 class=\"gform_title\">Postpartum Depression Test (EPDS-US)<\/h2>\n                            <p class='gform_description'><\/p>\n\t\t\t\t\t\t\t<p class='gform_required_legend'>&quot;<span class=\"gfield_required gfield_required_asterisk\">*<\/span>&quot; indicates required fields<\/p>\n                        <\/div><form method='post' enctype='multipart\/form-data'  id='gform_77'  class='clearfix' action='\/es\/wp-json\/wp\/v2\/screen\/788' data-formid='77' 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_77_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_77' class='gform_fields top_label form_sublabel_below description_above validation_below'><div id=\"field_77_106\" 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_77_106'>Phone<\/label><div class='gfield_description' id='gfield_description_77_106'>This field is for validation purposes and should be left unchanged.<\/div><div class='ginput_container'><input name='input_106' id='input_77_106' type='text' value='' autocomplete='new-password'\/><\/div><\/div><div id=\"field_77_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>This is a test for depression in <strong>new and expecting parents<\/strong>.<\/p>\n\n<p>Please select the answer that comes closest to how you have felt in the <strong>past 7 days<\/strong>&ndash;not just how you feel today.<\/p><p>Please note, all fields are required.<\/p>\n<\/div><div id=\"field_77_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_77_38' type='hidden' class='gform_hidden'  aria-invalid=\"false\" value='' \/><\/div><\/div><div id=\"field_77_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_77_39\" type=\"hidden\" class=\"gform_hidden\" aria-invalid=\"false\" value=\"788\"><\/div><div id=\"field_77_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_77_40\" type=\"hidden\" class=\"gform_hidden\" aria-invalid=\"false\" value=\"1065b15f1fb646497a4b06db21f9fba2\"><\/div><div id=\"field_77_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_77_41' type='hidden' class='gform_hidden'  aria-invalid=\"false\" value='' \/><\/div><\/div><div id=\"field_77_57\" 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_57' id='input_77_57' type='hidden' class='gform_hidden'  aria-invalid=\"false\" value='' \/><\/div><\/div><div id=\"field_77_87\" 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_87' id='input_77_87' type='hidden' class='gform_hidden'  aria-invalid=\"false\" value='' \/><\/div><\/div><div id=\"field_77_88\" 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_88' id='input_77_88' type='hidden' class='gform_hidden'  aria-invalid=\"false\" value='' \/><\/div><\/div><div id=\"field_77_89\" 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_89' id='input_77_89' type='hidden' class='gform_hidden'  aria-invalid=\"false\" value='' \/><\/div><\/div><div id=\"field_77_99\" 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_99' id='input_77_99' type='hidden' class='gform_hidden'  aria-invalid=\"false\" value='' \/><\/div><\/div><div id=\"field_77_105\" 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_105' id='input_77_105' type='hidden' class='gform_hidden'  aria-invalid=\"false\" value='lang--es' \/><\/div><\/div><fieldset id=\"field_77_48\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio question wide gfield_contains_required field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >1. I have been able to laugh and see the funny side of things<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_77_48'>\n\t\t\t<div class='gchoice gchoice_77_48_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_48' type='radio' value='0'  id='choice_77_48_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_77_48_0' id='label_77_48_0' class='gform-field-label gform-field-label--type-inline'>As much as I always could<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_77_48_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_48' type='radio' value='1'  id='choice_77_48_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_77_48_1' id='label_77_48_1' class='gform-field-label gform-field-label--type-inline'>Not quite as much now<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_77_48_2'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_48' type='radio' value='2'  id='choice_77_48_2' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_77_48_2' id='label_77_48_2' class='gform-field-label gform-field-label--type-inline'>Definitely not as much now<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_77_48_3'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_48' type='radio' value='3'  id='choice_77_48_3' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_77_48_3' id='label_77_48_3' class='gform-field-label gform-field-label--type-inline'>Not at all<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_77_49\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio question wide gfield_contains_required field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >2. I have looked forward with enjoyment to things<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_77_49'>\n\t\t\t<div class='gchoice gchoice_77_49_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_49' type='radio' value='0'  id='choice_77_49_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_77_49_0' id='label_77_49_0' class='gform-field-label gform-field-label--type-inline'>As much as I ever did<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_77_49_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_49' type='radio' value='1'  id='choice_77_49_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_77_49_1' id='label_77_49_1' class='gform-field-label gform-field-label--type-inline'>Somewhat less than I used to<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_77_49_2'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_49' type='radio' value='2'  id='choice_77_49_2' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_77_49_2' id='label_77_49_2' class='gform-field-label gform-field-label--type-inline'>Definitely less than I used to<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_77_49_3'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_49' type='radio' value='3'  id='choice_77_49_3' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_77_49_3' id='label_77_49_3' class='gform-field-label