[{"id":259548,"date":"2026-04-14T15:04:15","date_gmt":"2026-04-14T19:04:15","guid":{"rendered":"https:\/\/screening.mhanational.org\/?post_type=screen&#038;p=259548"},"modified":"2026-04-14T15:04:15","modified_gmt":"2026-04-14T19:04:15","slug":"ai-mental-health-survey-theresa-sandbox","status":"publish","type":"screen","link":"https:\/\/screening.mhanational.org\/es\/screening-tools\/ai-mental-health-survey-theresa-sandbox\/","title":{"rendered":"AI &#038; Mental Health Survey &#8211; Theresa sandbox"},"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 full-pager_wrapper' data-form-theme='gravity-theme' data-form-index='0' id='gform_wrapper_94' 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_94' class='full-pager' class='clearfix' action='\/es\/wp-json\/wp\/v2\/screen' data-formid='94' novalidate><ol class=\"full-progress-bar clearfix step-1-of-3\"><li class=\"step-1 active\"><span>Survey Questions<\/span><\/li><li class=\"step-2 empty\"><span>Optional Questions<\/span><\/li><\/ol>\n                        <div class='gform-body gform_body'><div id='gform_page_94_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_94' class='gform_fields top_label form_sublabel_below description_above validation_below'><div id=\"field_94_158\" 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_94_158'>Facebook<\/label><div class='gfield_description' id='gfield_description_94_158'>This field is for validation purposes and should be left unchanged.<\/div><div class='ginput_container'><input name='input_158' id='input_94_158' type='text' value='' autocomplete='new-password'\/><\/div><\/div><div id=\"field_94_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 survey was developed to help us explore your opinions about artificial intelligence (AI) and mental mealth.<\/p><p>Sharing these thoughts will help us understand what resources and policies to consider when thinking about the future of AI in mental health. Thank you for participating!<\/p><\/div><div id=\"field_94_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_94_38' type='hidden' class='gform_hidden'  aria-invalid=\"false\" value='' \/><\/div><\/div><div id=\"field_94_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_94_39\" type=\"hidden\" class=\"gform_hidden\" aria-invalid=\"false\" value=\"259548\"><\/div><div id=\"field_94_40\" class=\"gfield gfield--type-hidden gfield--input-type-hidden gform_hidden field_sublabel_below gfield--no-description field_description_above field_validation_below 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value='http:\/\/screening.mhanational.org\/es\/wp-json\/wp\/v2\/screen' \/><\/div><\/div><div id=\"field_94_81\" class=\"gfield gfield--type-hidden gfield--input-type-hidden gform_hidden field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><div class='ginput_container ginput_container_text'><input name='input_81' id='input_94_81' type='hidden' class='gform_hidden'  aria-invalid=\"false\" value='' \/><\/div><\/div><div id=\"field_94_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_94_82' type='hidden' class='gform_hidden'  aria-invalid=\"false\" value='' \/><\/div><\/div><div id=\"field_94_83\" class=\"gfield gfield--type-hidden gfield--input-type-hidden gform_hidden field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><div class='ginput_container ginput_container_text'><input name='input_83' id='input_94_83' type='hidden' class='gform_hidden'  aria-invalid=\"false\" value='' \/><\/div><\/div><div id=\"field_94_93\" class=\"gfield gfield--type-hidden gfield--input-type-hidden gfield--width-full gform_hidden field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><div class='ginput_container ginput_container_text'><input name='input_93' id='input_94_93' type='hidden' class='gform_hidden'  aria-invalid=\"false\" value='' \/><\/div><\/div><div id=\"field_94_157\" 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_157' id='input_94_157' type='hidden' class='gform_hidden'  aria-invalid=\"false\" value='lang--es' \/><\/div><\/div><fieldset id=\"field_94_103\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio traditional 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' >Which of the following <strong>best<\/strong> describes your use of AI?<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_94_103'>\n\t\t\t<div class='gchoice gchoice_94_103_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_103' type='radio' value='I have never used AI, but I would like to'  id='choice_94_103_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_94_103_0' id='label_94_103_0' class='gform-field-label gform-field-label--type-inline'>I have never used AI, but I would like to<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_94_103_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_103' type='radio' value='I will never use AI if I can avoid it'  id='choice_94_103_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_94_103_1' id='label_94_103_1' class='gform-field-label gform-field-label--type-inline'>I will never use AI if I can avoid it<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_94_103_2'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_103' type='radio' value='I have only used AI when forced to'  id='choice_94_103_2' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_94_103_2' id='label_94_103_2' class='gform-field-label gform-field-label--type-inline'>I have only used AI when forced to<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_94_103_3'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_103' type='radio' value='I only use AI when it\u2019s included in another product (ex: Zoom, Office, Google)'  id='choice_94_103_3' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_94_103_3' id='label_94_103_3' class='gform-field-label gform-field-label--type-inline'>I only use AI when it\u2019s included in another product (ex: Zoom, Office, Google)<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_94_103_4'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_103' type='radio' value='I use AI less than once a month'  id='choice_94_103_4' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_94_103_4' id='label_94_103_4' class='gform-field-label gform-field-label--type-inline'>I use AI less than once a month<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_94_103_5'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_103' type='radio' value='I use AI once a month'  id='choice_94_103_5' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_94_103_5' id='label_94_103_5' class='gform-field-label gform-field-label--type-inline'>I use AI once a month<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_94_103_6'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_103' type='radio' value='I use AI once or twice a week'  id='choice_94_103_6' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_94_103_6' id='label_94_103_6' class='gform-field-label gform-field-label--type-inline'>I use AI once or twice a week<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_94_103_7'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_103' type='radio' value='I use AI every day'  id='choice_94_103_7' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_94_103_7' id='label_94_103_7' class='gform-field-label gform-field-label--type-inline'>I use AI every day<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_94_110\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield--input-type-checkbox gfield--width-full traditional limit-3 gfield_contains_required field_sublabel_below gfield--has-description field_description_above field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' >What prevents you from using AI?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class='gfield_description' id='gfield_description_94_110'>Select your top 3.<\/div><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox ' id='input_94_110'><div class='gchoice gchoice_94_110_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_110.1' type='checkbox'  value='AI doesn\u2019t seem interesting or useful to me'  id='choice_94_110_1'   aria-describedby=\"gfield_description_94_110\"\/>\n\t\t\t\t\t\t\t\t<label for='choice_94_110_1' id='label_94_110_1' class='gform-field-label gform-field-label--type-inline'>AI doesn\u2019t seem interesting or useful to me<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_94_110_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_110.2' type='checkbox'  value='I don\u2019t know how to use AI'  id='choice_94_110_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_94_110_2' id='label_94_110_2' class='gform-field-label gform-field-label--type-inline'>I don\u2019t know how to use AI<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_94_110_3'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_110.3' type='checkbox'  value='I don\u2019t have access to AI'  id='choice_94_110_3'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_94_110_3' id='label_94_110_3' class='gform-field-label gform-field-label--type-inline'>I don\u2019t have access to AI<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_94_110_4'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_110.4' type='checkbox'  value='AI can\u2019t do anything for me that I can\u2019t do for myself'  id='choice_94_110_4'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_94_110_4' id='label_94_110_4' class='gform-field-label gform-field-label--type-inline'>AI can\u2019t do anything for me that I can\u2019t do for myself<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_94_110_5'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_110.5' type='checkbox'  value='I don\u2019t trust AI to give me good advice or accurate information'  id='choice_94_110_5'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_94_110_5' id='label_94_110_5' class='gform-field-label gform-field-label--type-inline'>I don\u2019t trust AI to give me good advice or accurate information<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_94_110_6'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_110.6' type='checkbox'  value='I don\u2019t want my personal information to be tracked'  id='choice_94_110_6'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_94_110_6' id='label_94_110_6' class='gform-field-label gform-field-label--type-inline'>I don\u2019t want my personal information to be tracked<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_94_110_7'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_110.7' type='checkbox'  value='I don\u2019t trust the companies behind AI'  id='choice_94_110_7'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_94_110_7' id='label_94_110_7' class='gform-field-label gform-field-label--type-inline'>I don\u2019t trust the companies behind AI<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_94_110_8'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_110.8' type='checkbox'  value='I am opposed to using AI because of its negative impact on society'  id='choice_94_110_8'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_94_110_8' id='label_94_110_8' class='gform-field-label gform-field-label--type-inline'>I am opposed to using AI because of its negative impact on society<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_94_110_9'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_110.9' type='checkbox'  value='The technology isn\u2019t good enough yet'  id='choice_94_110_9'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_94_110_9' id='label_94_110_9' class='gform-field-label gform-field-label--type-inline'>The technology isn\u2019t good enough yet<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_94_140\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-full traditional 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' >Which AI system do you use <strong>the most<\/strong>?<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_94_140'>\n\t\t\t<div class='gchoice gchoice_94_140_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_140' type='radio' value='ChatGPT'  id='choice_94_140_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_94_140_0' id='label_94_140_0' class='gform-field-label gform-field-label--type-inline'>ChatGPT<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_94_140_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_140' type='radio' value='Claude (Anthropic)'  id='choice_94_140_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_94_140_1' id='label_94_140_1' class='gform-field-label gform-field-label--type-inline'>Claude (Anthropic)<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_94_140_2'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_140' type='radio' value='Gemini (Google)'  id='choice_94_140_2' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_94_140_2' id='label_94_140_2' class='gform-field-label gform-field-label--type-inline'>Gemini (Google)<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_94_140_3'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_140' type='radio' value='Character AI'  id='choice_94_140_3' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_94_140_3' id='label_94_140_3' class='gform-field-label gform-field-label--type-inline'>Character AI<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_94_140_4'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_140' type='radio' value='Grok'  id='choice_94_140_4' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_94_140_4' id='label_94_140_4' class='gform-field-label gform-field-label--type-inline'>Grok<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_94_140_5'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_140' type='radio' value='Microsoft Copilot'  id='choice_94_140_5' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_94_140_5' id='label_94_140_5' class='gform-field-label gform-field-label--type-inline'>Microsoft Copilot<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_94_140_6'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_140' type='radio' value='Meta AI'  id='choice_94_140_6' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_94_140_6' id='label_94_140_6' class='gform-field-label gform-field-label--type-inline'>Meta AI<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_94_140_7'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_140' type='radio' value='Other (examples: Perplexity, Snapchat AI)'  id='choice_94_140_7' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_94_140_7' id='label_94_140_7' class='gform-field-label gform-field-label--type-inline'>Other (examples: Perplexity, Snapchat AI)<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_94_141\" 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_94_141'>What other AI system do you use the most?<\/label><div class='ginput_container ginput_container_text'><input name='input_141' id='input_94_141' type='text' value='' class='medium'    placeholder='Tell us more...'  aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_94_132\" class=\"gfield gfield--type-section gfield--input-type-section gsection field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><h3 class=\"gsection_title\"><\/h3><\/div><fieldset id=\"field_94_114\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield--input-type-checkbox gfield--width-full traditional limit-3 gfield_contains_required field_sublabel_below gfield--has-description field_description_above field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Imagine the future 5 years from now. What do you hope AI will help you do?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class='gfield_description' id='gfield_description_94_114'>Select your top 3.<\/div><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox ' id='input_94_114'><div class='gchoice gchoice_94_114_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_114.1' type='checkbox'  value='Save time and effort by doing tasks for me'  id='choice_94_114_1'   aria-describedby=\"gfield_description_94_114\"\/>\n\t\t\t\t\t\t\t\t<label for='choice_94_114_1' id='label_94_114_1' class='gform-field-label gform-field-label--type-inline'>Save time and effort by doing tasks for me<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_94_114_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_114.2' type='checkbox'  value='Organizing my life \u2014 reminders, to-do lists, calendars, files, and photos'  id='choice_94_114_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_94_114_2' id='label_94_114_2' class='gform-field-label gform-field-label--type-inline'>Organizing my life \u2014 reminders, to-do lists, calendars, files, and photos<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_94_114_3'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_114.3' type='checkbox'  value='Easier access to information'  id='choice_94_114_3'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_94_114_3' id='label_94_114_3' class='gform-field-label gform-field-label--type-inline'>Easier access to information<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_94_114_4'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_114.4' type='checkbox'  value='Improve my problem solving or decision making'  id='choice_94_114_4'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_94_114_4' id='label_94_114_4' class='gform-field-label gform-field-label--type-inline'>Improve my problem solving or decision making<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_94_114_5'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_114.5' type='checkbox'  value='Learning new skills'  id='choice_94_114_5'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_94_114_5' id='label_94_114_5' class='gform-field-label gform-field-label--type-inline'>Learning new skills<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_94_114_6'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_114.6' type='checkbox'  value='Find new ways to express myself creatively'  id='choice_94_114_6'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_94_114_6' id='label_94_114_6' class='gform-field-label gform-field-label--type-inline'>Find new ways to express myself creatively<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_94_114_7'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_114.7' type='checkbox'  value='Support my health and wellness'  id='choice_94_114_7'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_94_114_7' id='label_94_114_7' class='gform-field-label gform-field-label--type-inline'>Support my health and wellness<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_94_114_8'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_114.8' type='checkbox'  value='Enhance my communication with other people'  id='choice_94_114_8'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_94_114_8' id='label_94_114_8' class='gform-field-label gform-field-label--type-inline'>Enhance my communication with other people<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_94_114_9'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_114.9' type='checkbox'  value='Help me feel less lonely'  id='choice_94_114_9'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_94_114_9' id='label_94_114_9' class='gform-field-label gform-field-label--type-inline'>Help me feel less lonely<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_94_114_11'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_114.11' type='checkbox'  value='Other people will use AI to make new inventions or discoveries that will improve my life'  id='choice_94_114_11'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_94_114_11' id='label_94_114_11' class='gform-field-label gform-field-label--type-inline'>Other people will use AI to make new inventions or discoveries that will improve my life<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_94_114_12'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_114.12' type='checkbox'  value='Nothing. I don&#039;t like AI and don&#039;t want it to affect my life in any way'  id='choice_94_114_12'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_94_114_12' id='label_94_114_12' class='gform-field-label gform-field-label--type-inline'>Nothing. I don't like AI and don't want it to affect my life in any way<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_94_114_13'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_114.13' type='checkbox'  value='Other...'  id='choice_94_114_13'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_94_114_13' id='label_94_114_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_94_117\" 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_94_117'>What else do you hope AI will help you do?<\/label><div class='ginput_container ginput_container_text'><input name='input_117' id='input_94_117' type='text' value='' class='medium'    placeholder='Tell us more...'  aria-invalid=\"false\"   \/><\/div><\/div><fieldset id=\"field_94_118\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield--input-type-checkbox gfield--width-full traditional limit-3 gfield_contains_required field_sublabel_below gfield--has-description field_description_above field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Imagine the future 5 years from now. What scares you the most about the impact of AI?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class='gfield_description' id='gfield_description_94_118'>Select your top 3.<\/div><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox ' id='input_94_118'><div class='gchoice gchoice_94_118_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_118.1' type='checkbox'  value='Losing human skills (social, reading, writing, creating)'  id='choice_94_118_1'   aria-describedby=\"gfield_description_94_118\"\/>\n\t\t\t\t\t\t\t\t<label for='choice_94_118_1' id='label_94_118_1' class='gform-field-label gform-field-label--type-inline'>Losing human skills (social, reading, writing, creating)<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_94_118_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_118.2' type='checkbox'  value='Being monitored and tracked online'  id='choice_94_118_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_94_118_2' id='label_94_118_2' class='gform-field-label gform-field-label--type-inline'>Being monitored and tracked online<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_94_118_3'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_118.3' type='checkbox'  value='Companies stealing my information or work to train AI models'  id='choice_94_118_3'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_94_118_3' id='label_94_118_3' class='gform-field-label gform-field-label--type-inline'>Companies stealing my information or work to train AI models<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_94_118_4'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_118.4' type='checkbox'  value='Job loss or being replaced by AI'  id='choice_94_118_4'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_94_118_4' id='label_94_118_4' class='gform-field-label gform-field-label--type-inline'>Job loss or being replaced by AI<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_94_118_5'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_118.5' type='checkbox'  value='AI making biased decisions about me (what healthcare or jobs I can get, where I can live, etc.)'  id='choice_94_118_5'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_94_118_5' id='label_94_118_5' class='gform-field-label gform-field-label--type-inline'>AI making biased decisions about me (what healthcare or jobs I can get, where I can live, etc.)<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_94_118_6'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_118.6' type='checkbox'  value='Replacing in-person connection with other people'  id='choice_94_118_6'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_94_118_6' id='label_94_118_6' class='gform-field-label gform-field-label--type-inline'>Replacing in-person connection with other people<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_94_118_7'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_118.7' type='checkbox'  value='Can cause brain changes that are harmful (addiction, attention problems)'  id='choice_94_118_7'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_94_118_7' id='label_94_118_7' class='gform-field-label gform-field-label--type-inline'>Can cause brain changes that are harmful (addiction, attention problems)<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_94_118_8'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_118.8' type='checkbox'  value='Becoming dependent on AI (can\u2019t make decisions without AI)'  id='choice_94_118_8'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_94_118_8' id='label_94_118_8' class='gform-field-label gform-field-label--type-inline'>Becoming dependent on AI (can\u2019t make decisions without AI)<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_94_118_9'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_118.9' type='checkbox'  value='Providing bad information (bad advice, wrong answers, deep fakes)'  id='choice_94_118_9'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_94_118_9' id='label_94_118_9' class='gform-field-label gform-field-label--type-inline'>Providing bad information (bad advice, wrong answers, deep fakes)<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_94_118_11'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_118.11' type='checkbox'  value='Flooding the internet with junk and making it harder to find quality content'  id='choice_94_118_11'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_94_118_11' id='label_94_118_11' class='gform-field-label gform-field-label--type-inline'>Flooding the internet with junk and making it harder to find quality content<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_94_118_12'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_118.12' type='checkbox'  value='Nothing. I think AI will only have positive effects.'  id='choice_94_118_12'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_94_118_12' id='label_94_118_12' class='gform-field-label gform-field-label--type-inline'>Nothing. I think AI will only have positive effects.<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_94_118_13'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_118.13' type='checkbox'  value='Other...'  id='choice_94_118_13'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_94_118_13' id='label_94_118_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_94_119\" 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_94_119'>What else scares you about the impact of AI?<\/label><div class='ginput_container ginput_container_text'><input name='input_119' id='input_94_119' type='text' value='' class='medium'    placeholder='Tell us more...'  aria-invalid=\"false\"   \/><\/div><\/div><fieldset id=\"field_94_105\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio traditional 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 you used AI for emotional support?<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_94_105'>\n\t\t\t<div class='gchoice gchoice_94_105_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_105' type='radio' value='No, never'  id='choice_94_105_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_94_105_0' id='label_94_105_0' class='gform-field-label gform-field-label--type-inline'>No, never<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_94_105_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_105' type='radio' value='Yes, a few times'  id='choice_94_105_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_94_105_1' id='label_94_105_1' class='gform-field-label gform-field-label--type-inline'>Yes, a few times<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_94_105_2'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_105' type='radio' value='Yes, regularly \/ often'  id='choice_94_105_2' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_94_105_2' id='label_94_105_2' class='gform-field-label gform-field-label--type-inline'>Yes, regularly \/ often<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_94_120\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield--input-type-checkbox gfield--width-full traditional limit-3 gfield_contains_required field_sublabel_below gfield--has-description field_description_above field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' >What is preventing you from using AI for emotional support more often?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class='gfield_description' id='gfield_description_94_120'>Select your top 3.<\/div><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox ' id='input_94_120'><div class='gchoice gchoice_94_120_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_120.1' type='checkbox'  value='I don\u2019t trust AI to give me good advice or accurate information'  id='choice_94_120_1'   aria-describedby=\"gfield_description_94_120\"\/>\n\t\t\t\t\t\t\t\t<label for='choice_94_120_1' id='label_94_120_1' class='gform-field-label gform-field-label--type-inline'>I don\u2019t trust AI to give me good advice or accurate information<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_94_120_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_120.2' type='checkbox'  value='I\u2019m worried that my personal information could be tracked'  id='choice_94_120_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_94_120_2' id='label_94_120_2' class='gform-field-label gform-field-label--type-inline'>I\u2019m worried that my personal information could be tracked<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_94_120_3'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_120.3' type='checkbox'  value='I don\u2019t trust the companies behind AI'  id='choice_94_120_3'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_94_120_3' id='label_94_120_3' class='gform-field-label gform-field-label--type-inline'>I don\u2019t trust the companies behind AI<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_94_120_4'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_120.4' type='checkbox'  value='I don\u2019t know how to use it for this purpose'  id='choice_94_120_4'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_94_120_4' id='label_94_120_4' class='gform-field-label gform-field-label--type-inline'>I don\u2019t know how to use it for this purpose<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_94_120_5'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_120.5' type='checkbox'  value='I prefer to talk to a human'  id='choice_94_120_5'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_94_120_5' id='label_94_120_5' class='gform-field-label gform-field-label--type-inline'>I prefer to talk to a human<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_94_120_6'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_120.6' type='checkbox'  value='The technology isn\u2019t good enough yet'  id='choice_94_120_6'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_94_120_6' id='label_94_120_6' class='gform-field-label gform-field-label--type-inline'>The technology isn\u2019t good enough yet<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_94_120_7'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_120.7' type='checkbox'  value='I am opposed to using AI because of its negative impact on society'  id='choice_94_120_7'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_94_120_7' id='label_94_120_7' class='gform-field-label gform-field-label--type-inline'>I am opposed to using AI because of its negative impact on society<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_94_120_8'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_120.8' type='checkbox'  value='I don\u2019t need it because I am already receiving treatment or support another way'  id='choice_94_120_8'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_94_120_8' id='label_94_120_8' class='gform-field-label gform-field-label--type-inline'>I don\u2019t need it because I am already receiving treatment or support another way<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_94_120_9'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_120.9' type='checkbox'  value='I already got what I needed from it'  id='choice_94_120_9'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_94_120_9' id='label_94_120_9' class='gform-field-label gform-field-label--type-inline'>I already got what I needed from it<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_94_133\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-full traditional 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' >How positive or negative was your experience?<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_94_133'>\n\t\t\t<div class='gchoice gchoice_94_133_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_133' type='radio' value='Very positive'  id='choice_94_133_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_94_133_0' id='label_94_133_0' class='gform-field-label gform-field-label--type-inline'>Very positive<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_94_133_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_133' type='radio' value='Positive'  id='choice_94_133_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_94_133_1' id='label_94_133_1' class='gform-field-label gform-field-label--type-inline'>Positive<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_94_133_2'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_133' type='radio' value='Negative'  id='choice_94_133_2' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_94_133_2' id='label_94_133_2' class='gform-field-label gform-field-label--type-inline'>Negative<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_94_133_3'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_133' type='radio' value='Very negative'  id='choice_94_133_3' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_94_133_3' id='label_94_133_3' class='gform-field-label gform-field-label--type-inline'>Very negative<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_94_123\" 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_94_123'>Can you tell us more about why your experience was positive?<\/label><div class='ginput_container ginput_container_text'><input name='input_123' id='input_94_123' type='text' value='' class='large'    placeholder='Tell us more...'  aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_94_124\" 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_94_124'>Can you tell us more about why your experience was negative?<\/label><div class='ginput_container ginput_container_text'><input name='input_124' id='input_94_124' type='text' value='' class='large'    placeholder='Tell us more...'  aria-invalid=\"false\"   \/><\/div><\/div><fieldset id=\"field_94_125\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-full question short gfield_contains_required field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >Would you ever consider using AI for emotional support?<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_94_125'>\n\t\t\t<div class='gchoice gchoice_94_125_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_125' type='radio' value='Yes'  id='choice_94_125_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_94_125_0' id='label_94_125_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_94_125_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_125' type='radio' value='No'  id='choice_94_125_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_94_125_1' id='label_94_125_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_94_127\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield--input-type-checkbox gfield--width-full traditional limit-3 gfield_contains_required field_sublabel_below gfield--has-description field_description_above field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' >What would prevent you from using AI for emotional support?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class='gfield_description' id='gfield_description_94_127'>Select your top 3.<\/div><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox ' id='input_94_127'><div class='gchoice gchoice_94_127_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_127.1' type='checkbox'  value='I don\u2019t trust AI to give me good advice or accurate information'  id='choice_94_127_1'   aria-describedby=\"gfield_description_94_127\"\/>\n\t\t\t\t\t\t\t\t<label for='choice_94_127_1' id='label_94_127_1' class='gform-field-label gform-field-label--type-inline'>I don\u2019t trust AI to give me good advice or accurate information<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_94_127_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_127.2' type='checkbox'  value='I\u2019m worried that my personal information could be tracked'  id='choice_94_127_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_94_127_2' id='label_94_127_2' class='gform-field-label gform-field-label--type-inline'>I\u2019m worried that my personal information could be tracked<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_94_127_3'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_127.3' type='checkbox'  value='I don\u2019t trust the companies behind AI'  id='choice_94_127_3'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_94_127_3' id='label_94_127_3' class='gform-field-label gform-field-label--type-inline'>I don\u2019t trust the companies behind AI<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_94_127_4'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_127.4' type='checkbox'  value='I don\u2019t know how to use it for this purpose'  id='choice_94_127_4'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_94_127_4' id='label_94_127_4' class='gform-field-label gform-field-label--type-inline'>I don\u2019t know how to use it for this purpose<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_94_127_5'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_127.5' type='checkbox'  value='I prefer to talk to a human'  id='choice_94_127_5'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_94_127_5' id='label_94_127_5' class='gform-field-label gform-field-label--type-inline'>I prefer to talk to a human<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_94_127_6'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_127.6' type='checkbox'  value='The technology isn\u2019t good enough yet'  id='choice_94_127_6'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_94_127_6' id='label_94_127_6' class='gform-field-label gform-field-label--type-inline'>The technology isn\u2019t good enough yet<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_94_127_7'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_127.7' type='checkbox'  value='I am opposed to using AI because of its negative impact on society'  id='choice_94_127_7'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_94_127_7' id='label_94_127_7' class='gform-field-label gform-field-label--type-inline'>I am opposed to using AI because of its negative impact on society<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_94_127_8'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_127.8' type='checkbox'  value='I don\u2019t need it because I am already receiving treatment or support another way'  id='choice_94_127_8'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_94_127_8' id='label_94_127_8' class='gform-field-label gform-field-label--type-inline'>I don\u2019t need it because I am already receiving treatment or support another way<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_94_127_9'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_127.9' type='checkbox'  value='I already got what I needed from it'  id='choice_94_127_9'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_94_127_9' id='label_94_127_9' class='gform-field-label gform-field-label--type-inline'>I already got what I needed from it<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_94_139\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield--input-type-checkbox gfield--width-full traditional limit-3 gfield_contains_required field_sublabel_below gfield--has-description field_description_above field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Why would you consider using AI for mental or emotional support?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class='gfield_description' id='gfield_description_94_139'>Select your top 3.<\/div><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox ' id='input_94_139'><div class='gchoice gchoice_94_139_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_139.1' type='checkbox'  value='I feel more comfortable talking to a bot than to a human'  id='choice_94_139_1'   aria-describedby=\"gfield_description_94_139\"\/>\n\t\t\t\t\t\t\t\t<label for='choice_94_139_1' id='label_94_139_1' class='gform-field-label gform-field-label--type-inline'>I feel more comfortable talking to a bot than to a human<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_94_139_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_139.2' type='checkbox'  value='It\u2019s convenient\/available 24\/7'  id='choice_94_139_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_94_139_2' id='label_94_139_2' class='gform-field-label gform-field-label--type-inline'>It\u2019s convenient\/available 24\/7<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_94_139_3'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_139.3' type='checkbox'  value='It\u2019s free'  id='choice_94_139_3'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_94_139_3' id='label_94_139_3' class='gform-field-label gform-field-label--type-inline'>It\u2019s free<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_94_139_4'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_139.4' type='checkbox'  value='Traditional therapy isn\u2019t available to me'  id='choice_94_139_4'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_94_139_4' id='label_94_139_4' class='gform-field-label gform-field-label--type-inline'>Traditional therapy isn\u2019t available to me<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_94_139_5'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_139.5' type='checkbox'  value='It\u2019s safer. It lets me stay anonymous'  id='choice_94_139_5'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_94_139_5' id='label_94_139_5' class='gform-field-label gform-field-label--type-inline'>It\u2019s safer. It lets me stay anonymous<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_94_139_6'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_139.6' type='checkbox'  value='It lets me get help without telling my family'  id='choice_94_139_6'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_94_139_6' id='label_94_139_6' class='gform-field-label gform-field-label--type-inline'>It lets me get help without telling my family<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_94_139_7'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_139.7' type='checkbox'  value='Therapy or help I\u2019ve received from people has not helped'  id='choice_94_139_7'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_94_139_7' id='label_94_139_7' class='gform-field-label gform-field-label--type-inline'>Therapy or help I\u2019ve received from people has not helped<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_94_139_8'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_139.8' type='checkbox'  value='It\u2019s entertaining\/engaging'  id='choice_94_139_8'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_94_139_8' id='label_94_139_8' class='gform-field-label gform-field-label--type-inline'>It\u2019s entertaining\/engaging<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_94_137\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield--input-type-checkbox gfield--width-full traditional limit-3 gfield_contains_required field_sublabel_below gfield--has-description field_description_above field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' >In what ways have you <strong>used AI the most<\/strong> for emotional support?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class='gfield_description' id='gfield_description_94_137'>Select your top 3.<\/div><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox ' id='input_94_137'><div class='gchoice gchoice_94_137_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_137.1' type='checkbox'  value='Help me answer questions about mental health'  id='choice_94_137_1'   aria-describedby=\"gfield_description_94_137\"\/>\n\t\t\t\t\t\t\t\t<label for='choice_94_137_1' id='label_94_137_1' class='gform-field-label gform-field-label--type-inline'>Help me answer questions about mental health<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_94_137_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_137.2' type='checkbox'  value='Help me with a mental health diagnosis'  id='choice_94_137_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_94_137_2' id='label_94_137_2' class='gform-field-label gform-field-label--type-inline'>Help me with a mental health diagnosis<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_94_137_3'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_137.3' type='checkbox'  value='Help me get treatment options'  id='choice_94_137_3'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_94_137_3' id='label_94_137_3' class='gform-field-label gform-field-label--type-inline'>Help me get treatment options<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_94_137_4'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_137.4' type='checkbox'  value='Tracking my mood or habits (logs, reminders)'  id='choice_94_137_4'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_94_137_4' id='label_94_137_4' class='gform-field-label gform-field-label--type-inline'>Tracking my mood or habits (logs, reminders)<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_94_137_5'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_137.5' type='checkbox'  value='A structured tool or app that uses AI in the activity (worksheets, exercises, journaling prompts)'  id='choice_94_137_5'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_94_137_5' id='label_94_137_5' class='gform-field-label gform-field-label--type-inline'>A structured tool or app that uses AI in the activity (worksheets, exercises, journaling prompts)<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_94_137_6'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_137.6' type='checkbox'  value='A conversation with AI (learns your habits\/needs over time, provides listening and advice, helps me make decisions, helps me deal with hard issues)'  id='choice_94_137_6'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_94_137_6' id='label_94_137_6' class='gform-field-label gform-field-label--type-inline'>A conversation with AI (learns your habits\/needs over time, provides listening and advice, helps me make decisions, helps me deal with hard issues)<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_94_128\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield--input-type-checkbox gfield--width-full traditional limit-3 gfield_contains_required field_sublabel_below gfield--has-description field_description_above field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' >In what ways are you <strong>most interested in using AI<\/strong> for emotional support?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class='gfield_description' id='gfield_description_94_128'>Select your top 3.<\/div><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox ' id='input_94_128'><div class='gchoice gchoice_94_128_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_128.1' type='checkbox'  value='Help me answer questions about mental health'  id='choice_94_128_1'   aria-describedby=\"gfield_description_94_128\"\/>\n\t\t\t\t\t\t\t\t<label for='choice_94_128_1' id='label_94_128_1' class='gform-field-label gform-field-label--type-inline'>Help me answer questions about mental health<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_94_128_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_128.2' type='checkbox'  value='Help me with a mental health diagnosis'  id='choice_94_128_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_94_128_2' id='label_94_128_2' class='gform-field-label gform-field-label--type-inline'>Help me with a mental health diagnosis<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_94_128_3'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_128.3' type='checkbox'  value='Help me get treatment options'  id='choice_94_128_3'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_94_128_3' id='label_94_128_3' class='gform-field-label gform-field-label--type-inline'>Help me get treatment options<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_94_128_4'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_128.4' type='checkbox'  value='Tracking my mood or habits (logs, reminders)'  id='choice_94_128_4'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_94_128_4' id='label_94_128_4' class='gform-field-label gform-field-label--type-inline'>Tracking my mood or habits (logs, reminders)<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_94_128_5'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_128.5' type='checkbox'  value='A structured tool or app that uses AI in the activity (worksheets, exercises, journaling prompts)'  id='choice_94_128_5'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_94_128_5' id='label_94_128_5' class='gform-field-label gform-field-label--type-inline'>A structured tool or app that uses AI in the activity (worksheets, exercises, journaling prompts)<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_94_128_6'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_128.6' type='checkbox'  value='A conversation with AI (learns your habits\/needs over time, provides listening and advice, helps me make decisions, helps me deal with hard issues)'  id='choice_94_128_6'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_94_128_6' id='label_94_128_6' class='gform-field-label gform-field-label--type-inline'>A conversation with AI (learns your habits\/needs over time, provides listening and advice, helps me make decisions, helps me deal with hard issues)<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_94_149\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield--input-type-checkbox gfield--width-full traditional limit-3 gfield_contains_required field_sublabel_below gfield--has-description field_description_above field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' >When people use AI for emotional support, what is the best thing the AI can do to respond to their needs?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class='gfield_description' id='gfield_description_94_149'>Select your top 3.<\/div><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox ' id='input_94_149'><div class='gchoice gchoice_94_149_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_149.1' type='checkbox'  value='Ask them directly about risk of harm (hurting yourself or others)'  id='choice_94_149_1'   aria-describedby=\"gfield_description_94_149\"\/>\n\t\t\t\t\t\t\t\t<label for='choice_94_149_1' id='label_94_149_1' class='gform-field-label gform-field-label--type-inline'>Ask them directly about risk of harm (hurting yourself or others)<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_94_149_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_149.2' type='checkbox'  value='Listen and support their emotional concerns'  id='choice_94_149_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_94_149_2' id='label_94_149_2' class='gform-field-label gform-field-label--type-inline'>Listen and support their emotional concerns<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_94_149_3'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_149.3' type='checkbox'  value='Help them figure out how to feel better (e.g making a plan, learning some skils)'  id='choice_94_149_3'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_94_149_3' id='label_94_149_3' class='gform-field-label gform-field-label--type-inline'>Help them figure out how to feel better (e.g making a plan, learning some skils)<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_94_149_4'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_149.4' type='checkbox'  value='Give them information about mental health'  id='choice_94_149_4'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_94_149_4' id='label_94_149_4' class='gform-field-label gform-field-label--type-inline'>Give them information about mental health<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_94_149_5'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_149.5' type='checkbox'  value='Explore all the different support systems they have'  id='choice_94_149_5'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_94_149_5' id='label_94_149_5' class='gform-field-label gform-field-label--type-inline'>Explore all the different support systems they have<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_94_149_6'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_149.6' type='checkbox'  value='Help them figure out how to talk to someone'  id='choice_94_149_6'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_94_149_6' id='label_94_149_6' class='gform-field-label gform-field-label--type-inline'>Help them figure out how to talk to someone<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_94_149_7'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_149.7' type='checkbox'  value='Send them resources, including how to connect to a person'  id='choice_94_149_7'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_94_149_7' id='label_94_149_7' class='gform-field-label gform-field-label--type-inline'>Send them resources, including how to connect to a person<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_94_138\" class=\"gfield gfield--type-textarea gfield--input-type-textarea gfield--width-full field_sublabel_below gfield--has-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_94_138'><strong>Optional:<\/strong> Think back to a time when you used AI for emotional support. Can you share anything about how that conversation went? What did you talk about? How did you feel?<\/label><div class='gfield_description' id='gfield_description_94_138'><em><strong>Share as much or as little as you like.<\/strong> For example, you could just describe your experience in one sentence, share prompts you've used that have been particularly effective, or anything in between.<\/em><\/div><div class='ginput_container ginput_container_textarea'><textarea name='input_138' id='input_94_138' class='textarea medium'  aria-describedby=\"gfield_description_94_138\"    aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/div><fieldset id=\"field_94_142\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield--input-type-checkbox gfield--width-full limit-3 traditional question gfield_contains_required field_sublabel_below gfield--has-description field_description_above field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Who do you think are the top 3 groups who should be most responsible for implementing mental health protections for people who use AI?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class='gfield_description' id='gfield_description_94_142'>Select up to 3.<\/div><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox ' id='input_94_142'><div class='gchoice gchoice_94_142_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_142.1' type='checkbox'  value='Myself \/ individual users'  id='choice_94_142_1'   aria-describedby=\"gfield_description_94_142\"\/>\n\t\t\t\t\t\t\t\t<label for='choice_94_142_1' id='label_94_142_1' class='gform-field-label gform-field-label--type-inline'>Myself \/ individual users<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_94_142_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_142.2' type='checkbox'  value='Parents \/ guardians'  id='choice_94_142_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_94_142_2' id='label_94_142_2' class='gform-field-label gform-field-label--type-inline'>Parents \/ guardians<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_94_142_3'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_142.3' type='checkbox'  value='Technology companies'  id='choice_94_142_3'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_94_142_3' id='label_94_142_3' class='gform-field-label gform-field-label--type-inline'>Technology companies<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_94_142_4'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_142.4' type='checkbox'  value='Companies using AI software (employers, healthcare, schools)'  id='choice_94_142_4'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_94_142_4' id='label_94_142_4' class='gform-field-label gform-field-label--type-inline'>Companies using AI software (employers, healthcare, schools)<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_94_142_5'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_142.5' type='checkbox'  value='Government'  id='choice_94_142_5'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_94_142_5' id='label_94_142_5' class='gform-field-label gform-field-label--type-inline'>Government<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_94_142_6'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_142.6' type='checkbox'  value='Other...'  id='choice_94_142_6'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_94_142_6' id='label_94_142_6' 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_94_143\" 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_94_143'>Who else do you think is the most responsible for implementing mental health protections?<\/label><div class='ginput_container ginput_container_text'><input name='input_143' id='input_94_143' type='text' value='' class='large'    placeholder='Tell us more...'  aria-invalid=\"false\"   \/><\/div><\/div><fieldset id=\"field_94_144\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield--input-type-checkbox gfield--width-full limit-3 traditional question gfield_contains_required field_sublabel_below gfield--has-description field_description_above field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' >What are the top 3 things that technology companies can do to protect people from harm when they\u2019re getting mental health support from AI?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class='gfield_description' id='gfield_description_94_144'>Select up to 3.<\/div><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox ' id='input_94_144'><div class='gchoice gchoice_94_144_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_144.1' type='checkbox'  value='Refer me to a mental health professional instead of providing direct advice'  id='choice_94_144_1'   aria-describedby=\"gfield_description_94_144\"\/>\n\t\t\t\t\t\t\t\t<label for='choice_94_144_1' id='label_94_144_1' class='gform-field-label gform-field-label--type-inline'>Refer me to a mental health professional instead of providing direct advice<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_94_144_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_144.2' type='checkbox'  value='Remind me that I\u2019m talking to a machine and not a human'  id='choice_94_144_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_94_144_2' id='label_94_144_2' class='gform-field-label gform-field-label--type-inline'>Remind me that I\u2019m talking to a machine and not a human<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_94_144_3'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_144.3' type='checkbox'  value='Make the AI less like a human'  id='choice_94_144_3'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_94_144_3' id='label_94_144_3' class='gform-field-label gform-field-label--type-inline'>Make the AI less like a human<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_94_144_4'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_144.4' type='checkbox'  value='Make the AI more like a human'  id='choice_94_144_4'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_94_144_4' id='label_94_144_4' class='gform-field-label gform-field-label--type-inline'>Make the AI more like a human<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_94_144_5'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_144.5' type='checkbox'  value='Tell me about my emotional risks when I\u2019m using AI'  id='choice_94_144_5'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_94_144_5' id='label_94_144_5' class='gform-field-label gform-field-label--type-inline'>Tell me about my emotional risks when I\u2019m using AI<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_94_144_6'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_144.6' type='checkbox'  value='Guarantee that my conversations won\u2019t be used to train the AI'  id='choice_94_144_6'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_94_144_6' id='label_94_144_6' class='gform-field-label gform-field-label--type-inline'>Guarantee that my conversations won\u2019t be used to train the AI<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_94_144_7'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_144.7' type='checkbox'  value='Make sure no one else can ever see the conversations I have with AI'  id='choice_94_144_7'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_94_144_7' id='label_94_144_7' class='gform-field-label gform-field-label--type-inline'>Make sure no one else can ever see the conversations I have with AI<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_94_144_8'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_144.8' type='checkbox'  value='Develop industry standards for measuring impact on communities of users'  id='choice_94_144_8'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_94_144_8' id='label_94_144_8' class='gform-field-label gform-field-label--type-inline'>Develop industry standards for measuring impact on communities of users<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_94_144_9'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_144.9' type='checkbox'  value='Other...'  id='choice_94_144_9'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_94_144_9' id='label_94_144_9' 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_94_145\" 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_94_145'>What else can technology companies do to protect the mental health of people who use their AI?<\/label><div class='ginput_container ginput_container_text'><input name='input_145' id='input_94_145' type='text' value='' class='large'    placeholder='Tell us more...'  aria-invalid=\"false\"   \/><\/div><\/div><fieldset id=\"field_94_146\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield--input-type-checkbox gfield--width-full limit-3 traditional question gfield_contains_required field_sublabel_below gfield--has-description field_description_above field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' >What are the top 3 things that the government can do to protect the mental health of people who use AI?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class='gfield_description' id='gfield_description_94_146'>Select up to 3.