gform-field-label--type-inline'>Hardly at all<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_77_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' >3. I have blamed myself when things went 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_77_50'>\n\t\t\t<div class='gchoice gchoice_77_50_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_50' type='radio' value='3'  id='choice_77_50_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_77_50_0' id='label_77_50_0' class='gform-field-label gform-field-label--type-inline'>Yes, most of the time<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_77_50_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_50' type='radio' value='2'  id='choice_77_50_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_77_50_1' id='label_77_50_1' class='gform-field-label gform-field-label--type-inline'>Yes, some of the time<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_77_50_2'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_50' type='radio' value='1'  id='choice_77_50_2' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_77_50_2' id='label_77_50_2' class='gform-field-label gform-field-label--type-inline'>Not very often<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_77_50_3'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_50' type='radio' value='0'  id='choice_77_50_3' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_77_50_3' id='label_77_50_3' class='gform-field-label gform-field-label--type-inline'>No, never<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_77_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' >4. I have felt anxious or worried<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_77_51'>\n\t\t\t<div class='gchoice gchoice_77_51_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_51' type='radio' value='0'  id='choice_77_51_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_77_51_0' id='label_77_51_0' class='gform-field-label gform-field-label--type-inline'>No, not at all<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_77_51_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_51' type='radio' value='1'  id='choice_77_51_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_77_51_1' id='label_77_51_1' class='gform-field-label gform-field-label--type-inline'>Hardly ever<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_77_51_2'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_51' type='radio' value='2'  id='choice_77_51_2' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_77_51_2' id='label_77_51_2' class='gform-field-label gform-field-label--type-inline'>Yes, sometimes<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_77_51_3'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_51' type='radio' value='3'  id='choice_77_51_3' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_77_51_3' id='label_77_51_3' class='gform-field-label gform-field-label--type-inline'>Yes, very often<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_77_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' >5. I have felt scared or panicky<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_77_52'>\n\t\t\t<div class='gchoice gchoice_77_52_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_52' type='radio' value='3'  id='choice_77_52_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_77_52_0' id='label_77_52_0' class='gform-field-label gform-field-label--type-inline'>Yes, quite a lot<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_77_52_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_52' type='radio' value='2'  id='choice_77_52_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_77_52_1' id='label_77_52_1' class='gform-field-label gform-field-label--type-inline'>Yes, sometimes<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_77_52_2'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_52' type='radio' value='1'  id='choice_77_52_2' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_77_52_2' id='label_77_52_2' class='gform-field-label gform-field-label--type-inline'>No, not much<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_77_52_3'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_52' type='radio' value='0'  id='choice_77_52_3' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_77_52_3' id='label_77_52_3' class='gform-field-label gform-field-label--type-inline'>No, not at all<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_77_53\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio question wide 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' >6. I have felt overwhelmed<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_77_53'>\n\t\t\t<div class='gchoice gchoice_77_53_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_53' type='radio' value='3'  id='choice_77_53_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_77_53_0' id='label_77_53_0' class='gform-field-label gform-field-label--type-inline'>Yes, most of the time I haven't been able to cope at all<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_77_53_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_53' type='radio' value='2'  id='choice_77_53_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_77_53_1' id='label_77_53_1' class='gform-field-label gform-field-label--type-inline'>Yes, sometimes I haven't been coping as well as usual<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_77_53_2'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_53' type='radio' value='1'  id='choice_77_53_2' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_77_53_2' id='label_77_53_2' class='gform-field-label gform-field-label--type-inline'>No, most of the time I have coped quite well<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_77_53_3'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_53' type='radio' value='0'  id='choice_77_53_3' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_77_53_3' id='label_77_53_3' class='gform-field-label gform-field-label--type-inline'>No, I have been coping as well as ever<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_77_54\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio question wide 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' >7.  I have had difficulty sleeping even when I have the opportunity to sleep<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_77_54'>\n\t\t\t<div class='gchoice gchoice_77_54_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_54' type='radio' value='3'  id='choice_77_54_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_77_54_0' id='label_77_54_0' class='gform-field-label gform-field-label--type-inline'>Yes, most of the time<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_77_54_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_54' type='radio' value='2'  id='choice_77_54_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_77_54_1' id='label_77_54_1' class='gform-field-label gform-field-label--type-inline'>Yes, quite often<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_77_54_2'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_54' type='radio' value='1'  id='choice_77_54_2' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_77_54_2' id='label_77_54_2' class='gform-field-label gform-field-label--type-inline'>Not very often<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_77_54_3'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_54' type='radio' value='0'  id='choice_77_54_3' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_77_54_3' id='label_77_54_3' class='gform-field-label gform-field-label--type-inline'>No, not at all<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_77_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' >8. I have felt sad or miserable<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_77_55'>\n\t\t\t<div class='gchoice gchoice_77_55_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_55' type='radio' value='3'  id='choice_77_55_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_77_55_0' id='label_77_55_0' class='gform-field-label gform-field-label--type-inline'>Yes, most of the time<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_77_55_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_55' type='radio' value='2'  id='choice_77_55_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_77_55_1' id='label_77_55_1' class='gform-field-label gform-field-label--type-inline'>Yes, quite often<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_77_55_2'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_55' type='radio' value='1'  id='choice_77_55_2' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_77_55_2' id='label_77_55_2' class='gform-field-label gform-field-label--type-inline'>Not very often<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_77_55_3'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_55' type='radio' value='0'  id='choice_77_55_3' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_77_55_3' id='label_77_55_3' class='gform-field-label gform-field-label--type-inline'>No, not at all<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_77_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' >9. I have felt so unhappy that I have been crying<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_77_56'>\n\t\t\t<div class='gchoice gchoice_77_56_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_56' type='radio' value='3'  id='choice_77_56_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_77_56_0' id='label_77_56_0' class='gform-field-label gform-field-label--type-inline'>Yes, most of the time<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_77_56_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_56' type='radio' value='2'  id='choice_77_56_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_77_56_1' id='label_77_56_1' class='gform-field-label gform-field-label--type-inline'>Yes, quite often<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_77_56_2'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_56' type='radio' value='1'  id='choice_77_56_2' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_77_56_2' id='label_77_56_2' class='gform-field-label gform-field-label--type-inline'>Only occasionally<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_77_56_3'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_56' type='radio' value='0'  id='choice_77_56_3' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_77_56_3' id='label_77_56_3' class='gform-field-label gform-field-label--type-inline'>No, never<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_77_47\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio question alert 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' >10. The thought of harming myself has occurred to me<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_77_47'>\n\t\t\t<div class='gchoice gchoice_77_47_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_47' type='radio' value='3'  id='choice_77_47_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_77_47_0' id='label_77_47_0' class='gform-field-label gform-field-label--type-inline'>Yes, quite often<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_77_47_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_47' type='radio' value='2'  id='choice_77_47_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_77_47_1' id='label_77_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_77_47_2'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_47' type='radio' value='1'  id='choice_77_47_2' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_77_47_2' id='label_77_47_2' class='gform-field-label gform-field-label--type-inline'>Hardly ever<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_77_47_3'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_47' type='radio' value='0'  id='choice_77_47_3' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_77_47_3' id='label_77_47_3' class='gform-field-label gform-field-label--type-inline'>Never<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_77_16\" class=\"gfield gfield--type-html gfield--input-type-html warning 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 need immediate help, you can reach the Suicide &amp; Crisis Lifeline by calling or texting <a href=\"tel:+1-988\">988<\/a> or using the chat box at <a href=\"http:\/\/988lifeline.org\/chat\">988lifeline.org\/chat<\/a>. You can also <a href=\"sms:+1-741-741?body=HOME\">text \"HOME\" to 741-741<\/a> to reach the Crisis Text Line. <a href=\"https:\/\/screening.mhanational.org\/content\/need-talk-someone-warmlines\/\">Warmlines<\/a> are an excellent place for non-crisis support.