<\/div><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox ' id='input_94_146'><div class='gchoice gchoice_94_146_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_146.1' type='checkbox'  value='Set policies\/laws that tech companies have to follow'  id='choice_94_146_1'   aria-describedby=\"gfield_description_94_146\"\/>\n\t\t\t\t\t\t\t\t<label for='choice_94_146_1' id='label_94_146_1' class='gform-field-label gform-field-label--type-inline'>Set policies\/laws that tech companies have to follow<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_94_146_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_146.2' type='checkbox'  value='Create a group of people responsible for reviewing and giving limitations on safety'  id='choice_94_146_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_94_146_2' id='label_94_146_2' class='gform-field-label gform-field-label--type-inline'>Create a group of people responsible for reviewing and giving limitations on safety<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_94_146_3'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_146.3' type='checkbox'  value='Create guidelines and incentives for safety'  id='choice_94_146_3'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_94_146_3' id='label_94_146_3' class='gform-field-label gform-field-label--type-inline'>Create guidelines and incentives for safety<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_94_146_4'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_146.4' type='checkbox'  value='Incentivize research on potential harms or positive impacts of AI'  id='choice_94_146_4'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_94_146_4' id='label_94_146_4' class='gform-field-label gform-field-label--type-inline'>Incentivize research on potential harms or positive impacts of AI<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_94_146_5'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_146.5' type='checkbox'  value='Fine technology companies for harm towards people'  id='choice_94_146_5'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_94_146_5' id='label_94_146_5' class='gform-field-label gform-field-label--type-inline'>Fine technology companies for harm towards people<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_94_146_6'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_146.6' type='checkbox'  value='Invest in public education on using AIsafely'  id='choice_94_146_6'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_94_146_6' id='label_94_146_6' class='gform-field-label gform-field-label--type-inline'>Invest in public education on using AIsafely<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_94_146_7'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_146.7' type='checkbox'  value='Other...'  id='choice_94_146_7'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_94_146_7' id='label_94_146_7' 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_94_147\" 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_94_147'>What else can the government do to protect the mental health of people who use AI?<\/label><div class='ginput_container ginput_container_text'><input name='input_147' id='input_94_147' type='text' value='' class='large'    placeholder='Tell us more...'  aria-invalid=\"false\"   \/><\/div><\/div><fieldset id=\"field_94_152\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio 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' >When you use AI tools, which mode do you use most often?<\/legend><div class='gfield_description' id='gfield_description_94_152'>Select 1.<\/div><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_94_152'>\n\t\t\t<div class='gchoice gchoice_94_152_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_152' type='radio' value='Text-based chat (typing)'  id='choice_94_152_0' onchange='gformToggleRadioOther( this )' aria-describedby=\"gfield_description_94_152\"   \/>\n\t\t\t\t\t<label for='choice_94_152_0' id='label_94_152_0' class='gform-field-label gform-field-label--type-inline'>Text-based chat (typing)<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_94_152_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_152' type='radio' value='Voice-based conversation (speaking\/listening)'  id='choice_94_152_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_94_152_1' id='label_94_152_1' class='gform-field-label gform-field-label--type-inline'>Voice-based conversation (speaking\/listening)<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_94_152_2'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_152' type='radio' value='Both equally'  id='choice_94_152_2' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_94_152_2' id='label_94_152_2' class='gform-field-label gform-field-label--type-inline'>Both equally<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_94_152_3'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_152' type='radio' value='Other...'  id='choice_94_152_3' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_94_152_3' id='label_94_152_3' class='gform-field-label gform-field-label--type-inline'>Other...<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_94_152_4'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_152' type='radio' value='I don&#039;t know \/ not sure'  id='choice_94_152_4' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_94_152_4' id='label_94_152_4' class='gform-field-label gform-field-label--type-inline'>I don't know \/ not sure<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_94_153\" 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_94_153'>What other way do you interact with AI tools most often?<\/label><div class='ginput_container ginput_container_text'><input name='input_153' id='input_94_153' type='text' value='' class='medium'    placeholder='Tell us more...'  aria-invalid=\"false\"   \/><\/div><\/div><fieldset id=\"field_94_154\" 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' >When you interact with AI tools using text-based chat, how natural or human-like does the interaction feel?<\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_94_154'>\n\t\t\t<div class='gchoice gchoice_94_154_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_154' type='radio' value='Not natural at all'  id='choice_94_154_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_94_154_0' id='label_94_154_0' class='gform-field-label gform-field-label--type-inline'>Not natural at all<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_94_154_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_154' type='radio' value='Somewhat natural'  id='choice_94_154_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_94_154_1' id='label_94_154_1' class='gform-field-label gform-field-label--type-inline'>Somewhat natural<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_94_154_2'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_154' type='radio' value='Very natural'  id='choice_94_154_2' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_94_154_2' id='label_94_154_2' class='gform-field-label gform-field-label--type-inline'>Very natural<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_94_155\" 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' >When you interact with AI tools using voice-based conversation, how natural or human-like does the interaction feel?<\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_94_155'>\n\t\t\t<div class='gchoice gchoice_94_155_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_155' type='radio' value='Not natural at all'  id='choice_94_155_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_94_155_0' id='label_94_155_0' class='gform-field-label gform-field-label--type-inline'>Not natural at all<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_94_155_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_155' type='radio' value='Somewhat natural'  id='choice_94_155_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_94_155_1' id='label_94_155_1' class='gform-field-label gform-field-label--type-inline'>Somewhat natural<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_94_155_2'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_155' type='radio' value='Very natural'  id='choice_94_155_2' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_94_155_2' id='label_94_155_2' class='gform-field-label gform-field-label--type-inline'>Very natural<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_94_151\" 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_94_129\" 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' >We sometimes run paid research studies on topics like AI and mental health. Would you like to hear about future opportunities?<\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_94_129'>\n\t\t\t<div class='gchoice gchoice_94_129_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_129' type='radio' value='Yes, I&#039;m interested!'  id='choice_94_129_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_94_129_0' id='label_94_129_0' class='gform-field-label gform-field-label--type-inline'>Yes, I'm interested!<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_94_129_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_129' type='radio' value='No, thank you.'  id='choice_94_129_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_94_129_1' id='label_94_129_1' class='gform-field-label gform-field-label--type-inline'>No, thank you.<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_94_131\" class=\"gfield gfield--type-html gfield--input-type-html gfield--width-full gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  >Great! Drop your email below so we can reach out when something comes up:<\/div><div id=\"field_94_130\" class=\"gfield gfield--type-email gfield--input-type-email 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_94_130'>Email<\/label><div class='ginput_container ginput_container_email'>\n                            <input name='input_130' id='input_94_130' type='email' value='' class='small'   placeholder='Enter your email address...'  aria-invalid=\"false\"  \/>\n                        <\/div><\/div><\/div>\n                    <\/div>\n                    <div class='gform-page-footer gform_page_footer top_label'>\n                         <input type='button' id='gform_next_button_94_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_94_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_94_2' class='gform_fields top_label form_sublabel_below description_above validation_below'><div id=\"field_94_53\" class=\"gfield gfield--type-html gfield--input-type-html section-title gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><h2>About You<\/h2><\/div><div id=\"field_94_54\" class=\"gfield gfield--type-select gfield--input-type-select optional taxonomy field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_94_54'>Age Range<\/label><div class='ginput_container ginput_container_select'><select name='input_54' id='input_94_54' class='medium gfield_select'     aria-invalid=\"false\" ><option value='' ><\/option><option value='8-10' >8-10<\/option><option value='11-13' >11-13<\/option><option value='14-15' >14-15<\/option><option value='16-17' >16-17<\/option><option value='18-24' >18-24<\/option><option value='25-34' >25-34<\/option><option value='35-44' >35-44<\/option><option value='45-54' >45-54<\/option><option value='55-64' >55-64<\/option><option value='65+' >65+<\/option><option value='Prefer not to answer' >Prefer not to answer<\/option><\/select><\/div><\/div><fieldset id=\"field_94_55\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio optional mb-2 short 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_94_55'>\n\t\t\t<div class='gchoice gchoice_94_55_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_55' type='radio' value='Female'  id='choice_94_55_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_94_55_0' id='label_94_55_0' class='gform-field-label gform-field-label--type-inline'>Female<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_94_55_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_55' type='radio' value='Male'  id='choice_94_55_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_94_55_1' id='label_94_55_1' class='gform-field-label gform-field-label--type-inline'>Male<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_94_55_2'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_55' type='radio' value='Non-Binary'  id='choice_94_55_2' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_94_55_2' id='label_94_55_2' class='gform-field-label gform-field-label--type-inline'>Non-Binary<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_94_55_3'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_55' type='radio' value='Prefer not to answer'  id='choice_94_55_3' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_94_55_3' id='label_94_55_3' class='gform-field-label gform-field-label--type-inline'>Prefer not to answer<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_94_156\" 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_94_156'>\n\t\t\t<div class='gchoice gchoice_94_156_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_156' type='radio' value='Yes'  id='choice_94_156_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_94_156_0' id='label_94_156_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_94_156_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_156' type='radio' value='No'  id='choice_94_156_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_94_156_1' id='label_94_156_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_94_135\" 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_94_135'>How would you describe your gender?<\/label><div class='ginput_container ginput_container_text'><input name='input_135' id='input_94_135' type='text' value='' class='medium'      aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_94_58\" class=\"gfield gfield--type-select gfield--input-type-select optional field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_94_58'>Race\/Ethnicity<\/label><div class='ginput_container ginput_container_select'><select name='input_58' id='input_94_58' class='medium gfield_select'     aria-invalid=\"false\" ><option value='' ><\/option><option value='American Indian or Alaska Native' >American Indian or Alaska Native<\/option><option value='Asian' >Asian<\/option><option value='Black or African American (non-Hispanic)' >Black or African American (non-Hispanic)<\/option><option value='Hispanic or Latino' >Hispanic or Latino<\/option><option value='Middle Eastern or North African' >Middle Eastern or North African<\/option><option value='Native Hawaiian or other Pacific Islander' >Native Hawaiian or other Pacific Islander<\/option><option value='White (non-Hispanic)' >White (non-Hispanic)<\/option><option value='More than one of the above' >More than one of the above<\/option><option value='Other...' >Other...<\/option><\/select><\/div><\/div><div id=\"field_94_134\" 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_94_134'>How would you describe your race\/ethnicity?<\/label><div class='ginput_container ginput_container_text'><input name='input_134' id='input_94_134' type='text' value='' class='medium'      aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_94_59\" class=\"gfield gfield--type-select gfield--input-type-select optional field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_94_59'>Household Income<\/label><div class='ginput_container ginput_container_select'><select name='input_59' id='input_94_59' class='medium gfield_select'     aria-invalid=\"false\" ><option value='' ><\/option><option value='Less than $20,000' >Less than $20,000<\/option><option value='$20,000 - $39,999' >$20,000 - $39,999<\/option><option value='$40,000 - $59,999' >$40,000 - $59,999<\/option><option value='$60,000 - $79,999' >$60,000 - $79,999<\/option><option value='$80,000 - $99,999' >$80,000 - $99,999<\/option><option value='$100,000 - $149,999' >$100,000 - $149,999<\/option><option value='$150,000+' >$150,000+<\/option><\/select><\/div><\/div><fieldset id=\"field_94_87\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-full field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >Do you live in the United States or another country?<\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_94_87'>\n\t\t\t<div class='gchoice gchoice_94_87_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_87' type='radio' value='I live in the United States'  id='choice_94_87_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_94_87_0' id='label_94_87_0' class='gform-field-label gform-field-label--type-inline'>I live in the United States<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_94_87_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_87' type='radio' value='I live in another country'  id='choice_94_87_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_94_87_1' id='label_94_87_1' class='gform-field-label gform-field-label--type-inline'>I live in another country<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_94_78\" class=\"gfield gfield--type-select gfield--input-type-select gfield--width-full optional field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_94_78'>State<\/label><div class='ginput_container ginput_container_select'><select name='input_78' id='input_94_78' class='medium gfield_select'     aria-invalid=\"false\" ><option value='' ><\/option><option value='Alabama' >Alabama<\/option><option value='Alaska' >Alaska<\/option><option value='Arizona' >Arizona<\/option><option value='Arkansas' >Arkansas<\/option><option value='California' >California<\/option><option value='Colorado' >Colorado<\/option><option value='Connecticut' >Connecticut<\/option><option value='Delaware' >Delaware<\/option><option value='District of Columbia' >District of Columbia<\/option><option value='Florida' >Florida<\/option><option value='Georgia' >Georgia<\/option><option value='Hawaii' >Hawaii<\/option><option value='Idaho' >Idaho<\/option><option value='Illinois' >Illinois<\/option><option value='Indiana' >Indiana<\/option><option value='Iowa' >Iowa<\/option><option value='Kansas' >Kansas<\/option><option value='Kentucky' >Kentucky<\/option><option value='Louisiana' >Louisiana<\/option><option value='Maine' >Maine<\/option><option value='Maryland' >Maryland<\/option><option value='Massachusetts' >Massachusetts<\/option><option value='Michigan' >Michigan<\/option><option value='Minnesota' >Minnesota<\/option><option value='Mississippi' >Mississippi<\/option><option value='Missouri' >Missouri<\/option><option value='Montana' >Montana<\/option><option value='Nebraska' >Nebraska<\/option><option value='Nevada' >Nevada<\/option><option value='New Hampshire' >New Hampshire<\/option><option value='New Jersey' >New Jersey<\/option><option value='New Mexico' >New Mexico<\/option><option value='New York' >New York<\/option><option value='North Carolina' >North Carolina<\/option><option value='North Dakota' >North Dakota<\/option><option value='Ohio' >Ohio<\/option><option value='Oklahoma' >Oklahoma<\/option><option value='Oregon' >Oregon<\/option><option value='Pennsylvania' >Pennsylvania<\/option><option value='Rhode Island' >Rhode Island<\/option><option value='South Carolina' >South Carolina<\/option><option value='South Dakota' >South Dakota<\/option><option value='Tennessee' >Tennessee<\/option><option value='Texas' >Texas<\/option><option value='Utah' >Utah<\/option><option value='Vermont' >Vermont<\/option><option value='Virginia' >Virginia<\/option><option value='Washington' >Washington<\/option><option value='West Virginia' >West Virginia<\/option><option value='Wisconsin' >Wisconsin<\/option><option value='Wyoming' >Wyoming<\/option><option value='I live in a U.S. Territory' >I live in a U.S. Territory<\/option><\/select><\/div><\/div><div id=\"field_94_80\" class=\"gfield gfield--type-select gfield--input-type-select gfield--width-full optional field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_94_80'>What country do you live in?<\/label><div class='ginput_container ginput_container_select'><select name='input_80' id='input_94_80' class='medium gfield_select'     aria-invalid=\"false\" ><option value='' ><\/option><option value='Afghanistan' >Afghanistan<\/option><option value='Albania' >Albania<\/option><option value='Algeria' >Algeria<\/option><option value='American Samoa' >American Samoa<\/option><option value='Andorra' >Andorra<\/option><option value='Angola' >Angola<\/option><option value='Anguilla' >Anguilla<\/option><option value='Antarctica' >Antarctica<\/option><option value='Antigua and Barbuda' >Antigua and Barbuda<\/option><option value='Argentina' >Argentina<\/option><option value='Armenia' >Armenia<\/option><option value='Aruba' >Aruba<\/option><option value='Australia' >Australia<\/option><option value='Austria' >Austria<\/option><option value='Azerbaijan' >Azerbaijan<\/option><option value='Bahamas' >Bahamas<\/option><option value='Bahrain' >Bahrain<\/option><option value='Bangladesh' >Bangladesh<\/option><option value='Barbados' >Barbados<\/option><option value='Belarus' >Belarus<\/option><option value='Belgium' >Belgium<\/option><option value='Belize' >Belize<\/option><option value='Benin' >Benin<\/option><option value='Bermuda' >Bermuda<\/option><option value='Bhutan' >Bhutan<\/option><option value='Bolivia' >Bolivia<\/option><option value='Bonaire, Sint Eustatius and Saba' >Bonaire, Sint Eustatius and Saba<\/option><option value='Bosnia and Herzegovina' >Bosnia and Herzegovina<\/option><option value='Botswana' >Botswana<\/option><option value='Bouvet Island' >Bouvet Island<\/option><option value='Brazil' >Brazil<\/option><option value='British Indian Ocean Territory' >British Indian Ocean Territory<\/option><option value='Brunei Darussalam' >Brunei Darussalam<\/option><option value='Bulgaria' >Bulgaria<\/option><option value='Burkina Faso' >Burkina Faso<\/option><option value='Burundi' >Burundi<\/option><option value='Cambodia' >Cambodia<\/option><option value='Cameroon' >Cameroon<\/option><option value='Canada' >Canada<\/option><option value='Cape Verde' >Cape Verde<\/option><option value='Cayman Islands' >Cayman Islands<\/option><option value='Central African Republic' >Central African Republic<\/option><option value='Chad' >Chad<\/option><option value='Chile' >Chile<\/option><option value='China' >China<\/option><option value='Christmas Island' >Christmas Island<\/option><option value='Cocos Islands' >Cocos Islands<\/option><option value='Colombia' >Colombia<\/option><option value='Comoros' >Comoros<\/option><option value='Congo, Democratic Republic of the' >Congo, Democratic Republic of the<\/option><option value='Congo, Republic of the' >Congo, Republic of the<\/option><option value='Cook Islands' >Cook Islands<\/option><option value='Costa Rica' >Costa Rica<\/option><option value='Croatia' >Croatia<\/option><option value='Cuba' >Cuba<\/option><option value='Cura\u00e7ao' >Cura\u00e7ao<\/option><option value='Cyprus' >Cyprus<\/option><option value='Czech Republic' >Czech Republic<\/option><option value='C\u00f4te d&#039;Ivoire' >C\u00f4te d&#039;Ivoire<\/option><option value='Denmark' >Denmark<\/option><option value='Djibouti' >Djibouti<\/option><option value='Dominica' >Dominica<\/option><option value='Dominican Republic' >Dominican Republic<\/option><option value='Ecuador' >Ecuador<\/option><option value='Egypt' >Egypt<\/option><option value='El Salvador' >El Salvador<\/option><option value='Equatorial Guinea' >Equatorial Guinea<\/option><option value='Eritrea' >Eritrea<\/option><option value='Estonia' >Estonia<\/option><option value='Eswatini (Swaziland)' >Eswatini (Swaziland)<\/option><option value='Ethiopia' >Ethiopia<\/option><option value='Falkland Islands' >Falkland Islands<\/option><option value='Faroe Islands' >Faroe Islands<\/option><option value='Fiji' >Fiji<\/option><option value='Finland' >Finland<\/option><option value='France' >France<\/option><option value='French Guiana' >French Guiana<\/option><option value='French Polynesia' >French Polynesia<\/option><option value='French Southern Territories' >French Southern Territories<\/option><option value='Gabon' >Gabon<\/option><option value='Gambia' >Gambia<\/option><option value='Georgia' >Georgia<\/option><option value='Germany' >Germany<\/option><option value='Ghana' >Ghana<\/option><option value='Gibraltar' >Gibraltar<\/option><option value='Greece' >Greece<\/option><option value='Greenland' >Greenland<\/option><option value='Grenada' >Grenada<\/option><option value='Guadeloupe' >Guadeloupe<\/option><option value='Guam' >Guam<\/option><option value='Guatemala' >Guatemala<\/option><option value='Guernsey' >Guernsey<\/option><option value='Guinea' >Guinea<\/option><option value='Guinea-Bissau' >Guinea-Bissau<\/option><option value='Guyana' >Guyana<\/option><option value='Haiti' >Haiti<\/option><option value='Heard and McDonald Islands' >Heard and McDonald Islands<\/option><option value='Holy See' >Holy See<\/option><option value='Honduras' >Honduras<\/option><option value='Hong Kong' >Hong Kong<\/option><option value='Hungary' >Hungary<\/option><option value='Iceland' >Iceland<\/option><option value='India' >India<\/option><option value='Indonesia' >Indonesia<\/option><option value='Iran' >Iran<\/option><option value='Iraq' >Iraq<\/option><option value='Ireland' >Ireland<\/option><option value='Isle of Man' >Isle of Man<\/option><option value='Israel' >Israel<\/option><option value='Italy' >Italy<\/option><option value='Jamaica' >Jamaica<\/option><option value='Japan' >Japan<\/option><option value='Jersey' >Jersey<\/option><option value='Jordan' >Jordan<\/option><option value='Kazakhstan' >Kazakhstan<\/option><option value='Kenya' >Kenya<\/option><option value='Kiribati' >Kiribati<\/option><option value='Kuwait' >Kuwait<\/option><option value='Kyrgyzstan' >Kyrgyzstan<\/option><option value='Lao People&#039;s Democratic Republic' >Lao People&#039;s Democratic Republic<\/option><option value='Latvia' >Latvia<\/option><option value='Lebanon' >Lebanon<\/option><option value='Lesotho' >Lesotho<\/option><option value='Liberia' >Liberia<\/option><option value='Libya' >Libya<\/option><option value='Liechtenstein' >Liechtenstein<\/option><option value='Lithuania' >Lithuania<\/option><option value='Luxembourg' >Luxembourg<\/option><option value='Macau' >Macau<\/option><option value='Macedonia' >Macedonia<\/option><option value='Madagascar' >Madagascar<\/option><option value='Malawi' >Malawi<\/option><option value='Malaysia' >Malaysia<\/option><option value='Maldives' >Maldives<\/option><option value='Mali' >Mali<\/option><option value='Malta' >Malta<\/option><option value='Marshall Islands' >Marshall Islands<\/option><option value='Martinique' >Martinique<\/option><option value='Mauritania' >Mauritania<\/option><option value='Mauritius' >Mauritius<\/option><option value='Mayotte' >Mayotte<\/option><option value='Mexico' >Mexico<\/option><option value='Micronesia' >Micronesia<\/option><option value='Moldova' >Moldova<\/option><option value='Monaco' >Monaco<\/option><option value='Mongolia' >Mongolia<\/option><option value='Montenegro' >Montenegro<\/option><option value='Montserrat' >Montserrat<\/option><option value='Morocco' >Morocco<\/option><option value='Mozambique' >Mozambique<\/option><option value='Myanmar' >Myanmar<\/option><option value='Namibia' >Namibia<\/option><option value='Nauru' >Nauru<\/option><option value='Nepal' >Nepal<\/option><option value='Netherlands' >Netherlands<\/option><option value='New Caledonia' >New Caledonia<\/option><option value='New Zealand' >New Zealand<\/option><option value='Nicaragua' >Nicaragua<\/option><option value='Niger' >Niger<\/option><option value='Nigeria' >Nigeria<\/option><option value='Niue' >Niue<\/option><option value='Norfolk Island' >Norfolk Island<\/option><option value='North Korea' >North Korea<\/option><option value='Northern Mariana Islands' >Northern Mariana Islands<\/option><option value='Norway' >Norway<\/option><option value='Oman' >Oman<\/option><option value='Pakistan' >Pakistan<\/option><option value='Palau' >Palau<\/option><option value='Palestine, State of' >Palestine, State of<\/option><option value='Panama' >Panama<\/option><option value='Papua New Guinea' >Papua New Guinea<\/option><option value='Paraguay' >Paraguay<\/option><option value='Peru' >Peru<\/option><option value='Philippines' >Philippines<\/option><option value='Pitcairn' >Pitcairn<\/option><option value='Poland' >Poland<\/option><option value='Portugal' >Portugal<\/option><option value='Puerto Rico' >Puerto Rico<\/option><option value='Qatar' >Qatar<\/option><option value='Romania' >Romania<\/option><option value='Russia' >Russia<\/option><option value='Rwanda' >Rwanda<\/option><option value='R\u00e9union' >R\u00e9union<\/option><option value='Saint Barth\u00e9lemy' >Saint Barth\u00e9lemy<\/option><option value='Saint Helena' >Saint Helena<\/option><option value='Saint Kitts and Nevis' >Saint Kitts and Nevis<\/option><option value='Saint Lucia' >Saint Lucia<\/option><option value='Saint Martin' >Saint Martin<\/option><option value='Saint Pierre and Miquelon' >Saint Pierre and Miquelon<\/option><option value='Saint Vincent and the Grenadines' >Saint Vincent and the Grenadines<\/option><option value='Samoa' >Samoa<\/option><option value='San Marino' >San Marino<\/option><option value='Sao Tome and Principe' >Sao Tome and Principe<\/option><option value='Saudi Arabia' >Saudi Arabia<\/option><option value='Senegal' >Senegal<\/option><option value='Serbia' >Serbia<\/option><option value='Seychelles' >Seychelles<\/option><option value='Sierra Leone' >Sierra Leone<\/option><option value='Singapore' >Singapore<\/option><option value='Sint Maarten' >Sint Maarten<\/option><option value='Slovakia' >Slovakia<\/option><option value='Slovenia' >Slovenia<\/option><option value='Solomon Islands' >Solomon Islands<\/option><option value='Somalia' >Somalia<\/option><option value='South Africa' >South Africa<\/option><option value='South Georgia' >South Georgia<\/option><option value='South Korea' >South Korea<\/option><option value='South Sudan' >South Sudan<\/option><option value='Spain' >Spain<\/option><option value='Sri Lanka' >Sri Lanka<\/option><option value='Sudan' >Sudan<\/option><option value='Suriname' >Suriname<\/option><option value='Svalbard and Jan Mayen Islands' >Svalbard and Jan Mayen Islands<\/option><option value='Sweden' >Sweden<\/option><option value='Switzerland' >Switzerland<\/option><option value='Syria' >Syria<\/option><option value='Taiwan' >Taiwan<\/option><option value='Tajikistan' >Tajikistan<\/option><option value='Tanzania' >Tanzania<\/option><option value='Thailand' >Thailand<\/option><option value='Timor-Leste' >Timor-Leste<\/option><option value='Togo' >Togo<\/option><option value='Tokelau' >Tokelau<\/option><option value='Tonga' >Tonga<\/option><option value='Trinidad and Tobago' >Trinidad and Tobago<\/option><option value='Tunisia' >Tunisia<\/option><option value='Turkey' >Turkey<\/option><option value='Turkmenistan' >Turkmenistan<\/option><option value='Turks and Caicos Islands' >Turks and Caicos Islands<\/option><option value='Tuvalu' >Tuvalu<\/option><option value='US Minor Outlying Islands' >US Minor Outlying Islands<\/option><option value='Uganda' >Uganda<\/option><option value='Ukraine' >Ukraine<\/option><option value='United Arab Emirates' >United Arab Emirates<\/option><option value='United Kingdom' >United Kingdom<\/option><option value='Uruguay' >Uruguay<\/option><option value='Uzbekistan' >Uzbekistan<\/option><option value='Vanuatu' >Vanuatu<\/option><option value='Venezuela' >Venezuela<\/option><option value='Vietnam' >Vietnam<\/option><option value='Virgin Islands, British' >Virgin Islands, British<\/option><option value='Virgin Islands, U.S.' >Virgin Islands, U.S.<\/option><option value='Wallis and Futuna' >Wallis and Futuna<\/option><option value='Western Sahara' >Western Sahara<\/option><option value='Yemen' >Yemen<\/option><option value='Zambia' >Zambia<\/option><option value='Zimbabwe' >Zimbabwe<\/option><option value='\u00c5land Islands' >\u00c5land Islands<\/option><\/select><\/div><\/div><fieldset id=\"field_94_109\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield--input-type-checkbox gfield--width-full traditional gfield_contains_required field_sublabel_below gfield--has-description field_description_above field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Do you live with any of the following disabilities or conditions?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class='gfield_description' id='gfield_description_94_109'>Select all that apply.<\/div><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox ' id='input_94_109'><div class='gchoice gchoice_94_109_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_109.1' type='checkbox'  value='Blind\/Low vision'  id='choice_94_109_1'   aria-describedby=\"gfield_description_94_109\"\/>\n\t\t\t\t\t\t\t\t<label for='choice_94_109_1' id='label_94_109_1' class='gform-field-label gform-field-label--type-inline'>Blind\/Low vision<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_94_109_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_109.2' type='checkbox'  value='Hearing impairment'  id='choice_94_109_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_94_109_2' id='label_94_109_2' class='gform-field-label gform-field-label--type-inline'>Hearing impairment<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_94_109_3'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_109.3' type='checkbox'  value='Limited Mobility'  id='choice_94_109_3'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_94_109_3' id='label_94_109_3' class='gform-field-label gform-field-label--type-inline'>Limited Mobility<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_94_109_4'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_109.4' type='checkbox'  value='Arthritis or other chronic pain'  id='choice_94_109_4'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_94_109_4' id='label_94_109_4' 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_94_109_5'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_109.5' type='checkbox'  value='Anxiety'  id='choice_94_109_5'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_94_109_5' id='label_94_109_5' class='gform-field-label gform-field-label--type-inline'>Anxiety<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_94_109_6'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_109.6' type='checkbox'  value='Mood conditions: depression or bipolar'  id='choice_94_109_6'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_94_109_6' id='label_94_109_6' class='gform-field-label gform-field-label--type-inline'>Mood conditions: depression or bipolar<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_94_109_7'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_109.7' type='checkbox'  value='Autism spectrum and\/or ADHD'  id='choice_94_109_7'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_94_109_7' id='label_94_109_7' class='gform-field-label gform-field-label--type-inline'>Autism spectrum and\/or ADHD<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_94_109_8'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_109.8' type='checkbox'  value='Intellectual or learning disability'  id='choice_94_109_8'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_94_109_8' id='label_94_109_8' class='gform-field-label gform-field-label--type-inline'>Intellectual or learning disability<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_94_109_9'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_109.9' type='checkbox'  value='Neurological condition (epilepsy, etc.) or traumatic brain injury (TBI)'  id='choice_94_109_9'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_94_109_9' id='label_94_109_9' class='gform-field-label gform-field-label--type-inline'>Neurological condition (epilepsy, etc.) or traumatic brain injury (TBI)<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_94_109_11'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_109.11' type='checkbox'  value='None of the above'  id='choice_94_109_11'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_94_109_11' id='label_94_109_11' class='gform-field-label gform-field-label--type-inline'>None of the above<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_94_109_12'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_109.12' type='checkbox'  value='Other mental health condition...'  id='choice_94_109_12'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_94_109_12' id='label_94_109_12' class='gform-field-label gform-field-label--type-inline'>Other mental health condition...<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_94_109_13'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_109.13' type='checkbox'  value='Other...'  id='choice_94_109_13'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_94_109_13' id='label_94_109_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_94_111\" 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_94_111'>What other mental health conditions do you have?<\/label><div class='ginput_container ginput_container_text'><input name='input_111' id='input_94_111' type='text' value='' class='medium'    placeholder='Tell us more...'  aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_94_112\" 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_94_112'>What other disabilities or conditions do you 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&#038; Schizophrenia Test (staging)"},"content":{"rendered":"\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_9' style='display:none'>\n                        <div class='gform_heading'>\n                            <h2 class=\"gform_title\">Psychosis Test<\/h2>\n                            <p class='gform_description'><\/p>\n\t\t\t\t\t\t\t<p class='gform_required_legend'>&quot;<span class=\"gfield_required gfield_required_asterisk\">*<\/span>&quot; indicates required fields<\/p>\n                        <\/div><form method='post' enctype='multipart\/form-data'  id='gform_9'  class='clearfix' action='\/es\/wp-json\/wp\/v2\/screen' data-formid='9' 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_9_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_9' class='gform_fields top_label form_sublabel_below description_above validation_below'><div id=\"field_9_157\" 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_9_157'>Comments<\/label><div class='gfield_description' id='gfield_description_9_157'>This field is for validation purposes and should be left unchanged.<\/div><div class='ginput_container'><input name='input_157' id='input_9_157' type='text' value='' autocomplete='new-password'\/><\/div><\/div><div id=\"field_9_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_9_38' type='hidden' class='gform_hidden'  aria-invalid=\"false\" value='' \/><\/div><\/div><div id=\"field_9_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_9_39\" type=\"hidden\" class=\"gform_hidden\" aria-invalid=\"false\" value=\"256835\"><\/div><div id=\"field_9_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_9_40\" type=\"hidden\" class=\"gform_hidden\" aria-invalid=\"false\" value=\"34c0972926eed1ef42815dc87b83c969\"><\/div><div id=\"field_9_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_9_41' type='hidden' class='gform_hidden'  aria-invalid=\"false\" value='' \/><\/div><\/div><div id=\"field_9_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_9_89' type='hidden' class='gform_hidden'  aria-invalid=\"false\" value='http:\/\/screening.mhanational.org\/es\/wp-json\/wp\/v2\/screen' \/><\/div><\/div><div id=\"field_9_119\" 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_119' id='input_9_119' type='hidden' class='gform_hidden'  aria-invalid=\"false\" value='' \/><\/div><\/div><div id=\"field_9_120\" 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_120' id='input_9_120' type='hidden' class='gform_hidden'  aria-invalid=\"false\" value='' \/><\/div><\/div><div id=\"field_9_121\" 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_121' id='input_9_121' type='hidden' class='gform_hidden'  aria-invalid=\"false\" value='' \/><\/div><\/div><div id=\"field_9_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_9_133' type='hidden' class='gform_hidden'  aria-invalid=\"false\" value='' \/><\/div><\/div><div id=\"field_9_134\" 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_134' id='input_9_134' type='hidden' class='gform_hidden'  aria-invalid=\"false\" value='https:\/\/screening.mhanational.org\/es\/wp-json\/wp\/v2\/screen' \/><\/div><\/div><div id=\"field_9_156\" 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_156' id='input_9_156' type='hidden' class='gform_hidden'  aria-invalid=\"false\" value='lang--es' \/><\/div><\/div><div id=\"field_9_4\" class=\"gfield gfield--type-html gfield--input-type-html gfield--width-full gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><p>Have you recently had the following thoughts, feelings, or experiences? Check \u201cyes\u201d or \u201cno\u201d for each item.<\/p>\n\n<p>Do not include experiences that occur only while under the influence of alcohol, drugs or medications that were not prescribed to you.<\/p>\n\n<p>If you answer \u201cYES\u201d to an item, also indicate how distressing that experience has been for you.<\/p>\n\n<p>Please note, all fields are required.<\/p><\/div><div id=\"field_9_145\" 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\"  ><h2 class=\"section-title\">In the last 3 months...<\/h2><\/div><fieldset id=\"field_9_135\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' ><strong>In the last three months<\/strong>, did you ever hear the voice of someone talking that other people cannot hear?<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_9_135'>\n\t\t\t<div class='gchoice gchoice_9_135_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_135' type='radio' value='Yes'  id='choice_9_135_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_9_135_0' id='label_9_135_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_9_135_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_135' type='radio' value='No'  id='choice_9_135_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_9_135_1' id='label_9_135_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_9_136\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' ><strong>In the last three months<\/strong>, had you ever felt that someone was playing with your mind?<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_9_136'>\n\t\t\t<div class='gchoice gchoice_9_136_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_136' type='radio' value='Yes'  id='choice_9_136_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_9_136_0' id='label_9_136_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_9_136_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_136' type='radio' value='No'  id='choice_9_136_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_9_136_1' id='label_9_136_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_9_137\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' ><strong>In the last three months<\/strong>, have familiar surroundings sometimes seemed unreal 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_9_137'>\n\t\t\t<div class='gchoice gchoice_9_137_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_137' type='radio' value='Yes'  id='choice_9_137_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_9_137_0' id='label_9_137_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_9_137_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_137' type='radio' value='No'  id='choice_9_137_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_9_137_1' id='label_9_137_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_9_138\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' ><strong>In the last three months<\/strong>, have you seen things that other people can't see or don't seem to see?<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_9_138'>\n\t\t\t<div class='gchoice gchoice_9_138_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_138' type='radio' value='Yes'  id='choice_9_138_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_9_138_0' id='label_9_138_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_9_138_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_138' type='radio' value='No'  id='choice_9_138_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_9_138_1' id='label_9_138_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_9_143\" 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\"  ><h2 class=\"section-title\">In the past month...<\/h2><\/div><fieldset id=\"field_9_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' >1. Do familiar surroundings sometimes seem strange, confusing, threatening or unreal 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_9_47'>\n\t\t\t<div class='gchoice gchoice_9_47_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_47' type='radio' value='No'  id='choice_9_47_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_9_47_0' id='label_9_47_0' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_9_47_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_47' type='radio' value='Yes'  id='choice_9_47_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_9_47_1' id='label_9_47_1' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_9_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' >If YES: When this happens, I feel frightened, concerned, or it causes problems for me (Q1):<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_9_48'>\n\t\t\t<div class='gchoice gchoice_9_48_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_48' type='radio' value='1'  id='choice_9_48_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_9_48_0' id='label_9_48_0' class='gform-field-label gform-field-label--type-inline'>Strongly disagree<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_9_48_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_48' type='radio' value='2'  id='choice_9_48_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_9_48_1' id='label_9_48_1' class='gform-field-label gform-field-label--type-inline'>Disagree<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_9_48_2'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_48' type='radio' value='3'  id='choice_9_48_2' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_9_48_2' id='label_9_48_2' class='gform-field-label gform-field-label--type-inline'>Neutral<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_9_48_3'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_48' type='radio' value='4'  id='choice_9_48_3' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_9_48_3' id='label_9_48_3' class='gform-field-label gform-field-label--type-inline'>Agree<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_9_48_4'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_48' type='radio' value='5'  id='choice_9_48_4' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_9_48_4' id='label_9_48_4' class='gform-field-label gform-field-label--type-inline'>Strongly agree<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_9_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' >2. Have you heard unusual sounds like banging, clicking, hissing, clapping or ringing in your ears?<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_9_49'>\n\t\t\t<div class='gchoice gchoice_9_49_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_49' type='radio' value='No'  id='choice_9_49_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_9_49_0' id='label_9_49_0' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_9_49_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_49' type='radio' value='Yes'  id='choice_9_49_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_9_49_1' id='label_9_49_1' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_9_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' >If YES: When this happens, I feel frightened, concerned, or it causes problems for me (Q2):<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_9_50'>\n\t\t\t<div class='gchoice gchoice_9_50_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_50' type='radio' value='1'  id='choice_9_50_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_9_50_0' id='label_9_50_0' class='gform-field-label gform-field-label--type-inline'>Strongly disagree<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_9_50_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_50' type='radio' value='2'  id='choice_9_50_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_9_50_1' id='label_9_50_1' class='gform-field-label gform-field-label--type-inline'>Disagree<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_9_50_2'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_50' type='radio' value='3'  id='choice_9_50_2' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_9_50_2' id='label_9_50_2' class='gform-field-label gform-field-label--type-inline'>Neutral<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_9_50_3'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_50' type='radio' value='4'  id='choice_9_50_3' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_9_50_3' id='label_9_50_3' class='gform-field-label gform-field-label--type-inline'>Agree<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_9_50_4'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_50' type='radio' value='5'  id='choice_9_50_4' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_9_50_4' id='label_9_50_4' class='gform-field-label gform-field-label--type-inline'>Strongly agree<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_9_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' >3. Do things that you see appear different from the way they usually do?<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_9_51'>\n\t\t\t<div class='gchoice gchoice_9_51_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_51' type='radio' value='No'  id='choice_9_51_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_9_51_0' id='label_9_51_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_9_51_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_51' type='radio' value='Yes'  id='choice_9_51_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_9_51_1' id='label_9_51_1' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_9_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' >If YES: When this happens, I feel frightened, concerned, or it causes problems for me (Q3):<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_9_52'>\n\t\t\t<div class='gchoice gchoice_9_52_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_52' type='radio' value='1'  id='choice_9_52_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_9_52_0' id='label_9_52_0' class='gform-field-label gform-field-label--type-inline'>Strongly disagree<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_9_52_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_52' type='radio' value='2'  id='choice_9_52_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_9_52_1' id='label_9_52_1' class='gform-field-label gform-field-label--type-inline'>Disagree<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_9_52_2'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_52' type='radio' value='3'  id='choice_9_52_2' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_9_52_2' id='label_9_52_2' class='gform-field-label gform-field-label--type-inline'>Neutral<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_9_52_3'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_52' type='radio' value='4'  id='choice_9_52_3' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_9_52_3' id='label_9_52_3' class='gform-field-label gform-field-label--type-inline'>Agree<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_9_52_4'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_52' type='radio' value='5'  id='choice_9_52_4' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_9_52_4' id='label_9_52_4' class='gform-field-label gform-field-label--type-inline'>Strongly agree<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_9_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' >4. Have you had experiences with telepathy, psychic forces, or fortune telling?<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_9_55'>\n\t\t\t<div class='gchoice gchoice_9_55_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_55' type='radio' value='No'  id='choice_9_55_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_9_55_0' id='label_9_55_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_9_55_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_55' type='radio' value='Yes'  id='choice_9_55_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_9_55_1' id='label_9_55_1' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_9_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' >If YES: When this happens, I feel frightened, concerned, or it causes problems for me (Q4):<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_9_54'>\n\t\t\t<div class='gchoice gchoice_9_54_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_54' type='radio' value='1'  id='choice_9_54_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_9_54_0' id='label_9_54_0' class='gform-field-label gform-field-label--type-inline'>Strongly disagree<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_9_54_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_54' type='radio' value='2'  id='choice_9_54_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_9_54_1' id='label_9_54_1' class='gform-field-label gform-field-label--type-inline'>Disagree<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_9_54_2'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_54' type='radio' value='3'  id='choice_9_54_2' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_9_54_2' id='label_9_54_2' class='gform-field-label gform-field-label--type-inline'>Neutral<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_9_54_3'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_54' type='radio' value='4'  id='choice_9_54_3' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_9_54_3' id='label_9_54_3' class='gform-field-label gform-field-label--type-inline'>Agree<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_9_54_4'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_54' type='radio' value='5'  id='choice_9_54_4' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_9_54_4' id='label_9_54_4' class='gform-field-label gform-field-label--type-inline'>Strongly agree<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_9_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' >5. Have you felt that you are not in control of your own ideas or thoughts?<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_9_53'>\n\t\t\t<div class='gchoice gchoice_9_53_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_53' type='radio' value='No'  id='choice_9_53_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_9_53_0' id='label_9_53_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_9_53_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_53' type='radio' value='Yes'  id='choice_9_53_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_9_53_1' id='label_9_53_1' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_9_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' >If YES: When this happens, I feel frightened, concerned, or it causes problems for me (Q5):<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_9_56'>\n\t\t\t<div class='gchoice gchoice_9_56_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_56' type='radio' value='1'  id='choice_9_56_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_9_56_0' id='label_9_56_0' class='gform-field-label gform-field-label--type-inline'>Strongly disagree<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_9_56_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_56' type='radio' value='2'  id='choice_9_56_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_9_56_1' id='label_9_56_1' class='gform-field-label gform-field-label--type-inline'>Disagree<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_9_56_2'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_56' type='radio' value='3'  id='choice_9_56_2' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_9_56_2' id='label_9_56_2' class='gform-field-label gform-field-label--type-inline'>Neutral<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_9_56_3'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_56' type='radio' value='4'  id='choice_9_56_3' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_9_56_3' id='label_9_56_3' class='gform-field-label gform-field-label--type-inline'>Agree<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_9_56_4'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_56' type='radio' value='5'  id='choice_9_56_4' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_9_56_4' id='label_9_56_4' class='gform-field-label gform-field-label--type-inline'>Strongly agree<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_9_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' >6. Do you have difficulty getting your point across, because you ramble or go off the track a lot when you talk?<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_9_57'>\n\t\t\t<div class='gchoice gchoice_9_57_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_57' type='radio' value='No'  id='choice_9_57_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_9_57_0' id='label_9_57_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_9_57_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_57' type='radio' value='Yes'  id='choice_9_57_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_9_57_1' id='label_9_57_1' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_9_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' >If YES: When this happens, I feel frightened, concerned, or it causes problems for me (Q6):<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_9_58'>\n\t\t\t<div class='gchoice gchoice_9_58_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_58' type='radio' value='1'  id='choice_9_58_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_9_58_0' id='label_9_58_0' class='gform-field-label gform-field-label--type-inline'>Strongly disagree<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_9_58_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_58' type='radio' value='2'  id='choice_9_58_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_9_58_1' id='label_9_58_1' class='gform-field-label gform-field-label--type-inline'>Disagree<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_9_58_2'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_58' type='radio' value='3'  id='choice_9_58_2' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_9_58_2' id='label_9_58_2' class='gform-field-label gform-field-label--type-inline'>Neutral<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_9_58_3'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_58' type='radio' value='4'  id='choice_9_58_3' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_9_58_3' id='label_9_58_3' class='gform-field-label gform-field-label--type-inline'>Agree<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_9_58_4'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_58' type='radio' value='5'  id='choice_9_58_4' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_9_58_4' id='label_9_58_4' class='gform-field-label gform-field-label--type-inline'>Strongly agree<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_9_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' >7. Do you have strong feelings or beliefs about being unusually gifted or talented in some way?<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_9_59'>\n\t\t\t<div class='gchoice gchoice_9_59_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_59' type='radio' value='No'  id='choice_9_59_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_9_59_0' id='label_9_59_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_9_59_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_59' type='radio' value='Yes'  id='choice_9_59_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_9_59_1' id='label_9_59_1' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_9_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' >If YES: When this happens, I feel frightened, concerned, or it causes problems for me (Q7):<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_9_60'>\n\t\t\t<div class='gchoice gchoice_9_60_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_60' type='radio' value='1'  id='choice_9_60_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_9_60_0' id='label_9_60_0' class='gform-field-label gform-field-label--type-inline'>Strongly disagree<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_9_60_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_60' type='radio' value='2'  id='choice_9_60_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_9_60_1' id='label_9_60_1' class='gform-field-label gform-field-label--type-inline'>Disagree<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_9_60_2'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_60' type='radio' value='3'  id='choice_9_60_2' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_9_60_2' id='label_9_60_2' class='gform-field-label gform-field-label--type-inline'>Neutral<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_9_60_3'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_60' type='radio' value='4'  id='choice_9_60_3' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_9_60_3' id='label_9_60_3' class='gform-field-label gform-field-label--type-inline'>Agree<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_9_60_4'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_60' type='radio' value='5'  id='choice_9_60_4' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_9_60_4' id='label_9_60_4' class='gform-field-label gform-field-label--type-inline'>Strongly agree<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_9_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' >8. Do you feel that other people are watching you or talking about 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_9_61'>\n\t\t\t<div class='gchoice gchoice_9_61_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_61' type='radio' value='No'  id='choice_9_61_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_9_61_0' id='label_9_61_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_9_61_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_61' type='radio' value='Yes'  id='choice_9_61_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_9_61_1' id='label_9_61_1' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_9_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' >If YES: When this happens, I feel frightened, concerned, or it causes problems for me (Q8):<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_9_62'>\n\t\t\t<div class='gchoice gchoice_9_62_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_62' type='radio' value='1'  id='choice_9_62_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_9_62_0' id='label_9_62_0' class='gform-field-label gform-field-label--type-inline'>Strongly disagree<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_9_62_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_62' type='radio' value='2'  id='choice_9_62_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_9_62_1' id='label_9_62_1' class='gform-field-label gform-field-label--type-inline'>Disagree<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_9_62_2'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_62' type='radio' value='3'  id='choice_9_62_2' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_9_62_2' id='label_9_62_2' class='gform-field-label gform-field-label--type-inline'>Neutral<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_9_62_3'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_62' type='radio' value='4'  id='choice_9_62_3' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_9_62_3' id='label_9_62_3' class='gform-field-label gform-field-label--type-inline'>Agree<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_9_62_4'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_62' type='radio' value='5'  id='choice_9_62_4' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_9_62_4' id='label_9_62_4' class='gform-field-label gform-field-label--type-inline'>Strongly agree<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_9_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' >9. Do you sometimes get strange feelings on or just beneath your skin, like bugs crawling?