<\/div><\/div>\n                    <\/div>\n                    <div class='gform-page-footer gform_page_footer top_label'>\n                         <input type='button' id='gform_next_button_77_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_77_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_77_2' class='gform_fields top_label form_sublabel_below description_above validation_below'><div id=\"field_77_58\" 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_77_90\" 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_77_91\" 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_77_91'>\n\t\t\t<div class='gchoice gchoice_77_91_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_91' type='radio' value='For myself'  id='choice_77_91_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_77_91_0' id='label_77_91_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_77_91_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_91' type='radio' value='For someone else'  id='choice_77_91_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_77_91_1' id='label_77_91_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_77_92\" 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_77_59\" 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_77_60\" 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_77_60'>Age Range<\/label><div class='ginput_container ginput_container_select'><select name='input_60' id='input_77_60' class='medium gfield_select'     aria-invalid=\"false\" ><option value='' ><\/option><option value='8-10' >8-10<\/option><option value='11-13' >11-13<\/option><option value='14-15' >14-15<\/option><option value='16-17' >16-17<\/option><option value='18-24' >18-24<\/option><option value='25-34' >25-34<\/option><option value='35-44' >35-44<\/option><option value='45-54' >45-54<\/option><option value='55-64' >55-64<\/option><option value='65+' >65+<\/option><\/select><\/div><\/div><fieldset id=\"field_77_61\" 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_77_61'>\n\t\t\t<div class='gchoice gchoice_77_61_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_61' type='radio' value='Female'  id='choice_77_61_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_77_61_0' id='label_77_61_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_77_61_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_61' type='radio' value='Male'  id='choice_77_61_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_77_61_1' id='label_77_61_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_77_61_2'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_61' type='radio' value='Non-Binary'  id='choice_77_61_2' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_77_61_2' id='label_77_61_2' class='gform-field-label gform-field-label--type-inline'>Non-Binary<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_77_102\" 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_77_102'>\n\t\t\t<div class='gchoice gchoice_77_102_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_102' type='radio' value='Yes'  id='choice_77_102_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_77_102_0' id='label_77_102_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_77_102_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_102' type='radio' value='No'  id='choice_77_102_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_77_102_1' id='label_77_102_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_77_62\" 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_77_62'>How would you describe your gender?<\/label><div class='ginput_container ginput_container_text'><input name='input_62' id='input_77_62' type='text' value='' class='small'    placeholder='Enter gender...'  aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_77_64\" 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_77_64'>Race\/Ethnicity<\/label><div class='ginput_container ginput_container_select'><select name='input_64' id='input_77_64' 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_77_65\" 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_77_65'>Household Income<\/label><div class='ginput_container ginput_container_select'><select name='input_65' id='input_77_65' 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_77_93\" 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_77_93'>\n\t\t\t<div class='gchoice gchoice_77_93_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_93' type='radio' value='I live in the United States'  id='choice_77_93_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_77_93_0' id='label_77_93_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_77_93_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_93' type='radio' value='I live in another country'  id='choice_77_93_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_77_93_1' id='label_77_93_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_77_84\" 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_77_84'>State<\/label><div class='ginput_container ginput_container_select'><select name='input_84' id='input_77_84' 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_77_86\" 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_77_86'>What country do you live in?<\/label><div class='ginput_container ginput_container_select'><select name='input_86' id='input_77_86' 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_77_85\" 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_77_85'>Zip\/Postal Code<\/label><div class='ginput_container ginput_container_text'><input name='input_85' id='input_77_85' type='text' value='' class='small'      aria-invalid=\"false\"   \/><\/div><\/div><fieldset id=\"field_77_66\" 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_77_66'>Select all that apply.<\/div><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox ' id='input_77_66'><div class='gchoice gchoice_77_66_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_66.1' type='checkbox'  value='Veteran or active-duty military'  id='choice_77_66_1'   aria-describedby=\"gfield_description_77_66\"\/>\n\t\t\t\t\t\t\t\t<label for='choice_77_66_1' id='label_77_66_1' class='gform-field-label gform-field-label--type-inline'>Veteran or active-duty military<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_77_66_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_66.2' type='checkbox'  value='Caregiver of someone living with emotional or physical illness'  id='choice_77_66_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_77_66_2' id='label_77_66_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_77_66_3'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_66.3' type='checkbox'  value='LGBTQ+'  id='choice_77_66_3'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_77_66_3' id='label_77_66_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_77_66_4'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_66.4' type='checkbox'  value='Student'  id='choice_77_66_4'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_77_66_4' id='label_77_66_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_77_66_5'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_66.5' type='checkbox'  value='Trauma survivor'  id='choice_77_66_5'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_77_66_5' id='label_77_66_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_77_66_6'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_66.6' type='checkbox'  value='New or expecting parent'  id='choice_77_66_6'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_77_66_6' id='label_77_66_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_77_66_7'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_66.7' type='checkbox'  value='Healthcare worker'  id='choice_77_66_7'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_77_66_7' id='label_77_66_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_77_94\" 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_77_94'>\n\t\t\t<div class='gchoice gchoice_77_94_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_94' type='radio' value='Mental health condition'  id='choice_77_94_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_77_94_0' id='label_77_94_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_77_94_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_94' type='radio' value='Physical health condition'  id='choice_77_94_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_77_94_1' id='label_77_94_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_77_94_2'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_94' type='radio' value='Both mental and physical health conditions'  id='choice_77_94_2' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_77_94_2' id='label_77_94_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_77_95\" 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_77_95'>Which of the following best describes your sexual orientation?<\/label><div class='ginput_container ginput_container_select'><select name='input_95' id='input_77_95' 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_77_72\" class=\"gfield gfield--type-text gfield--input-type-text optional field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_77_72'>What is your sexual orientation?<\/label><div class='ginput_container ginput_container_text'><input name='input_72' id='input_77_72' type='text' value='' class='small'    placeholder='Enter sexual orientation...'  aria-invalid=\"false\"   \/><\/div><\/div><fieldset id=\"field_77_96\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield--input-type-checkbox gfield--width-full traditional field_sublabel_below gfield--has-description field_description_above field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Which of the following describe your experience of trauma?<\/legend><div class='gfield_description' id='gfield_description_77_96'>Select all that apply.<\/div><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox ' id='input_77_96'><div class='gchoice gchoice_77_96_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_96.1' type='checkbox'  value='Child abuse\/violence'  id='choice_77_96_1'   aria-describedby=\"gfield_description_77_96\"\/>\n\t\t\t\t\t\t\t\t<label for='choice_77_96_1' id='label_77_96_1' class='gform-field-label gform-field-label--type-inline'>Child abuse\/violence<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_77_96_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_96.2' type='checkbox'  value='Intimate partner violence'  id='choice_77_96_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_77_96_2' id='label_77_96_2' class='gform-field-label gform-field-label--type-inline'>Intimate partner violence<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_77_96_3'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_96.3' type='checkbox'  value='Sexual assault\/violence'  id='choice_77_96_3'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_77_96_3' id='label_77_96_3' class='gform-field-label gform-field-label--type-inline'>Sexual assault\/violence<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_77_96_4'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_96.4' type='checkbox'  value='Serious illness\/injury\/assault'  id='choice_77_96_4'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_77_96_4' id='label_77_96_4' class='gform-field-label gform-field-label--type-inline'>Serious illness\/injury\/assault<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_77_96_5'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_96.5' type='checkbox'  value='Family conflict (identity acceptance\/separation\/divorce)'  id='choice_77_96_5'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_77_96_5' id='label_77_96_5' class='gform-field-label gform-field-label--type-inline'>Family conflict (identity acceptance\/separation\/divorce)<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_77_96_6'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_96.6' type='checkbox'  value='Traumatic event (natural disaster, accident, witnessing violence, etc.)'  id='choice_77_96_6'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_77_96_6' id='label_77_96_6' class='gform-field-label gform-field-label--type-inline'>Traumatic event (natural disaster, accident, witnessing violence, etc.)