<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_9_63'>\n\t\t\t<div class='gchoice gchoice_9_63_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_63' type='radio' value='No'  id='choice_9_63_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_9_63_0' id='label_9_63_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_9_63_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_63' type='radio' value='Yes'  id='choice_9_63_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_9_63_1' id='label_9_63_1' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_9_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' >If YES: When this happens, I feel frightened, concerned, or it causes problems for me (Q9):<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_9_64'>\n\t\t\t<div class='gchoice gchoice_9_64_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_64' type='radio' value='1'  id='choice_9_64_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_9_64_0' id='label_9_64_0' class='gform-field-label gform-field-label--type-inline'>Strongly disagree<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_9_64_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_64' type='radio' value='2'  id='choice_9_64_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_9_64_1' id='label_9_64_1' class='gform-field-label gform-field-label--type-inline'>Disagree<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_9_64_2'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_64' type='radio' value='3'  id='choice_9_64_2' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_9_64_2' id='label_9_64_2' class='gform-field-label gform-field-label--type-inline'>Neutral<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_9_64_3'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_64' type='radio' value='4'  id='choice_9_64_3' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_9_64_3' id='label_9_64_3' class='gform-field-label gform-field-label--type-inline'>Agree<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_9_64_4'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_64' type='radio' value='5'  id='choice_9_64_4' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_9_64_4' id='label_9_64_4' class='gform-field-label gform-field-label--type-inline'>Strongly agree<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_9_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' >10. Do you sometimes feel suddenly distracted by distant sounds that you are not normally aware of?<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_9_65'>\n\t\t\t<div class='gchoice gchoice_9_65_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_65' type='radio' value='No'  id='choice_9_65_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_9_65_0' id='label_9_65_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_9_65_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_65' type='radio' value='Yes'  id='choice_9_65_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_9_65_1' id='label_9_65_1' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_9_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' >If YES: When this happens, I feel frightened, concerned, or it causes problems for me (Q10):<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_9_66'>\n\t\t\t<div class='gchoice gchoice_9_66_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_66' type='radio' value='1'  id='choice_9_66_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_9_66_0' id='label_9_66_0' class='gform-field-label gform-field-label--type-inline'>Strongly disagree<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_9_66_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_66' type='radio' value='2'  id='choice_9_66_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_9_66_1' id='label_9_66_1' class='gform-field-label gform-field-label--type-inline'>Disagree<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_9_66_2'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_66' type='radio' value='3'  id='choice_9_66_2' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_9_66_2' id='label_9_66_2' class='gform-field-label gform-field-label--type-inline'>Neutral<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_9_66_3'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_66' type='radio' value='4'  id='choice_9_66_3' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_9_66_3' id='label_9_66_3' class='gform-field-label gform-field-label--type-inline'>Agree<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_9_66_4'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_66' type='radio' value='5'  id='choice_9_66_4' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_9_66_4' id='label_9_66_4' class='gform-field-label gform-field-label--type-inline'>Strongly agree<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_9_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' >11. Have you had the sense that some person or force is around you, although you couldn\u2019t see anyone?<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_9_67'>\n\t\t\t<div class='gchoice gchoice_9_67_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_67' type='radio' value='No'  id='choice_9_67_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_9_67_0' id='label_9_67_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_9_67_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_67' type='radio' value='Yes'  id='choice_9_67_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_9_67_1' id='label_9_67_1' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_9_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' >If YES: When this happens, I feel frightened, concerned, or it causes problems for me (Q11):<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_9_68'>\n\t\t\t<div class='gchoice gchoice_9_68_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_68' type='radio' value='1'  id='choice_9_68_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_9_68_0' id='label_9_68_0' class='gform-field-label gform-field-label--type-inline'>Strongly disagree<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_9_68_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_68' type='radio' value='2'  id='choice_9_68_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_9_68_1' id='label_9_68_1' class='gform-field-label gform-field-label--type-inline'>Disagree<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_9_68_2'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_68' type='radio' value='3'  id='choice_9_68_2' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_9_68_2' id='label_9_68_2' class='gform-field-label gform-field-label--type-inline'>Neutral<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_9_68_3'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_68' type='radio' value='4'  id='choice_9_68_3' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_9_68_3' id='label_9_68_3' class='gform-field-label gform-field-label--type-inline'>Agree<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_9_68_4'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_68' type='radio' value='5'  id='choice_9_68_4' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_9_68_4' id='label_9_68_4' class='gform-field-label gform-field-label--type-inline'>Strongly agree<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_9_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' >12. Do you worry at times that something may be wrong with your mind?<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_9_69'>\n\t\t\t<div class='gchoice gchoice_9_69_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_69' type='radio' value='No'  id='choice_9_69_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_9_69_0' id='label_9_69_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_9_69_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_69' type='radio' value='Yes'  id='choice_9_69_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_9_69_1' id='label_9_69_1' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_9_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' >If YES: When this happens, I feel frightened, concerned, or it causes problems for me (Q12):<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_9_70'>\n\t\t\t<div class='gchoice gchoice_9_70_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_70' type='radio' value='1'  id='choice_9_70_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_9_70_0' id='label_9_70_0' class='gform-field-label gform-field-label--type-inline'>Strongly disagree<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_9_70_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_70' type='radio' value='2'  id='choice_9_70_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_9_70_1' id='label_9_70_1' class='gform-field-label gform-field-label--type-inline'>Disagree<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_9_70_2'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_70' type='radio' value='3'  id='choice_9_70_2' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_9_70_2' id='label_9_70_2' class='gform-field-label gform-field-label--type-inline'>Neutral<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_9_70_3'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_70' type='radio' value='4'  id='choice_9_70_3' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_9_70_3' id='label_9_70_3' class='gform-field-label gform-field-label--type-inline'>Agree<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_9_70_4'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_70' type='radio' value='5'  id='choice_9_70_4' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_9_70_4' id='label_9_70_4' class='gform-field-label gform-field-label--type-inline'>Strongly agree<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_9_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' >13. Have you ever felt that you don&#039;t exist, the world does not exist, or that you are dead?<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_9_71'>\n\t\t\t<div class='gchoice gchoice_9_71_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_71' type='radio' value='No'  id='choice_9_71_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_9_71_0' id='label_9_71_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_9_71_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_71' type='radio' value='Yes'  id='choice_9_71_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_9_71_1' id='label_9_71_1' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_9_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' >If YES: When this happens, I feel frightened, concerned, or it causes problems for me (Q13):<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_9_72'>\n\t\t\t<div class='gchoice gchoice_9_72_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_72' type='radio' value='1'  id='choice_9_72_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_9_72_0' id='label_9_72_0' class='gform-field-label gform-field-label--type-inline'>Strongly disagree<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_9_72_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_72' type='radio' value='2'  id='choice_9_72_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_9_72_1' id='label_9_72_1' class='gform-field-label gform-field-label--type-inline'>Disagree<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_9_72_2'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_72' type='radio' value='3'  id='choice_9_72_2' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_9_72_2' id='label_9_72_2' class='gform-field-label gform-field-label--type-inline'>Neutral<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_9_72_3'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_72' type='radio' value='4'  id='choice_9_72_3' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_9_72_3' id='label_9_72_3' class='gform-field-label gform-field-label--type-inline'>Agree<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_9_72_4'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_72' type='radio' value='5'  id='choice_9_72_4' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_9_72_4' id='label_9_72_4' class='gform-field-label gform-field-label--type-inline'>Strongly agree<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_9_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' >14. Have you been confused at times whether something you experienced was real or imaginary?<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_9_73'>\n\t\t\t<div class='gchoice gchoice_9_73_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_73' type='radio' value='No'  id='choice_9_73_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_9_73_0' id='label_9_73_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_9_73_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_73' type='radio' value='Yes'  id='choice_9_73_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_9_73_1' id='label_9_73_1' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_9_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' >If YES: When this happens, I feel frightened, concerned, or it causes problems for me (Q14):<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_9_74'>\n\t\t\t<div class='gchoice gchoice_9_74_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_74' type='radio' value='1'  id='choice_9_74_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_9_74_0' id='label_9_74_0' class='gform-field-label gform-field-label--type-inline'>Strongly disagree<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_9_74_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_74' type='radio' value='2'  id='choice_9_74_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_9_74_1' id='label_9_74_1' class='gform-field-label gform-field-label--type-inline'>Disagree<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_9_74_2'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_74' type='radio' value='3'  id='choice_9_74_2' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_9_74_2' id='label_9_74_2' class='gform-field-label gform-field-label--type-inline'>Neutral<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_9_74_3'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_74' type='radio' value='4'  id='choice_9_74_3' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_9_74_3' id='label_9_74_3' class='gform-field-label gform-field-label--type-inline'>Agree<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_9_74_4'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_74' type='radio' value='5'  id='choice_9_74_4' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_9_74_4' id='label_9_74_4' class='gform-field-label gform-field-label--type-inline'>Strongly agree<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_9_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' >15. Do you hold beliefs that other people would find unusual or bizarre?<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_9_75'>\n\t\t\t<div class='gchoice gchoice_9_75_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_75' type='radio' value='No'  id='choice_9_75_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_9_75_0' id='label_9_75_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_9_75_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_75' type='radio' value='Yes'  id='choice_9_75_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_9_75_1' id='label_9_75_1' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_9_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' >If YES: When this happens, I feel frightened, concerned, or it causes problems for me (Q15):<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_9_76'>\n\t\t\t<div class='gchoice gchoice_9_76_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_76' type='radio' value='1'  id='choice_9_76_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_9_76_0' id='label_9_76_0' class='gform-field-label gform-field-label--type-inline'>Strongly disagree<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_9_76_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_76' type='radio' value='2'  id='choice_9_76_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_9_76_1' id='label_9_76_1' class='gform-field-label gform-field-label--type-inline'>Disagree<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_9_76_2'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_76' type='radio' value='3'  id='choice_9_76_2' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_9_76_2' id='label_9_76_2' class='gform-field-label gform-field-label--type-inline'>Neutral<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_9_76_3'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_76' type='radio' value='4'  id='choice_9_76_3' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_9_76_3' id='label_9_76_3' class='gform-field-label gform-field-label--type-inline'>Agree<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_9_76_4'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_76' type='radio' value='5'  id='choice_9_76_4' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_9_76_4' id='label_9_76_4' class='gform-field-label gform-field-label--type-inline'>Strongly agree<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_9_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' >16. Do you feel that parts of your body have changed in some way, or that parts of your body are working differently?<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_9_77'>\n\t\t\t<div class='gchoice gchoice_9_77_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_77' type='radio' value='No'  id='choice_9_77_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_9_77_0' id='label_9_77_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_9_77_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_77' type='radio' value='Yes'  id='choice_9_77_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_9_77_1' id='label_9_77_1' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_9_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' >If YES: When this happens, I feel frightened, concerned, or it causes problems for me (Q16):<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_9_78'>\n\t\t\t<div class='gchoice gchoice_9_78_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_78' type='radio' value='1'  id='choice_9_78_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_9_78_0' id='label_9_78_0' class='gform-field-label gform-field-label--type-inline'>Strongly disagree<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_9_78_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_78' type='radio' value='2'  id='choice_9_78_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_9_78_1' id='label_9_78_1' class='gform-field-label gform-field-label--type-inline'>Disagree<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_9_78_2'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_78' type='radio' value='3'  id='choice_9_78_2' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_9_78_2' id='label_9_78_2' class='gform-field-label gform-field-label--type-inline'>Neutral<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_9_78_3'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_78' type='radio' value='4'  id='choice_9_78_3' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_9_78_3' id='label_9_78_3' class='gform-field-label gform-field-label--type-inline'>Agree<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_9_78_4'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_78' type='radio' value='5'  id='choice_9_78_4' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_9_78_4' id='label_9_78_4' class='gform-field-label gform-field-label--type-inline'>Strongly agree<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_9_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' >17. Are your thoughts sometimes so strong that you can almost hear them?<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_9_79'>\n\t\t\t<div class='gchoice gchoice_9_79_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_79' type='radio' value='No'  id='choice_9_79_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_9_79_0' id='label_9_79_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_9_79_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_79' type='radio' value='Yes'  id='choice_9_79_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_9_79_1' id='label_9_79_1' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_9_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' >If YES: When this happens, I feel frightened, concerned, or it causes problems for me (Q17):<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_9_80'>\n\t\t\t<div class='gchoice gchoice_9_80_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_80' type='radio' value='1'  id='choice_9_80_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_9_80_0' id='label_9_80_0' class='gform-field-label gform-field-label--type-inline'>Strongly disagree<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_9_80_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_80' type='radio' value='2'  id='choice_9_80_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_9_80_1' id='label_9_80_1' class='gform-field-label gform-field-label--type-inline'>Disagree<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_9_80_2'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_80' type='radio' value='3'  id='choice_9_80_2' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_9_80_2' id='label_9_80_2' class='gform-field-label gform-field-label--type-inline'>Neutral<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_9_80_3'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_80' type='radio' value='4'  id='choice_9_80_3' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_9_80_3' id='label_9_80_3' class='gform-field-label gform-field-label--type-inline'>Agree<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_9_80_4'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_80' type='radio' value='5'  id='choice_9_80_4' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_9_80_4' id='label_9_80_4' class='gform-field-label gform-field-label--type-inline'>Strongly agree<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_9_81\" 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' >18. Do you find yourself feeling mistrustful or suspicious of other people?<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_9_81'>\n\t\t\t<div class='gchoice gchoice_9_81_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_81' type='radio' value='No'  id='choice_9_81_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_9_81_0' id='label_9_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_9_81_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_81' type='radio' value='Yes'  id='choice_9_81_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_9_81_1' id='label_9_81_1' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_9_82\" 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' >If YES: When this happens, I feel frightened, concerned, or it causes problems for me (Q18):<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_9_82'>\n\t\t\t<div class='gchoice gchoice_9_82_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_82' type='radio' value='1'  id='choice_9_82_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_9_82_0' id='label_9_82_0' class='gform-field-label gform-field-label--type-inline'>Strongly disagree<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_9_82_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_82' type='radio' value='2'  id='choice_9_82_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_9_82_1' id='label_9_82_1' class='gform-field-label gform-field-label--type-inline'>Disagree<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_9_82_2'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_82' type='radio' value='3'  id='choice_9_82_2' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_9_82_2' id='label_9_82_2' class='gform-field-label gform-field-label--type-inline'>Neutral<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_9_82_3'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_82' type='radio' value='4'  id='choice_9_82_3' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_9_82_3' id='label_9_82_3' class='gform-field-label gform-field-label--type-inline'>Agree<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_9_82_4'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_82' type='radio' value='5'  id='choice_9_82_4' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_9_82_4' id='label_9_82_4' class='gform-field-label gform-field-label--type-inline'>Strongly agree<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_9_83\" 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' >19. Have you seen unusual things like flashes, flames, blinding light, or geometric figures?<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_9_83'>\n\t\t\t<div class='gchoice gchoice_9_83_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_83' type='radio' value='No'  id='choice_9_83_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_9_83_0' id='label_9_83_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_9_83_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_83' type='radio' value='Yes'  id='choice_9_83_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_9_83_1' id='label_9_83_1' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_9_84\" 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' >If YES: When this happens, I feel frightened, concerned, or it causes problems for me (Q19):<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_9_84'>\n\t\t\t<div class='gchoice gchoice_9_84_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_84' type='radio' value='1'  id='choice_9_84_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_9_84_0' id='label_9_84_0' class='gform-field-label gform-field-label--type-inline'>Strongly disagree<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_9_84_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_84' type='radio' value='2'  id='choice_9_84_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_9_84_1' id='label_9_84_1' class='gform-field-label gform-field-label--type-inline'>Disagree<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_9_84_2'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_84' type='radio' value='3'  id='choice_9_84_2' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_9_84_2' id='label_9_84_2' class='gform-field-label gform-field-label--type-inline'>Neutral<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_9_84_3'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_84' type='radio' value='4'  id='choice_9_84_3' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_9_84_3' id='label_9_84_3' class='gform-field-label gform-field-label--type-inline'>Agree<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_9_84_4'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_84' type='radio' value='5'  id='choice_9_84_4' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_9_84_4' id='label_9_84_4' class='gform-field-label gform-field-label--type-inline'>Strongly agree<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_9_85\" 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' >20. Have you seen things that other people can&#039;t see or don&#039;t seem to see?<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_9_85'>\n\t\t\t<div class='gchoice gchoice_9_85_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_85' type='radio' value='No'  id='choice_9_85_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_9_85_0' id='label_9_85_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_9_85_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_85' type='radio' value='Yes'  id='choice_9_85_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_9_85_1' id='label_9_85_1' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_9_86\" 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' >If YES: When this happens, I feel frightened, concerned, or it causes problems for me (Q20):<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_9_86'>\n\t\t\t<div class='gchoice gchoice_9_86_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_86' type='radio' value='1'  id='choice_9_86_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_9_86_0' id='label_9_86_0' class='gform-field-label gform-field-label--type-inline'>Strongly disagree<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_9_86_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_86' type='radio' value='2'  id='choice_9_86_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_9_86_1' id='label_9_86_1' class='gform-field-label gform-field-label--type-inline'>Disagree<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_9_86_2'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_86' type='radio' value='3'  id='choice_9_86_2' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_9_86_2' id='label_9_86_2' class='gform-field-label gform-field-label--type-inline'>Neutral<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_9_86_3'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_86' type='radio' value='4'  id='choice_9_86_3' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_9_86_3' id='label_9_86_3' class='gform-field-label gform-field-label--type-inline'>Agree<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_9_86_4'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_86' type='radio' value='5'  id='choice_9_86_4' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_9_86_4' id='label_9_86_4' class='gform-field-label gform-field-label--type-inline'>Strongly agree<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_9_87\" 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' >21. Do people sometimes find it hard to understand what you are saying?<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_9_87'>\n\t\t\t<div class='gchoice gchoice_9_87_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_87' type='radio' value='No'  id='choice_9_87_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_9_87_0' id='label_9_87_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_9_87_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_87' type='radio' value='Yes'  id='choice_9_87_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_9_87_1' id='label_9_87_1' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_9_88\" 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' >If YES: When this happens, I feel frightened, concerned, or it causes problems for me (Q21):<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_9_88'>\n\t\t\t<div class='gchoice gchoice_9_88_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_88' type='radio' value='1'  id='choice_9_88_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_9_88_0' id='label_9_88_0' class='gform-field-label gform-field-label--type-inline'>Strongly disagree<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_9_88_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_88' type='radio' value='2'  id='choice_9_88_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_9_88_1' id='label_9_88_1' class='gform-field-label gform-field-label--type-inline'>Disagree<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_9_88_2'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_88' type='radio' value='3'  id='choice_9_88_2' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_9_88_2' id='label_9_88_2' class='gform-field-label gform-field-label--type-inline'>Neutral<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_9_88_3'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_88' type='radio' value='4'  id='choice_9_88_3' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_9_88_3' id='label_9_88_3' class='gform-field-label gform-field-label--type-inline'>Agree<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_9_88_4'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_88' type='radio' value='5'  id='choice_9_88_4' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_9_88_4' id='label_9_88_4' class='gform-field-label gform-field-label--type-inline'>Strongly agree<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_9_144\" 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\"  ><h2 class=\"section-title\">In the last 3 months...<\/h2><\/div><fieldset id=\"field_9_139\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' ><strong>In the last three months<\/strong>, did you ever hear the voice of someone talking that other people cannot hear?<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_9_139'>\n\t\t\t<div class='gchoice gchoice_9_139_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_139' type='radio' value='Yes'  id='choice_9_139_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_9_139_0' id='label_9_139_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_9_139_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_139' type='radio' value='No'  id='choice_9_139_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_9_139_1' id='label_9_139_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_9_140\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' ><strong>In the last three months<\/strong>, had you ever felt that someone was playing with your mind?<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_9_140'>\n\t\t\t<div class='gchoice gchoice_9_140_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_140' type='radio' value='Yes'  id='choice_9_140_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_9_140_0' id='label_9_140_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_9_140_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_140' type='radio' value='No'  id='choice_9_140_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_9_140_1' id='label_9_140_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_9_141\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' ><strong>In the last three months<\/strong>, have familiar surroundings sometimes seemed unreal 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_9_141'>\n\t\t\t<div class='gchoice gchoice_9_141_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_141' type='radio' value='Yes'  id='choice_9_141_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_9_141_0' id='label_9_141_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_9_141_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_141' type='radio' value='No'  id='choice_9_141_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_9_141_1' id='label_9_141_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_9_142\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' ><strong>In the last three months<\/strong>, have you seen things that other people can't see or don't seem to see?<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_9_142'>\n\t\t\t<div class='gchoice gchoice_9_142_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_142' type='radio' value='Yes'  id='choice_9_142_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_9_142_0' id='label_9_142_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_9_142_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_142' type='radio' value='No'  id='choice_9_142_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_9_142_1' id='label_9_142_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><\/div>\n                    <\/div>\n                    <div class='gform-page-footer gform_page_footer top_label'>\n                         <input type='button' id='gform_next_button_9_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_9_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_9_2' class='gform_fields top_label form_sublabel_below description_above validation_below'><div id=\"field_9_90\" 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_9_122\" 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_9_146\" 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 believe you need to do something to improve your emotional or mental health?<\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_9_146'>\n\t\t\t<div class='gchoice gchoice_9_146_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_146' type='radio' value='Yes'  id='choice_9_146_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_9_146_0' id='label_9_146_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_9_146_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_146' type='radio' value='No'  id='choice_9_146_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_9_146_1' id='label_9_146_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_9_146_2'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_146' type='radio' value='I&#039;m not sure'  id='choice_9_146_2' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_9_146_2' id='label_9_146_2' class='gform-field-label gform-field-label--type-inline'>I'm not sure<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_9_147\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield--input-type-checkbox gfield--width-full 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 next steps would you be most interested in taking in the next month to feel better?<\/legend><div class='gfield_description' id='gfield_description_9_147'>Choose up to 3.<\/div><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox ' id='input_9_147'><div class='gchoice gchoice_9_147_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_147.1' type='checkbox'  value='Learn more about my mental health (material to read or watch)'  id='choice_9_147_1'   aria-describedby=\"gfield_description_9_147\"\/>\n\t\t\t\t\t\t\t\t<label for='choice_9_147_1' id='label_9_147_1' class='gform-field-label gform-field-label--type-inline'>Learn more about my mental health (material to read or watch)<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_9_147_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_147.2' type='checkbox'  value='Share how I&#039;m feeling with someone in my life (friend or relative)'  id='choice_9_147_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_9_147_2' id='label_9_147_2' class='gform-field-label gform-field-label--type-inline'>Share how I'm feeling with someone in my life (friend or relative)<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_9_147_3'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_147.3' type='checkbox'  value='Talk to someone who&#039;s been through a similar experience (peer supporter or mentor)'  id='choice_9_147_3'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_9_147_3' id='label_9_147_3' class='gform-field-label gform-field-label--type-inline'>Talk to someone who's been through a similar experience (peer supporter or mentor)<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_9_147_4'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_147.4' type='checkbox'  value='Learn about therapy or treatment options'  id='choice_9_147_4'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_9_147_4' id='label_9_147_4' class='gform-field-label gform-field-label--type-inline'>Learn about therapy or treatment options<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_9_147_5'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_147.5' type='checkbox'  value='Obtain a diagnosis\/understand what I\u2019ve been experiencing'  id='choice_9_147_5'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_9_147_5' id='label_9_147_5' class='gform-field-label gform-field-label--type-inline'>Obtain a diagnosis\/understand what I\u2019ve been experiencing<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_9_147_6'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_147.6' type='checkbox'  value='Learn and practice skills to manage mental health on my own'  id='choice_9_147_6'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_9_147_6' id='label_9_147_6' class='gform-field-label gform-field-label--type-inline'>Learn and practice skills to manage mental health on my own<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_9_147_7'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_147.7' type='checkbox'  value='None'  id='choice_9_147_7'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_9_147_7' id='label_9_147_7' class='gform-field-label gform-field-label--type-inline'>None<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_9_147_8'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_147.8' type='checkbox'  value='Other...'  id='choice_9_147_8'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_9_147_8' id='label_9_147_8' 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_9_148\" 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_9_148'><strong>What other next steps<\/strong> would you be most interested in taking in the next month to feel better?<\/label><div class='ginput_container ginput_container_text'><input name='input_148' id='input_9_148' type='text' value='' class='large'    placeholder='Tell us more...'  aria-invalid=\"false\"   \/><\/div><\/div><fieldset id=\"field_9_154\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield--input-type-checkbox gfield--width-full 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 might keep you from taking these next steps if you wanted to?<\/legend><div class='gfield_description' id='gfield_description_9_154'>Choose up to 3.<\/div><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox ' id='input_9_154'><div class='gchoice gchoice_9_154_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_154.1' type='checkbox'  value='I am concerned about what others might think about me'  id='choice_9_154_1'   aria-describedby=\"gfield_description_9_154\"\/>\n\t\t\t\t\t\t\t\t<label for='choice_9_154_1' id='label_9_154_1' class='gform-field-label gform-field-label--type-inline'>I am concerned about what others might think about me<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_9_154_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_154.2' type='checkbox'  value='I&#039;m worried about what my experiences mean for me and my future'  id='choice_9_154_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_9_154_2' id='label_9_154_2' class='gform-field-label gform-field-label--type-inline'>I'm worried about what my experiences mean for me and my future<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_9_154_3'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_154.3' type='checkbox'  value='I feel I can help myself well enough without treatment'  id='choice_9_154_3'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_9_154_3' id='label_9_154_3' class='gform-field-label gform-field-label--type-inline'>I feel I can help myself well enough without treatment<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_9_154_4'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_154.4' type='checkbox'  value='I can&#039;t afford it'  id='choice_9_154_4'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_9_154_4' id='label_9_154_4' class='gform-field-label gform-field-label--type-inline'>I can't afford it<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_9_154_5'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_154.5' type='checkbox'  value='I am concerned about my privacy\/confidentiality'  id='choice_9_154_5'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_9_154_5' id='label_9_154_5' class='gform-field-label gform-field-label--type-inline'>I am concerned about my privacy\/confidentiality<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_9_154_6'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_154.6' type='checkbox'  value='I don&#039;t know if I can trust a professional'  id='choice_9_154_6'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_9_154_6' id='label_9_154_6' class='gform-field-label gform-field-label--type-inline'>I don't know if I can trust a professional<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_9_154_7'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_154.7' type='checkbox'  value='I am concerned about getting parental\/caregiver consent or involvement'  id='choice_9_154_7'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_9_154_7' id='label_9_154_7' class='gform-field-label gform-field-label--type-inline'>I am concerned about getting parental\/caregiver consent or involvement<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_9_154_8'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_154.8' type='checkbox'  value='I don&#039;t have time'  id='choice_9_154_8'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_9_154_8' id='label_9_154_8' class='gform-field-label gform-field-label--type-inline'>I don't have time<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_9_154_9'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_154.9' type='checkbox'  value='It&#039;s too big of an effort\/I don&#039;t have the energy'  id='choice_9_154_9'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_9_154_9' id='label_9_154_9' class='gform-field-label gform-field-label--type-inline'>It's too big of an effort\/I don't have the energy<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_9_154_11'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_154.11' type='checkbox'  value='Logistical problems (transportation, wi-fi access, private space to talk)'  id='choice_9_154_11'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_9_154_11' id='label_9_154_11' class='gform-field-label gform-field-label--type-inline'>Logistical problems (transportation, wi-fi access, private space to talk)<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_9_154_12'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_154.12' type='checkbox'  value='I don&#039;t think it will work\/make me feel better'  id='choice_9_154_12'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_9_154_12' id='label_9_154_12' class='gform-field-label gform-field-label--type-inline'>I don't think it will work\/make me feel better<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_9_154_13'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_154.13' type='checkbox'  value='I&#039;m confused about what to do next'  id='choice_9_154_13'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_9_154_13' id='label_9_154_13' class='gform-field-label gform-field-label--type-inline'>I'm confused about what to do next<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_9_154_14'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_154.14' type='checkbox'  value='Other...'  id='choice_9_154_14'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_9_154_14' id='label_9_154_14' 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_9_155\" 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_9_155'><strong>What else<\/strong> might keep you from taking these next steps?<\/label><div class='ginput_container ginput_container_text'><input name='input_155' id='input_9_155' type='text' value='' class='large'    placeholder='Tell us more...'  aria-invalid=\"false\"   \/><\/div><\/div><fieldset id=\"field_9_123\" 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_9_123'>\n\t\t\t<div class='gchoice gchoice_9_123_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_123' type='radio' value='For myself'  id='choice_9_123_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_9_123_0' id='label_9_123_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_9_123_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_123' type='radio' value='For someone else'  id='choice_9_123_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_9_123_1' id='label_9_123_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_9_124\" 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_9_91\" 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_9_92\" 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_9_92'>Age Range<\/label><div class='ginput_container ginput_container_select'><select name='input_92' id='input_9_92' 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_9_93\" 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_9_93'>\n\t\t\t<div class='gchoice gchoice_9_93_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_93' type='radio' value='Female'  id='choice_9_93_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_9_93_0' id='label_9_93_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_9_93_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_93' type='radio' value='Male'  id='choice_9_93_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_9_93_1' id='label_9_93_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_9_93_2'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_93' type='radio' value='Non-Binary'  id='choice_9_93_2' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_9_93_2' id='label_9_93_2' class='gform-field-label gform-field-label--type-inline'>Non-Binary<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_9_151\" 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_9_151'>\n\t\t\t<div class='gchoice gchoice_9_151_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_151' type='radio' value='Yes'  id='choice_9_151_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_9_151_0' id='label_9_151_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_9_151_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_151' type='radio' value='No'  id='choice_9_151_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_9_151_1' id='label_9_151_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_9_94\" 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_9_94'>How would you describe your gender?<\/label><div class='ginput_container ginput_container_text'><input name='input_94' id='input_9_94' type='text' value='' class='small'    placeholder='Enter gender...'  aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_9_96\" 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_9_96'>Race\/Ethnicity<\/label><div class='ginput_container ginput_container_select'><select name='input_96' id='input_9_96' 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_9_97\" 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_9_97'>Household Income<\/label><div class='ginput_container ginput_container_select'><select name='input_97' id='input_9_97' 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_9_125\" 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_9_125'>\n\t\t\t<div class='gchoice gchoice_9_125_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_125' type='radio' value='I live in the United States'  id='choice_9_125_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_9_125_0' id='label_9_125_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_9_125_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_125' type='radio' value='I live in another country'  id='choice_9_125_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_9_125_1' id='label_9_125_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_9_116\" 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_9_116'>State<\/label><div class='ginput_container ginput_container_select'><select name='input_116' id='input_9_116' 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_9_118\" 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_9_118'>What country do you live in?<\/label><div class='ginput_container ginput_container_select'><select name='input_118' id='input_9_118' 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_9_117\" 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_9_117'>Zip\/Postal Code<\/label><div class='ginput_container ginput_container_text'><input name='input_117' id='input_9_117' type='text' value='' class='small'      aria-invalid=\"false\"   \/><\/div><\/div><fieldset id=\"field_9_98\" 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_9_98'>Select all that apply.<\/div><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox ' id='input_9_98'><div class='gchoice gchoice_9_98_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_98.1' type='checkbox'  value='Veteran or active-duty military'  id='choice_9_98_1'   aria-describedby=\"gfield_description_9_98\"\/>\n\t\t\t\t\t\t\t\t<label for='choice_9_98_1' id='label_9_98_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_9_98_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_98.2' type='checkbox'  value='Caregiver of someone living with emotional or physical illness'  id='choice_9_98_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_9_98_2' id='label_9_98_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_9_98_3'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_98.3' type='checkbox'  value='LGBTQ+'  id='choice_9_98_3'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_9_98_3' id='label_9_98_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_9_98_4'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_98.4' type='checkbox'  value='Student'  id='choice_9_98_4'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_9_98_4' id='label_9_98_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_9_98_5'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_98.5' type='checkbox'  value='Trauma survivor'  id='choice_9_98_5'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_9_98_5' id='label_9_98_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_9_98_6'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_98.6' type='checkbox'  value='New or expecting parent'  id='choice_9_98_6'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_9_98_6' id='label_9_98_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_9_98_7'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_98.7' type='checkbox'  value='Healthcare worker'  id='choice_9_98_7'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_9_98_7' id='label_9_98_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_9_126\" 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_9_126'>\n\t\t\t<div class='gchoice gchoice_9_126_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_126' type='radio' value='Mental health condition'  id='choice_9_126_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_9_126_0' id='label_9_126_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_9_126_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_126' type='radio' value='Physical health condition'  id='choice_9_126_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_9_126_1' id='label_9_126_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_9_126_2'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_126' type='radio' value='Both mental and physical health conditions'  id='choice_9_126_2' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_9_126_2' id='label_9_126_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_9_127\" 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_9_127'>Which of the following best describes your sexual orientation?<\/label><div class='ginput_container ginput_container_select'><select name='input_127' id='input_9_127' 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_9_104\" 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_9_104'>What is your sexual orientation?<\/label><div class='ginput_container ginput_container_text'><input name='input_104' id='input_9_104' type='text' value='' class='small'    placeholder='Enter sexual orientation...'  aria-invalid=\"false\"   \/><\/div><\/div><fieldset id=\"field_9_128\" 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_9_128'>Select all that apply.<\/div><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox ' id='input_9_128'><div class='gchoice gchoice_9_128_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_128.1' type='checkbox'  value='Child abuse\/violence'  id='choice_9_128_1'   aria-describedby=\"gfield_description_9_128\"\/>\n\t\t\t\t\t\t\t\t<label for='choice_9_128_1' id='label_9_128_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_9_128_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_128.2' type='checkbox'  value='Intimate partner violence'  id='choice_9_128_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_9_128_2' id='label_9_128_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_9_128_3'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_128.3' type='checkbox'  value='Sexual assault\/violence'  id='choice_9_128_3'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_9_128_3' id='label_9_128_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_9_128_4'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_128.4' type='checkbox'  value='Serious illness\/injury\/assault'  id='choice_9_128_4'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_9_128_4' id='label_9_128_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_9_128_5'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_128.5' type='checkbox'  value='Family conflict (identity acceptance\/separation\/divorce)'  id='choice_9_128_5'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_9_128_5' id='label_9_128_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_9_128_6'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_128.6' type='checkbox'  value='Traumatic event (natural disaster, accident, witnessing violence, etc.)'  id='choice_9_128_6'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_9_128_6' id='label_9_128_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_9_128_7'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_128.7' type='checkbox'  value='Death of a loved one'  id='choice_9_128_7'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_9_128_7' id='label_9_128_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_9_128_8'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_128.8' type='checkbox'  value='Other and\/or tell us more about your trauma'  id='choice_9_128_8'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_9_128_8' id='label_9_128_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_9_129\" 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_9_129'>Please tell us more about your experience of trauma:<\/label><div class='ginput_container ginput_container_text'><input name='input_129' id='input_9_129' type='text' value='' class='medium'    placeholder='Tell us more...'  aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_9_105\" 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_9_107\" 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_9_107'>\n\t\t\t<div class='gchoice gchoice_9_107_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_107' type='radio' value='Yes'  id='choice_9_107_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_9_107_0' id='label_9_107_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_9_107_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_107' type='radio' value='No'  id='choice_9_107_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_9_107_1' id='label_9_107_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_9_108\" 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_9_108'>\n\t\t\t<div class='gchoice gchoice_9_108_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_108' type='radio' value='Yes'  id='choice_9_108_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_9_108_0' id='label_9_108_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_9_108_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_108' type='radio' value='No'  id='choice_9_108_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_9_108_1' id='label_9_108_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_9_152\" 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_9_152'>Choose up to 3.<\/div><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox ' id='input_9_152'><div class='gchoice gchoice_9_152_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_152.1' type='checkbox'  value='I wanted to handle my mental health on my own'  id='choice_9_152_1'   aria-describedby=\"gfield_description_9_152\"\/>\n\t\t\t\t\t\t\t\t<label for='choice_9_152_1' id='label_9_152_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_9_152_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_152.2' type='checkbox'  value='I didn\u2019t know how or where to start'  id='choice_9_152_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_9_152_2' id='label_9_152_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_9_152_3'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_152.3' type='checkbox'  value='I thought it would cost too much'  id='choice_9_152_3'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_9_152_3' id='label_9_152_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_9_152_4'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_152.4' type='checkbox'  value='I didn\u2019t have time'  id='choice_9_152_4'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_9_152_4' id='label_9_152_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_9_152_5'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_152.5' type='checkbox'  value='I didn\u2019t think it would help me'  id='choice_9_152_5'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_9_152_5' id='label_9_152_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_9_152_6'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_152.6' type='checkbox'  value='I didn&#039;t feel ready to start treatment'  id='choice_9_152_6'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_9_152_6' id='label_9_152_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_9_152_7'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_152.7' type='checkbox'  value='I was worried about what people would think or say if I got treatment'  id='choice_9_152_7'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_9_152_7' id='label_9_152_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_9_152_8'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_152.8' type='checkbox'  value='I was afraid of being forced into a hospital or forced to take medication'  id='choice_9_152_8'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_9_152_8' id='label_9_152_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_9_152_9'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_152.9' type='checkbox'  value='I tried, but couldn\u2019t find available treatment (no openings, wouldn\u2019t take insurance, etc.)'  id='choice_9_152_9'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_9_152_9' id='label_9_152_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_9_152_11'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_152.11' type='checkbox'  value='My parent(s) or guardian wouldn&#039;t let me, or I didn&#039;t want to ask'  id='choice_9_152_11'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_9_152_11' id='label_9_152_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_9_152_12'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_152.12' type='checkbox'  value='Other...'  