<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_77_96_7'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_96.7' type='checkbox'  value='Death of a loved one'  id='choice_77_96_7'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_77_96_7' id='label_77_96_7' class='gform-field-label gform-field-label--type-inline'>Death of a loved one<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_77_96_8'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_96.8' type='checkbox'  value='Other and\/or tell us more about your trauma'  id='choice_77_96_8'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_77_96_8' id='label_77_96_8' class='gform-field-label gform-field-label--type-inline'>Other and\/or tell us more about your trauma<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_77_97\" 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_77_97'>Please tell us more about your experience of trauma:<\/label><div class='ginput_container ginput_container_text'><input name='input_97' id='input_77_97' type='text' value='' class='medium'    placeholder='Tell us more...'  aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_77_73\" class=\"gfield gfield--type-html gfield--input-type-html section-title gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><h2>About Your Mental Health<\/h2><\/div><fieldset id=\"field_77_75\" 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_77_75'>\n\t\t\t<div class='gchoice gchoice_77_75_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_75' type='radio' value='Yes'  id='choice_77_75_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_77_75_0' id='label_77_75_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_77_75_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_75' type='radio' value='No'  id='choice_77_75_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_77_75_1' id='label_77_75_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_77_76\" 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_77_76'>\n\t\t\t<div class='gchoice gchoice_77_76_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_76' type='radio' value='Yes'  id='choice_77_76_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_77_76_0' id='label_77_76_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_77_76_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_76' type='radio' value='No'  id='choice_77_76_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_77_76_1' id='label_77_76_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_77_103\" 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_77_103'>Choose up to 3.<\/div><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox ' id='input_77_103'><div class='gchoice gchoice_77_103_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_103.1' type='checkbox'  value='I wanted to handle my mental health on my own'  id='choice_77_103_1'   aria-describedby=\"gfield_description_77_103\"\/>\n\t\t\t\t\t\t\t\t<label for='choice_77_103_1' id='label_77_103_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_77_103_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_103.2' type='checkbox'  value='I didn\u2019t know how or where to start'  id='choice_77_103_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_77_103_2' id='label_77_103_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_77_103_3'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_103.3' type='checkbox'  value='I thought it would cost too much'  id='choice_77_103_3'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_77_103_3' id='label_77_103_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_77_103_4'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_103.4' type='checkbox'  value='I didn\u2019t have time'  id='choice_77_103_4'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_77_103_4' id='label_77_103_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_77_103_5'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_103.5' type='checkbox'  value='I didn\u2019t think it would help me'  id='choice_77_103_5'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_77_103_5' id='label_77_103_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_77_103_6'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_103.6' type='checkbox'  value='I didn&#039;t feel ready to start treatment'  id='choice_77_103_6'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_77_103_6' id='label_77_103_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_77_103_7'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_103.7' type='checkbox'  value='I was worried about what people would think or say if I got treatment'  id='choice_77_103_7'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_77_103_7' id='label_77_103_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_77_103_8'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_103.8' type='checkbox'  value='I was afraid of being forced into a hospital or forced to take medication'  id='choice_77_103_8'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_77_103_8' id='label_77_103_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_77_103_9'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_103.9' type='checkbox'  value='I tried, but couldn\u2019t find available treatment (no openings, wouldn\u2019t take insurance, etc.)'  id='choice_77_103_9'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_77_103_9' id='label_77_103_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_77_103_11'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_103.11' type='checkbox'  value='My parent(s) or guardian wouldn&#039;t let me, or I didn&#039;t want to ask'  id='choice_77_103_11'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_77_103_11' id='label_77_103_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_77_103_12'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_103.12' type='checkbox'  value='Other...'  id='choice_77_103_12'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_77_103_12' id='label_77_103_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_77_104\" 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_77_104'>What else has prevented you from seeking treatment in the past?<\/label><div class='ginput_container ginput_container_text'><input name='input_104' id='input_77_104' type='text' value='' class='medium'    placeholder='Tell us more...'  aria-invalid=\"false\"   \/><\/div><\/div><fieldset id=\"field_77_77\" 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_77_77'>Choose up to 3.