id='choice_9_152_12'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_9_152_12' id='label_9_152_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_9_153\" 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_9_153'>What else has prevented you from seeking treatment in the past?<\/label><div class='ginput_container ginput_container_text'><input name='input_153' id='input_9_153' type='text' value='' class='medium'    placeholder='Tell us more...'  aria-invalid=\"false\"   \/><\/div><\/div><fieldset id=\"field_9_109\" 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_9_109'>Choose up to 3.<\/div><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox ' id='input_9_109'><div class='gchoice gchoice_9_109_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_109.1' type='checkbox'  value='Abuse or violence'  id='choice_9_109_1'   aria-describedby=\"gfield_description_9_109\"\/>\n\t\t\t\t\t\t\t\t<label for='choice_9_109_1' id='label_9_109_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_9_109_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_109.2' type='checkbox'  value='Relationship problems (friends, family, or significant other)'  id='choice_9_109_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_9_109_2' id='label_9_109_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_9_109_3'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_109.3' type='checkbox'  value='Body image'  id='choice_9_109_3'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_9_109_3' id='label_9_109_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_9_109_4'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_109.4' type='checkbox'  value='Low self-esteem or self-image'  id='choice_9_109_4'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_9_109_4' id='label_9_109_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_9_109_5'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_109.5' type='checkbox'  value='School or work problems'  id='choice_9_109_5'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_9_109_5' id='label_9_109_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_9_109_6'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_109.6' type='checkbox'  value='Financial problems'  id='choice_9_109_6'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_9_109_6' id='label_9_109_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_9_109_7'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_109.7' type='checkbox'  value='Loneliness or isolation'  id='choice_9_109_7'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_9_109_7' id='label_9_109_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_9_109_8'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_109.8' type='checkbox'  value='Grief or loss of someone or something'  id='choice_9_109_8'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_9_109_8' id='label_9_109_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_9_109_9'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_109.9' type='checkbox'  value='Experiencing hate\/bullying (including racism, homophobia, transphobia, or discrimination)'  id='choice_9_109_9'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_9_109_9' id='label_9_109_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_9_109_11'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_109.11' type='checkbox'  value='State of the world (war, climate, politics, immigration)'  id='choice_9_109_11'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_9_109_11' id='label_9_109_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_9_109_12'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_109.12' type='checkbox'  value='I don\u2019t know (something just feels wrong)'  id='choice_9_109_12'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_9_109_12' id='label_9_109_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_9_109_13'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_109.13' type='checkbox'  value='Other...'  id='choice_9_109_13'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_9_109_13' id='label_9_109_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_9_110\" 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_9_110'>What else is contributing to your mental health problems right now?<\/label><div class='ginput_container ginput_container_text'><input name='input_110' id='input_9_110' type='text' value='' class='medium'    placeholder='Tell us more...'  aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_9_132\" 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_9_132'>What about the state of the world is affecting you the most?<\/label><div class='ginput_container ginput_container_text'><input name='input_132' id='input_9_132' type='text' value='' class='large'    placeholder='Tell us more...'  aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_9_111\" 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_9_112\" 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_9_112'>\n\t\t\t<div class='gchoice gchoice_9_112_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_112' type='radio' value='Yes'  id='choice_9_112_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_9_112_0' id='label_9_112_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_9_112_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_112' type='radio' value='No'  id='choice_9_112_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_9_112_1' id='label_9_112_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_9_112_2'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_112' type='radio' value='I don&#039;t know'  id='choice_9_112_2' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_9_112_2' id='label_9_112_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_9_113\" 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_9_113'>Select all that apply.<\/div><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox ' id='input_9_113'><div class='gchoice gchoice_9_113_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_113.1' type='checkbox'  value='Heart disease'  id='choice_9_113_1'   aria-describedby=\"gfield_description_9_113\"\/>\n\t\t\t\t\t\t\t\t<label for='choice_9_113_1' id='label_9_113_1' class='gform-field-label gform-field-label--type-inline'>Heart disease<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_9_113_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_113.2' type='checkbox'  value='Reproductive health concerns (PCOS, endometriosis, infertility, etc.)'  id='choice_9_113_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_9_113_2' id='label_9_113_2' class='gform-field-label gform-field-label--type-inline'>Reproductive health concerns (PCOS, endometriosis, infertility, etc.)<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_9_113_3'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_113.3' type='checkbox'  value='Diabetes'  id='choice_9_113_3'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_9_113_3' id='label_9_113_3' class='gform-field-label gform-field-label--type-inline'>Diabetes<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_9_113_4'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_113.4' type='checkbox'  value='Cancer'  id='choice_9_113_4'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_9_113_4' id='label_9_113_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_9_113_5'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_113.5' type='checkbox'  value='Arthritis or other chronic pain'  id='choice_9_113_5'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_9_113_5' id='label_9_113_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_9_113_6'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_113.6' type='checkbox'  value='Asthma, COPD or other lung conditions'  id='choice_9_113_6'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_9_113_6' id='label_9_113_6' class='gform-field-label gform-field-label--type-inline'>Asthma, COPD or other lung conditions<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_9_113_7'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_113.7' type='checkbox'  value='Movement Disorders (involuntary tics, tardive dyskinesia, etc.)'  id='choice_9_113_7'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_9_113_7' id='label_9_113_7' class='gform-field-label gform-field-label--type-inline'>Movement Disorders (involuntary tics, tardive dyskinesia, etc.)<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_9_113_8'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_113.8' type='checkbox'  value='Digestive problems (Crohn\u2019s, colitis, IBS, etc.)'  id='choice_9_113_8'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_9_113_8' id='label_9_113_8' class='gform-field-label gform-field-label--type-inline'>Digestive problems (Crohn\u2019s, colitis, IBS, etc.)<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_9_113_9'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_113.9' type='checkbox'  value='Neurological conditions (epilepsy, etc.) or traumatic brain injury (TBI)'  id='choice_9_113_9'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_9_113_9' id='label_9_113_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_9_113_11'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_113.11' type='checkbox'  value='Other...'  id='choice_9_113_11'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_9_113_11' id='label_9_113_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_9_114\" 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_9_114'>What other physical health conditions do you have?<\/label><div class='ginput_container 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(2011). Psychosis risk screening with the Prodromal Questionnaire\u2014Brief Version (PQ-B). <em>Schizophrenia Research 12<\/em>(1) pp. 42-46. <a href=\"https:\/\/doi.org\/10.1016\/j.schres.2011.03.029\">DOI: 10.1016\/j.schres.2011.03.029<\/a><\/p>\n<p>Savill, M., D&#8217;Ambrosio, J., Cannon, T. D., Loewy, R. (2017). Psychosis risk screening in different populations using the Prodromal Questionnaire: A systematic review. <em>Early Intervention in Psychiatry 12<\/em>(1), pp. 3-14. <a href=\"https:\/\/doi.org\/10.1111\/eip.12446\">DOI: 10.1111\/eip.12446<\/a><\/p>\n<p>A positive score on the Prodromal Questionnaire-Brief Version (PQ-B) suggests the need for further evaluation by a qualified health (M.D., R.N.) or mental health (Ph.D., Psy.D., LCSW) professional who is trained in recognizing the early signs of psychosis.\u00a0 The PQ-B is designed to test for Prodrome or Ultra high-risk of Psychosis and is considered the first step in a two-stage screening process.<\/p>\n<p><a href=\"https:\/\/screening.mhanational.org\/about-our-mental-health-tests\/\" target=\"_blank\" rel=\"noopener\">For more information about our screening tools, please click here.<\/a><\/p>\n<p><strong><em>Please note:<\/em><\/strong><span style=\"font-style: normal !msorm;\"><em> Online screening tools are not diagnostic instruments. You are encouraged to share your results with a physician or healthcare provider. Mental Health America Inc., sponsors, partners, and advertisers disclaim any liability, loss, or risk incurred as a consequence, directly or indirectly, from the use and application of these screens.<\/em><\/span><\/p>\n<\/div>\n","protected":false},"excerpt":{"rendered":"<p>Para personas que sienten que su cerebro les juega malas pasadas (ven, oyen o creen cosas que no parecen reales o del todo correctas).<\/p>","protected":false},"template":"","tags":[],"age_group":[],"condition":[89],"class_list":["post-256835","screen","type-screen","status-publish","hentry","condition-psychosis"],"acf":[],"yoast_head":"<title>Psychosis &amp; Schizophrenia Test (staging) &#8211; Free, quick, &amp; confidential<\/title>\n<meta name=\"description\" content=\"Is your brain playing tricks on you? 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Mental Health Treatments Survey"},"content":{"rendered":"\n                <div class='gf_browser_gecko gform_wrapper gravity-theme gform-theme--no-framework full-pager_wrapper' data-form-theme='gravity-theme' data-form-index='0' id='gform_wrapper_93' style='display:none'><form method='post' enctype='multipart\/form-data'  id='gform_93' class='full-pager' class='clearfix' action='\/es\/wp-json\/wp\/v2\/screen' data-formid='93' novalidate><input id=partial_entry_id_93 class=\"partial_entry_id\" type=hidden name=\"partial_entry_id\" value=\"pending\" data-form_id=\"93\"\/><ol class=\"full-progress-bar clearfix step-1-of-3\"><li class=\"step-1 active\"><span>Survey Questions<\/span><\/li><li class=\"step-2 empty\"><span>Optional Questions<\/span><\/li><\/ol>\n                        <div class='gform-body gform_body'><div id='gform_page_93_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_93' class='gform_fields top_label form_sublabel_below description_above validation_below'><div id=\"field_93_144\" 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_93_144'>LinkedIn<\/label><div class='gfield_description' id='gfield_description_93_144'>This field is for validation purposes and should be left unchanged.<\/div><div class='ginput_container'><input name='input_144' id='input_93_144' type='text' value='' autocomplete='new-password'\/><\/div><\/div><div id=\"field_93_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_93_38' type='hidden' class='gform_hidden'  aria-invalid=\"false\" value='' \/><\/div><\/div><div id=\"field_93_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_93_39\" type=\"hidden\" class=\"gform_hidden\" aria-invalid=\"false\" value=\"256450\"><\/div><div id=\"field_93_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_93_40\" type=\"hidden\" class=\"gform_hidden\" aria-invalid=\"false\" value=\"34c0972926eed1ef42815dc87b83c969\"><\/div><div id=\"field_93_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_93_41' type='hidden' class='gform_hidden'  aria-invalid=\"false\" value='' \/><\/div><\/div><div id=\"field_93_51\" class=\"gfield gfield--type-hidden gfield--input-type-hidden gform_hidden field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><div class='ginput_container ginput_container_text'><input name='input_51' id='input_93_51' type='hidden' class='gform_hidden'  aria-invalid=\"false\" value='http:\/\/screening.mhanational.org\/es\/wp-json\/wp\/v2\/screen' \/><\/div><\/div><div id=\"field_93_81\" class=\"gfield gfield--type-hidden gfield--input-type-hidden gform_hidden field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><div class='ginput_container ginput_container_text'><input name='input_81' id='input_93_81' type='hidden' class='gform_hidden'  aria-invalid=\"false\" value='' \/><\/div><\/div><div id=\"field_93_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_93_82' type='hidden' class='gform_hidden'  aria-invalid=\"false\" value='' \/><\/div><\/div><div id=\"field_93_83\" class=\"gfield gfield--type-hidden gfield--input-type-hidden gform_hidden field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><div class='ginput_container ginput_container_text'><input name='input_83' id='input_93_83' type='hidden' class='gform_hidden'  aria-invalid=\"false\" value='' \/><\/div><\/div><div id=\"field_93_93\" class=\"gfield gfield--type-hidden gfield--input-type-hidden gfield--width-full gform_hidden field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><div class='ginput_container ginput_container_text'><input name='input_93' id='input_93_93' type='hidden' class='gform_hidden'  aria-invalid=\"false\" value='' \/><\/div><\/div><div id=\"field_93_143\" 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_143' id='input_93_143' type='hidden' class='gform_hidden'  aria-invalid=\"false\" value='lang--es' \/><\/div><\/div><div id=\"field_93_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>In this survey, we'll ask you about digital treatments for depression. Your answers will help us understand what people know and feel about their options.<\/p><p>Thank you for participating!<\/p>\n<hr \/><\/div><fieldset id=\"field_93_106\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield--input-type-checkbox gfield--width-full traditional question-optional show-only-value hide-score question field_sublabel_below gfield--has-description field_description_above field_validation_below gfield_visibility_unchanged\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Are you currently receiving any treatment for depression?<\/legend><div class='gfield_description' id='gfield_description_93_106'>Select all that apply.<\/div><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox ' id='input_93_106'><div class='gchoice gchoice_93_106_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_106.1' type='checkbox'  value='Medication'  id='choice_93_106_1'   aria-describedby=\"gfield_description_93_106\"\/>\n\t\t\t\t\t\t\t\t<label for='choice_93_106_1' id='label_93_106_1' class='gform-field-label gform-field-label--type-inline'>Medication<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_93_106_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_106.2' type='checkbox'  value='Therapy\/counseling'  id='choice_93_106_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_93_106_2' id='label_93_106_2' class='gform-field-label gform-field-label--type-inline'>Therapy\/counseling<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_93_106_3'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_106.3' type='checkbox'  value='Prescription digital therapeutic'  id='choice_93_106_3'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_93_106_3' id='label_93_106_3' class='gform-field-label gform-field-label--type-inline'>Prescription digital therapeutic<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_93_106_4'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_106.4' type='checkbox'  value='Other digital tool'  id='choice_93_106_4'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_93_106_4' id='label_93_106_4' class='gform-field-label gform-field-label--type-inline'>Other digital tool<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_93_106_5'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_106.5' type='checkbox'  value='Not currently in treatment'  id='choice_93_106_5'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_93_106_5' id='label_93_106_5' class='gform-field-label gform-field-label--type-inline'>Not currently in treatment<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_93_107\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield--input-type-checkbox gfield--width-full traditional question-optional show-only-value hide-score question field_sublabel_below gfield--has-description field_description_above field_validation_below gfield_visibility_unchanged\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Have you ever received treatment for depression in the past?<\/legend><div class='gfield_description' id='gfield_description_93_107'>Select all that apply.<\/div><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox ' id='input_93_107'><div class='gchoice gchoice_93_107_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_107.1' type='checkbox'  value='Medication'  id='choice_93_107_1'   aria-describedby=\"gfield_description_93_107\"\/>\n\t\t\t\t\t\t\t\t<label for='choice_93_107_1' id='label_93_107_1' class='gform-field-label gform-field-label--type-inline'>Medication<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_93_107_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_107.2' type='checkbox'  value='Therapy\/counseling'  id='choice_93_107_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_93_107_2' id='label_93_107_2' class='gform-field-label gform-field-label--type-inline'>Therapy\/counseling<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_93_107_3'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_107.3' type='checkbox'  value='Prescription digital therapeutic'  id='choice_93_107_3'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_93_107_3' id='label_93_107_3' class='gform-field-label gform-field-label--type-inline'>Prescription digital therapeutic<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_93_107_4'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_107.4' type='checkbox'  value='Other digital tool'  id='choice_93_107_4'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_93_107_4' id='label_93_107_4' class='gform-field-label gform-field-label--type-inline'>Other digital tool<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_93_107_5'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_107.5' type='checkbox'  value='No past treatment'  id='choice_93_107_5'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_93_107_5' id='label_93_107_5' class='gform-field-label gform-field-label--type-inline'>No past treatment<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_93_108\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield--input-type-checkbox gfield--width-full traditional question-optional show-only-value hide-score question field_sublabel_below gfield--has-description field_description_above field_validation_below gfield_visibility_unchanged\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Have you ever been diagnosed with a mental health condition?<\/legend><div class='gfield_description' id='gfield_description_93_108'>Select all that apply.<\/div><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox ' id='input_93_108'><div class='gchoice gchoice_93_108_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_108.1' type='checkbox'  value='Depression'  id='choice_93_108_1'   aria-describedby=\"gfield_description_93_108\"\/>\n\t\t\t\t\t\t\t\t<label for='choice_93_108_1' id='label_93_108_1' class='gform-field-label gform-field-label--type-inline'>Depression<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_93_108_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_108.2' type='checkbox'  value='Anxiety'  id='choice_93_108_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_93_108_2' id='label_93_108_2' class='gform-field-label gform-field-label--type-inline'>Anxiety<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_93_108_3'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_108.3' type='checkbox'  value='Bipolar disorder'  id='choice_93_108_3'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_93_108_3' id='label_93_108_3' class='gform-field-label gform-field-label--type-inline'>Bipolar disorder<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_93_108_4'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_108.4' type='checkbox'  value='PTSD'  id='choice_93_108_4'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_93_108_4' id='label_93_108_4' class='gform-field-label gform-field-label--type-inline'>PTSD<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_93_108_5'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_108.5' type='checkbox'  value='Other'  id='choice_93_108_5'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_93_108_5' id='label_93_108_5' class='gform-field-label gform-field-label--type-inline'>Other<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_93_108_6'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_108.6' type='checkbox'  value='No diagnosis'  id='choice_93_108_6'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_93_108_6' id='label_93_108_6' class='gform-field-label gform-field-label--type-inline'>No diagnosis<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_93_119\" class=\"gfield gfield--type-html gfield--input-type-html gfield--width-full gfield_html gfield_html_formatted field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><hr \/>\n<strong>How much do you agree or disagree with the following statements?<\/strong><\/div><fieldset id=\"field_93_120\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-full question-optional show-only-value hide-score question field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_unchanged\"  ><legend class='gfield_label gform-field-label' >I know what health resources are available about depression.<\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_93_120'>\n\t\t\t<div class='gchoice gchoice_93_120_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_120' type='radio' value='-2'  id='choice_93_120_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_93_120_0' id='label_93_120_0' class='gform-field-label gform-field-label--type-inline'>Strongly Disagree<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_93_120_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_120' type='radio' value='-1'  id='choice_93_120_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_93_120_1' id='label_93_120_1' class='gform-field-label gform-field-label--type-inline'>Disagree<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_93_120_2'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_120' type='radio' value='0'  id='choice_93_120_2' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_93_120_2' id='label_93_120_2' class='gform-field-label gform-field-label--type-inline'>Unsure<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_93_120_3'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_120' type='radio' value='1'  id='choice_93_120_3' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_93_120_3' id='label_93_120_3' class='gform-field-label gform-field-label--type-inline'>Agree<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_93_120_4'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_120' type='radio' value='2'  id='choice_93_120_4' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_93_120_4' id='label_93_120_4' class='gform-field-label gform-field-label--type-inline'>Strongly Agree<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_93_121\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-full question-optional show-only-value hide-score question field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_unchanged\"  ><legend class='gfield_label gform-field-label' >I know how to find helpful information about depression online.<\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_93_121'>\n\t\t\t<div class='gchoice gchoice_93_121_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_121' type='radio' value='-2'  id='choice_93_121_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_93_121_0' id='label_93_121_0' class='gform-field-label gform-field-label--type-inline'>Strongly Disagree<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_93_121_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_121' type='radio' value='-1'  id='choice_93_121_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_93_121_1' id='label_93_121_1' class='gform-field-label gform-field-label--type-inline'>Disagree<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_93_121_2'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_121' type='radio' value='0'  id='choice_93_121_2' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_93_121_2' id='label_93_121_2' class='gform-field-label gform-field-label--type-inline'>Unsure<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_93_121_3'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_121' type='radio' value='1'  id='choice_93_121_3' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_93_121_3' id='label_93_121_3' class='gform-field-label gform-field-label--type-inline'>Agree<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_93_121_4'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_121' type='radio' value='2'  id='choice_93_121_4' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_93_121_4' id='label_93_121_4' class='gform-field-label gform-field-label--type-inline'>Strongly Agree<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_93_122\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-full question-optional show-only-value hide-score question field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_unchanged\"  ><legend class='gfield_label gform-field-label' >I know how to use information I find to help manage depression.<\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_93_122'>\n\t\t\t<div class='gchoice gchoice_93_122_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_122' type='radio' value='-2'  id='choice_93_122_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_93_122_0' id='label_93_122_0' class='gform-field-label gform-field-label--type-inline'>Strongly Disagree<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_93_122_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_122' type='radio' value='-1'  id='choice_93_122_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_93_122_1' id='label_93_122_1' class='gform-field-label gform-field-label--type-inline'>Disagree<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_93_122_2'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_122' type='radio' value='0'  id='choice_93_122_2' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_93_122_2' id='label_93_122_2' class='gform-field-label gform-field-label--type-inline'>Unsure<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_93_122_3'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_122' type='radio' value='1'  id='choice_93_122_3' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_93_122_3' id='label_93_122_3' class='gform-field-label gform-field-label--type-inline'>Agree<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_93_122_4'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_122' type='radio' value='2'  id='choice_93_122_4' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_93_122_4' id='label_93_122_4' class='gform-field-label gform-field-label--type-inline'>Strongly Agree<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_93_123\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-full question-optional show-only-value hide-score question field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_unchanged\"  ><legend class='gfield_label gform-field-label' >I know how to tell if information about depression is trustworthy.<\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_93_123'>\n\t\t\t<div class='gchoice gchoice_93_123_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_123' type='radio' value='-2'  id='choice_93_123_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_93_123_0' id='label_93_123_0' class='gform-field-label gform-field-label--type-inline'>Strongly Disagree<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_93_123_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_123' type='radio' value='-1'  id='choice_93_123_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_93_123_1' id='label_93_123_1' class='gform-field-label gform-field-label--type-inline'>Disagree<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_93_123_2'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_123' type='radio' value='0'  id='choice_93_123_2' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_93_123_2' id='label_93_123_2' class='gform-field-label gform-field-label--type-inline'>Unsure<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_93_123_3'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_123' type='radio' value='1'  id='choice_93_123_3' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_93_123_3' id='label_93_123_3' class='gform-field-label gform-field-label--type-inline'>Agree<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_93_123_4'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_123' type='radio' value='2'  id='choice_93_123_4' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_93_123_4' id='label_93_123_4' class='gform-field-label gform-field-label--type-inline'>Strongly Agree<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_93_124\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-full question-optional show-only-value hide-score question field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_unchanged\"  ><legend class='gfield_label gform-field-label' >I have the skills needed to evaluate online information about depression.<\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_93_124'>\n\t\t\t<div class='gchoice gchoice_93_124_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_124' type='radio' value='-2'  id='choice_93_124_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_93_124_0' id='label_93_124_0' class='gform-field-label gform-field-label--type-inline'>Strongly Disagree<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_93_124_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_124' type='radio' value='-1'  id='choice_93_124_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_93_124_1' id='label_93_124_1' class='gform-field-label gform-field-label--type-inline'>Disagree<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_93_124_2'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_124' type='radio' value='0'  id='choice_93_124_2' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_93_124_2' id='label_93_124_2' class='gform-field-label gform-field-label--type-inline'>Unsure<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_93_124_3'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_124' type='radio' value='1'  id='choice_93_124_3' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_93_124_3' id='label_93_124_3' class='gform-field-label gform-field-label--type-inline'>Agree<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_93_124_4'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_124' type='radio' value='2'  id='choice_93_124_4' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_93_124_4' id='label_93_124_4' class='gform-field-label gform-field-label--type-inline'>Strongly Agree<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_93_125\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-full question-optional show-only-value hide-score question field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_unchanged\"  ><legend class='gfield_label gform-field-label' >I feel confident using online information to make decisions about depression care.<\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_93_125'>\n\t\t\t<div class='gchoice gchoice_93_125_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_125' type='radio' value='-2'  id='choice_93_125_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_93_125_0' id='label_93_125_0' class='gform-field-label gform-field-label--type-inline'>Strongly Disagree<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_93_125_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_125' type='radio' value='-1'  id='choice_93_125_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_93_125_1' id='label_93_125_1' class='gform-field-label gform-field-label--type-inline'>Disagree<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_93_125_2'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_125' type='radio' value='0'  id='choice_93_125_2' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_93_125_2' id='label_93_125_2' class='gform-field-label gform-field-label--type-inline'>Unsure<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_93_125_3'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_125' type='radio' value='1'  id='choice_93_125_3' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_93_125_3' id='label_93_125_3' class='gform-field-label gform-field-label--type-inline'>Agree<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_93_125_4'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_125' type='radio' value='2'  id='choice_93_125_4' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_93_125_4' id='label_93_125_4' class='gform-field-label gform-field-label--type-inline'>Strongly Agree<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_93_126\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-full question-optional show-only-value hide-score question field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_unchanged\"  ><legend class='gfield_label gform-field-label' >Online information helps me understand my depression treatment options.<\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_93_126'>\n\t\t\t<div class='gchoice gchoice_93_126_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_126' type='radio' value='-2'  id='choice_93_126_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_93_126_0' id='label_93_126_0' class='gform-field-label gform-field-label--type-inline'>Strongly Disagree<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_93_126_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_126' type='radio' value='-1'  id='choice_93_126_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_93_126_1' id='label_93_126_1' class='gform-field-label gform-field-label--type-inline'>Disagree<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_93_126_2'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_126' type='radio' value='0'  id='choice_93_126_2' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_93_126_2' id='label_93_126_2' class='gform-field-label gform-field-label--type-inline'>Unsure<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_93_126_3'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_126' type='radio' value='1'  id='choice_93_126_3' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_93_126_3' id='label_93_126_3' class='gform-field-label gform-field-label--type-inline'>Agree<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_93_126_4'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_126' type='radio' value='2'  id='choice_93_126_4' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_93_126_4' id='label_93_126_4' class='gform-field-label gform-field-label--type-inline'>Strongly Agree<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_93_127\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-full question-optional show-only-value hide-score question field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_unchanged\"  ><legend class='gfield_label gform-field-label' >I feel informed about digital treatment options for depression.<\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_93_127'>\n\t\t\t<div class='gchoice gchoice_93_127_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_127' type='radio' value='-2'  id='choice_93_127_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_93_127_0' id='label_93_127_0' class='gform-field-label gform-field-label--type-inline'>Strongly Disagree<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_93_127_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_127' type='radio' value='-1'  id='choice_93_127_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_93_127_1' id='label_93_127_1' class='gform-field-label gform-field-label--type-inline'>Disagree<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_93_127_2'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_127' type='radio' value='0'  id='choice_93_127_2' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_93_127_2' id='label_93_127_2' class='gform-field-label gform-field-label--type-inline'>Unsure<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_93_127_3'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_127' type='radio' value='1'  id='choice_93_127_3' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_93_127_3' id='label_93_127_3' class='gform-field-label gform-field-label--type-inline'>Agree<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_93_127_4'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_127' type='radio' value='2'  id='choice_93_127_4' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_93_127_4' id='label_93_127_4' class='gform-field-label gform-field-label--type-inline'>Strongly Agree<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_93_142\" 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 \/>\n<strong>How much do you agree or disagree with the following statements?<\/strong><\/div><fieldset id=\"field_93_129\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-full question-optional show-only-value hide-score question field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_unchanged\"  ><legend class='gfield_label gform-field-label' >A digital tool for treating depression must be tested in clinical trials for me to trust that it works.<\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_93_129'>\n\t\t\t<div class='gchoice gchoice_93_129_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_129' type='radio' value='-2'  id='choice_93_129_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_93_129_0' id='label_93_129_0' class='gform-field-label gform-field-label--type-inline'>Strongly Disagree<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_93_129_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_129' type='radio' value='-1'  id='choice_93_129_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_93_129_1' id='label_93_129_1' class='gform-field-label gform-field-label--type-inline'>Disagree<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_93_129_2'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_129' type='radio' value='0'  id='choice_93_129_2' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_93_129_2' id='label_93_129_2' class='gform-field-label gform-field-label--type-inline'>Neither agree nor disagree<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_93_129_3'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_129' type='radio' value='1'  id='choice_93_129_3' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_93_129_3' id='label_93_129_3' class='gform-field-label gform-field-label--type-inline'>Agree<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_93_129_4'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_129' type='radio' value='2'  id='choice_93_129_4' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_93_129_4' id='label_93_129_4' class='gform-field-label gform-field-label--type-inline'>Strongly Agree<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_93_130\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-full question-optional show-only-value hide-score question field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_unchanged\"  ><legend class='gfield_label gform-field-label' >I would only use a digital tool to treat depression if my doctor or clinician recommended it.<\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_93_130'>\n\t\t\t<div class='gchoice gchoice_93_130_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_130' type='radio' value='-2'  id='choice_93_130_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_93_130_0' id='label_93_130_0' class='gform-field-label gform-field-label--type-inline'>Strongly Disagree<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_93_130_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_130' type='radio' value='-1'  id='choice_93_130_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_93_130_1' id='label_93_130_1' class='gform-field-label gform-field-label--type-inline'>Disagree<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_93_130_2'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_130' type='radio' value='0'  id='choice_93_130_2' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_93_130_2' id='label_93_130_2' class='gform-field-label gform-field-label--type-inline'>Neither agree nor disagree<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_93_130_3'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_130' type='radio' value='1'  id='choice_93_130_3' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_93_130_3' id='label_93_130_3' class='gform-field-label gform-field-label--type-inline'>Agree<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_93_130_4'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_130' type='radio' value='2'  id='choice_93_130_4' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_93_130_4' id='label_93_130_4' class='gform-field-label gform-field-label--type-inline'>Strongly Agree<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_93_131\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-full question-optional show-only-value hide-score question field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_unchanged\"  ><legend class='gfield_label gform-field-label' >A digital tool for depression should be cleared or authorized by the FDA for me to feel comfortable using it.<\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_93_131'>\n\t\t\t<div class='gchoice gchoice_93_131_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_131' type='radio' value='-2'  id='choice_93_131_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_93_131_0' id='label_93_131_0' class='gform-field-label gform-field-label--type-inline'>Strongly Disagree<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_93_131_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_131' type='radio' value='-1'  id='choice_93_131_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_93_131_1' id='label_93_131_1' class='gform-field-label gform-field-label--type-inline'>Disagree<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_93_131_2'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_131' type='radio' value='0'  id='choice_93_131_2' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_93_131_2' id='label_93_131_2' class='gform-field-label gform-field-label--type-inline'>Neither agree nor disagree<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_93_131_3'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_131' type='radio' value='1'  id='choice_93_131_3' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_93_131_3' id='label_93_131_3' class='gform-field-label gform-field-label--type-inline'>Agree<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_93_131_4'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_131' type='radio' value='2'  id='choice_93_131_4' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_93_131_4' id='label_93_131_4' class='gform-field-label gform-field-label--type-inline'>Strongly Agree<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_93_132\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-full question-optional show-only-value hide-score question field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_unchanged\"  ><legend class='gfield_label gform-field-label' >High ratings in the app store are the most important factor for me when choosing a digital tool for depression.<\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_93_132'>\n\t\t\t<div class='gchoice gchoice_93_132_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_132' type='radio' value='-2'  id='choice_93_132_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_93_132_0' id='label_93_132_0' class='gform-field-label gform-field-label--type-inline'>Strongly Disagree<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_93_132_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_132' type='radio' value='-1'  id='choice_93_132_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_93_132_1' id='label_93_132_1' class='gform-field-label gform-field-label--type-inline'>Disagree<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_93_132_2'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_132' type='radio' value='0'  id='choice_93_132_2' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_93_132_2' id='label_93_132_2' class='gform-field-label gform-field-label--type-inline'>Neither agree nor disagree<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_93_132_3'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_132' type='radio' value='1'  id='choice_93_132_3' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_93_132_3' id='label_93_132_3' class='gform-field-label gform-field-label--type-inline'>Agree<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_93_132_4'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_132' type='radio' value='2'  id='choice_93_132_4' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_93_132_4' id='label_93_132_4' class='gform-field-label gform-field-label--type-inline'>Strongly Agree<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_93_133\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-full question-optional show-only-value hide-score question field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_unchanged\"  ><legend class='gfield_label gform-field-label' >When choosing a digital tool for depression, the opinions of my friends or family are more important than my doctor\u2019s recommendation.<\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_93_133'>\n\t\t\t<div class='gchoice gchoice_93_133_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_133' type='radio' value='-2'  id='choice_93_133_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_93_133_0' id='label_93_133_0' class='gform-field-label gform-field-label--type-inline'>Strongly Disagree<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_93_133_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_133' type='radio' value='-1'  id='choice_93_133_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_93_133_1' id='label_93_133_1' class='gform-field-label gform-field-label--type-inline'>Disagree<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_93_133_2'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_133' type='radio' value='0'  id='choice_93_133_2' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_93_133_2' id='label_93_133_2' class='gform-field-label gform-field-label--type-inline'>Neither agree nor disagree<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_93_133_3'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_133' type='radio' value='1'  id='choice_93_133_3' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_93_133_3' id='label_93_133_3' class='gform-field-label gform-field-label--type-inline'>Agree<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_93_133_4'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_133' type='radio' value='2'  id='choice_93_133_4' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_93_133_4' id='label_93_133_4' class='gform-field-label gform-field-label--type-inline'>Strongly Agree<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_93_134\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-full question-optional show-only-value hide-score question field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_unchanged\"  ><legend class='gfield_label gform-field-label' >I am comfortable sharing sensitive information about my depression (such as symptoms or diagnosis) with a digital health company.<\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_93_134'>\n\t\t\t<div class='gchoice gchoice_93_134_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_134' type='radio' value='-2'  id='choice_93_134_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_93_134_0' id='label_93_134_0' class='gform-field-label gform-field-label--type-inline'>Strongly Disagree<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_93_134_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_134' type='radio' value='-1'  id='choice_93_134_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_93_134_1' id='label_93_134_1' class='gform-field-label gform-field-label--type-inline'>Disagree<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_93_134_2'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_134' type='radio' value='0'  id='choice_93_134_2' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_93_134_2' id='label_93_134_2' class='gform-field-label gform-field-label--type-inline'>Neither agree nor disagree<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_93_134_3'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_134' type='radio' value='1'  id='choice_93_134_3' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_93_134_3' id='label_93_134_3' class='gform-field-label gform-field-label--type-inline'>Agree<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_93_134_4'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_134' type='radio' value='2'  id='choice_93_134_4' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_93_134_4' id='label_93_134_4' class='gform-field-label gform-field-label--type-inline'>Strongly Agree<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_93_138\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-full question-optional show-only-value hide-score question field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_unchanged\"  ><label class='gfield_label gform-field-label' for='input_93_138'>Optional: What would make a prescription digital therapeutic for depression feel worth trying for you?<\/label><div class='ginput_container ginput_container_text'><input name='input_138' id='input_93_138' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_93_140\" class=\"gfield gfield--type-html gfield--input-type-html gfield--width-full gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><hr \/>\n\nThe following questions ask about your knowledge of <strong>prescription digital therapeutics<\/strong>. If you haven't heard this term before, that's okay! You can still answer these questions.<\/div><fieldset id=\"field_93_109\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-full question-optional show-only-value hide-score question field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_unchanged\"  ><legend class='gfield_label gform-field-label' >Before today, had you ever heard the term \u201cprescription digital therapeutic\u201d?<\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_93_109'>\n\t\t\t<div class='gchoice gchoice_93_109_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_109' type='radio' value='Yes'  id='choice_93_109_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_93_109_0' id='label_93_109_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_93_109_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_109' type='radio' value='No'  id='choice_93_109_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_93_109_1' id='label_93_109_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_93_109_2'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_109' type='radio' value='Not sure'  id='choice_93_109_2' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_93_109_2' id='label_93_109_2' class='gform-field-label gform-field-label--type-inline'>Not sure<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_93_110\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-full traditional question-optional show-only-value hide-score question field_sublabel_below gfield--has-description field_description_above field_validation_below gfield_visibility_unchanged\"  ><legend class='gfield_label gform-field-label' >Which best describes a prescription digital therapeutic?<\/legend><div class='gfield_description' id='gfield_description_93_110'><em>(If you're not sure, you can give your best guess.)<\/em><\/div><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_93_110'>\n\t\t\t<div class='gchoice gchoice_93_110_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_110' type='radio' value='A digital treatment approved by the FDA and prescribed by a clinician'  id='choice_93_110_0' onchange='gformToggleRadioOther( this )' aria-describedby=\"gfield_description_93_110\"   \/>\n\t\t\t\t\t<label for='choice_93_110_0' id='label_93_110_0' class='gform-field-label gform-field-label--type-inline'>A digital treatment approved by the FDA and prescribed by a clinician<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_93_110_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_110' type='radio' value='A wellness app'  id='choice_93_110_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_93_110_1' id='label_93_110_1' class='gform-field-label gform-field-label--type-inline'>A wellness app<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_93_110_2'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_110' type='radio' value='A telehealth app'  id='choice_93_110_2' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_93_110_2' id='label_93_110_2' class='gform-field-label gform-field-label--type-inline'>A telehealth app<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_93_110_3'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_110' type='radio' value='An online support group'  id='choice_93_110_3' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_93_110_3' id='label_93_110_3' class='gform-field-label gform-field-label--type-inline'>An online support group<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_93_110_4'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_110' type='radio' value='Not sure'  id='choice_93_110_4' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_93_110_4' id='label_93_110_4' class='gform-field-label gform-field-label--type-inline'>Not sure<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_93_111\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-full question-optional show-only-value hide-score question field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_unchanged\"  ><legend class='gfield_label gform-field-label' >Before today, had you ever heard of using a prescription digital therapeutic to treat depression?<\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_93_111'>\n\t\t\t<div class='gchoice gchoice_93_111_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_111' type='radio' value='Yes'  id='choice_93_111_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_93_111_0' id='label_93_111_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_93_111_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_111' type='radio' value='No'  id='choice_93_111_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_93_111_1' id='label_93_111_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_93_111_2'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_111' type='radio' value='Not sure'  id='choice_93_111_2' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_93_111_2' id='label_93_111_2' class='gform-field-label gform-field-label--type-inline'>Not sure<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_93_112\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield--input-type-checkbox gfield--width-full traditional question-optional show-only-value hide-score question field_sublabel_below gfield--has-description field_description_above field_validation_below gfield_visibility_unchanged\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Where have you heard about prescription digital therapeutics for depression?<\/legend><div class='gfield_description' id='gfield_description_93_112'>Select all that apply.<\/div><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox ' id='input_93_112'><div class='gchoice gchoice_93_112_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_112.1' type='checkbox'  value='Doctor or clinician'  id='choice_93_112_1'   aria-describedby=\"gfield_description_93_112\"\/>\n\t\t\t\t\t\t\t\t<label for='choice_93_112_1' id='label_93_112_1' class='gform-field-label gform-field-label--type-inline'>Doctor or clinician<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_93_112_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_112.2' type='checkbox'  value='Therapist'  id='choice_93_112_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_93_112_2' id='label_93_112_2' class='gform-field-label gform-field-label--type-inline'>Therapist<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_93_112_3'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_112.3' type='checkbox'  value='Pharmacist'  id='choice_93_112_3'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_93_112_3' id='label_93_112_3' class='gform-field-label gform-field-label--type-inline'>Pharmacist<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_93_112_4'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_112.4' type='checkbox'  value='Insurance plan'  id='choice_93_112_4'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_93_112_4' id='label_93_112_4' class='gform-field-label gform-field-label--type-inline'>Insurance plan<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_93_112_5'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_112.5' type='checkbox'  value='Online search'  id='choice_93_112_5'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_93_112_5' id='label_93_112_5' class='gform-field-label gform-field-label--type-inline'>Online search<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_93_112_6'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_112.6' type='checkbox'  value='Social media'  id='choice_93_112_6'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_93_112_6' id='label_93_112_6' class='gform-field-label gform-field-label--type-inline'>Social media<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_93_112_7'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_112.7' type='checkbox'  value='Friends\/family'  id='choice_93_112_7'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_93_112_7' id='label_93_112_7' class='gform-field-label gform-field-label--type-inline'>Friends\/family<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_93_112_8'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_112.8' type='checkbox'  value='Community organization'  id='choice_93_112_8'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_93_112_8' id='label_93_112_8' class='gform-field-label gform-field-label--type-inline'>Community organization<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_93_112_9'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_112.9' type='checkbox'  value='Have never heard of them'  id='choice_93_112_9'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_93_112_9' id='label_93_112_9' class='gform-field-label gform-field-label--type-inline'>Have never heard of them<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_93_113\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield--input-type-checkbox gfield--width-full traditional limit-3 question-optional show-only-value hide-score question field_sublabel_below gfield--has-description field_description_above field_validation_below gfield_visibility_unchanged\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Where would you look first to find a new treatment or tool for depression?<\/legend><div class='gfield_description' id='gfield_description_93_113'>Choose up to 3.