<\/div><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox ' id='input_77_77'><div class='gchoice gchoice_77_77_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_77.1' type='checkbox'  value='Abuse or violence'  id='choice_77_77_1'   aria-describedby=\"gfield_description_77_77\"\/>\n\t\t\t\t\t\t\t\t<label for='choice_77_77_1' id='label_77_77_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_77_77_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_77.2' type='checkbox'  value='Relationship problems (friends, family, or significant other)'  id='choice_77_77_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_77_77_2' id='label_77_77_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_77_77_3'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_77.3' type='checkbox'  value='Body image'  id='choice_77_77_3'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_77_77_3' id='label_77_77_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_77_77_4'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_77.4' type='checkbox'  value='Low self-esteem or self-image'  id='choice_77_77_4'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_77_77_4' id='label_77_77_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_77_77_5'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_77.5' type='checkbox'  value='School or work problems'  id='choice_77_77_5'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_77_77_5' id='label_77_77_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_77_77_6'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_77.6' type='checkbox'  value='Financial problems'  id='choice_77_77_6'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_77_77_6' id='label_77_77_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_77_77_7'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_77.7' type='checkbox'  value='Loneliness or isolation'  id='choice_77_77_7'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_77_77_7' id='label_77_77_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_77_77_8'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_77.8' type='checkbox'  value='Grief or loss of someone or something'  id='choice_77_77_8'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_77_77_8' id='label_77_77_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_77_77_9'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_77.9' type='checkbox'  value='Experiencing hate\/bullying (including racism, homophobia, transphobia, or discrimination)'  id='choice_77_77_9'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_77_77_9' id='label_77_77_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_77_77_11'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_77.11' type='checkbox'  value='State of the world (war, climate, politics, immigration)'  id='choice_77_77_11'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_77_77_11' id='label_77_77_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_77_77_12'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_77.12' type='checkbox'  value='I don\u2019t know (something just feels wrong)'  id='choice_77_77_12'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_77_77_12' id='label_77_77_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_77_77_13'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_77.13' type='checkbox'  value='Other...'  id='choice_77_77_13'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_77_77_13' id='label_77_77_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_77_78\" 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_77_78'>What else is contributing to your mental health problems right now?<\/label><div class='ginput_container ginput_container_text'><input name='input_78' id='input_77_78' type='text' value='' class='medium'    placeholder='Tell us more...'  aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_77_98\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-full field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_77_98'>What about the state of the world is affecting you the most?<\/label><div class='ginput_container ginput_container_text'><input name='input_98' id='input_77_98' type='text' value='' class='medium'    placeholder='Tell us more...'  aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_77_79\" 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_77_80\" 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_77_80'>\n\t\t\t<div class='gchoice gchoice_77_80_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_80' type='radio' value='Yes'  id='choice_77_80_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_77_80_0' id='label_77_80_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_77_80_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_80' type='radio' value='No'  id='choice_77_80_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_77_80_1' id='label_77_80_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_77_80_2'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_80' type='radio' value='I don&#039;t know'  id='choice_77_80_2' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_77_80_2' id='label_77_80_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_77_81\" 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 general health conditions?<\/legend><div class='gfield_description' id='gfield_description_77_81'>Select all that apply.<\/div><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox ' id='input_77_81'><div class='gchoice gchoice_77_81_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_81.1' type='checkbox'  value='Heart disease'  id='choice_77_81_1'   aria-describedby=\"gfield_description_77_81\"\/>\n\t\t\t\t\t\t\t\t<label for='choice_77_81_1' id='label_77_81_1' class='gform-field-label gform-field-label--type-inline'>Heart 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class=\"smaller\">Source:<\/h2>\n<div class=\"references\">\n<p>Moyer et al. (2023). Development of the Edinburgh Postnatal Depression Scale-United States: An Updated Perinatal Mental Health Screening Tool Using a Respectful Care and Trauma-Informed Approach. <em>Journal of Women&#8217;s Health, 32(<\/em>10), pp. 1080\u20131085.<\/p>\n<p>Cox et al. (1987). Detection of postnatal depression: Development of the 10-item Edinburgh Postnatal Depression Scale. <em>The British Journal of Psychiatry 150<\/em>(6), pp. 782-786.<\/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. 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