<\/div><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox ' id='input_93_113'><div class='gchoice gchoice_93_113_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_113.1' type='checkbox'  value='Doctor or clinician'  id='choice_93_113_1'   aria-describedby=\"gfield_description_93_113\"\/>\n\t\t\t\t\t\t\t\t<label for='choice_93_113_1' id='label_93_113_1' class='gform-field-label gform-field-label--type-inline'>Doctor or clinician<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_93_113_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_113.2' type='checkbox'  value='Mental health specialist'  id='choice_93_113_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_93_113_2' id='label_93_113_2' class='gform-field-label gform-field-label--type-inline'>Mental health specialist<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_93_113_3'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_113.3' type='checkbox'  value='Online search'  id='choice_93_113_3'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_93_113_3' id='label_93_113_3' class='gform-field-label gform-field-label--type-inline'>Online search<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_93_113_4'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_113.4' type='checkbox'  value='Insurance plan'  id='choice_93_113_4'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_93_113_4' id='label_93_113_4' class='gform-field-label gform-field-label--type-inline'>Insurance plan<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_93_113_5'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_113.5' type='checkbox'  value='Friends\/family'  id='choice_93_113_5'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_93_113_5' id='label_93_113_5' class='gform-field-label gform-field-label--type-inline'>Friends\/family<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_93_113_6'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_113.6' type='checkbox'  value='Community organization'  id='choice_93_113_6'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_93_113_6' id='label_93_113_6' class='gform-field-label gform-field-label--type-inline'>Community organization<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_93_113_7'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_113.7' type='checkbox'  value='App store'  id='choice_93_113_7'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_93_113_7' id='label_93_113_7' class='gform-field-label gform-field-label--type-inline'>App store<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_93_115\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield--input-type-checkbox gfield--width-full traditional limit-3 question-optional show-only-value hide-score question field_sublabel_below gfield--has-description field_description_above field_validation_below gfield_visibility_unchanged\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Who would you trust most to recommend a prescription digital therapeutic for depression?<\/legend><div class='gfield_description' id='gfield_description_93_115'>Choose up to 3.<\/div><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox ' id='input_93_115'><div class='gchoice gchoice_93_115_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_115.1' type='checkbox'  value='Doctor or nurse'  id='choice_93_115_1'   aria-describedby=\"gfield_description_93_115\"\/>\n\t\t\t\t\t\t\t\t<label for='choice_93_115_1' id='label_93_115_1' class='gform-field-label gform-field-label--type-inline'>Doctor or nurse<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_93_115_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_115.2' type='checkbox'  value='Therapist'  id='choice_93_115_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_93_115_2' id='label_93_115_2' class='gform-field-label gform-field-label--type-inline'>Therapist<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_93_115_3'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_115.3' type='checkbox'  value='Community health worker'  id='choice_93_115_3'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_93_115_3' id='label_93_115_3' class='gform-field-label gform-field-label--type-inline'>Community health worker<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_93_115_4'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_115.4' type='checkbox'  value='Insurance plan'  id='choice_93_115_4'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_93_115_4' id='label_93_115_4' class='gform-field-label gform-field-label--type-inline'>Insurance plan<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_93_115_5'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_115.5' type='checkbox'  value='Family or friend'  id='choice_93_115_5'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_93_115_5' id='label_93_115_5' class='gform-field-label gform-field-label--type-inline'>Family or friend<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_93_115_6'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_115.6' type='checkbox'  value='Social media'  id='choice_93_115_6'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_93_115_6' id='label_93_115_6' class='gform-field-label gform-field-label--type-inline'>Social media<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_93_115_7'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_115.7' type='checkbox'  value='No one'  id='choice_93_115_7'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_93_115_7' id='label_93_115_7' class='gform-field-label gform-field-label--type-inline'>No one<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_93_128\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-full question-optional show-only-value hide-score question field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_unchanged\"  ><legend class='gfield_label gform-field-label' >If a prescription digital therapeutic for depression were offered to you at low or no cost, how likely would you be to try it?<\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_93_128'>\n\t\t\t<div class='gchoice gchoice_93_128_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_128' type='radio' value='-2'  id='choice_93_128_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_93_128_0' id='label_93_128_0' class='gform-field-label gform-field-label--type-inline'>Very unlikely<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_93_128_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_128' type='radio' value='-1'  id='choice_93_128_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_93_128_1' id='label_93_128_1' class='gform-field-label gform-field-label--type-inline'>Unlikely<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_93_128_2'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_128' type='radio' value='0'  id='choice_93_128_2' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_93_128_2' id='label_93_128_2' class='gform-field-label gform-field-label--type-inline'>Unsure<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_93_128_3'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_128' type='radio' value='1'  id='choice_93_128_3' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_93_128_3' id='label_93_128_3' class='gform-field-label gform-field-label--type-inline'>Somewhat likely<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_93_128_4'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_128' type='radio' value='2'  id='choice_93_128_4' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_93_128_4' id='label_93_128_4' class='gform-field-label gform-field-label--type-inline'>Very likely<\/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_93_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_93_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_93_2' class='gform_fields top_label form_sublabel_below description_above validation_below'><div id=\"field_93_94\" 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_93_95\" class=\"gfield gfield--type-html gfield--input-type-html gfield--width-full layout-action show-actions_b gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><hr \/><\/div><div id=\"field_93_96\" 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_93_97\" 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_93_97'>Age Range<\/label><div class='ginput_container ginput_container_select'><select name='input_97' id='input_93_97' class='medium gfield_select'     aria-invalid=\"false\" ><option value='' ><\/option><option value='under 18' >under 18<\/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_93_98\" 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 identity<\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_93_98'>\n\t\t\t<div class='gchoice gchoice_93_98_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_98' type='radio' value='Woman'  id='choice_93_98_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_93_98_0' id='label_93_98_0' class='gform-field-label gform-field-label--type-inline'>Woman<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_93_98_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_98' type='radio' value='Man'  id='choice_93_98_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_93_98_1' id='label_93_98_1' class='gform-field-label gform-field-label--type-inline'>Man<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_93_98_2'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_98' type='radio' value='Non-Binary'  id='choice_93_98_2' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_93_98_2' id='label_93_98_2' class='gform-field-label gform-field-label--type-inline'>Non-Binary<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_93_98_3'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_98' type='radio' value='Another identity'  id='choice_93_98_3' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_93_98_3' id='label_93_98_3' class='gform-field-label gform-field-label--type-inline'>Another identity<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_93_98_4'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_98' type='radio' value='Prefer not to say'  id='choice_93_98_4' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_93_98_4' id='label_93_98_4' class='gform-field-label gform-field-label--type-inline'>Prefer not to say<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_93_100\" 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_93_100'>How would you describe your gender?<\/label><div class='ginput_container ginput_container_text'><input name='input_100' id='input_93_100' type='text' value='' class='small'    placeholder='Enter gender...'  aria-invalid=\"false\"   \/><\/div><\/div><fieldset id=\"field_93_105\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-full optional field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >Sex assigned at birth<\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_93_105'>\n\t\t\t<div class='gchoice gchoice_93_105_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_105' type='radio' value='Female'  id='choice_93_105_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_93_105_0' id='label_93_105_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_93_105_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_105' type='radio' value='Male'  id='choice_93_105_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_93_105_1' id='label_93_105_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_93_105_2'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_105' type='radio' value='Intersex'  id='choice_93_105_2' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_93_105_2' id='label_93_105_2' class='gform-field-label gform-field-label--type-inline'>Intersex<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_93_105_3'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_105' type='radio' value='Prefer not to say'  id='choice_93_105_3' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_93_105_3' id='label_93_105_3' class='gform-field-label gform-field-label--type-inline'>Prefer not to say<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_93_101\" 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_93_101'>\n\t\t\t<div class='gchoice gchoice_93_101_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_101' type='radio' value='I live in the United States'  id='choice_93_101_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_93_101_0' id='label_93_101_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_93_101_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_101' type='radio' value='I live in another country'  id='choice_93_101_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_93_101_1' id='label_93_101_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_93_103\" 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_93_103'>Zip\/Postal Code<\/label><div class='ginput_container ginput_container_text'><input name='input_103' id='input_93_103' type='text' value='' class='small'      aria-invalid=\"false\"   \/><\/div><\/div><fieldset id=\"field_93_136\" 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' >What type of health insurance do you currently have?<\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_93_136'>\n\t\t\t<div class='gchoice gchoice_93_136_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_136' type='radio' value='Medicaid'  id='choice_93_136_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_93_136_0' id='label_93_136_0' class='gform-field-label gform-field-label--type-inline'>Medicaid<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_93_136_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_136' type='radio' value='Medicare'  id='choice_93_136_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_93_136_1' id='label_93_136_1' class='gform-field-label gform-field-label--type-inline'>Medicare<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_93_136_2'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_136' type='radio' value='Employer-sponsored'  id='choice_93_136_2' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_93_136_2' id='label_93_136_2' class='gform-field-label gform-field-label--type-inline'>Employer-sponsored<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_93_136_3'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_136' type='radio' value='Marketplace\/ACA'  id='choice_93_136_3' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_93_136_3' id='label_93_136_3' class='gform-field-label gform-field-label--type-inline'>Marketplace\/ACA<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_93_136_4'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_136' type='radio' value='Uninsured'  id='choice_93_136_4' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_93_136_4' id='label_93_136_4' class='gform-field-label gform-field-label--type-inline'>Uninsured<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_93_136_5'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_136' type='radio' value='Other'  id='choice_93_136_5' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_93_136_5' id='label_93_136_5' class='gform-field-label gform-field-label--type-inline'>Other<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_93_137\" 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' >What is your current employment status?<\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_93_137'>\n\t\t\t<div class='gchoice gchoice_93_137_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_137' type='radio' value='Employed full-time'  id='choice_93_137_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_93_137_0' id='label_93_137_0' class='gform-field-label gform-field-label--type-inline'>Employed full-time<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_93_137_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_137' type='radio' value='Employed part-time'  id='choice_93_137_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_93_137_1' id='label_93_137_1' class='gform-field-label gform-field-label--type-inline'>Employed part-time<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_93_137_2'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_137' type='radio' value='Unemployed'  id='choice_93_137_2' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_93_137_2' id='label_93_137_2' class='gform-field-label gform-field-label--type-inline'>Unemployed<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_93_137_3'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_137' type='radio' value='Student'  id='choice_93_137_3' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_93_137_3' id='label_93_137_3' class='gform-field-label gform-field-label--type-inline'>Student<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_93_137_4'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_137' type='radio' value='Retired'  id='choice_93_137_4' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_93_137_4' id='label_93_137_4' class='gform-field-label gform-field-label--type-inline'>Retired<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_93_137_5'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_137' type='radio' value='Unable to work'  id='choice_93_137_5' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_93_137_5' id='label_93_137_5' class='gform-field-label gform-field-label--type-inline'>Unable to work<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><\/div><\/div>\n        <div class='gform-page-footer gform_page_footer top_label'><input type='submit' id='gform_previous_button_93' class='gform_previous_button gform-theme-button gform-theme-button--secondary button' onclick='gform.submission.handleButtonClick(this);' data-submission-type='previous' value='Previous'  \/> <input type='submit' id='gform_submit_button_93' class='gform_button button' onclick='gform.submission.handleButtonClick(this);' 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This means that psychedelics can be prescribed and possibly covered by health insurance.<\/p>\n<p>This survey was developed to help us explore your opinions about psychedelics and mental health. Sharing these thoughts will help us understand who is interested or not interested in this treatment and which resources and policies we can develop. <strong>No personally identifiable information will be shared outside of MHA.<\/strong><\/p>\n<p>Thank you for participating!<\/p>\n<hr \/><\/div><div id=\"field_92_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_92_38' type='hidden' class='gform_hidden'  aria-invalid=\"false\" value='' \/><\/div><\/div><div id=\"field_92_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_92_39\" type=\"hidden\" class=\"gform_hidden\" aria-invalid=\"false\" value=\"255654\"><\/div><div id=\"field_92_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_92_40\" type=\"hidden\" class=\"gform_hidden\" aria-invalid=\"false\" value=\"34c0972926eed1ef42815dc87b83c969\"><\/div><div id=\"field_92_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_92_41' type='hidden' class='gform_hidden'  aria-invalid=\"false\" value='' \/><\/div><\/div><div id=\"field_92_51\" class=\"gfield gfield--type-hidden gfield--input-type-hidden gform_hidden field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><div class='ginput_container ginput_container_text'><input name='input_51' id='input_92_51' type='hidden' class='gform_hidden'  aria-invalid=\"false\" value='http:\/\/screening.mhanational.org\/es\/wp-json\/wp\/v2\/screen' \/><\/div><\/div><div id=\"field_92_81\" class=\"gfield gfield--type-hidden gfield--input-type-hidden gform_hidden field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><div class='ginput_container ginput_container_text'><input name='input_81' id='input_92_81' type='hidden' class='gform_hidden'  aria-invalid=\"false\" value='' \/><\/div><\/div><div id=\"field_92_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_92_82' type='hidden' class='gform_hidden'  aria-invalid=\"false\" value='' \/><\/div><\/div><div id=\"field_92_83\" class=\"gfield gfield--type-hidden gfield--input-type-hidden gform_hidden field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><div class='ginput_container ginput_container_text'><input name='input_83' id='input_92_83' type='hidden' class='gform_hidden'  aria-invalid=\"false\" value='' \/><\/div><\/div><div id=\"field_92_93\" class=\"gfield gfield--type-hidden gfield--input-type-hidden gfield--width-full gform_hidden field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><div class='ginput_container ginput_container_text'><input name='input_93' id='input_92_93' type='hidden' class='gform_hidden'  aria-invalid=\"false\" value='' \/><\/div><\/div><div id=\"field_92_172\" 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_172' id='input_92_172' type='hidden' class='gform_hidden'  aria-invalid=\"false\" value='lang--es' \/><\/div><\/div><fieldset id=\"field_92_157\" 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' >Have you used any psychedelics now or in the past? Pick one that most represents you.<\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_92_157'>\n\t\t\t<div class='gchoice gchoice_92_157_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_157' type='radio' value='No, and I don&#039;t want to'  id='choice_92_157_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_92_157_0' id='label_92_157_0' class='gform-field-label gform-field-label--type-inline'>No, and I don't want to<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_92_157_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_157' type='radio' value='No, but I would like to'  id='choice_92_157_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_92_157_1' id='label_92_157_1' class='gform-field-label gform-field-label--type-inline'>No, but I would like to<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_92_157_2'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_157' type='radio' value='Yes, and I would like to try them again'  id='choice_92_157_2' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_92_157_2' id='label_92_157_2' class='gform-field-label gform-field-label--type-inline'>Yes, and I would like to try them again<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_92_157_3'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_157' type='radio' value='Yes, but I don&#039;t want to use them again'  id='choice_92_157_3' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_92_157_3' id='label_92_157_3' class='gform-field-label gform-field-label--type-inline'>Yes, but I don't want to use them again<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_92_157_4'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_157' type='radio' value='Yes, I use psychedelics regularly'  id='choice_92_157_4' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_92_157_4' id='label_92_157_4' class='gform-field-label gform-field-label--type-inline'>Yes, I use psychedelics regularly<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_92_158\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield--input-type-checkbox gfield--width-full traditional limit-2 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 psychedelics did you try or use most often?<\/legend><div class='gfield_description' id='gfield_description_92_158'>Select up to 2. (For this question, we are intentionally leaving out cannabis.)<\/div><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox ' id='input_92_158'><div class='gchoice gchoice_92_158_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_158.1' type='checkbox'  value='Ayahuasca'  id='choice_92_158_1'   aria-describedby=\"gfield_description_92_158\"\/>\n\t\t\t\t\t\t\t\t<label for='choice_92_158_1' id='label_92_158_1' class='gform-field-label gform-field-label--type-inline'>Ayahuasca<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_92_158_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_158.2' type='checkbox'  value='DMT'  id='choice_92_158_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_92_158_2' id='label_92_158_2' class='gform-field-label gform-field-label--type-inline'>DMT<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_92_158_3'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_158.3' type='checkbox'  value='Ibogaine'  id='choice_92_158_3'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_92_158_3' id='label_92_158_3' class='gform-field-label gform-field-label--type-inline'>Ibogaine<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_92_158_4'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_158.4' type='checkbox'  value='Ketamine'  id='choice_92_158_4'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_92_158_4' id='label_92_158_4' class='gform-field-label gform-field-label--type-inline'>Ketamine<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_92_158_5'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_158.5' type='checkbox'  value='LSD (acid)'  id='choice_92_158_5'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_92_158_5' id='label_92_158_5' class='gform-field-label gform-field-label--type-inline'>LSD (acid)<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_92_158_6'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_158.6' type='checkbox'  value='MDMA (ecstasy, molly)'  id='choice_92_158_6'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_92_158_6' id='label_92_158_6' class='gform-field-label gform-field-label--type-inline'>MDMA (ecstasy, molly)<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_92_158_7'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_158.7' type='checkbox'  value='Mescaline (peyote)'  id='choice_92_158_7'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_92_158_7' id='label_92_158_7' class='gform-field-label gform-field-label--type-inline'>Mescaline (peyote)<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_92_158_8'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_158.8' type='checkbox'  value='Psilocybin (mushrooms)'  id='choice_92_158_8'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_92_158_8' id='label_92_158_8' class='gform-field-label gform-field-label--type-inline'>Psilocybin (mushrooms)<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_92_158_9'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_158.9' type='checkbox'  value='Other...'  id='choice_92_158_9'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_92_158_9' id='label_92_158_9' 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_92_141\" 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_92_141'>What other psychedelic did you try or use most often?<\/label><div class='ginput_container ginput_container_text'><input name='input_141' id='input_92_141' type='text' value='' class='medium'    placeholder='Tell us more...'  aria-invalid=\"false\"   \/><\/div><\/div><fieldset id=\"field_92_159\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield--input-type-checkbox gfield--width-full traditional limit-2 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 psychedelics are you most interested in trying?<\/legend><div class='gfield_description' id='gfield_description_92_159'>Select up to 2. (For this question, we are intentionally leaving out cannabis.)<\/div><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox ' id='input_92_159'><div class='gchoice gchoice_92_159_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_159.1' type='checkbox'  value='Ayahuasca'  id='choice_92_159_1'   aria-describedby=\"gfield_description_92_159\"\/>\n\t\t\t\t\t\t\t\t<label for='choice_92_159_1' id='label_92_159_1' class='gform-field-label gform-field-label--type-inline'>Ayahuasca<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_92_159_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_159.2' type='checkbox'  value='DMT'  id='choice_92_159_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_92_159_2' id='label_92_159_2' class='gform-field-label gform-field-label--type-inline'>DMT<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_92_159_3'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_159.3' type='checkbox'  value='Ibogaine'  id='choice_92_159_3'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_92_159_3' id='label_92_159_3' class='gform-field-label gform-field-label--type-inline'>Ibogaine<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_92_159_4'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_159.4' type='checkbox'  value='Ketamine'  id='choice_92_159_4'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_92_159_4' id='label_92_159_4' class='gform-field-label gform-field-label--type-inline'>Ketamine<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_92_159_5'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_159.5' type='checkbox'  value='LSD (acid)'  id='choice_92_159_5'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_92_159_5' id='label_92_159_5' class='gform-field-label gform-field-label--type-inline'>LSD (acid)<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_92_159_6'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_159.6' type='checkbox'  value='MDMA (ecstasy, molly)'  id='choice_92_159_6'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_92_159_6' id='label_92_159_6' class='gform-field-label gform-field-label--type-inline'>MDMA (ecstasy, molly)<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_92_159_7'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_159.7' type='checkbox'  value='Mescaline (peyote)'  id='choice_92_159_7'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_92_159_7' id='label_92_159_7' class='gform-field-label gform-field-label--type-inline'>Mescaline (peyote)<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_92_159_8'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_159.8' type='checkbox'  value='Psilocybin (mushrooms)'  id='choice_92_159_8'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_92_159_8' id='label_92_159_8' class='gform-field-label gform-field-label--type-inline'>Psilocybin (mushrooms)<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_92_159_9'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_159.9' type='checkbox'  value='Other...'  id='choice_92_159_9'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_92_159_9' id='label_92_159_9' 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_92_160\" 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_92_160'>What other psychedelic are you most interested in trying?<\/label><div class='ginput_container ginput_container_text'><input name='input_160' id='input_92_160' type='text' value='' class='medium'    placeholder='Tell us more...'  aria-invalid=\"false\"   \/><\/div><\/div><fieldset id=\"field_92_161\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield--input-type-checkbox gfield--width-full 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 prevents you from using psychedelics?<\/legend><div class='gfield_description' id='gfield_description_92_161'>Select your top 3.<\/div><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox ' id='input_92_161'><div class='gchoice gchoice_92_161_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_161.1' type='checkbox'  value='I don\u2019t know enough about psychedelics'  id='choice_92_161_1'   aria-describedby=\"gfield_description_92_161\"\/>\n\t\t\t\t\t\t\t\t<label for='choice_92_161_1' id='label_92_161_1' class='gform-field-label gform-field-label--type-inline'>I don\u2019t know enough about psychedelics<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_92_161_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_161.2' type='checkbox'  value='I don\u2019t think people should use drugs'  id='choice_92_161_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_92_161_2' id='label_92_161_2' class='gform-field-label gform-field-label--type-inline'>I don\u2019t think people should use drugs<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_92_161_3'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_161.3' type='checkbox'  value='I think it could make my mental health worse'  id='choice_92_161_3'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_92_161_3' id='label_92_161_3' class='gform-field-label gform-field-label--type-inline'>I think it could make my mental health worse<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_92_161_4'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_161.4' type='checkbox'  value='I\u2019m afraid of becoming addicted'  id='choice_92_161_4'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_92_161_4' id='label_92_161_4' class='gform-field-label gform-field-label--type-inline'>I\u2019m afraid of becoming addicted<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_92_161_5'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_161.5' type='checkbox'  value='I\u2019m afraid of a bad experience (bad trip)'  id='choice_92_161_5'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_92_161_5' id='label_92_161_5' class='gform-field-label gform-field-label--type-inline'>I\u2019m afraid of a bad experience (bad trip)<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_92_161_6'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_161.6' type='checkbox'  value='They are illegal'  id='choice_92_161_6'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_92_161_6' id='label_92_161_6' class='gform-field-label gform-field-label--type-inline'>They are illegal<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_92_161_7'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_161.7' type='checkbox'  value='I don\u2019t know if it\u2019s safe (because it\u2019s unregulated)'  id='choice_92_161_7'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_92_161_7' id='label_92_161_7' class='gform-field-label gform-field-label--type-inline'>I don\u2019t know if it\u2019s safe (because it\u2019s unregulated)<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_92_161_8'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_161.8' type='checkbox'  value='I can\u2019t because of my job (e.g. clearance, drug testing)'  id='choice_92_161_8'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_92_161_8' id='label_92_161_8' class='gform-field-label gform-field-label--type-inline'>I can\u2019t because of my job (e.g. clearance, drug testing)<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_92_161_9'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_161.9' type='checkbox'  value='It\u2019s hard to get even though I want to try them'  id='choice_92_161_9'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_92_161_9' id='label_92_161_9' class='gform-field-label gform-field-label--type-inline'>It\u2019s hard to get even though I want to try them<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_92_161_11'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_161.11' type='checkbox'  value='They\u2019re too expensive'  id='choice_92_161_11'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_92_161_11' id='label_92_161_11' class='gform-field-label gform-field-label--type-inline'>They\u2019re too expensive<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_92_161_12'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_161.12' type='checkbox'  value='Other...'  id='choice_92_161_12'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_92_161_12' id='label_92_161_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_92_162\" 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_92_162'>What else prevents you from using psychedelics?<\/label><div class='ginput_container ginput_container_text'><input name='input_162' id='input_92_162' type='text' value='' class='medium'    placeholder='Tell us more...'  aria-invalid=\"false\"   \/><\/div><\/div><fieldset id=\"field_92_164\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield--input-type-checkbox gfield--width-full 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 prevents you from using psychedelics as much as you&#039;d like?<\/legend><div class='gfield_description' id='gfield_description_92_164'>Select your top 3.<\/div><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox ' id='input_92_164'><div class='gchoice gchoice_92_164_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_164.1' type='checkbox'  value='Nothing, I use psychedelics as much as I&#039;d like to'  id='choice_92_164_1'   aria-describedby=\"gfield_description_92_164\"\/>\n\t\t\t\t\t\t\t\t<label for='choice_92_164_1' id='label_92_164_1' class='gform-field-label gform-field-label--type-inline'>Nothing, I use psychedelics as much as I'd like to<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_92_164_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_164.2' type='checkbox'  value='I don\u2019t know enough about psychedelics'  id='choice_92_164_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_92_164_2' id='label_92_164_2' class='gform-field-label gform-field-label--type-inline'>I don\u2019t know enough about psychedelics<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_92_164_3'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_164.3' type='checkbox'  value='I think it could make my mental health worse'  id='choice_92_164_3'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_92_164_3' id='label_92_164_3' class='gform-field-label gform-field-label--type-inline'>I think it could make my mental health worse<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_92_164_4'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_164.4' type='checkbox'  value='I\u2019m afraid of becoming addicted'  id='choice_92_164_4'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_92_164_4' id='label_92_164_4' class='gform-field-label gform-field-label--type-inline'>I\u2019m afraid of becoming addicted<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_92_164_5'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_164.5' type='checkbox'  value='I\u2019m afraid of a bad experience (bad trip)'  id='choice_92_164_5'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_92_164_5' id='label_92_164_5' class='gform-field-label gform-field-label--type-inline'>I\u2019m afraid of a bad experience (bad trip)<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_92_164_6'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_164.6' type='checkbox'  value='They are illegal'  id='choice_92_164_6'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_92_164_6' id='label_92_164_6' class='gform-field-label gform-field-label--type-inline'>They are illegal<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_92_164_7'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_164.7' type='checkbox'  value='I don\u2019t know if it\u2019s safe (because it\u2019s unregulated)'  id='choice_92_164_7'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_92_164_7' id='label_92_164_7' class='gform-field-label gform-field-label--type-inline'>I don\u2019t know if it\u2019s safe (because it\u2019s unregulated)<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_92_164_8'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_164.8' type='checkbox'  value='I can\u2019t because of my job (e.g. clearance, drug testing)'  id='choice_92_164_8'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_92_164_8' id='label_92_164_8' class='gform-field-label gform-field-label--type-inline'>I can\u2019t because of my job (e.g. clearance, drug testing)<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_92_164_9'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_164.9' type='checkbox'  value='It\u2019s hard to get even though I want to try them'  id='choice_92_164_9'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_92_164_9' id='label_92_164_9' class='gform-field-label gform-field-label--type-inline'>It\u2019s hard to get even though I want to try them<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_92_164_11'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_164.11' type='checkbox'  value='They\u2019re too expensive'  id='choice_92_164_11'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_92_164_11' id='label_92_164_11' class='gform-field-label gform-field-label--type-inline'>They\u2019re too expensive<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_92_164_12'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_164.12' type='checkbox'  value='Other...'  id='choice_92_164_12'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_92_164_12' id='label_92_164_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_92_163\" 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_92_163'>What else prevents you from using psychedelics as much as you&#039;d like to?<\/label><div class='ginput_container ginput_container_text'><input name='input_163' id='input_92_163' type='text' value='' class='medium'    placeholder='Tell us more...'  aria-invalid=\"false\"   \/><\/div><\/div><fieldset id=\"field_92_165\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield--input-type-checkbox gfield--width-full 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 did or would you use psychedelics for?<\/legend><div class='gfield_description' id='gfield_description_92_165'>Select your top 3.<\/div><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox ' id='input_92_165'><div class='gchoice gchoice_92_165_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_165.1' type='checkbox'  value='I was\/am curious'  id='choice_92_165_1'   aria-describedby=\"gfield_description_92_165\"\/>\n\t\t\t\t\t\t\t\t<label for='choice_92_165_1' id='label_92_165_1' class='gform-field-label gform-field-label--type-inline'>I was\/am curious<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_92_165_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_165.2' type='checkbox'  value='I felt or feel pressured to use them'  id='choice_92_165_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_92_165_2' id='label_92_165_2' class='gform-field-label gform-field-label--type-inline'>I felt or feel pressured to use them<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_92_165_3'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_165.3' type='checkbox'  value='To feel more social - for fun'  id='choice_92_165_3'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_92_165_3' id='label_92_165_3' class='gform-field-label gform-field-label--type-inline'>To feel more social - for fun<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_92_165_4'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_165.4' type='checkbox'  value='To reduce my sadness or anxiety'  id='choice_92_165_4'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_92_165_4' id='label_92_165_4' class='gform-field-label gform-field-label--type-inline'>To reduce my sadness or anxiety<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_92_165_5'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_165.5' type='checkbox'  value='To recover from trauma'  id='choice_92_165_5'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_92_165_5' id='label_92_165_5' class='gform-field-label gform-field-label--type-inline'>To recover from trauma<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_92_165_6'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_165.6' type='checkbox'  value='To have a spiritual or beyond conscious experience'  id='choice_92_165_6'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_92_165_6' id='label_92_165_6' class='gform-field-label gform-field-label--type-inline'>To have a spiritual or beyond conscious experience<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_92_165_7'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_165.7' type='checkbox'  value='To boost energy or motivation'  id='choice_92_165_7'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_92_165_7' id='label_92_165_7' class='gform-field-label gform-field-label--type-inline'>To boost energy or motivation<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_92_165_8'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_165.8' type='checkbox'  value='To boost creativity (art, music, creative writing)'  id='choice_92_165_8'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_92_165_8' id='label_92_165_8' class='gform-field-label gform-field-label--type-inline'>To boost creativity (art, music, creative writing)<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_92_165_9'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_165.9' type='checkbox'  value='Other...'  id='choice_92_165_9'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_92_165_9' id='label_92_165_9' 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_92_166\" 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_92_166'>What else would or did you use psychedelics for?<\/label><div class='ginput_container ginput_container_text'><input name='input_166' id='input_92_166' type='text' value='' class='medium'    placeholder='Tell us more...'  aria-invalid=\"false\"   \/><\/div><\/div><fieldset id=\"field_92_167\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield--input-type-checkbox gfield--width-full traditional limit-2 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' >When thinking about psychedelics and your mental health, which of the following apply most to you?<\/legend><div class='gfield_description' id='gfield_description_92_167'>Select up to 2.<\/div><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox ' id='input_92_167'><div class='gchoice gchoice_92_167_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_167.1' type='checkbox'  value='Psychedelics are\/seem more enjoyable than other types of mental health treatment'  id='choice_92_167_1'   aria-describedby=\"gfield_description_92_167\"\/>\n\t\t\t\t\t\t\t\t<label for='choice_92_167_1' id='label_92_167_1' class='gform-field-label gform-field-label--type-inline'>Psychedelics are\/seem more enjoyable than other types of mental health treatment<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_92_167_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_167.2' type='checkbox'  value='I feel safer using psychedelics than using antidepressants or other medications'  id='choice_92_167_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_92_167_2' id='label_92_167_2' class='gform-field-label gform-field-label--type-inline'>I feel safer using psychedelics than using antidepressants or other medications<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_92_167_3'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_167.3' type='checkbox'  value='I use psychedelics for other reasons, but the emotional benefits are an added bonus'  id='choice_92_167_3'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_92_167_3' id='label_92_167_3' class='gform-field-label gform-field-label--type-inline'>I use psychedelics for other reasons, but the emotional benefits are an added bonus<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_92_167_4'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_167.4' type='checkbox'  value='Traditional therapy alone hasn\u2019t worked for me'  id='choice_92_167_4'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_92_167_4' id='label_92_167_4' class='gform-field-label gform-field-label--type-inline'>Traditional therapy alone hasn\u2019t worked for me<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_92_167_5'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_167.5' type='checkbox'  value='Traditional therapy isn&#039;t as available for me'  id='choice_92_167_5'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_92_167_5' id='label_92_167_5' class='gform-field-label gform-field-label--type-inline'>Traditional therapy isn't as available for me<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_92_167_6'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_167.6' type='checkbox'  value='I\u2019m using traditional treatments and psychedelics'  id='choice_92_167_6'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_92_167_6' id='label_92_167_6' class='gform-field-label gform-field-label--type-inline'>I\u2019m using traditional treatments and psychedelics<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_92_167_7'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_167.7' type='checkbox'  value='None of the above'  id='choice_92_167_7'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_92_167_7' id='label_92_167_7' class='gform-field-label gform-field-label--type-inline'>None of the above<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_92_168\" 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' >If psychedelics became medically available (prescribed and covered by insurance), would you be interested in trying them?<\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_92_168'>\n\t\t\t<div class='gchoice gchoice_92_168_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_168' type='radio' value='Yes, and having them monitored by a doctor is most important'  id='choice_92_168_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_92_168_0' id='label_92_168_0' class='gform-field-label gform-field-label--type-inline'>Yes, and having them monitored by a doctor is most important<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_92_168_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_168' type='radio' value='Yes, and having it with a guided therapy session is most important'  id='choice_92_168_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_92_168_1' id='label_92_168_1' class='gform-field-label gform-field-label--type-inline'>Yes, and having it with a guided therapy session is most important<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_92_168_2'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_168' type='radio' value='Yes, but only if they\u2019re affordable'  id='choice_92_168_2' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_92_168_2' id='label_92_168_2' class='gform-field-label gform-field-label--type-inline'>Yes, but only if they\u2019re affordable<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_92_168_3'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_168' type='radio' value='I would still use them but not through medical care'  id='choice_92_168_3' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_92_168_3' id='label_92_168_3' class='gform-field-label gform-field-label--type-inline'>I would still use them but not through medical care<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_92_168_4'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_168' type='radio' value='No, I still wouldn\u2019t want to try them'  id='choice_92_168_4' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_92_168_4' id='label_92_168_4' class='gform-field-label gform-field-label--type-inline'>No, I still wouldn\u2019t want to try them<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_92_169\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield--input-type-checkbox gfield--width-full traditional limit-2 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 do you think is the most important priority for the government regarding psychedelics today?<\/legend><div class='gfield_description' id='gfield_description_92_169'>Select up to 2.<\/div><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox ' id='input_92_169'><div class='gchoice gchoice_92_169_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_169.1' type='checkbox'  value='Ban psychedelics entirely'  id='choice_92_169_1'   aria-describedby=\"gfield_description_92_169\"\/>\n\t\t\t\t\t\t\t\t<label for='choice_92_169_1' id='label_92_169_1' class='gform-field-label gform-field-label--type-inline'>Ban psychedelics entirely<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_92_169_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_169.2' type='checkbox'  value='Make psychedelics legal'  id='choice_92_169_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_92_169_2' id='label_92_169_2' class='gform-field-label gform-field-label--type-inline'>Make psychedelics legal<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_92_169_3'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_169.3' type='checkbox'  value='Create a regulated recreational market for psychedelics'  id='choice_92_169_3'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_92_169_3' id='label_92_169_3' class='gform-field-label gform-field-label--type-inline'>Create a regulated recreational market for psychedelics<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_92_169_4'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_169.4' type='checkbox'  value='Make medically available psychedelics accessible (FDA approval)'  id='choice_92_169_4'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_92_169_4' id='label_92_169_4' class='gform-field-label gform-field-label--type-inline'>Make medically available psychedelics accessible (FDA approval)<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_92_169_5'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_169.5' type='checkbox'  value='Make medical psychedelics more affordable'  id='choice_92_169_5'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_92_169_5' id='label_92_169_5' class='gform-field-label gform-field-label--type-inline'>Make medical psychedelics more affordable<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_92_169_6'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_169.6' type='checkbox'  value='Invest in more research on psychedelics'  id='choice_92_169_6'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_92_169_6' id='label_92_169_6' class='gform-field-label gform-field-label--type-inline'>Invest in more research on psychedelics<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_92_169_7'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_169.7' type='checkbox'  value='Invest in public education on using psychedelics'  id='choice_92_169_7'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_92_169_7' id='label_92_169_7' class='gform-field-label gform-field-label--type-inline'>Invest in public education on using psychedelics<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_92_169_8'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_169.8' type='checkbox'  value='Other...'  id='choice_92_169_8'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_92_169_8' id='label_92_169_8' 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_92_170\" 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_92_170'>What else do you think is the most important priority for the government regarding psychedelics today?<\/label><div class='ginput_container ginput_container_text'><input name='input_170' id='input_92_170' type='text' value='' class='medium'    placeholder='Tell us more...'  aria-invalid=\"false\"   \/><\/div><\/div><\/div>\n                    <\/div>\n                    <div class='gform-page-footer gform_page_footer top_label'>\n                         <input type='button' id='gform_next_button_92_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_92_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_92_2' class='gform_fields top_label form_sublabel_below description_above validation_below'><div id=\"field_92_171\" class=\"gfield gfield--type-html gfield--input-type-html gfield--width-full gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><p>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\".<\/p><\/div><div id=\"field_92_53\" class=\"gfield gfield--type-html gfield--input-type-html section-title gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><h2>About You<\/h2><\/div><div id=\"field_92_54\" class=\"gfield gfield--type-select gfield--input-type-select optional taxonomy field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_92_54'>Age Range<\/label><div class='ginput_container ginput_container_select'><select name='input_54' id='input_92_54' class='medium gfield_select'     aria-invalid=\"false\" ><option value='' ><\/option><option value='Under 18' >Under 18<\/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><option value='Prefer not to answer' >Prefer not to answer<\/option><\/select><\/div><\/div><fieldset id=\"field_92_55\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio optional mb-2 short 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_92_55'>\n\t\t\t<div class='gchoice gchoice_92_55_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_55' type='radio' value='Female'  id='choice_92_55_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_92_55_0' id='label_92_55_0' class='gform-field-label gform-field-label--type-inline'>Female<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_92_55_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_55' type='radio' value='Male'  id='choice_92_55_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_92_55_1' id='label_92_55_1' class='gform-field-label gform-field-label--type-inline'>Male<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_92_55_2'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_55' type='radio' value='Non-Binary'  id='choice_92_55_2' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_92_55_2' id='label_92_55_2' class='gform-field-label gform-field-label--type-inline'>Non-Binary<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_92_55_3'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_55' type='radio' value='Prefer not to answer'  id='choice_92_55_3' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_92_55_3' id='label_92_55_3' class='gform-field-label gform-field-label--type-inline'>Prefer not to answer<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_92_156\" 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_92_156'>\n\t\t\t<div class='gchoice gchoice_92_156_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_156' type='radio' value='Yes'  id='choice_92_156_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_92_156_0' id='label_92_156_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_92_156_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_156' type='radio' value='No'  id='choice_92_156_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_92_156_1' id='label_92_156_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_92_135\" 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_92_135'>How would you describe your gender?<\/label><div class='ginput_container ginput_container_text'><input name='input_135' id='input_92_135' type='text' value='' class='medium'      aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_92_58\" class=\"gfield gfield--type-select gfield--input-type-select optional field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_92_58'>Race\/Ethnicity<\/label><div class='ginput_container ginput_container_select'><select name='input_58' id='input_92_58' class='medium gfield_select'     aria-invalid=\"false\" ><option value='' ><\/option><option value='American Indian or Alaska Native' >American Indian or Alaska Native<\/option><option value='Asian' >Asian<\/option><option value='Black or African American (non-Hispanic)' >Black or African American (non-Hispanic)<\/option><option value='Hispanic or Latino' >Hispanic or Latino<\/option><option value='Middle Eastern or North African' >Middle Eastern or North African<\/option><option value='Native Hawaiian or other Pacific Islander' >Native Hawaiian or other Pacific Islander<\/option><option value='White (non-Hispanic)' >White (non-Hispanic)<\/option><option value='More than one of the above' >More than one of the above<\/option><option value='Other...' >Other...<\/option><\/select><\/div><\/div><div id=\"field_92_134\" 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_92_134'>How would you describe your race\/ethnicity?<\/label><div class='ginput_container ginput_container_text'><input name='input_134' id='input_92_134' type='text' value='' class='medium'      aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_92_59\" class=\"gfield gfield--type-select gfield--input-type-select optional field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_92_59'>Household Income<\/label><div class='ginput_container ginput_container_select'><select name='input_59' id='input_92_59' class='medium gfield_select'     aria-invalid=\"false\" ><option value='' ><\/option><option value='Less than $20,000' >Less than $20,000<\/option><option value='$20,000 - $39,999' >$20,000 - $39,999<\/option><option value='$40,000 - $59,999' >$40,000 - $59,999<\/option><option value='$60,000 - $79,999' >$60,000 - $79,999<\/option><option value='$80,000 - $99,999' >$80,000 - $99,999<\/option><option value='$100,000 - $149,999' >$100,000 - $149,999<\/option><option value='$150,000+' >$150,000+<\/option><\/select><\/div><\/div><fieldset id=\"field_92_87\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-full field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >Do you live in the United States or another country?<\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_92_87'>\n\t\t\t<div class='gchoice gchoice_92_87_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_87' type='radio' value='I live in the United States'  id='choice_92_87_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_92_87_0' id='label_92_87_0' class='gform-field-label gform-field-label--type-inline'>I live in the United States<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_92_87_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_87' type='radio' value='I live in another country'  id='choice_92_87_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_92_87_1' id='label_92_87_1' class='gform-field-label gform-field-label--type-inline'>I live in another country<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_92_78\" class=\"gfield gfield--type-select gfield--input-type-select gfield--width-full optional field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_92_78'>State<\/label><div class='ginput_container ginput_container_select'><select name='input_78' id='input_92_78' class='medium gfield_select'     aria-invalid=\"false\" ><option value='' ><\/option><option value='Alabama' >Alabama<\/option><option value='Alaska' >Alaska<\/option><option value='Arizona' >Arizona<\/option><option value='Arkansas' >Arkansas<\/option><option value='California' >California<\/option><option value='Colorado' >Colorado<\/option><option value='Connecticut' >Connecticut<\/option><option value='Delaware' >Delaware<\/option><option value='District of Columbia' >District of Columbia<\/option><option value='Florida' >Florida<\/option><option value='Georgia' >Georgia<\/option><option value='Hawaii' >Hawaii<\/option><option value='Idaho' >Idaho<\/option><option value='Illinois' >Illinois<\/option><option value='Indiana' >Indiana<\/option><option value='Iowa' >Iowa<\/option><option value='Kansas' >Kansas<\/option><option value='Kentucky' >Kentucky<\/option><option value='Louisiana' >Louisiana<\/option><option value='Maine' >Maine<\/option><option value='Maryland' >Maryland<\/option><option value='Massachusetts' >Massachusetts<\/option><option value='Michigan' >Michigan<\/option><option value='Minnesota' >Minnesota<\/option><option value='Mississippi' >Mississippi<\/option><option value='Missouri' >Missouri<\/option><option value='Montana' >Montana<\/option><option value='Nebraska' >Nebraska<\/option><option value='Nevada' >Nevada<\/option><option value='New Hampshire' >New Hampshire<\/option><option value='New Jersey' >New Jersey<\/option><option value='New Mexico' >New Mexico<\/option><option value='New York' >New York<\/option><option value='North Carolina' >North Carolina<\/option><option value='North Dakota' >North Dakota<\/option><option value='Ohio' >Ohio<\/option><option value='Oklahoma' >Oklahoma<\/option><option value='Oregon' >Oregon<\/option><option value='Pennsylvania' >Pennsylvania<\/option><option value='Rhode Island' >Rhode Island<\/option><option value='South Carolina' >South Carolina<\/option><option value='South Dakota' >South Dakota<\/option><option value='Tennessee' >Tennessee<\/option><option value='Texas' >Texas<\/option><option value='Utah' >Utah<\/option><option value='Vermont' >Vermont<\/option><option value='Virginia' >Virginia<\/option><option value='Washington' >Washington<\/option><option value='West Virginia' >West Virginia<\/option><option value='Wisconsin' >Wisconsin<\/option><option value='Wyoming' >Wyoming<\/option><option value='I live in a U.S. Territory' >I live in a U.S. Territory<\/option><\/select><\/div><\/div><fieldset id=\"field_92_109\" 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' >Do you live with any of the following disabilities or conditions?<\/legend><div class='gfield_description' id='gfield_description_92_109'>Select all that apply.<\/div><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox ' id='input_92_109'><div class='gchoice gchoice_92_109_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_109.1' type='checkbox'  value='Physical disability (blind\/low vision, hearing, mobility)'  id='choice_92_109_1'   aria-describedby=\"gfield_description_92_109\"\/>\n\t\t\t\t\t\t\t\t<label for='choice_92_109_1' id='label_92_109_1' class='gform-field-label gform-field-label--type-inline'>Physical disability (blind\/low vision, hearing, mobility)<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_92_109_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_109.2' type='checkbox'  value='Arthritis or other chronic pain'  id='choice_92_109_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_92_109_2' id='label_92_109_2' 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_92_109_3'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_109.3' type='checkbox'  value='Anxiety'  id='choice_92_109_3'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_92_109_3' id='label_92_109_3' class='gform-field-label gform-field-label--type-inline'>Anxiety<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_92_109_4'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_109.4' type='checkbox'  value='Autism spectrum and\/or ADHD'  id='choice_92_109_4'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_92_109_4' id='label_92_109_4' class='gform-field-label gform-field-label--type-inline'>Autism spectrum and\/or ADHD<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_92_109_5'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_109.5' type='checkbox'  value='Mood conditions: depression or mania'  id='choice_92_109_5'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_92_109_5' id='label_92_109_5' class='gform-field-label gform-field-label--type-inline'>Mood conditions: depression or mania<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_92_109_6'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_109.6' type='checkbox'  value='Intellectual or learning disability'  id='choice_92_109_6'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_92_109_6' id='label_92_109_6' class='gform-field-label gform-field-label--type-inline'>Intellectual or learning disability<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_92_109_7'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_109.7' type='checkbox'  value='Neurological condition (epilepsy, etc.) or traumatic brain injury (TBI)'  id='choice_92_109_7'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_92_109_7' id='label_92_109_7' class='gform-field-label gform-field-label--type-inline'>Neurological condition (epilepsy, etc.) or traumatic brain injury (TBI)<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_92_109_8'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_109.8' type='checkbox'  value='Trauma'  id='choice_92_109_8'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_92_109_8' id='label_92_109_8' class='gform-field-label gform-field-label--type-inline'>Trauma<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_92_109_9'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_109.9' type='checkbox'  value='None of the above'  id='choice_92_109_9'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_92_109_9' id='label_92_109_9' class='gform-field-label gform-field-label--type-inline'>None of the above<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_92_109_11'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_109.11' type='checkbox'  value='Other mental health condition...'  id='choice_92_109_11'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_92_109_11' id='label_92_109_11' class='gform-field-label gform-field-label--type-inline'>Other mental health condition...<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_92_109_12'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_109.12' type='checkbox'  value='Other...'  id='choice_92_109_12'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_92_109_12' id='label_92_109_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_92_111\" 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_92_111'>What other mental health condition(s) do you have?<\/label><div class='ginput_container ginput_container_text'><input name='input_111' id='input_92_111' type='text' value='' class='medium'    placeholder='Tell us more...'  aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_92_112\" 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_92_112'>What other disabilities or condition(s) do you have?<\/label><div class='ginput_container ginput_container_text'><input name='input_112' id='input_92_112' type='text' value='' class='medium'    placeholder='Tell us more...'  aria-invalid=\"false\"   \/><\/div><\/div><\/div><\/div>\n        <div class='gform-page-footer gform_page_footer top_label'><input type='submit' id='gform_previous_button_92' class='gform_previous_button gform-theme-button gform-theme-button--secondary button' 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here.","potentialAction":[{"@type":"SearchAction","target":{"@type":"EntryPoint","urlTemplate":"https:\/\/screening.mhanational.org\/?s={search_term_string}"},"query-input":{"@type":"PropertyValueSpecification","valueRequired":true,"valueName":"search_term_string"}}],"inLanguage":"es"}]}},"_links":{"self":[{"href":"https:\/\/screening.mhanational.org\/es\/wp-json\/wp\/v2\/screen\/255654","targetHints":{"allow":["GET"]}}],"collection":[{"href":"https:\/\/screening.mhanational.org\/es\/wp-json\/wp\/v2\/screen"}],"about":[{"href":"https:\/\/screening.mhanational.org\/es\/wp-json\/wp\/v2\/types\/screen"}],"wp:attachment":[{"href":"https:\/\/screening.mhanational.org\/es\/wp-json\/wp\/v2\/media?parent=255654"}],"wp:term":[{"taxonomy":"post_tag","embeddable":true,"href":"https:\/\/screening.mhanational.org\/es\/wp-json\/wp\/v2\/tags?post=255654"},{"taxonomy":"age_group","embeddable":true,"href":"https:\/\/screening.mhanational.org\/es\/wp-json\/wp\/v2\/age_group?post=255654"},{"taxonomy":"condition","embeddable":true,"href":"https:\/\/screening.mhanational.org\/es\/wp-json\/wp\/v2\/condition?post=255654"}],"curies":[{"name":"wp","href":"https:\/\/api.w.org\/{rel}","templated":true}]}},{"id":254207,"date":"2026-01-15T11:56:59","date_gmt":"2026-01-15T16:56:59","guid":{"rendered":"https:\/\/screening.mhanational.org\/?post_type=screen&#038;p=254207"},"modified":"2026-03-23T13:01:21","modified_gmt":"2026-03-23T17:01:21","slug":"survey-what-makes-a-good-day","status":"publish","type":"screen","link":"https:\/\/screening.mhanational.org\/es\/screening-tools\/survey-what-makes-a-good-day\/","title":{"rendered":"Encuesta: \u00bfQu\u00e9 hace que un d\u00eda sea bueno?"},"content":{"rendered":"\n                <div class='gf_browser_gecko gform_wrapper gravity-theme gform-theme--no-framework full-pager_wrapper' data-form-theme='gravity-theme' data-form-index='0' id='gform_wrapper_90' style='display:none'><form method='post' enctype='multipart\/form-data'  id='gform_90' class='full-pager' class='clearfix' action='\/es\/wp-json\/wp\/v2\/screen' data-formid='90' novalidate><ol class=\"full-progress-bar clearfix step-1-of-3\"><li class=\"step-1 active\"><span>Survey Questions<\/span><\/li><li class=\"step-2 empty\"><span>Optional Questions<\/span><\/li><\/ol>\n                        <div class='gform-body gform_body'><div id='gform_page_90_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_90' class='gform_fields top_label form_sublabel_below description_above validation_below'><div id=\"field_90_139\" 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_90_139'>X\/Twitter<\/label><div class='gfield_description' id='gfield_description_90_139'>This field is for validation purposes and should be left unchanged.<\/div><div class='ginput_container'><input name='input_139' id='input_90_139' type='text' value='' autocomplete='new-password'\/><\/div><\/div><div id=\"field_90_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_90_38' type='hidden' class='gform_hidden'  aria-invalid=\"false\" value='' \/><\/div><\/div><div id=\"field_90_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_90_39\" type=\"hidden\" class=\"gform_hidden\" aria-invalid=\"false\" value=\"254207\"><\/div><div id=\"field_90_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_90_40\" type=\"hidden\" class=\"gform_hidden\" aria-invalid=\"false\" value=\"34c0972926eed1ef42815dc87b83c969\"><\/div><div id=\"field_90_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_90_41' type='hidden' class='gform_hidden'  aria-invalid=\"false\" value='' \/><\/div><\/div><div id=\"field_90_51\" class=\"gfield gfield--type-hidden gfield--input-type-hidden gform_hidden field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><div class='ginput_container ginput_container_text'><input name='input_51' id='input_90_51' type='hidden' class='gform_hidden'  aria-invalid=\"false\" value='http:\/\/screening.mhanational.org\/es\/wp-json\/wp\/v2\/screen' \/><\/div><\/div><div id=\"field_90_81\" class=\"gfield gfield--type-hidden gfield--input-type-hidden gform_hidden field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><div class='ginput_container ginput_container_text'><input name='input_81' id='input_90_81' type='hidden' class='gform_hidden'  aria-invalid=\"false\" value='' \/><\/div><\/div><div id=\"field_90_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_90_82' type='hidden' class='gform_hidden'  aria-invalid=\"false\" value='' \/><\/div><\/div><div id=\"field_90_83\" class=\"gfield gfield--type-hidden gfield--input-type-hidden gform_hidden field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><div class='ginput_container ginput_container_text'><input name='input_83' id='input_90_83' type='hidden' class='gform_hidden'  aria-invalid=\"false\" value='' \/><\/div><\/div><div id=\"field_90_93\" class=\"gfield gfield--type-hidden gfield--input-type-hidden gfield--width-full gform_hidden field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><div class='ginput_container ginput_container_text'><input name='input_93' id='input_90_93' type='hidden' class='gform_hidden'  aria-invalid=\"false\" value='' \/><\/div><\/div><div id=\"field_90_138\" 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_138' id='input_90_138' type='hidden' class='gform_hidden'  aria-invalid=\"false\" value='lang--es' \/><\/div><\/div><div id=\"field_90_99\" class=\"gfield gfield--type-html gfield--input-type-html gfield--width-full gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><p>We want to know what it means for you personally to have a good day. Your answers will help us promote strategies to help us all have more good days.<\/p><\/div><div id=\"field_90_95\" class=\"gfield gfield--type-textarea gfield--input-type-textarea 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_90_95'>For you, <strong>what makes a good day<\/strong>?<\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_95' id='input_90_95' class='textarea small'      aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/div><fieldset id=\"field_90_96\" 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' >How many &quot;good days&quot; do you have per week?<\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_90_96'>\n\t\t\t<div class='gchoice gchoice_90_96_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_96' type='radio' value='Zero'  id='choice_90_96_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_90_96_0' id='label_90_96_0' class='gform-field-label gform-field-label--type-inline'>Zero<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_90_96_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_96' type='radio' value='1 or 2'  id='choice_90_96_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_90_96_1' id='label_90_96_1' class='gform-field-label gform-field-label--type-inline'>1 or 2<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_90_96_2'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_96' type='radio' value='3 or 4'  id='choice_90_96_2' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_90_96_2' id='label_90_96_2' class='gform-field-label gform-field-label--type-inline'>3 or 4<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_90_96_3'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_96' type='radio' value='5 or 6'  id='choice_90_96_3' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_90_96_3' id='label_90_96_3' class='gform-field-label gform-field-label--type-inline'>5 or 6<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_90_96_4'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_96' type='radio' value='7'  id='choice_90_96_4' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_90_96_4' id='label_90_96_4' class='gform-field-label gform-field-label--type-inline'>7<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_90_97\" class=\"gfield gfield--type-textarea gfield--input-type-textarea 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_90_97'>What are some things you do to improve your mood when you&#039;ve been having a bad day?<\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_97' id='input_90_97' class='textarea small'      aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/div><div id=\"field_90_136\" class=\"gfield gfield--type-html gfield--input-type-html gfield--width-full gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  >Sometimes both good and bad things happen in the same day, but our brain only notices the bad things.<\/div><div id=\"field_90_98\" class=\"gfield gfield--type-textarea gfield--input-type-textarea 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_90_98'>Think of a \"bad day\" you had recently. <strong>What is one good thing that happened that day<\/strong>\u2014even if it's something very small?<\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_98' id='input_90_98' class='textarea small'      aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/div><\/div>\n                    <\/div>\n                    <div class='gform-page-footer gform_page_footer top_label'>\n                         <input type='button' id='gform_next_button_90_100' 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_90_2' class='gform_page demographics' data-js='page-field-id-100' style='display:none;'>\n                    <div class='gform_page_fields'>\n                        <div id='gform_fields_90_2' class='gform_fields top_label form_sublabel_below description_above validation_below'><div id=\"field_90_103\" class=\"gfield gfield--type-html gfield--input-type-html gfield--width-full gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><p>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><fieldset id=\"field_90_101\" 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' >Have you already answered these optional questions on our website today?<\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_90_101'>\n\t\t\t<div class='gchoice gchoice_90_101_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_101' type='radio' value='Yes'  id='choice_90_101_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_90_101_0' id='label_90_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_90_101_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_101' type='radio' value='No'  id='choice_90_101_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_90_101_1' id='label_90_101_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_90_137\" class=\"gfield gfield--type-html gfield--input-type-html gfield--width-full gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  >Okay! We'll skip them this time.<\/div><div id=\"field_90_104\" class=\"gfield gfield--type-html gfield--input-type-html gfield--width-full gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><hr \/><\/div><div id=\"field_90_105\" 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_90_106\" 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_90_106'>Age Range<\/label><div class='ginput_container ginput_container_select'><select name='input_106' id='input_90_106' 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_90_107\" 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_90_107'>\n\t\t\t<div class='gchoice gchoice_90_107_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_107' type='radio' value='Female'  id='choice_90_107_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_90_107_0' id='label_90_107_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_90_107_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_107' type='radio' value='Male'  id='choice_90_107_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_90_107_1' id='label_90_107_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_90_107_2'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_107' type='radio' value='Non-Binary'  id='choice_90_107_2' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_90_107_2' id='label_90_107_2' class='gform-field-label gform-field-label--type-inline'>Non-Binary<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_90_108\" 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_90_108'>\n\t\t\t<div class='gchoice gchoice_90_108_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_108' type='radio' value='Yes'  id='choice_90_108_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_90_108_0' id='label_90_108_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_90_108_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_108' type='radio' value='No'  id='choice_90_108_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_90_108_1' id='label_90_108_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_90_109\" 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_90_109'>How would you describe your gender?<\/label><div class='ginput_container ginput_container_text'><input name='input_109' id='input_90_109' type='text' value='' class='small'    placeholder='Enter gender...'  aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_90_110\" 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_90_110'>Race\/Ethnicity<\/label><div class='ginput_container ginput_container_select'><select name='input_110' id='input_90_110' 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_90_111\" 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_90_111'>Household Income<\/label><div class='ginput_container ginput_container_select'><select name='input_111' id='input_90_111' 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_90_112\" 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_90_112'>\n\t\t\t<div class='gchoice gchoice_90_112_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_112' type='radio' value='I live in the United States'  id='choice_90_112_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_90_112_0' id='label_90_112_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_90_112_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_112' type='radio' value='I live in another country'  id='choice_90_112_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_90_112_1' id='label_90_112_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_90_113\" 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_90_113'>State<\/label><div class='ginput_container ginput_container_select'><select name='input_113' id='input_90_113' 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_90_114\" 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_90_114'>What country do you live in?<\/label><div class='ginput_container ginput_container_select'><select name='input_114' id='input_90_114' 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_90_115\" 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_90_115'>Zip\/Postal Code<\/label><div class='ginput_container ginput_container_text'><input name='input_115' id='input_90_115' type='text' value='' class='small'      aria-invalid=\"false\"   \/><\/div><\/div><fieldset id=\"field_90_116\" 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_90_116'>Select all that apply.<\/div><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox ' id='input_90_116'><div class='gchoice gchoice_90_116_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_116.1' type='checkbox'  value='Veteran or active-duty military'  id='choice_90_116_1'   aria-describedby=\"gfield_description_90_116\"\/>\n\t\t\t\t\t\t\t\t<label for='choice_90_116_1' id='label_90_116_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_90_116_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_116.2' type='checkbox'  value='Caregiver of someone living with emotional or physical illness'  id='choice_90_116_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_90_116_2' id='label_90_116_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_90_116_3'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_116.3' type='checkbox'  value='LGBTQ+'  id='choice_90_116_3'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_90_116_3' id='label_90_116_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_90_116_4'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_116.4' type='checkbox'  value='Student'  id='choice_90_116_4'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_90_116_4' id='label_90_116_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_90_116_5'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_116.5' type='checkbox'  value='Trauma survivor'  id='choice_90_116_5'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_90_116_5' id='label_90_116_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_90_116_6'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_116.6' type='checkbox'  value='New or expecting parent'  id='choice_90_116_6'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_90_116_6' id='label_90_116_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_90_116_7'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_116.7' type='checkbox'  value='Healthcare worker'  id='choice_90_116_7'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_90_116_7' id='label_90_116_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_90_117\" 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_90_117'>\n\t\t\t<div class='gchoice gchoice_90_117_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_117' type='radio' value='Mental health condition'  id='choice_90_117_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_90_117_0' id='label_90_117_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_90_117_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_117' type='radio' value='Physical health condition'  id='choice_90_117_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_90_117_1' id='label_90_117_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_90_117_2'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_117' type='radio' value='Both mental and physical health conditions'  id='choice_90_117_2' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_90_117_2' id='label_90_117_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_90_118\" 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_90_118'>Which of the following best describes your sexual orientation?<\/label><div class='ginput_container ginput_container_select'><select name='input_118' id='input_90_118' 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_90_119\" 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_90_119'>What is your sexual orientation?<\/label><div class='ginput_container ginput_container_text'><input name='input_119' id='input_90_119' type='text' value='' class='small'    placeholder='Enter sexual orientation...'  aria-invalid=\"false\"   \/><\/div><\/div><fieldset id=\"field_90_120\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield--input-type-checkbox gfield--width-full traditional field_sublabel_below gfield--no-description field_description_above 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='ginput_container ginput_container_checkbox'><div class='gfield_checkbox ' id='input_90_120'><div class='gchoice gchoice_90_120_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_120.1' type='checkbox'  value='Child abuse\/violence'  id='choice_90_120_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_90_120_1' id='label_90_120_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_90_120_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_120.2' type='checkbox'  value='Intimate partner violence'  id='choice_90_120_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_90_120_2' id='label_90_120_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_90_120_3'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_120.3' type='checkbox'  value='Sexual assault\/violence'  id='choice_90_120_3'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_90_120_3' id='label_90_120_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_90_120_4'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_120.4' type='checkbox'  value='Serious illness\/injury\/assault'  id='choice_90_120_4'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_90_120_4' id='label_90_120_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_90_120_5'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_120.5' type='checkbox'  value='Family conflict (identity acceptance\/separation\/divorce)'  id='choice_90_120_5'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_90_120_5' id='label_90_120_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_90_120_6'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_120.6' type='checkbox'  value='Traumatic event (natural disaster, accident, witnessing violence, etc.)'  id='choice_90_120_6'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_90_120_6' id='label_90_120_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_90_120_7'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_120.7' type='checkbox'  value='Death of a loved one'  id='choice_90_120_7'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_90_120_7' id='label_90_120_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_90_120_8'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_120.8' type='checkbox'  value='Other and\/or tell us more about your trauma'  id='choice_90_120_8'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_90_120_8' id='label_90_120_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_90_121\" 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_90_121'>Please tell us more about your experience of trauma:<\/label><div class='ginput_container ginput_container_text'><input name='input_121' id='input_90_121' type='text' value='' class='medium'    placeholder='Tell us more...'  aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_90_122\" 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_90_123\" 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_90_123'>\n\t\t\t<div class='gchoice gchoice_90_123_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_123' type='radio' value='Yes'  id='choice_90_123_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_90_123_0' id='label_90_123_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_90_123_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_123' type='radio' value='No'  id='choice_90_123_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_90_123_1' id='label_90_123_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_90_124\" 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_90_124'>\n\t\t\t<div class='gchoice gchoice_90_124_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_124' type='radio' value='Yes'  id='choice_90_124_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_90_124_0' id='label_90_124_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_90_124_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_124' type='radio' value='No'  id='choice_90_124_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_90_124_1' id='label_90_124_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_90_125\" 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_90_125'>Choose up to 3.<\/div><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox ' id='input_90_125'><div class='gchoice gchoice_90_125_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_125.1' type='checkbox'  value='I wanted to handle my mental health on my own'  id='choice_90_125_1'   aria-describedby=\"gfield_description_90_125\"\/>\n\t\t\t\t\t\t\t\t<label for='choice_90_125_1' id='label_90_125_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_90_125_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_125.2' type='checkbox'  value='I didn\u2019t know how or where to start'  id='choice_90_125_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_90_125_2' id='label_90_125_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_90_125_3'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_125.3' type='checkbox'  value='I thought it would cost too much'  id='choice_90_125_3'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_90_125_3' id='label_90_125_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_90_125_4'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_125.4' type='checkbox'  value='I didn\u2019t have time'  id='choice_90_125_4'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_90_125_4' id='label_90_125_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_90_125_5'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_125.5' type='checkbox'  value='I didn\u2019t think it would help me'  id='choice_90_125_5'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_90_125_5' id='label_90_125_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_90_125_6'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_125.6' type='checkbox'  value='I didn&#039;t feel ready to start treatment'  id='choice_90_125_6'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_90_125_6' id='label_90_125_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_90_125_7'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_125.7' type='checkbox'  value='I was worried about what people would think or say if I got treatment'  id='choice_90_125_7'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_90_125_7' id='label_90_125_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_90_125_8'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_125.8' type='checkbox'  value='I was afraid of being forced into a hospital or forced to take medication'  id='choice_90_125_8'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_90_125_8' id='label_90_125_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_90_125_9'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_125.9' type='checkbox'  value='I tried, but couldn\u2019t find available treatment (no openings, wouldn\u2019t take insurance, etc.)'  id='choice_90_125_9'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_90_125_9' id='label_90_125_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_90_125_11'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_125.11' type='checkbox'  value='My parent(s) or guardian wouldn&#039;t let me, or I didn&#039;t want to ask'  id='choice_90_125_11'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_90_125_11' id='label_90_125_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_90_125_12'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_125.12' type='checkbox'  value='Other...'  id='choice_90_125_12'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_90_125_12' id='label_90_125_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_90_126\" 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_90_126'>What else has prevented you from seeking treatment in the past?<\/label><div class='ginput_container ginput_container_text'><input name='input_126' id='input_90_126' type='text' value='' class='medium'    placeholder='Tell us more...'  aria-invalid=\"false\"   \/><\/div><\/div><fieldset id=\"field_90_127\" 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_90_127'>Choose up to 3.<\/div><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox ' id='input_90_127'><div class='gchoice gchoice_90_127_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_127.1' type='checkbox'  value='Abuse or violence'  id='choice_90_127_1'   aria-describedby=\"gfield_description_90_127\"\/>\n\t\t\t\t\t\t\t\t<label for='choice_90_127_1' id='label_90_127_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_90_127_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_127.2' type='checkbox'  value='Relationship problems (friends, family, or significant other)'  id='choice_90_127_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_90_127_2' id='label_90_127_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_90_127_3'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_127.3' type='checkbox'  value='Body image'  id='choice_90_127_3'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_90_127_3' id='label_90_127_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_90_127_4'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_127.4' type='checkbox'  value='Low self-esteem or self-image'  id='choice_90_127_4'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_90_127_4' id='label_90_127_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_90_127_5'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_127.5' type='checkbox'  value='School or work problems'  id='choice_90_127_5'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_90_127_5' id='label_90_127_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_90_127_6'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_127.6' type='checkbox'  value='Financial problems'  id='choice_90_127_6'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_90_127_6' id='label_90_127_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_90_127_7'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_127.7' type='checkbox'  value='Loneliness or isolation'  id='choice_90_127_7'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_90_127_7' id='label_90_127_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_90_127_8'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_127.8' type='checkbox'  value='Grief or loss of someone or something'  id='choice_90_127_8'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_90_127_8' id='label_90_127_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_90_127_9'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_127.9' type='checkbox'  value='Experiencing hate\/bullying (including racism, homophobia, transphobia, or discrimination)'  id='choice_90_127_9'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_90_127_9' id='label_90_127_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_90_127_11'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_127.11' type='checkbox'  value='State of the world (war, climate, politics, immigration)'  id='choice_90_127_11'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_90_127_11' id='label_90_127_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_90_127_12'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_127.12' type='checkbox'  value='I don\u2019t know (something just feels wrong)'  id='choice_90_127_12'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_90_127_12' id='label_90_127_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_90_127_13'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_127.13' type='checkbox'  value='Other...'  id='choice_90_127_13'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_90_127_13' id='label_90_127_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_90_128\" 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_90_128'>What else is contributing to your mental health problems right now?<\/label><div class='ginput_container ginput_container_text'><input name='input_128' id='input_90_128' type='text' value='' class='medium'    placeholder='Tell us more...'  aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_90_129\" 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_90_129'>What about the state of the world is affecting you the most?<\/label><div class='ginput_container ginput_container_text'><input name='input_129' id='input_90_129' type='text' value='' class='medium'    placeholder='Tell us more...'  aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_90_130\" 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_90_131\" 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_90_131'>\n\t\t\t<div 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Esto es una encuesta, no una prueba de salud mental.<\/p>","protected":false},"template":"","tags":[],"age_group":[],"condition":[],"class_list":["post-254207","screen","type-screen","status-publish","hentry"],"acf":[],"yoast_head":"<title>Survey: What Makes a Good Day? &#8211; Mental Health America<\/title>\n<meta name=\"description\" content=\"We want to learn more about how to help us all have more good days.\" \/>\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\/survey-what-makes-a-good-day\/\" \/>\n<meta property=\"og:locale\" content=\"es_MX\" \/>\n<meta property=\"og:type\" content=\"article\" \/>\n<meta property=\"og:title\" content=\"Survey: What Makes a Good Day? &#8211; Mental Health America\" \/>\n<meta property=\"og:description\" content=\"We want to learn more about how to help us all have more good days.\" \/>\n<meta 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demogr\u00e1ficas (prueba)"},"content":{"rendered":"\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_89' style='display:none'>\n                        <div class='gform_heading'>\n                            <h2 class=\"gform_title\">Demographics Questions (test)<\/h2>\n                            <p class='gform_description'><\/p>\n                        <\/div><form method='post' enctype='multipart\/form-data'  id='gform_89'  class='clearfix' action='\/es\/wp-json\/wp\/v2\/screen' data-formid='89' novalidate>\n                        <div class='gform-body gform_body'><div id='gform_fields_89' class='gform_fields top_label form_sublabel_below description_above validation_below'><div id=\"field_89_84\" 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_89_84'>Instagram<\/label><div class='gfield_description' id='gfield_description_89_84'>This field is for validation purposes and should be left unchanged.<\/div><div class='ginput_container'><input name='input_84' id='input_89_84' type='text' value='' autocomplete='new-password'\/><\/div><\/div><div id=\"field_89_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_89_38' type='hidden' class='gform_hidden'  aria-invalid=\"false\" value='' \/><\/div><\/div><div id=\"field_89_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_89_39\" type=\"hidden\" class=\"gform_hidden\" aria-invalid=\"false\" value=\"252437\"><\/div><div id=\"field_89_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_89_40\" type=\"hidden\" class=\"gform_hidden\" aria-invalid=\"false\" value=\"34c0972926eed1ef42815dc87b83c969\"><\/div><div id=\"field_89_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_89_41' type='hidden' class='gform_hidden'  aria-invalid=\"false\" value='' \/><\/div><\/div><div id=\"field_89_47\" 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_47' id='input_89_47' type='hidden' class='gform_hidden'  aria-invalid=\"false\" value='http:\/\/screening.mhanational.org\/es\/wp-json\/wp\/v2\/screen' \/><\/div><\/div><div id=\"field_89_58\" 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_58' id='input_89_58' type='hidden' class='gform_hidden'  aria-invalid=\"false\" value='' \/><\/div><\/div><div id=\"field_89_59\" 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_59' id='input_89_59' type='hidden' class='gform_hidden'  aria-invalid=\"false\" value='' \/><\/div><\/div><div id=\"field_89_60\" 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_60' id='input_89_60' type='hidden' class='gform_hidden'  aria-invalid=\"false\" value='' \/><\/div><\/div><div id=\"field_89_77\" 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_77' id='input_89_77' type='hidden' class='gform_hidden'  aria-invalid=\"false\" value='https:\/\/screening.mhanational.org\/es\/wp-json\/wp\/v2\/screen' \/><\/div><\/div><div id=\"field_89_83\" 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_83' id='input_89_83' type='hidden' class='gform_hidden'  aria-invalid=\"false\" value='lang--es' \/><\/div><\/div><div id=\"field_89_18\" 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_89_61\" 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_89_69\" 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' >What is the main thing you want to do after taking this mental health test? (Select one)<\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_89_69'>\n\t\t\t<div class='gchoice gchoice_89_69_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_69' type='radio' value='Take another mental health test'  id='choice_89_69_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_89_69_0' id='label_89_69_0' class='gform-field-label gform-field-label--type-inline'>Take another mental health test<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_89_69_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_69' type='radio' value='Understand what depression is like (reading articles)'  id='choice_89_69_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_89_69_1' id='label_89_69_1' class='gform-field-label gform-field-label--type-inline'>Understand what depression is like (reading articles)<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_89_69_2'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_69' type='radio' value='Understand and manage self-harm or suicidal thoughts'  id='choice_89_69_2' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_89_69_2' id='label_89_69_2' class='gform-field-label gform-field-label--type-inline'>Understand and manage self-harm or suicidal thoughts<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_89_69_3'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_69' type='radio' value='Tips for managing depression (reading articles)'  id='choice_89_69_3' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_89_69_3' id='label_89_69_3' class='gform-field-label gform-field-label--type-inline'>Tips for managing depression (reading articles)<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_89_69_4'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_69' type='radio' value='Learn and practice skills for how to manage depression (try a free self-help tool)'  id='choice_89_69_4' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_89_69_4' id='label_89_69_4' class='gform-field-label gform-field-label--type-inline'>Learn and practice skills for how to manage depression (try a free self-help tool)<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_89_69_5'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_69' type='radio' value='Learn about what therapy\/treatment is like (reading articles)'  id='choice_89_69_5' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_89_69_5' id='label_89_69_5' class='gform-field-label gform-field-label--type-inline'>Learn about what therapy\/treatment is like (reading articles)<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_89_69_6'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_69' type='radio' value='Find a treatment provider near you'  id='choice_89_69_6' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_89_69_6' id='label_89_69_6' class='gform-field-label gform-field-label--type-inline'>Find a treatment provider near you<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_89_69_7'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_69' type='radio' value='Find a forum or support group for people with depression'  id='choice_89_69_7' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_89_69_7' id='label_89_69_7' class='gform-field-label gform-field-label--type-inline'>Find a forum or support group for people with depression<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_89_69_8'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_69' type='radio' value='Other...'  id='choice_89_69_8' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_89_69_8' id='label_89_69_8' class='gform-field-label gform-field-label--type-inline'>Other...<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_89_69_9'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_69' type='radio' value='I don\u2019t want to do anything'  id='choice_89_69_9' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_89_69_9' id='label_89_69_9' class='gform-field-label gform-field-label--type-inline'>I don\u2019t want to do anything<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_89_70\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-full field_sublabel_below gfield--no-description field_description_above hidden_label field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_89_70'>Next Steps - Other<\/label><div class='ginput_container ginput_container_text'><input name='input_70' id='input_89_70' type='text' value='' class='medium'    placeholder='Enter other...'  aria-invalid=\"false\"   \/><\/div><\/div><fieldset id=\"field_89_71\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-full layout-action show-actions_b traditional field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >Do you feel like you need to do something to improve your mental health?<\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_89_71'>\n\t\t\t<div class='gchoice gchoice_89_71_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_71' type='radio' value='Yes'  id='choice_89_71_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_89_71_0' id='label_89_71_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_89_71_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_71' type='radio' value='No'  id='choice_89_71_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_89_71_1' id='label_89_71_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_89_71_2'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_71' type='radio' value='I don&#039;t know'  id='choice_89_71_2' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_89_71_2' id='label_89_71_2' class='gform-field-label gform-field-label--type-inline'>I don't know<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_89_72\" class=\"gfield gfield--type-html gfield--input-type-html gfield--width-full layout-action show-actions_b 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_89_62\" 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_89_62'>\n\t\t\t<div class='gchoice gchoice_89_62_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_62' type='radio' value='For myself'  id='choice_89_62_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_89_62_0' id='label_89_62_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_89_62_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_62' type='radio' value='For someone else'  id='choice_89_62_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_89_62_1' id='label_89_62_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_89_63\" 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_89_42\" 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_89_19\" 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_89_19'>Age Range<\/label><div class='ginput_container ginput_container_select'><select name='input_19' id='input_89_19' 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_89_46\" 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_89_46'>\n\t\t\t<div class='gchoice gchoice_89_46_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_46' type='radio' value='Female'  id='choice_89_46_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_89_46_0' id='label_89_46_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_89_46_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_46' type='radio' value='Male'  id='choice_89_46_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_89_46_1' id='label_89_46_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_89_46_2'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_46' type='radio' value='Non-Binary'  id='choice_89_46_2' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_89_46_2' id='label_89_46_2' class='gform-field-label gform-field-label--type-inline'>Non-Binary<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_89_80\" 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_89_80'>\n\t\t\t<div class='gchoice gchoice_89_80_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_80' type='radio' value='Yes'  id='choice_89_80_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_89_80_0' id='label_89_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_89_80_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_80' type='radio' value='No'  id='choice_89_80_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_89_80_1' id='label_89_80_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_89_48\" 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_89_48'>How would you describe your gender?<\/label><div class='ginput_container ginput_container_text'><input name='input_48' id='input_89_48' type='text' value='' class='small'    placeholder='Enter gender...'  aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_89_22\" 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_89_22'>Race\/Ethnicity<\/label><div class='ginput_container ginput_container_select'><select name='input_22' id='input_89_22' 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_89_23\" 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_89_23'>Household Income<\/label><div class='ginput_container ginput_container_select'><select name='input_23' id='input_89_23' 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_89_64\" 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_89_64'>\n\t\t\t<div class='gchoice gchoice_89_64_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_64' type='radio' value='I live in the United States'  id='choice_89_64_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_89_64_0' id='label_89_64_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_89_64_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_64' type='radio' value='I live in another country'  id='choice_89_64_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_89_64_1' id='label_89_64_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_89_32\" 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_89_32'>State<\/label><div class='ginput_container ginput_container_select'><select name='input_32' id='input_89_32' 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_89_36\" 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_89_36'>What country do you live in?<\/label><div class='ginput_container ginput_container_select'><select name='input_36' id='input_89_36' 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_89_34\" 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_89_34'>Zip\/Postal Code<\/label><div class='ginput_container ginput_container_text'><input name='input_34' id='input_89_34' type='text' value='' class='small'      aria-invalid=\"false\"   \/><\/div><\/div><fieldset id=\"field_89_28\" 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_89_28'>Select all that apply.<\/div><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox ' id='input_89_28'><div class='gchoice gchoice_89_28_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_28.1' type='checkbox'  value='Veteran or active-duty military'  id='choice_89_28_1'   aria-describedby=\"gfield_description_89_28\"\/>\n\t\t\t\t\t\t\t\t<label for='choice_89_28_1' id='label_89_28_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_89_28_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_28.2' type='checkbox'  value='Caregiver of someone living with emotional or physical illness'  id='choice_89_28_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_89_28_2' id='label_89_28_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_89_28_3'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_28.3' type='checkbox'  value='LGBTQ+'  id='choice_89_28_3'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_89_28_3' id='label_89_28_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_89_28_4'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_28.4' type='checkbox'  value='Student'  id='choice_89_28_4'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_89_28_4' id='label_89_28_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_89_28_5'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_28.5' type='checkbox'  value='Trauma survivor'  id='choice_89_28_5'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_89_28_5' id='label_89_28_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_89_28_6'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_28.6' type='checkbox'  value='New or expecting parent'  id='choice_89_28_6'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_89_28_6' id='label_89_28_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_89_28_7'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_28.7' type='checkbox'  value='Healthcare worker'  id='choice_89_28_7'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_89_28_7' id='label_89_28_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_89_65\" 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_89_65'>\n\t\t\t<div class='gchoice gchoice_89_65_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_65' type='radio' value='Mental health condition'  id='choice_89_65_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_89_65_0' id='label_89_65_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_89_65_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_65' type='radio' value='Physical health condition'  id='choice_89_65_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_89_65_1' id='label_89_65_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_89_65_2'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_65' type='radio' value='Both mental and physical health conditions'  id='choice_89_65_2' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_89_65_2' id='label_89_65_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_89_66\" 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_89_66'>Which of the following best describes your sexual orientation?<\/label><div class='ginput_container ginput_container_select'><select name='input_66' id='input_89_66' 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_89_50\" 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_89_50'>What is your sexual orientation?<\/label><div class='ginput_container ginput_container_text'><input name='input_50' id='input_89_50' type='text' value='' class='small'    placeholder='Enter sexual orientation...'  aria-invalid=\"false\"   \/><\/div><\/div><fieldset id=\"field_89_67\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield--input-type-checkbox gfield--width-full traditional field_sublabel_below gfield--no-description field_description_above 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='ginput_container ginput_container_checkbox'><div class='gfield_checkbox ' id='input_89_67'><div class='gchoice gchoice_89_67_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_67.1' type='checkbox'  value='Child abuse\/violence'  id='choice_89_67_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_89_67_1' id='label_89_67_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_89_67_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_67.2' type='checkbox'  value='Intimate partner violence'  id='choice_89_67_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_89_67_2' id='label_89_67_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_89_67_3'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_67.3' type='checkbox'  value='Sexual assault\/violence'  id='choice_89_67_3'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_89_67_3' id='label_89_67_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_89_67_4'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_67.4' type='checkbox'  value='Serious illness\/injury\/assault'  id='choice_89_67_4'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_89_67_4' id='label_89_67_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_89_67_5'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_67.5' type='checkbox'  value='Family conflict (identity acceptance\/separation\/divorce)'  id='choice_89_67_5'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_89_67_5' id='label_89_67_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_89_67_6'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_67.6' type='checkbox'  value='Traumatic event (natural disaster, accident, witnessing violence, etc.)'  id='choice_89_67_6'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_89_67_6' id='label_89_67_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_89_67_7'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_67.7' type='checkbox'  value='Death of a loved one'  id='choice_89_67_7'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_89_67_7' id='label_89_67_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_89_67_8'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_67.8' type='checkbox'  value='Other and\/or tell us more about your trauma'  id='choice_89_67_8'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_89_67_8' id='label_89_67_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_89_68\" 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_89_68'>Please tell us more about your experience of trauma:<\/label><div class='ginput_container ginput_container_text'><input name='input_68' id='input_89_68' type='text' value='' class='medium'    placeholder='Tell us more...'  aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_89_43\" 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_89_25\" 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_89_25'>\n\t\t\t<div class='gchoice gchoice_89_25_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_25' type='radio' value='Yes'  id='choice_89_25_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_89_25_0' id='label_89_25_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_89_25_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_25' type='radio' value='No'  id='choice_89_25_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_89_25_1' id='label_89_25_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_89_57\" 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_89_57'>\n\t\t\t<div class='gchoice gchoice_89_57_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_57' type='radio' value='Yes'  id='choice_89_57_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_89_57_0' id='label_89_57_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_89_57_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_57' type='radio' value='No'  id='choice_89_57_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_89_57_1' id='label_89_57_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_89_81\" 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_89_81'>Choose up to 3.<\/div><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox ' id='input_89_81'><div class='gchoice gchoice_89_81_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_81.1' type='checkbox'  value='I wanted to handle my mental health on my own'  id='choice_89_81_1'   aria-describedby=\"gfield_description_89_81\"\/>\n\t\t\t\t\t\t\t\t<label for='choice_89_81_1' id='label_89_81_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_89_81_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_81.2' type='checkbox'  value='I didn\u2019t know how or where to start'  id='choice_89_81_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_89_81_2' id='label_89_81_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_89_81_3'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_81.3' type='checkbox'  value='I thought it would cost too much'  id='choice_89_81_3'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_89_81_3' id='label_89_81_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_89_81_4'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_81.4' type='checkbox'  value='I didn\u2019t have time'  id='choice_89_81_4'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_89_81_4' id='label_89_81_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_89_81_5'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_81.5' type='checkbox'  value='I didn\u2019t think it would help me'  id='choice_89_81_5'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_89_81_5' id='label_89_81_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_89_81_6'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_81.6' type='checkbox'  value='I didn&#039;t feel ready to start treatment'  id='choice_89_81_6'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_89_81_6' id='label_89_81_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_89_81_7'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_81.7' type='checkbox'  value='I was worried about what people would think or say if I got treatment'  id='choice_89_81_7'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_89_81_7' id='label_89_81_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_89_81_8'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_81.8' type='checkbox'  value='I was afraid of being forced into a hospital or forced to take medication'  id='choice_89_81_8'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_89_81_8' id='label_89_81_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_89_81_9'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_81.9' type='checkbox'  value='I tried, but couldn\u2019t find available treatment (no openings, wouldn\u2019t take insurance, etc.)'  id='choice_89_81_9'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_89_81_9' id='label_89_81_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_89_81_11'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_81.11' type='checkbox'  value='My parent(s) or guardian wouldn&#039;t let me, or I didn&#039;t want to ask'  id='choice_89_81_11'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_89_81_11' id='label_89_81_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_89_81_12'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_81.12' type='checkbox'  value='Other...'  id='choice_89_81_12'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_89_81_12' id='label_89_81_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_89_82\" 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_89_82'>What else has prevented you from seeking treatment in the past?<\/label><div class='ginput_container ginput_container_text'><input name='input_82' id='input_89_82' type='text' value='' class='medium'    placeholder='Tell us more...'  aria-invalid=\"false\"   \/><\/div><\/div><fieldset id=\"field_89_26\" 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_89_26'>Choose up to 3.<\/div><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox ' id='input_89_26'><div class='gchoice gchoice_89_26_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_26.1' type='checkbox'  value='Abuse or violence'  id='choice_89_26_1'   aria-describedby=\"gfield_description_89_26\"\/>\n\t\t\t\t\t\t\t\t<label for='choice_89_26_1' id='label_89_26_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_89_26_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_26.2' type='checkbox'  value='Relationship problems (friends, family, or significant other)'  id='choice_89_26_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_89_26_2' id='label_89_26_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_89_26_3'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_26.3' type='checkbox'  value='Body image'  id='choice_89_26_3'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_89_26_3' id='label_89_26_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_89_26_4'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_26.4' type='checkbox'  value='Low self-esteem or self-image'  id='choice_89_26_4'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_89_26_4' id='label_89_26_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_89_26_5'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_26.5' type='checkbox'  value='School or work problems'  id='choice_89_26_5'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_89_26_5' id='label_89_26_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_89_26_6'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_26.6' type='checkbox'  value='Financial problems'  id='choice_89_26_6'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_89_26_6' id='label_89_26_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_89_26_7'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_26.7' type='checkbox'  value='Loneliness or isolation'  id='choice_89_26_7'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_89_26_7' id='label_89_26_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_89_26_8'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_26.8' type='checkbox'  value='Grief or loss of someone or something'  id='choice_89_26_8'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_89_26_8' id='label_89_26_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_89_26_9'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_26.9' type='checkbox'  value='Experiencing hate\/bullying (including racism, homophobia, transphobia, or discrimination)'  id='choice_89_26_9'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_89_26_9' id='label_89_26_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_89_26_11'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_26.11' type='checkbox'  value='State of the world (war, climate, politics, immigration)'  id='choice_89_26_11'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_89_26_11' id='label_89_26_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_89_26_12'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_26.12' type='checkbox'  value='I don\u2019t know (something just feels wrong)'  id='choice_89_26_12'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_89_26_12' id='label_89_26_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_89_26_13'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_26.13' type='checkbox'  value='Other...'  id='choice_89_26_13'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_89_26_13' id='label_89_26_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_89_27\" 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_89_27'>What else is contributing to your mental health problems right now?<\/label><div class='ginput_container ginput_container_text'><input name='input_27' id='input_89_27' type='text' value='' class='medium'    placeholder='Tell us more...'  aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_89_74\" 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_89_74'>What about the state of the world is affecting you the most?<\/label><div class='ginput_container ginput_container_text'><input name='input_74' id='input_89_74' type='text' value='' class='medium'    placeholder='Tell us more...'  aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_89_44\" 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_89_29\" 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_89_29'>\n\t\t\t<div class='gchoice gchoice_89_29_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_29' type='radio' value='Yes'  id='choice_89_29_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_89_29_0' id='label_89_29_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_89_29_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_29' type='radio' value='No'  id='choice_89_29_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_89_29_1' id='label_89_29_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_89_29_2'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_29' type='radio' value='I don&#039;t know'  id='choice_89_29_2' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_89_29_2' id='label_89_29_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_89_30\" 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_89_30'>Select all that apply.<\/div><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox ' id='input_89_30'><div class='gchoice gchoice_89_30_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_30.1' type='checkbox'  value='Heart disease'  id='choice_89_30_1'   aria-describedby=\"gfield_description_89_30\"\/>\n\t\t\t\t\t\t\t\t<label for='choice_89_30_1' id='label_89_30_1' class='gform-field-label gform-field-label--type-inline'>Heart disease<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_89_30_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_30.2' type='checkbox'  value='Reproductive health concerns (PCOS, endometriosis, infertility, etc.)'  id='choice_89_30_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_89_30_2' id='label_89_30_2' class='gform-field-label gform-field-label--type-inline'>Reproductive health concerns (PCOS, endometriosis, infertility, etc.)<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_89_30_3'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_30.3' type='checkbox'  value='Diabetes'  id='choice_89_30_3'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_89_30_3' id='label_89_30_3' class='gform-field-label gform-field-label--type-inline'>Diabetes<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_89_30_4'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_30.4' type='checkbox'  value='Cancer'  id='choice_89_30_4'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_89_30_4' id='label_89_30_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_89_30_5'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_30.5' type='checkbox'  value='Arthritis or other chronic pain'  id='choice_89_30_5'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_89_30_5' id='label_89_30_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_89_30_6'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_30.6' type='checkbox'  value='Asthma, COPD or other lung conditions'  id='choice_89_30_6'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_89_30_6' id='label_89_30_6' class='gform-field-label gform-field-label--type-inline'>Asthma, COPD or other lung conditions<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_89_30_7'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_30.7' type='checkbox'  value='Movement Disorders (involuntary tics, tardive dyskinesia, etc.)'  id='choice_89_30_7'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_89_30_7' id='label_89_30_7' class='gform-field-label gform-field-label--type-inline'>Movement Disorders (involuntary tics, tardive dyskinesia, etc.)<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_89_30_8'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_30.8' type='checkbox'  value='Digestive problems (Crohn\u2019s, colitis, IBS, etc.)'  id='choice_89_30_8'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_89_30_8' id='label_89_30_8' class='gform-field-label gform-field-label--type-inline'>Digestive problems (Crohn\u2019s, colitis, IBS, etc.)<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_89_30_9'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_30.9' type='checkbox'  value='Neurological conditions (epilepsy, etc.) or traumatic brain injury (TBI)'  id='choice_89_30_9'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_89_30_9' id='label_89_30_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_89_30_11'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_30.11' type='checkbox'  value='Other...'  id='choice_89_30_11'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_89_30_11' id='label_89_30_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_89_31\" 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_89_31'>What other physical health conditions do you have?<\/label><div class='ginput_container ginput_container_text'><input name='input_31' id='input_89_31' type='text' value='' class='large'    placeholder='Tell us more...'  aria-invalid=\"false\"   \/><\/div><\/div><fieldset id=\"field_89_75\" 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_89_75'>\n\t\t\t<div class='gchoice gchoice_89_75_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_75' type='radio' value='Yes'  id='choice_89_75_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_89_75_0' id='label_89_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_89_75_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_75' type='radio' value='No'  id='choice_89_75_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_89_75_1' id='label_89_75_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_89_76\" 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_89_76'>\n\t\t\t<div class='gchoice gchoice_89_76_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_76' type='radio' value='Yes'  id='choice_89_76_0' 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(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. Mental Health America Inc., sponsors, partners, and advertisers disclaim any liability, loss, or risk incurred as a consequence, directly or indirectly, from the use and application of these screens.<\/em><\/p>\n<\/div>\n","protected":false},"excerpt":{"rendered":"<p>&nbsp; Fuente: Moyer et al. (2023). Desarrollo de la Escala de Depresi\u00f3n Posparto de Edimburgo-Estados Unidos: una herramienta actualizada de detecci\u00f3n de la salud mental perinatal que utiliza un enfoque respetuoso y basado en el trauma. Revista de Salud de la Mujer, 32(10), pp. 1080-1085. Cox et al. (1987). Detecci\u00f3n de la depresi\u00f3n posparto: desarrollo de la Escala de Depresi\u00f3n Posparto de Edimburgo de 10 \u00edtems. 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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_88_38' type='hidden' class='gform_hidden'  aria-invalid=\"false\" value='' \/><\/div><\/div><div id=\"field_88_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_88_39\" type=\"hidden\" class=\"gform_hidden\" aria-invalid=\"false\" value=\"251896\"><\/div><div id=\"field_88_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_88_40\" type=\"hidden\" class=\"gform_hidden\" aria-invalid=\"false\" value=\"34c0972926eed1ef42815dc87b83c969\"><\/div><div id=\"field_88_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_88_41' type='hidden' class='gform_hidden'  aria-invalid=\"false\" value='' \/><\/div><\/div><div id=\"field_88_54\" 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_54' id='input_88_54' type='hidden' class='gform_hidden'  aria-invalid=\"false\" value='http:\/\/screening.mhanational.org\/es\/wp-json\/wp\/v2\/screen' \/><\/div><\/div><div id=\"field_88_84\" 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_84' id='input_88_84' type='hidden' class='gform_hidden'  aria-invalid=\"false\" value='' \/><\/div><\/div><div id=\"field_88_85\" 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_85' id='input_88_85' type='hidden' class='gform_hidden'  aria-invalid=\"false\" value='' \/><\/div><\/div><div id=\"field_88_86\" 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_86' id='input_88_86' type='hidden' class='gform_hidden'  aria-invalid=\"false\" value='' \/><\/div><\/div><div id=\"field_88_96\" 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_96' id='input_88_96' type='hidden' class='gform_hidden'  aria-invalid=\"false\" value='' \/><\/div><\/div><div id=\"field_88_97\" 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_97' id='input_88_97' type='hidden' class='gform_hidden'  aria-invalid=\"false\" value='https:\/\/screening.mhanational.org\/es\/wp-json\/wp\/v2\/screen' \/><\/div><\/div><div id=\"field_88_144\" class=\"gfield gfield--type-hidden gfield--input-type-hidden gfield--width-full gform_hidden field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><div class='ginput_container ginput_container_text'><input name='input_144' id='input_88_144' type='hidden' class='gform_hidden'  aria-invalid=\"false\" value='lang--es' \/><\/div><\/div><div id=\"field_88_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\"  ><p>\nThe following questions ask about thoughts, feelings, and behaviors that you may have had about <strong>social situations<\/strong>. Usual social situations include:\n<\/p>\n<ul>\n<li>\npublic speaking\n<\/li><li>\nspeaking in meetings\n<\/li><li>\nattending social events or parties\n<\/li><li>\nintroducing yourself to others\n<\/li><li>\nhaving conversations\n<\/li><li>\ngiving and receiving compliments\n<\/li><li>\nmaking requests of others\n<\/li><li>\neating and writing in public\n<\/li><\/ul>\n\n<p>Please note, all questions are required.<\/p><\/div><div id=\"field_88_113\" 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 \/>\nWe're testing different ways to ask people about their social anxiety symptoms.<\/div><fieldset id=\"field_88_114\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-full field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >Can you help us answer 2 extra questions about your experiences over different periods of time (7 days vs. 3 months)?<\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_88_114'>\n\t\t\t<div class='gchoice gchoice_88_114_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_114' type='radio' value='Yes'  id='choice_88_114_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_88_114_0' id='label_88_114_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_88_114_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_114' type='radio' value='No'  id='choice_88_114_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_88_114_1' id='label_88_114_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_88_115\" class=\"gfield gfield--type-html gfield--input-type-html gfield--width-full gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  >Thank you for your help!<\/div><div id=\"field_88_116\" class=\"gfield gfield--type-html gfield--input-type-html gfield--width-full gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  >Okay! You will only see the normal questions we always ask.<\/div><div id=\"field_88_117\" 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_88_98\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' ><strong>In the last three months<\/strong>, have you often felt very nervous or uncomfortable when you have been with a group of people (like at lunch or at a party)?<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_88_98'>\n\t\t\t<div class='gchoice gchoice_88_98_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_98' type='radio' value='Yes'  id='choice_88_98_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_88_98_0' id='label_88_98_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_88_98_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_98' type='radio' value='No'  id='choice_88_98_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_88_98_1' id='label_88_98_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_88_134\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' ><strong>In the last three months<\/strong>, have you often felt very nervous when you've had to do things in front of people?<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_88_134'>\n\t\t\t<div class='gchoice gchoice_88_134_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_134' type='radio' value='Yes'  id='choice_88_134_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_88_134_0' id='label_88_134_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_88_134_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_134' type='radio' value='No'  id='choice_88_134_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_88_134_1' id='label_88_134_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_88_122\" class=\"gfield gfield--type-html gfield--input-type-html gfield--width-full gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><hr \/><\/div><div id=\"field_88_123\" class=\"gfield gfield--type-html gfield--input-type-html gfield--width-full 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>During the past 7 days, I have...<\/h2><\/div><fieldset id=\"field_88_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' >1. Felt moments of sudden terror, fear, or fright in social 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_88_47'>\n\t\t\t<div class='gchoice gchoice_88_47_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_47' type='radio' value='0'  id='choice_88_47_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_88_47_0' id='label_88_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_88_47_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_47' type='radio' value='1'  id='choice_88_47_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_88_47_1' id='label_88_47_1' class='gform-field-label gform-field-label--type-inline'>Occasionally<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_88_47_2'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_47' type='radio' value='2'  id='choice_88_47_2' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_88_47_2' id='label_88_47_2' class='gform-field-label gform-field-label--type-inline'>Half of the time<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_88_47_3'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_47' type='radio' value='3'  id='choice_88_47_3' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_88_47_3' id='label_88_47_3' class='gform-field-label gform-field-label--type-inline'>Most of the time<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_88_47_4'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_47' type='radio' value='4'  id='choice_88_47_4' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_88_47_4' id='label_88_47_4' class='gform-field-label gform-field-label--type-inline'>All of the time<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_88_131\" 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' >2. Felt anxious, worried, or nervous about social 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_88_131'>\n\t\t\t<div class='gchoice gchoice_88_131_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_131' type='radio' value='0'  id='choice_88_131_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_88_131_0' id='label_88_131_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_88_131_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_131' type='radio' value='1'  id='choice_88_131_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_88_131_1' id='label_88_131_1' class='gform-field-label gform-field-label--type-inline'>Occasionally<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_88_131_2'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_131' type='radio' value='2'  id='choice_88_131_2' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_88_131_2' id='label_88_131_2' class='gform-field-label gform-field-label--type-inline'>Half of the time<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_88_131_3'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_131' type='radio' value='3'  id='choice_88_131_3' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_88_131_3' id='label_88_131_3' class='gform-field-label gform-field-label--type-inline'>Most of the time<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_88_131_4'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_131' type='radio' value='4'  id='choice_88_131_4' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_88_131_4' id='label_88_131_4' class='gform-field-label gform-field-label--type-inline'>All of the time<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_88_130\" 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. Have had thoughts of being rejected, humiliated, embarrassed, ridiculed, or offending 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_88_130'>\n\t\t\t<div class='gchoice gchoice_88_130_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_130' type='radio' value='0'  id='choice_88_130_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_88_130_0' id='label_88_130_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_88_130_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_130' type='radio' value='1'  id='choice_88_130_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_88_130_1' id='label_88_130_1' class='gform-field-label gform-field-label--type-inline'>Occasionally<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_88_130_2'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_130' type='radio' value='2'  id='choice_88_130_2' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_88_130_2' id='label_88_130_2' class='gform-field-label gform-field-label--type-inline'>Half of the time<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_88_130_3'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_130' type='radio' value='3'  id='choice_88_130_3' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_88_130_3' id='label_88_130_3' class='gform-field-label gform-field-label--type-inline'>Most of the time<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_88_130_4'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_130' type='radio' value='4'  id='choice_88_130_4' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_88_130_4' id='label_88_130_4' class='gform-field-label gform-field-label--type-inline'>All of the time<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_88_129\" 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. Felt a racing heart, sweaty, trouble breathing, faint, or shaky in social 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_88_129'>\n\t\t\t<div class='gchoice gchoice_88_129_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_129' type='radio' value='0'  id='choice_88_129_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_88_129_0' id='label_88_129_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_88_129_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_129' type='radio' value='1'  id='choice_88_129_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_88_129_1' id='label_88_129_1' class='gform-field-label gform-field-label--type-inline'>Occasionally<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_88_129_2'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_129' type='radio' value='2'  id='choice_88_129_2' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_88_129_2' id='label_88_129_2' class='gform-field-label gform-field-label--type-inline'>Half of the time<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_88_129_3'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_129' type='radio' value='3'  id='choice_88_129_3' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_88_129_3' id='label_88_129_3' class='gform-field-label gform-field-label--type-inline'>Most of the time<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_88_129_4'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_129' type='radio' value='4'  id='choice_88_129_4' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_88_129_4' id='label_88_129_4' class='gform-field-label gform-field-label--type-inline'>All of the time<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_88_128\" 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. Felt tense muscles, felt on edge or restless, or had trouble relaxing in social 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_88_128'>\n\t\t\t<div class='gchoice gchoice_88_128_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_128' type='radio' value='0'  id='choice_88_128_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_88_128_0' id='label_88_128_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_88_128_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_128' type='radio' value='1'  id='choice_88_128_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_88_128_1' id='label_88_128_1' class='gform-field-label gform-field-label--type-inline'>Occasionally<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_88_128_2'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_128' type='radio' value='2'  id='choice_88_128_2' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_88_128_2' id='label_88_128_2' class='gform-field-label gform-field-label--type-inline'>Half of the time<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_88_128_3'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_128' type='radio' value='3'  id='choice_88_128_3' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_88_128_3' id='label_88_128_3' class='gform-field-label gform-field-label--type-inline'>Most of the time<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_88_128_4'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_128' type='radio' value='4'  id='choice_88_128_4' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_88_128_4' id='label_88_128_4' class='gform-field-label gform-field-label--type-inline'>All of the time<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_88_127\" 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' >6. Avoided, or did not approach or enter, social 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_88_127'>\n\t\t\t<div class='gchoice gchoice_88_127_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_127' type='radio' value='0'  id='choice_88_127_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_88_127_0' id='label_88_127_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_88_127_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_127' type='radio' value='1'  id='choice_88_127_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_88_127_1' id='label_88_127_1' class='gform-field-label gform-field-label--type-inline'>Occasionally<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_88_127_2'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_127' type='radio' value='2'  id='choice_88_127_2' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_88_127_2' id='label_88_127_2' class='gform-field-label gform-field-label--type-inline'>Half of the time<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_88_127_3'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_127' type='radio' value='3'  id='choice_88_127_3' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_88_127_3' id='label_88_127_3' class='gform-field-label gform-field-label--type-inline'>Most of the time<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_88_127_4'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_127' type='radio' value='4'  id='choice_88_127_4' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_88_127_4' id='label_88_127_4' class='gform-field-label gform-field-label--type-inline'>All of the time<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_88_126\" 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' >7. Left social situations early or participated only minimally (e.g., said little, avoided eye contact)<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_88_126'>\n\t\t\t<div class='gchoice gchoice_88_126_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_126' type='radio' value='0'  id='choice_88_126_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_88_126_0' id='label_88_126_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_88_126_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_126' type='radio' value='1'  id='choice_88_126_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_88_126_1' id='label_88_126_1' class='gform-field-label gform-field-label--type-inline'>Occasionally<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_88_126_2'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_126' type='radio' value='2'  id='choice_88_126_2' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_88_126_2' id='label_88_126_2' class='gform-field-label gform-field-label--type-inline'>Half of the time<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_88_126_3'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_126' type='radio' value='3'  id='choice_88_126_3' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_88_126_3' id='label_88_126_3' class='gform-field-label gform-field-label--type-inline'>Most of the time<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_88_126_4'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_126' type='radio' value='4'  id='choice_88_126_4' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_88_126_4' id='label_88_126_4' class='gform-field-label gform-field-label--type-inline'>All of the time<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_88_125\" 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. Spent a lot of time preparing what to say or how to act in social 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_88_125'>\n\t\t\t<div class='gchoice gchoice_88_125_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_125' type='radio' value='0'  id='choice_88_125_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_88_125_0' id='label_88_125_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_88_125_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_125' type='radio' value='1'  id='choice_88_125_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_88_125_1' id='label_88_125_1' class='gform-field-label gform-field-label--type-inline'>Occasionally<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_88_125_2'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_125' type='radio' value='2'  id='choice_88_125_2' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_88_125_2' id='label_88_125_2' class='gform-field-label gform-field-label--type-inline'>Half of the time<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_88_125_3'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_125' type='radio' value='3'  id='choice_88_125_3' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_88_125_3' id='label_88_125_3' class='gform-field-label gform-field-label--type-inline'>Most of the time<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_88_125_4'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_125' type='radio' value='4'  id='choice_88_125_4' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_88_125_4' id='label_88_125_4' class='gform-field-label gform-field-label--type-inline'>All of the time<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_88_124\" 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. Distracted myself to avoid thinking about social 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_88_124'>\n\t\t\t<div class='gchoice gchoice_88_124_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_124' type='radio' value='0'  id='choice_88_124_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_88_124_0' id='label_88_124_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_88_124_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_124' type='radio' value='1'  id='choice_88_124_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_88_124_1' id='label_88_124_1' class='gform-field-label gform-field-label--type-inline'>Occasionally<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_88_124_2'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_124' type='radio' value='2'  id='choice_88_124_2' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_88_124_2' id='label_88_124_2' class='gform-field-label gform-field-label--type-inline'>Half of the time<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_88_124_3'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_124' type='radio' value='3'  id='choice_88_124_3' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_88_124_3' id='label_88_124_3' class='gform-field-label gform-field-label--type-inline'>Most of the time<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_88_124_4'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_124' type='radio' value='4'  id='choice_88_124_4' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_88_124_4' id='label_88_124_4' class='gform-field-label gform-field-label--type-inline'>All of the time<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_88_133\" 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' >10. Needed help to cope with social situations (e.g., alcohol or medications, superstitious objects)<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_88_133'>\n\t\t\t<div class='gchoice gchoice_88_133_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_133' type='radio' value='0'  id='choice_88_133_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_88_133_0' id='label_88_133_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_88_133_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_133' type='radio' value='1'  id='choice_88_133_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_88_133_1' id='label_88_133_1' class='gform-field-label gform-field-label--type-inline'>Occasionally<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_88_133_2'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_133' type='radio' value='2'  id='choice_88_133_2' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_88_133_2' id='label_88_133_2' class='gform-field-label gform-field-label--type-inline'>Half of the time<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_88_133_3'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_133' type='radio' value='3'  id='choice_88_133_3' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_88_133_3' id='label_88_133_3' class='gform-field-label gform-field-label--type-inline'>Most of the time<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_88_133_4'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_133' type='radio' value='4'  id='choice_88_133_4' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_88_133_4' id='label_88_133_4' class='gform-field-label gform-field-label--type-inline'>All of the time<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_88_121\" 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_88_135\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' ><strong>In the last three months<\/strong>, have you often felt very nervous or uncomfortable when you have been with a group of people (like at lunch or at a party)?<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_88_135'>\n\t\t\t<div class='gchoice gchoice_88_135_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_135' type='radio' value='Yes'  id='choice_88_135_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_88_135_0' id='label_88_135_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_88_135_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_135' type='radio' value='No'  id='choice_88_135_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_88_135_1' id='label_88_135_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_88_136\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' ><strong>In the last three months<\/strong>, have you often felt very nervous when you've had to do things in front of people?<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_88_136'>\n\t\t\t<div class='gchoice gchoice_88_136_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_136' type='radio' value='Yes'  id='choice_88_136_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_88_136_0' id='label_88_136_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_88_136_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_136' type='radio' value='No'  id='choice_88_136_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_88_136_1' id='label_88_136_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_88_139\" class=\"gfield gfield--type-html gfield--input-type-html gfield--width-full gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><hr \/><\/div><div id=\"field_88_140\" 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_88_140'>Optional: What is most distressing to you about the social anxiety symptoms you&#039;ve been experiencing?<\/label><div class='ginput_container ginput_container_text'><input name='input_140' id='input_88_140' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/div><\/div>\n                    <\/div>\n                    <div class='gform-page-footer gform_page_footer top_label'>\n                         <input type='button' id='gform_next_button_88_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_88_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_88_2' class='gform_fields top_label form_sublabel_below description_above validation_below'><div id=\"field_88_55\" 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_88_87\" 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_88_88\" 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_88_88'>\n\t\t\t<div class='gchoice gchoice_88_88_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_88' type='radio' value='For myself'  id='choice_88_88_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_88_88_0' id='label_88_88_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_88_88_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_88' type='radio' value='For someone else'  id='choice_88_88_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_88_88_1' id='label_88_88_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_88_89\" 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_88_56\" 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_88_57\" 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_88_57'>Age Range<\/label><div class='ginput_container ginput_container_select'><select name='input_57' id='input_88_57' 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_88_58\" 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_88_58'>\n\t\t\t<div class='gchoice gchoice_88_58_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_58' type='radio' value='Female'  id='choice_88_58_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_88_58_0' id='label_88_58_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_88_58_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_58' type='radio' value='Male'  id='choice_88_58_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_88_58_1' id='label_88_58_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_88_58_2'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_58' type='radio' value='Non-Binary'  id='choice_88_58_2' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_88_58_2' id='label_88_58_2' class='gform-field-label gform-field-label--type-inline'>Non-Binary<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_88_141\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-full field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >Do you identify as transgender?<\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_88_141'>\n\t\t\t<div class='gchoice gchoice_88_141_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_141' type='radio' value='Yes'  id='choice_88_141_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_88_141_0' id='label_88_141_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_88_141_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_141' type='radio' value='No'  id='choice_88_141_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_88_141_1' id='label_88_141_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_88_59\" 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_88_59'>How would you describe your gender?<\/label><div class='ginput_container ginput_container_text'><input name='input_59' id='input_88_59' type='text' value='' class='small'    placeholder='Enter gender...'  aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_88_61\" 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_88_61'>Race\/Ethnicity<\/label><div class='ginput_container ginput_container_select'><select name='input_61' id='input_88_61' 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_88_62\" 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_88_62'>Household Income<\/label><div class='ginput_container ginput_container_select'><select name='input_62' id='input_88_62' 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_88_90\" 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_88_90'>\n\t\t\t<div class='gchoice gchoice_88_90_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_90' type='radio' value='I live in the United States'  id='choice_88_90_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_88_90_0' id='label_88_90_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_88_90_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_90' type='radio' value='I live in another country'  id='choice_88_90_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_88_90_1' id='label_88_90_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_88_81\" 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_88_81'>State<\/label><div class='ginput_container ginput_container_select'><select name='input_81' id='input_88_81' 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_88_83\" 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_88_83'>What country do you live in?<\/label><div class='ginput_container ginput_container_select'><select name='input_83' id='input_88_83' 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_88_82\" 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_88_82'>Zip\/Postal Code<\/label><div class='ginput_container ginput_container_text'><input name='input_82' id='input_88_82' type='text' value='' class='small'      aria-invalid=\"false\"   \/><\/div><\/div><fieldset id=\"field_88_63\" 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_88_63'>Select all that apply.<\/div><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox ' id='input_88_63'><div class='gchoice gchoice_88_63_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_63.1' type='checkbox'  value='Veteran or active-duty military'  id='choice_88_63_1'   aria-describedby=\"gfield_description_88_63\"\/>\n\t\t\t\t\t\t\t\t<label for='choice_88_63_1' id='label_88_63_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_88_63_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_63.2' type='checkbox'  value='Caregiver of someone living with emotional or physical illness'  id='choice_88_63_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_88_63_2' id='label_88_63_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_88_63_3'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_63.3' type='checkbox'  value='LGBTQ+'  id='choice_88_63_3'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_88_63_3' id='label_88_63_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_88_63_4'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_63.4' type='checkbox'  value='Student'  id='choice_88_63_4'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_88_63_4' id='label_88_63_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_88_63_5'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_63.5' type='checkbox'  value='Trauma survivor'  id='choice_88_63_5'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_88_63_5' id='label_88_63_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_88_63_6'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_63.6' type='checkbox'  value='New or expecting parent'  id='choice_88_63_6'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_88_63_6' id='label_88_63_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_88_63_7'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_63.7' type='checkbox'  value='Healthcare worker'  id='choice_88_63_7'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_88_63_7' id='label_88_63_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_88_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_88_94'>\n\t\t\t<div class='gchoice gchoice_88_94_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_94' type='radio' value='Mental health condition'  id='choice_88_94_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_88_94_0' id='label_88_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_88_94_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_94' type='radio' value='Physical health condition'  id='choice_88_94_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_88_94_1' id='label_88_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_88_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_88_94_2' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_88_94_2' id='label_88_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_88_91\" 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_88_91'>Which of the following best describes your sexual orientation?<\/label><div class='ginput_container ginput_container_select'><select name='input_91' id='input_88_91' 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_88_69\" 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_88_69'>What is your sexual orientation?<\/label><div class='ginput_container ginput_container_text'><input name='input_69' id='input_88_69' type='text' value='' class='small'    placeholder='Enter sexual orientation...'  aria-invalid=\"false\"   \/><\/div><\/div><fieldset id=\"field_88_92\" 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_88_92'>Select all that apply.<\/div><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox ' id='input_88_92'><div class='gchoice gchoice_88_92_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_92.1' type='checkbox'  value='Child abuse\/violence'  id='choice_88_92_1'   aria-describedby=\"gfield_description_88_92\"\/>\n\t\t\t\t\t\t\t\t<label for='choice_88_92_1' id='label_88_92_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_88_92_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_92.2' type='checkbox'  value='Intimate partner violence'  id='choice_88_92_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_88_92_2' id='label_88_92_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_88_92_3'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_92.3' type='checkbox'  value='Sexual assault\/violence'  id='choice_88_92_3'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_88_92_3' id='label_88_92_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_88_92_4'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_92.4' type='checkbox'  value='Serious illness\/injury\/assault'  id='choice_88_92_4'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_88_92_4' id='label_88_92_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_88_92_5'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_92.5' type='checkbox'  value='Family conflict (identity acceptance\/separation\/divorce)'  id='choice_88_92_5'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_88_92_5' id='label_88_92_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_88_92_6'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_92.6' type='checkbox'  value='Traumatic event (natural disaster, accident, witnessing violence, etc.)'  id='choice_88_92_6'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_88_92_6' id='label_88_92_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_88_92_7'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_92.7' type='checkbox'  value='Death of a loved one'  id='choice_88_92_7'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_88_92_7' id='label_88_92_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_88_92_8'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_92.8' type='checkbox'  value='Other and\/or tell us more about your trauma'  id='choice_88_92_8'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_88_92_8' id='label_88_92_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_88_93\" 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_88_93'>Please tell us more about your experience of trauma:<\/label><div class='ginput_container ginput_container_text'><input name='input_93' id='input_88_93' type='text' value='' class='medium'    placeholder='Tell us more...'  aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_88_70\" 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_88_72\" 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_88_72'>\n\t\t\t<div class='gchoice gchoice_88_72_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_72' type='radio' value='Yes'  id='choice_88_72_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_88_72_0' id='label_88_72_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_88_72_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_72' type='radio' value='No'  id='choice_88_72_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_88_72_1' id='label_88_72_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_88_73\" 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_88_73'>\n\t\t\t<div class='gchoice gchoice_88_73_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_73' type='radio' value='Yes'  id='choice_88_73_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_88_73_0' id='label_88_73_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_88_73_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_73' type='radio' value='No'  id='choice_88_73_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_88_73_1' id='label_88_73_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_88_142\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield--input-type-checkbox gfield--width-full optional traditional limit-3 field_sublabel_below gfield--has-description field_description_above field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' >What has prevented you from seeking treatment in the past?<\/legend><div class='gfield_description' id='gfield_description_88_142'>Choose up to 3.<\/div><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox ' id='input_88_142'><div class='gchoice gchoice_88_142_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_142.1' type='checkbox'  value='I wanted to handle my mental health on my own'  id='choice_88_142_1'   aria-describedby=\"gfield_description_88_142\"\/>\n\t\t\t\t\t\t\t\t<label for='choice_88_142_1' id='label_88_142_1' class='gform-field-label gform-field-label--type-inline'>I wanted to handle my mental health on my own<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_88_142_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_142.2' type='checkbox'  value='I didn\u2019t know how or where to start'  id='choice_88_142_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_88_142_2' id='label_88_142_2' class='gform-field-label gform-field-label--type-inline'>I didn\u2019t know how or where to start<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_88_142_3'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_142.3' type='checkbox'  value='I thought it would cost too much'  id='choice_88_142_3'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_88_142_3' id='label_88_142_3' class='gform-field-label gform-field-label--type-inline'>I thought it would cost too much<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_88_142_4'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_142.4' type='checkbox'  value='I didn\u2019t have time'  id='choice_88_142_4'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_88_142_4' id='label_88_142_4' class='gform-field-label gform-field-label--type-inline'>I didn\u2019t have time<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_88_142_5'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_142.5' type='checkbox'  value='I didn\u2019t think it would help me'  id='choice_88_142_5'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_88_142_5' id='label_88_142_5' class='gform-field-label gform-field-label--type-inline'>I didn\u2019t think it would help me<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_88_142_6'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_142.6' type='checkbox'  value='I didn&#039;t feel ready to start treatment'  id='choice_88_142_6'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_88_142_6' id='label_88_142_6' class='gform-field-label gform-field-label--type-inline'>I didn't feel ready to start treatment<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_88_142_7'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_142.7' type='checkbox'  value='I was worried about what people would think or say if I got treatment'  id='choice_88_142_7'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_88_142_7' id='label_88_142_7' class='gform-field-label gform-field-label--type-inline'>I was worried about what people would think or say if I got treatment<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_88_142_8'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_142.8' type='checkbox'  value='I was afraid of being forced into a hospital or forced to take medication'  id='choice_88_142_8'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_88_142_8' id='label_88_142_8' class='gform-field-label gform-field-label--type-inline'>I was afraid of being forced into a hospital or forced to take medication<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_88_142_9'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_142.9' type='checkbox'  value='I tried, but couldn\u2019t find available treatment (no openings, wouldn\u2019t take insurance, etc.)'  id='choice_88_142_9'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_88_142_9' id='label_88_142_9' class='gform-field-label gform-field-label--type-inline'>I tried, but couldn\u2019t find available treatment (no openings, wouldn\u2019t take insurance, etc.)<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_88_142_11'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_142.11' type='checkbox'  value='My parent(s) or guardian wouldn&#039;t let me, or I didn&#039;t want to ask'  id='choice_88_142_11'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_88_142_11' id='label_88_142_11' class='gform-field-label gform-field-label--type-inline'>My parent(s) or guardian wouldn't let me, or I didn't want to ask<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_88_142_12'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_142.12' type='checkbox'  value='Other...'  id='choice_88_142_12'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_88_142_12' id='label_88_142_12' class='gform-field-label gform-field-label--type-inline'>Other...<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_88_143\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-full optional field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_88_143'>What else has prevented you from seeking treatment in the past?<\/label><div class='ginput_container ginput_container_text'><input name='input_143' id='input_88_143' type='text' value='' class='medium'    placeholder='Tell us more...'  aria-invalid=\"false\"   \/><\/div><\/div><fieldset id=\"field_88_74\" 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_88_74'>Choose up to 3.<\/div><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox ' id='input_88_74'><div class='gchoice gchoice_88_74_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_74.1' type='checkbox'  value='Abuse or violence'  id='choice_88_74_1'   aria-describedby=\"gfield_description_88_74\"\/>\n\t\t\t\t\t\t\t\t<label for='choice_88_74_1' id='label_88_74_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_88_74_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_74.2' type='checkbox'  value='Relationship problems (friends, family, or significant other)'  id='choice_88_74_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_88_74_2' id='label_88_74_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_88_74_3'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_74.3' type='checkbox'  value='Body image'  id='choice_88_74_3'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_88_74_3' id='label_88_74_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_88_74_4'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_74.4' type='checkbox'  value='Low self-esteem or self-image'  id='choice_88_74_4'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_88_74_4' id='label_88_74_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_88_74_5'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_74.5' type='checkbox'  value='School or work problems'  id='choice_88_74_5'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_88_74_5' id='label_88_74_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_88_74_6'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_74.6' type='checkbox'  value='Financial problems'  id='choice_88_74_6'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_88_74_6' id='label_88_74_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_88_74_7'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_74.7' type='checkbox'  value='Loneliness or isolation'  id='choice_88_74_7'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_88_74_7' id='label_88_74_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_88_74_8'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_74.8' type='checkbox'  value='Grief or loss of someone or something'  id='choice_88_74_8'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_88_74_8' id='label_88_74_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_88_74_9'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_74.9' type='checkbox'  value='Experiencing hate\/bullying (including racism, homophobia, transphobia, or discrimination)'  id='choice_88_74_9'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_88_74_9' id='label_88_74_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_88_74_11'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_74.11' type='checkbox'  value='State of the world (war, climate, politics, immigration)'  id='choice_88_74_11'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_88_74_11' id='label_88_74_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_88_74_12'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_74.12' type='checkbox'  value='I don\u2019t know (something just feels wrong)'  id='choice_88_74_12'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_88_74_12' id='label_88_74_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_88_74_13'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_74.13' type='checkbox'  value='Other...'  id='choice_88_74_13'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_88_74_13' id='label_88_74_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_88_75\" 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_88_75'>What else is contributing to your mental health problems right now?<\/label><div class='ginput_container ginput_container_text'><input name='input_75' id='input_88_75' type='text' value='' class='medium'    placeholder='Tell us more...'  aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_88_95\" 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_88_95'>What about the state of the world is affecting you the most?<\/label><div class='ginput_container ginput_container_text'><input name='input_95' id='input_88_95' type='text' value='' class='medium'    placeholder='Tell us more...'  aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_88_76\" 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_88_77\" 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_88_77'>\n\t\t\t<div class='gchoice gchoice_88_77_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_77' type='radio' value='Yes'  id='choice_88_77_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_88_77_0' id='label_88_77_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_88_77_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_77' type='radio' value='No'  id='choice_88_77_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_88_77_1' id='label_88_77_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_88_77_2'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_77' type='radio' value='I don&#039;t know'  id='choice_88_77_2' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_88_77_2' id='label_88_77_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_88_78\" 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_88_78'>Select all that apply.<\/div><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox ' id='input_88_78'><div class='gchoice gchoice_88_78_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_78.1' type='checkbox'  value='Heart disease'  id='choice_88_78_1'   aria-describedby=\"gfield_description_88_78\"\/>\n\t\t\t\t\t\t\t\t<label for='choice_88_78_1' id='label_88_78_1' class='gform-field-label gform-field-label--type-inline'>Heart disease<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_88_78_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_78.2' type='checkbox'  value='Reproductive health concerns (PCOS, endometriosis, infertility, etc.)'  id='choice_88_78_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_88_78_2' id='label_88_78_2' class='gform-field-label gform-field-label--type-inline'>Reproductive health concerns (PCOS, endometriosis, infertility, etc.)<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_88_78_3'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_78.3' type='checkbox'  value='Diabetes'  id='choice_88_78_3'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_88_78_3' id='label_88_78_3' class='gform-field-label gform-field-label--type-inline'>Diabetes<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_88_78_4'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_78.4' type='checkbox'  value='Cancer'  id='choice_88_78_4'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_88_78_4' id='label_88_78_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_88_78_5'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_78.5' type='checkbox'  value='Arthritis or other chronic pain'  id='choice_88_78_5'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_88_78_5' id='label_88_78_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_88_78_6'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_78.6' type='checkbox'  value='Asthma, COPD or other lung conditions'  id='choice_88_78_6'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_88_78_6' id='label_88_78_6' class='gform-field-label gform-field-label--type-inline'>Asthma, COPD or other lung conditions<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_88_78_7'>\n\t\t\t\t\t\t\t\t<input 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T., et al. (2012). A dimensional approach to measuring anxiety for DSM-5. <i>International journal of methods in psychiatric research<\/i>\u00a0<i>21<\/i>(4), 258\u2013272. Retrieved from <a href=\"https:\/\/doi.org\/10.1002\/mpr.1369\">https:\/\/doi.org\/10.1002\/mpr.1369<\/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. 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Thank you for participating!<\/p><\/div><div id=\"field_87_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_87_38' type='hidden' class='gform_hidden'  aria-invalid=\"false\" value='' \/><\/div><\/div><div id=\"field_87_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_87_39\" type=\"hidden\" class=\"gform_hidden\" aria-invalid=\"false\" value=\"251583\"><\/div><div id=\"field_87_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_87_40\" type=\"hidden\" class=\"gform_hidden\" aria-invalid=\"false\" value=\"34c0972926eed1ef42815dc87b83c969\"><\/div><div id=\"field_87_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_87_41' type='hidden' class='gform_hidden'  aria-invalid=\"false\" value='' \/><\/div><\/div><div id=\"field_87_51\" class=\"gfield gfield--type-hidden gfield--input-type-hidden gform_hidden field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><div class='ginput_container ginput_container_text'><input name='input_51' id='input_87_51' type='hidden' class='gform_hidden'  aria-invalid=\"false\" value='http:\/\/screening.mhanational.org\/es\/wp-json\/wp\/v2\/screen' \/><\/div><\/div><div id=\"field_87_81\" class=\"gfield gfield--type-hidden gfield--input-type-hidden gform_hidden field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><div class='ginput_container ginput_container_text'><input name='input_81' id='input_87_81' type='hidden' class='gform_hidden'  aria-invalid=\"false\" value='' \/><\/div><\/div><div id=\"field_87_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_87_82' type='hidden' class='gform_hidden'  aria-invalid=\"false\" value='' \/><\/div><\/div><div id=\"field_87_83\" class=\"gfield gfield--type-hidden gfield--input-type-hidden gform_hidden field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><div class='ginput_container ginput_container_text'><input name='input_83' id='input_87_83' type='hidden' class='gform_hidden'  aria-invalid=\"false\" value='' \/><\/div><\/div><div id=\"field_87_93\" class=\"gfield gfield--type-hidden gfield--input-type-hidden gfield--width-full gform_hidden field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><div class='ginput_container ginput_container_text'><input name='input_93' id='input_87_93' type='hidden' class='gform_hidden'  aria-invalid=\"false\" value='' \/><\/div><\/div><div id=\"field_87_157\" 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_157' id='input_87_157' type='hidden' class='gform_hidden'  aria-invalid=\"false\" value='lang--es' \/><\/div><\/div><fieldset id=\"field_87_103\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio traditional 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' >Which of the following <strong>best<\/strong> describes your use of AI?<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_87_103'>\n\t\t\t<div class='gchoice gchoice_87_103_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_103' type='radio' value='I have never used AI, but I would like to'  id='choice_87_103_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_87_103_0' id='label_87_103_0' class='gform-field-label gform-field-label--type-inline'>I have never used AI, but I would like to<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_87_103_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_103' type='radio' value='I will never use AI if I can avoid it'  id='choice_87_103_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_87_103_1' id='label_87_103_1' class='gform-field-label gform-field-label--type-inline'>I will never use AI if I can avoid it<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_87_103_2'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_103' type='radio' value='I have only used AI when forced to'  id='choice_87_103_2' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_87_103_2' id='label_87_103_2' class='gform-field-label gform-field-label--type-inline'>I have only used AI when forced to<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_87_103_3'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_103' type='radio' value='I only use AI when it\u2019s included in another product (ex: Zoom, Office, Google)'  id='choice_87_103_3' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_87_103_3' id='label_87_103_3' class='gform-field-label gform-field-label--type-inline'>I only use AI when it\u2019s included in another product (ex: Zoom, Office, Google)<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_87_103_4'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_103' type='radio' value='I use AI less than once a month'  id='choice_87_103_4' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_87_103_4' id='label_87_103_4' class='gform-field-label gform-field-label--type-inline'>I use AI less than once a month<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_87_103_5'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_103' type='radio' value='I use AI once a month'  id='choice_87_103_5' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_87_103_5' id='label_87_103_5' class='gform-field-label gform-field-label--type-inline'>I use AI once a month<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_87_103_6'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_103' type='radio' value='I use AI once or twice a week'  id='choice_87_103_6' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_87_103_6' id='label_87_103_6' class='gform-field-label gform-field-label--type-inline'>I use AI once or twice a week<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_87_103_7'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_103' type='radio' value='I use AI every day'  id='choice_87_103_7' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_87_103_7' id='label_87_103_7' class='gform-field-label gform-field-label--type-inline'>I use AI every day<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_87_110\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield--input-type-checkbox gfield--width-full traditional limit-3 gfield_contains_required field_sublabel_below gfield--has-description field_description_above field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' >What prevents you from using AI?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class='gfield_description' id='gfield_description_87_110'>Select your top 3.<\/div><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox ' id='input_87_110'><div class='gchoice gchoice_87_110_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_110.1' type='checkbox'  value='AI doesn\u2019t seem interesting or useful to me'  id='choice_87_110_1'   aria-describedby=\"gfield_description_87_110\"\/>\n\t\t\t\t\t\t\t\t<label for='choice_87_110_1' id='label_87_110_1' class='gform-field-label gform-field-label--type-inline'>AI doesn\u2019t seem interesting or useful to me<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_87_110_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_110.2' type='checkbox'  value='I don\u2019t know how to use AI'  id='choice_87_110_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_87_110_2' id='label_87_110_2' class='gform-field-label gform-field-label--type-inline'>I don\u2019t know how to use AI<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_87_110_3'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_110.3' type='checkbox'  value='I don\u2019t have access to AI'  id='choice_87_110_3'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_87_110_3' id='label_87_110_3' class='gform-field-label gform-field-label--type-inline'>I don\u2019t have access to AI<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_87_110_4'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_110.4' type='checkbox'  value='AI can\u2019t do anything for me that I can\u2019t do for myself'  id='choice_87_110_4'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_87_110_4' id='label_87_110_4' class='gform-field-label gform-field-label--type-inline'>AI can\u2019t do anything for me that I can\u2019t do for myself<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_87_110_5'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_110.5' type='checkbox'  value='I don\u2019t trust AI to give me good advice or accurate information'  id='choice_87_110_5'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_87_110_5' id='label_87_110_5' class='gform-field-label gform-field-label--type-inline'>I don\u2019t trust AI to give me good advice or accurate information<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_87_110_6'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_110.6' type='checkbox'  value='I don\u2019t want my personal information to be tracked'  id='choice_87_110_6'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_87_110_6' id='label_87_110_6' class='gform-field-label gform-field-label--type-inline'>I don\u2019t want my personal information to be tracked<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_87_110_7'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_110.7' type='checkbox'  value='I don\u2019t trust the companies behind AI'  id='choice_87_110_7'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_87_110_7' id='label_87_110_7' class='gform-field-label gform-field-label--type-inline'>I don\u2019t trust the companies behind AI<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_87_110_8'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_110.8' type='checkbox'  value='I am opposed to using AI because of its negative impact on society'  id='choice_87_110_8'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_87_110_8' id='label_87_110_8' class='gform-field-label gform-field-label--type-inline'>I am opposed to using AI because of its negative impact on society<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_87_110_9'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_110.9' type='checkbox'  value='The technology isn\u2019t good enough yet'  id='choice_87_110_9'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_87_110_9' id='label_87_110_9' class='gform-field-label gform-field-label--type-inline'>The technology isn\u2019t good enough yet<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_87_140\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-full traditional 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' >Which AI system do you use <strong>the most<\/strong>?<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_87_140'>\n\t\t\t<div class='gchoice gchoice_87_140_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_140' type='radio' value='ChatGPT'  id='choice_87_140_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_87_140_0' id='label_87_140_0' class='gform-field-label gform-field-label--type-inline'>ChatGPT<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_87_140_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_140' type='radio' value='Claude (Anthropic)'  id='choice_87_140_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_87_140_1' id='label_87_140_1' class='gform-field-label gform-field-label--type-inline'>Claude (Anthropic)<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_87_140_2'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_140' type='radio' value='Gemini (Google)'  id='choice_87_140_2' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_87_140_2' id='label_87_140_2' class='gform-field-label gform-field-label--type-inline'>Gemini (Google)<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_87_140_3'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_140' type='radio' value='Character AI'  id='choice_87_140_3' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_87_140_3' id='label_87_140_3' class='gform-field-label gform-field-label--type-inline'>Character AI<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_87_140_4'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_140' type='radio' value='Grok'  id='choice_87_140_4' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_87_140_4' id='label_87_140_4' class='gform-field-label gform-field-label--type-inline'>Grok<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_87_140_5'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_140' type='radio' value='Microsoft Copilot'  id='choice_87_140_5' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_87_140_5' id='label_87_140_5' class='gform-field-label gform-field-label--type-inline'>Microsoft Copilot<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_87_140_6'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_140' type='radio' value='Meta AI'  id='choice_87_140_6' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_87_140_6' id='label_87_140_6' class='gform-field-label gform-field-label--type-inline'>Meta AI<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_87_140_7'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_140' type='radio' value='Other (examples: Perplexity, Snapchat AI)'  id='choice_87_140_7' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_87_140_7' id='label_87_140_7' class='gform-field-label gform-field-label--type-inline'>Other (examples: Perplexity, Snapchat AI)<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_87_141\" 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_87_141'>What other AI system do you use the most?<\/label><div class='ginput_container ginput_container_text'><input name='input_141' id='input_87_141' type='text' value='' class='medium'    placeholder='Tell us more...'  aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_87_132\" class=\"gfield gfield--type-section gfield--input-type-section gsection field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><h3 class=\"gsection_title\"><\/h3><\/div><fieldset id=\"field_87_114\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield--input-type-checkbox gfield--width-full traditional limit-3 gfield_contains_required field_sublabel_below gfield--has-description field_description_above field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Imagine the future 5 years from now. What do you hope AI will help you do?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class='gfield_description' id='gfield_description_87_114'>Select your top 3.<\/div><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox ' id='input_87_114'><div class='gchoice gchoice_87_114_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_114.1' type='checkbox'  value='Save time and effort by doing tasks for me'  id='choice_87_114_1'   aria-describedby=\"gfield_description_87_114\"\/>\n\t\t\t\t\t\t\t\t<label for='choice_87_114_1' id='label_87_114_1' class='gform-field-label gform-field-label--type-inline'>Save time and effort by doing tasks for me<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_87_114_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_114.2' type='checkbox'  value='Organizing my life \u2014 reminders, to-do lists, calendars, files, and photos'  id='choice_87_114_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_87_114_2' id='label_87_114_2' class='gform-field-label gform-field-label--type-inline'>Organizing my life \u2014 reminders, to-do lists, calendars, files, and photos<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_87_114_3'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_114.3' type='checkbox'  value='Easier access to information'  id='choice_87_114_3'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_87_114_3' id='label_87_114_3' class='gform-field-label gform-field-label--type-inline'>Easier access to information<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_87_114_4'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_114.4' type='checkbox'  value='Improve my problem solving or decision making'  id='choice_87_114_4'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_87_114_4' id='label_87_114_4' class='gform-field-label gform-field-label--type-inline'>Improve my problem solving or decision making<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_87_114_5'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_114.5' type='checkbox'  value='Learning new skills'  id='choice_87_114_5'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_87_114_5' id='label_87_114_5' class='gform-field-label gform-field-label--type-inline'>Learning new skills<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_87_114_6'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_114.6' type='checkbox'  value='Find new ways to express myself creatively'  id='choice_87_114_6'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_87_114_6' id='label_87_114_6' class='gform-field-label gform-field-label--type-inline'>Find new ways to express myself creatively<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_87_114_7'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_114.7' type='checkbox'  value='Support my health and wellness'  id='choice_87_114_7'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_87_114_7' id='label_87_114_7' class='gform-field-label gform-field-label--type-inline'>Support my health and wellness<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_87_114_8'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_114.8' type='checkbox'  value='Enhance my communication with other people'  id='choice_87_114_8'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_87_114_8' id='label_87_114_8' class='gform-field-label gform-field-label--type-inline'>Enhance my communication with other people<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_87_114_9'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_114.9' type='checkbox'  value='Help me feel less lonely'  id='choice_87_114_9'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_87_114_9' id='label_87_114_9' class='gform-field-label gform-field-label--type-inline'>Help me feel less lonely<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_87_114_11'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_114.11' type='checkbox'  value='Other people will use AI to make new inventions or discoveries that will improve my life'  id='choice_87_114_11'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_87_114_11' id='label_87_114_11' class='gform-field-label gform-field-label--type-inline'>Other people will use AI to make new inventions or discoveries that will improve my life<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_87_114_12'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_114.12' type='checkbox'  value='Nothing. I don&#039;t like AI and don&#039;t want it to affect my life in any way'  id='choice_87_114_12'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_87_114_12' id='label_87_114_12' class='gform-field-label gform-field-label--type-inline'>Nothing. I don't like AI and don't want it to affect my life in any way<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_87_114_13'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_114.13' type='checkbox'  value='Other...'  id='choice_87_114_13'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_87_114_13' id='label_87_114_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_87_117\" 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_87_117'>What else do you hope AI will help you do?<\/label><div class='ginput_container ginput_container_text'><input name='input_117' id='input_87_117' type='text' value='' class='medium'    placeholder='Tell us more...'  aria-invalid=\"false\"   \/><\/div><\/div><fieldset id=\"field_87_118\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield--input-type-checkbox gfield--width-full traditional limit-3 gfield_contains_required field_sublabel_below gfield--has-description field_description_above field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Imagine the future 5 years from now. What scares you the most about the impact of AI?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class='gfield_description' id='gfield_description_87_118'>Select your top 3.<\/div><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox ' id='input_87_118'><div class='gchoice gchoice_87_118_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_118.1' type='checkbox'  value='Losing human skills (social, reading, writing, creating)'  id='choice_87_118_1'   aria-describedby=\"gfield_description_87_118\"\/>\n\t\t\t\t\t\t\t\t<label for='choice_87_118_1' id='label_87_118_1' class='gform-field-label gform-field-label--type-inline'>Losing human skills (social, reading, writing, creating)<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_87_118_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_118.2' type='checkbox'  value='Being monitored and tracked online'  id='choice_87_118_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_87_118_2' id='label_87_118_2' class='gform-field-label gform-field-label--type-inline'>Being monitored and tracked online<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_87_118_3'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_118.3' type='checkbox'  value='Companies stealing my information or work to train AI models'  id='choice_87_118_3'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_87_118_3' id='label_87_118_3' class='gform-field-label gform-field-label--type-inline'>Companies stealing my information or work to train AI models<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_87_118_4'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_118.4' type='checkbox'  value='Job loss or being replaced by AI'  id='choice_87_118_4'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_87_118_4' id='label_87_118_4' class='gform-field-label gform-field-label--type-inline'>Job loss or being replaced by AI<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_87_118_5'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_118.5' type='checkbox'  value='AI making biased decisions about me (what healthcare or jobs I can get, where I can live, etc.)'  id='choice_87_118_5'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_87_118_5' id='label_87_118_5' class='gform-field-label gform-field-label--type-inline'>AI making biased decisions about me (what healthcare or jobs I can get, where I can live, etc.)<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_87_118_6'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_118.6' type='checkbox'  value='Replacing in-person connection with other people'  id='choice_87_118_6'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_87_118_6' id='label_87_118_6' class='gform-field-label gform-field-label--type-inline'>Replacing in-person connection with other people<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_87_118_7'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_118.7' type='checkbox'  value='Can cause brain changes that are harmful (addiction, attention problems)'  id='choice_87_118_7'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_87_118_7' id='label_87_118_7' class='gform-field-label gform-field-label--type-inline'>Can cause brain changes that are harmful (addiction, attention problems)<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_87_118_8'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_118.8' type='checkbox'  value='Becoming dependent on AI (can\u2019t make decisions without AI)'  id='choice_87_118_8'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_87_118_8' id='label_87_118_8' class='gform-field-label gform-field-label--type-inline'>Becoming dependent on AI (can\u2019t make decisions without AI)<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_87_118_9'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_118.9' type='checkbox'  value='Providing bad information (bad advice, wrong answers, deep fakes)'  id='choice_87_118_9'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_87_118_9' id='label_87_118_9' class='gform-field-label gform-field-label--type-inline'>Providing bad information (bad advice, wrong answers, deep fakes)<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_87_118_11'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_118.11' type='checkbox'  value='Flooding the internet with junk and making it harder to find quality content'  id='choice_87_118_11'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_87_118_11' id='label_87_118_11' class='gform-field-label gform-field-label--type-inline'>Flooding the internet with junk and making it harder to find quality content<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_87_118_12'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_118.12' type='checkbox'  value='Nothing. I think AI will only have positive effects.'  id='choice_87_118_12'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_87_118_12' id='label_87_118_12' class='gform-field-label gform-field-label--type-inline'>Nothing. I think AI will only have positive effects.<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_87_118_13'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_118.13' type='checkbox'  value='Other...'  id='choice_87_118_13'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_87_118_13' id='label_87_118_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_87_119\" 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_87_119'>What else scares you about the impact of AI?<\/label><div class='ginput_container ginput_container_text'><input name='input_119' id='input_87_119' type='text' value='' class='medium'    placeholder='Tell us more...'  aria-invalid=\"false\"   \/><\/div><\/div><fieldset id=\"field_87_105\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio traditional 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 you used AI for emotional support?<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_87_105'>\n\t\t\t<div class='gchoice gchoice_87_105_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_105' type='radio' value='No, never'  id='choice_87_105_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_87_105_0' id='label_87_105_0' class='gform-field-label gform-field-label--type-inline'>No, never<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_87_105_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_105' type='radio' value='Yes, a few times'  id='choice_87_105_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_87_105_1' id='label_87_105_1' class='gform-field-label gform-field-label--type-inline'>Yes, a few times<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_87_105_2'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_105' type='radio' value='Yes, regularly \/ often'  id='choice_87_105_2' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_87_105_2' id='label_87_105_2' class='gform-field-label gform-field-label--type-inline'>Yes, regularly \/ often<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_87_120\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield--input-type-checkbox gfield--width-full traditional limit-3 gfield_contains_required field_sublabel_below gfield--has-description field_description_above field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' >What is preventing you from using AI for emotional support more often?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class='gfield_description' id='gfield_description_87_120'>Select your top 3.<\/div><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox ' id='input_87_120'><div class='gchoice gchoice_87_120_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_120.1' type='checkbox'  value='I don\u2019t trust AI to give me good advice or accurate information'  id='choice_87_120_1'   aria-describedby=\"gfield_description_87_120\"\/>\n\t\t\t\t\t\t\t\t<label for='choice_87_120_1' id='label_87_120_1' class='gform-field-label gform-field-label--type-inline'>I don\u2019t trust AI to give me good advice or accurate information<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_87_120_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_120.2' type='checkbox'  value='I\u2019m worried that my personal information could be tracked'  id='choice_87_120_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_87_120_2' id='label_87_120_2' class='gform-field-label gform-field-label--type-inline'>I\u2019m worried that my personal information could be tracked<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_87_120_3'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_120.3' type='checkbox'  value='I don\u2019t trust the companies behind AI'  id='choice_87_120_3'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_87_120_3' id='label_87_120_3' class='gform-field-label gform-field-label--type-inline'>I don\u2019t trust the companies behind AI<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_87_120_4'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_120.4' type='checkbox'  value='I don\u2019t know how to use it for this purpose'  id='choice_87_120_4'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_87_120_4' id='label_87_120_4' class='gform-field-label gform-field-label--type-inline'>I don\u2019t know how to use it for this purpose<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_87_120_5'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_120.5' type='checkbox'  value='I prefer to talk to a human'  id='choice_87_120_5'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_87_120_5' id='label_87_120_5' class='gform-field-label gform-field-label--type-inline'>I prefer to talk to a human<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_87_120_6'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_120.6' type='checkbox'  value='The technology isn\u2019t good enough yet'  id='choice_87_120_6'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_87_120_6' id='label_87_120_6' class='gform-field-label gform-field-label--type-inline'>The technology isn\u2019t good enough yet<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_87_120_7'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_120.7' type='checkbox'  value='I am opposed to using AI because of its negative impact on society'  id='choice_87_120_7'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_87_120_7' id='label_87_120_7' class='gform-field-label gform-field-label--type-inline'>I am opposed to using AI because of its negative impact on society<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_87_120_8'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_120.8' type='checkbox'  value='I don\u2019t need it because I am already receiving treatment or support another way'  id='choice_87_120_8'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_87_120_8' id='label_87_120_8' class='gform-field-label gform-field-label--type-inline'>I don\u2019t need it because I am already receiving treatment or support another way<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_87_120_9'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_120.9' type='checkbox'  value='I already got what I needed from it'  id='choice_87_120_9'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_87_120_9' id='label_87_120_9' class='gform-field-label gform-field-label--type-inline'>I already got what I needed from it<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_87_133\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-full traditional 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' >How positive or negative was your experience?<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_87_133'>\n\t\t\t<div class='gchoice gchoice_87_133_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_133' type='radio' value='Very positive'  id='choice_87_133_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_87_133_0' id='label_87_133_0' class='gform-field-label gform-field-label--type-inline'>Very positive<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_87_133_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_133' type='radio' value='Positive'  id='choice_87_133_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_87_133_1' id='label_87_133_1' class='gform-field-label gform-field-label--type-inline'>Positive<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_87_133_2'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_133' type='radio' value='Negative'  id='choice_87_133_2' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_87_133_2' id='label_87_133_2' class='gform-field-label gform-field-label--type-inline'>Negative<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_87_133_3'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_133' type='radio' value='Very negative'  id='choice_87_133_3' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_87_133_3' id='label_87_133_3' class='gform-field-label gform-field-label--type-inline'>Very negative<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_87_123\" 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_87_123'>Can you tell us more about why your experience was positive?<\/label><div class='ginput_container ginput_container_text'><input name='input_123' id='input_87_123' type='text' value='' class='large'    placeholder='Tell us more...'  aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_87_124\" 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_87_124'>Can you tell us more about why your experience was negative?<\/label><div class='ginput_container ginput_container_text'><input name='input_124' id='input_87_124' type='text' value='' class='large'    placeholder='Tell us more...'  aria-invalid=\"false\"   \/><\/div><\/div><fieldset id=\"field_87_125\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-full question short gfield_contains_required field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >Would you ever consider using AI for emotional support?<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_87_125'>\n\t\t\t<div class='gchoice gchoice_87_125_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_125' type='radio' value='Yes'  id='choice_87_125_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_87_125_0' id='label_87_125_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_87_125_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_125' type='radio' value='No'  id='choice_87_125_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_87_125_1' id='label_87_125_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_87_127\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield--input-type-checkbox gfield--width-full traditional limit-3 gfield_contains_required field_sublabel_below gfield--has-description field_description_above field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' >What would prevent you from using AI for emotional support?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class='gfield_description' id='gfield_description_87_127'>Select your top 3.<\/div><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox ' id='input_87_127'><div class='gchoice gchoice_87_127_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_127.1' type='checkbox'  value='I don\u2019t trust AI to give me good advice or accurate information'  id='choice_87_127_1'   aria-describedby=\"gfield_description_87_127\"\/>\n\t\t\t\t\t\t\t\t<label for='choice_87_127_1' id='label_87_127_1' class='gform-field-label gform-field-label--type-inline'>I don\u2019t trust AI to give me good advice or accurate information<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_87_127_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_127.2' type='checkbox'  value='I\u2019m worried that my personal information could be tracked'  id='choice_87_127_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_87_127_2' id='label_87_127_2' class='gform-field-label gform-field-label--type-inline'>I\u2019m worried that my personal information could be tracked<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_87_127_3'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_127.3' type='checkbox'  value='I don\u2019t trust the companies behind AI'  id='choice_87_127_3'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_87_127_3' id='label_87_127_3' class='gform-field-label gform-field-label--type-inline'>I don\u2019t trust the companies behind AI<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_87_127_4'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_127.4' type='checkbox'  value='I don\u2019t know how to use it for this purpose'  id='choice_87_127_4'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_87_127_4' id='label_87_127_4' class='gform-field-label gform-field-label--type-inline'>I don\u2019t know how to use it for this purpose<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_87_127_5'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_127.5' type='checkbox'  value='I prefer to talk to a human'  id='choice_87_127_5'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_87_127_5' id='label_87_127_5' class='gform-field-label gform-field-label--type-inline'>I prefer to talk to a human<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_87_127_6'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_127.6' type='checkbox'  value='The technology isn\u2019t good enough yet'  id='choice_87_127_6'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_87_127_6' id='label_87_127_6' class='gform-field-label gform-field-label--type-inline'>The technology isn\u2019t good enough yet<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_87_127_7'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_127.7' type='checkbox'  value='I am opposed to using AI because of its negative impact on society'  id='choice_87_127_7'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_87_127_7' id='label_87_127_7' class='gform-field-label gform-field-label--type-inline'>I am opposed to using AI because of its negative impact on society<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_87_127_8'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_127.8' type='checkbox'  value='I don\u2019t need it because I am already receiving treatment or support another way'  id='choice_87_127_8'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_87_127_8' id='label_87_127_8' class='gform-field-label gform-field-label--type-inline'>I don\u2019t need it because I am already receiving treatment or support another way<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_87_127_9'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_127.9' type='checkbox'  value='I already got what I needed from it'  id='choice_87_127_9'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_87_127_9' id='label_87_127_9' class='gform-field-label gform-field-label--type-inline'>I already got what I needed from it<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_87_139\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield--input-type-checkbox gfield--width-full traditional limit-3 gfield_contains_required field_sublabel_below gfield--has-description field_description_above field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Why would you consider using AI for mental or emotional support?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class='gfield_description' id='gfield_description_87_139'>Select your top 3.<\/div><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox ' id='input_87_139'><div class='gchoice gchoice_87_139_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_139.1' type='checkbox'  value='I feel more comfortable talking to a bot than to a human'  id='choice_87_139_1'   aria-describedby=\"gfield_description_87_139\"\/>\n\t\t\t\t\t\t\t\t<label for='choice_87_139_1' id='label_87_139_1' class='gform-field-label gform-field-label--type-inline'>I feel more comfortable talking to a bot than to a human<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_87_139_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_139.2' type='checkbox'  value='It\u2019s convenient\/available 24\/7'  id='choice_87_139_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_87_139_2' id='label_87_139_2' class='gform-field-label gform-field-label--type-inline'>It\u2019s convenient\/available 24\/7<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_87_139_3'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_139.3' type='checkbox'  value='It\u2019s free'  id='choice_87_139_3'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_87_139_3' id='label_87_139_3' class='gform-field-label gform-field-label--type-inline'>It\u2019s free<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_87_139_4'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_139.4' type='checkbox'  value='Traditional therapy isn\u2019t available to me'  id='choice_87_139_4'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_87_139_4' id='label_87_139_4' class='gform-field-label gform-field-label--type-inline'>Traditional therapy isn\u2019t available to me<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_87_139_5'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_139.5' type='checkbox'  value='It\u2019s safer. It lets me stay anonymous'  id='choice_87_139_5'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_87_139_5' id='label_87_139_5' class='gform-field-label gform-field-label--type-inline'>It\u2019s safer. It lets me stay anonymous<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_87_139_6'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_139.6' type='checkbox'  value='It lets me get help without telling my family'  id='choice_87_139_6'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_87_139_6' id='label_87_139_6' class='gform-field-label gform-field-label--type-inline'>It lets me get help without telling my family<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_87_139_7'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_139.7' type='checkbox'  value='Therapy or help I\u2019ve received from people has not helped'  id='choice_87_139_7'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_87_139_7' id='label_87_139_7' class='gform-field-label gform-field-label--type-inline'>Therapy or help I\u2019ve received from people has not helped<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_87_139_8'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_139.8' type='checkbox'  value='It\u2019s entertaining\/engaging'  id='choice_87_139_8'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_87_139_8' id='label_87_139_8' class='gform-field-label gform-field-label--type-inline'>It\u2019s entertaining\/engaging<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_87_137\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield--input-type-checkbox gfield--width-full traditional limit-3 gfield_contains_required field_sublabel_below gfield--has-description field_description_above field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' >In what ways have you <strong>used AI the most<\/strong> for emotional support?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class='gfield_description' id='gfield_description_87_137'>Select your top 3.<\/div><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox ' id='input_87_137'><div class='gchoice gchoice_87_137_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_137.1' type='checkbox'  value='Help me answer questions about mental health'  id='choice_87_137_1'   aria-describedby=\"gfield_description_87_137\"\/>\n\t\t\t\t\t\t\t\t<label for='choice_87_137_1' id='label_87_137_1' class='gform-field-label gform-field-label--type-inline'>Help me answer questions about mental health<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_87_137_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_137.2' type='checkbox'  value='Help me with a mental health diagnosis'  id='choice_87_137_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_87_137_2' id='label_87_137_2' class='gform-field-label gform-field-label--type-inline'>Help me with a mental health diagnosis<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_87_137_3'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_137.3' type='checkbox'  value='Help me get treatment options'  id='choice_87_137_3'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_87_137_3' id='label_87_137_3' class='gform-field-label gform-field-label--type-inline'>Help me get treatment options<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_87_137_4'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_137.4' type='checkbox'  value='Tracking my mood or habits (logs, reminders)'  id='choice_87_137_4'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_87_137_4' id='label_87_137_4' class='gform-field-label gform-field-label--type-inline'>Tracking my mood or habits (logs, reminders)<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_87_137_5'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_137.5' type='checkbox'  value='A structured tool or app that uses AI in the activity (worksheets, exercises, journaling prompts)'  id='choice_87_137_5'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_87_137_5' id='label_87_137_5' class='gform-field-label gform-field-label--type-inline'>A structured tool or app that uses AI in the activity (worksheets, exercises, journaling prompts)<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_87_137_6'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_137.6' type='checkbox'  value='A conversation with AI (learns your habits\/needs over time, provides listening and advice, helps me make decisions, helps me deal with hard issues)'  id='choice_87_137_6'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_87_137_6' id='label_87_137_6' class='gform-field-label gform-field-label--type-inline'>A conversation with AI (learns your habits\/needs over time, provides listening and advice, helps me make decisions, helps me deal with hard issues)<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_87_128\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield--input-type-checkbox gfield--width-full traditional limit-3 gfield_contains_required field_sublabel_below gfield--has-description field_description_above field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' >In what ways are you <strong>most interested in using AI<\/strong> for emotional support?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class='gfield_description' id='gfield_description_87_128'>Select your top 3.<\/div><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox ' id='input_87_128'><div class='gchoice gchoice_87_128_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_128.1' type='checkbox'  value='Help me answer questions about mental health'  id='choice_87_128_1'   aria-describedby=\"gfield_description_87_128\"\/>\n\t\t\t\t\t\t\t\t<label for='choice_87_128_1' id='label_87_128_1' class='gform-field-label gform-field-label--type-inline'>Help me answer questions about mental health<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_87_128_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_128.2' type='checkbox'  value='Help me with a mental health diagnosis'  id='choice_87_128_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_87_128_2' id='label_87_128_2' class='gform-field-label gform-field-label--type-inline'>Help me with a mental health diagnosis<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_87_128_3'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_128.3' type='checkbox'  value='Help me get treatment options'  id='choice_87_128_3'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_87_128_3' id='label_87_128_3' class='gform-field-label gform-field-label--type-inline'>Help me get treatment options<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_87_128_4'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_128.4' type='checkbox'  value='Tracking my mood or habits (logs, reminders)'  id='choice_87_128_4'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_87_128_4' id='label_87_128_4' class='gform-field-label gform-field-label--type-inline'>Tracking my mood or habits (logs, reminders)<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_87_128_5'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_128.5' type='checkbox'  value='A structured tool or app that uses AI in the activity (worksheets, exercises, journaling prompts)'  id='choice_87_128_5'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_87_128_5' id='label_87_128_5' class='gform-field-label gform-field-label--type-inline'>A structured tool or app that uses AI in the activity (worksheets, exercises, journaling prompts)<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_87_128_6'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_128.6' type='checkbox'  value='A conversation with AI (learns your habits\/needs over time, provides listening and advice, helps me make decisions, helps me deal with hard issues)'  id='choice_87_128_6'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_87_128_6' id='label_87_128_6' class='gform-field-label gform-field-label--type-inline'>A conversation with AI (learns your habits\/needs over time, provides listening and advice, helps me make decisions, helps me deal with hard issues)<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_87_149\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield--input-type-checkbox gfield--width-full traditional limit-3 gfield_contains_required field_sublabel_below gfield--has-description field_description_above field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' >When people use AI for emotional support, what is the best thing the AI can do to respond to their needs?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class='gfield_description' id='gfield_description_87_149'>Select your top 3.<\/div><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox ' id='input_87_149'><div class='gchoice gchoice_87_149_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_149.1' type='checkbox'  value='Ask them directly about risk of harm (hurting yourself or others)'  id='choice_87_149_1'   aria-describedby=\"gfield_description_87_149\"\/>\n\t\t\t\t\t\t\t\t<label for='choice_87_149_1' id='label_87_149_1' class='gform-field-label gform-field-label--type-inline'>Ask them directly about risk of harm (hurting yourself or others)<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_87_149_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_149.2' type='checkbox'  value='Listen and support their emotional concerns'  id='choice_87_149_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_87_149_2' id='label_87_149_2' class='gform-field-label gform-field-label--type-inline'>Listen and support their emotional concerns<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_87_149_3'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_149.3' type='checkbox'  value='Help them figure out how to feel better (e.g making a plan, learning some skils)'  id='choice_87_149_3'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_87_149_3' id='label_87_149_3' class='gform-field-label gform-field-label--type-inline'>Help them figure out how to feel better (e.g making a plan, learning some skils)<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_87_149_4'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_149.4' type='checkbox'  value='Give them information about mental health'  id='choice_87_149_4'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_87_149_4' id='label_87_149_4' class='gform-field-label gform-field-label--type-inline'>Give them information about mental health<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_87_149_5'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_149.5' type='checkbox'  value='Explore all the different support systems they have'  id='choice_87_149_5'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_87_149_5' id='label_87_149_5' class='gform-field-label gform-field-label--type-inline'>Explore all the different support systems they have<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_87_149_6'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_149.6' type='checkbox'  value='Help them figure out how to talk to someone'  id='choice_87_149_6'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_87_149_6' id='label_87_149_6' class='gform-field-label gform-field-label--type-inline'>Help them figure out how to talk to someone<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_87_149_7'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_149.7' type='checkbox'  value='Send them resources, including how to connect to a person'  id='choice_87_149_7'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_87_149_7' id='label_87_149_7' class='gform-field-label gform-field-label--type-inline'>Send them resources, including how to connect to a person<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_87_138\" class=\"gfield gfield--type-textarea gfield--input-type-textarea gfield--width-full field_sublabel_below gfield--has-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_87_138'><strong>Optional:<\/strong> Think back to a time when you used AI for emotional support. Can you share anything about how that conversation went? What did you talk about? How did you feel?<\/label><div class='gfield_description' id='gfield_description_87_138'><em><strong>Share as much or as little as you like.<\/strong> For example, you could just describe your experience in one sentence, share prompts you've used that have been particularly effective, or anything in between.<\/em><\/div><div class='ginput_container ginput_container_textarea'><textarea name='input_138' id='input_87_138' class='textarea medium'  aria-describedby=\"gfield_description_87_138\"    aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/div><fieldset id=\"field_87_142\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield--input-type-checkbox gfield--width-full limit-3 traditional question gfield_contains_required field_sublabel_below gfield--has-description field_description_above field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Who do you think are the top 3 groups who should be most responsible for implementing mental health protections for people who use AI?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class='gfield_description' id='gfield_description_87_142'>Select up to 3.<\/div><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox ' id='input_87_142'><div class='gchoice gchoice_87_142_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_142.1' type='checkbox'  value='Myself \/ individual users'  id='choice_87_142_1'   aria-describedby=\"gfield_description_87_142\"\/>\n\t\t\t\t\t\t\t\t<label for='choice_87_142_1' id='label_87_142_1' class='gform-field-label gform-field-label--type-inline'>Myself \/ individual users<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_87_142_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_142.2' type='checkbox'  value='Parents \/ guardians'  id='choice_87_142_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_87_142_2' id='label_87_142_2' class='gform-field-label gform-field-label--type-inline'>Parents \/ guardians<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_87_142_3'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_142.3' type='checkbox'  value='Technology companies'  id='choice_87_142_3'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_87_142_3' id='label_87_142_3' class='gform-field-label gform-field-label--type-inline'>Technology companies<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_87_142_4'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_142.4' type='checkbox'  value='Companies using AI software (employers, healthcare, schools)'  id='choice_87_142_4'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_87_142_4' id='label_87_142_4' class='gform-field-label gform-field-label--type-inline'>Companies using AI software (employers, healthcare, schools)<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_87_142_5'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_142.5' type='checkbox'  value='Government'  id='choice_87_142_5'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_87_142_5' id='label_87_142_5' class='gform-field-label gform-field-label--type-inline'>Government<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_87_142_6'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_142.6' type='checkbox'  value='Other...'  id='choice_87_142_6'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_87_142_6' id='label_87_142_6' 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_87_143\" 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_87_143'>Who else do you think is the most responsible for implementing mental health protections?<\/label><div class='ginput_container ginput_container_text'><input name='input_143' id='input_87_143' type='text' value='' class='large'    placeholder='Tell us more...'  aria-invalid=\"false\"   \/><\/div><\/div><fieldset id=\"field_87_144\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield--input-type-checkbox gfield--width-full limit-3 traditional question gfield_contains_required field_sublabel_below gfield--has-description field_description_above field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' >What are the top 3 things that technology companies can do to protect people from harm when they\u2019re getting mental health support from AI?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class='gfield_description' id='gfield_description_87_144'>Select up to 3.<\/div><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox ' id='input_87_144'><div class='gchoice gchoice_87_144_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_144.1' type='checkbox'  value='Refer me to a mental health professional instead of providing direct advice'  id='choice_87_144_1'   aria-describedby=\"gfield_description_87_144\"\/>\n\t\t\t\t\t\t\t\t<label for='choice_87_144_1' id='label_87_144_1' class='gform-field-label gform-field-label--type-inline'>Refer me to a mental health professional instead of providing direct advice<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_87_144_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_144.2' type='checkbox'  value='Remind me that I\u2019m talking to a machine and not a human'  id='choice_87_144_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_87_144_2' id='label_87_144_2' class='gform-field-label gform-field-label--type-inline'>Remind me that I\u2019m talking to a machine and not a human<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_87_144_3'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_144.3' type='checkbox'  value='Make the AI less like a human'  id='choice_87_144_3'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_87_144_3' id='label_87_144_3' class='gform-field-label gform-field-label--type-inline'>Make the AI less like a human<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_87_144_4'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_144.4' type='checkbox'  value='Make the AI more like a human'  id='choice_87_144_4'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_87_144_4' id='label_87_144_4' class='gform-field-label gform-field-label--type-inline'>Make the AI more like a human<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_87_144_5'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_144.5' type='checkbox'  value='Tell me about my emotional risks when I\u2019m using AI'  id='choice_87_144_5'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_87_144_5' id='label_87_144_5' class='gform-field-label gform-field-label--type-inline'>Tell me about my emotional risks when I\u2019m using AI<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_87_144_6'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_144.6' type='checkbox'  value='Guarantee that my conversations won\u2019t be used to train the AI'  id='choice_87_144_6'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_87_144_6' id='label_87_144_6' class='gform-field-label gform-field-label--type-inline'>Guarantee that my conversations won\u2019t be used to train the AI<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_87_144_7'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_144.7' type='checkbox'  value='Make sure no one else can ever see the conversations I have with AI'  id='choice_87_144_7'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_87_144_7' id='label_87_144_7' class='gform-field-label gform-field-label--type-inline'>Make sure no one else can ever see the conversations I have with AI<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_87_144_8'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_144.8' type='checkbox'  value='Develop industry standards for measuring impact on communities of users'  id='choice_87_144_8'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_87_144_8' id='label_87_144_8' class='gform-field-label gform-field-label--type-inline'>Develop industry standards for measuring impact on communities of users<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_87_144_9'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_144.9' type='checkbox'  value='Other...'  id='choice_87_144_9'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_87_144_9' id='label_87_144_9' 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_87_145\" 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_87_145'>What else can technology companies do to protect the mental health of people who use their AI?<\/label><div class='ginput_container ginput_container_text'><input name='input_145' id='input_87_145' type='text' value='' class='large'    placeholder='Tell us more...'  aria-invalid=\"false\"   \/><\/div><\/div><fieldset id=\"field_87_146\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield--input-type-checkbox gfield--width-full limit-3 traditional question gfield_contains_required field_sublabel_below gfield--has-description field_description_above field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' >What are the top 3 things that the government can do to protect the mental health of people who use AI?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class='gfield_description' id='gfield_description_87_146'>Select up to 3.<\/div><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox ' id='input_87_146'><div class='gchoice gchoice_87_146_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_146.1' type='checkbox'  value='Set policies\/laws that tech companies have to follow'  id='choice_87_146_1'   aria-describedby=\"gfield_description_87_146\"\/>\n\t\t\t\t\t\t\t\t<label for='choice_87_146_1' id='label_87_146_1' class='gform-field-label gform-field-label--type-inline'>Set policies\/laws that tech companies have to follow<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_87_146_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_146.2' type='checkbox'  value='Create a group of people responsible for reviewing and giving limitations on safety'  id='choice_87_146_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_87_146_2' id='label_87_146_2' class='gform-field-label gform-field-label--type-inline'>Create a group of people responsible for reviewing and giving limitations on safety<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_87_146_3'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_146.3' type='checkbox'  value='Create guidelines and incentives for safety'  id='choice_87_146_3'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_87_146_3' id='label_87_146_3' class='gform-field-label gform-field-label--type-inline'>Create guidelines and incentives for safety<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_87_146_4'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_146.4' type='checkbox'  value='Incentivize research on potential harms or positive impacts of AI'  id='choice_87_146_4'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_87_146_4' id='label_87_146_4' class='gform-field-label gform-field-label--type-inline'>Incentivize research on potential harms or positive impacts of AI<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_87_146_5'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_146.5' type='checkbox'  value='Fine technology companies for harm towards people'  id='choice_87_146_5'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_87_146_5' id='label_87_146_5' class='gform-field-label gform-field-label--type-inline'>Fine technology companies for harm towards people<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_87_146_6'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_146.6' type='checkbox'  value='Invest in public education on using AIsafely'  id='choice_87_146_6'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_87_146_6' id='label_87_146_6' class='gform-field-label gform-field-label--type-inline'>Invest in public education on using AIsafely<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_87_146_7'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_146.7' type='checkbox'  value='Other...'  id='choice_87_146_7'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_87_146_7' id='label_87_146_7' 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_87_147\" 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_87_147'>What else can the government do to protect the mental health of people who use AI?<\/label><div class='ginput_container ginput_container_text'><input name='input_147' id='input_87_147' type='text' value='' class='large'    placeholder='Tell us more...'  aria-invalid=\"false\"   \/><\/div><\/div><fieldset id=\"field_87_152\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio 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' >When you use AI tools, which mode do you use most often?<\/legend><div class='gfield_description' id='gfield_description_87_152'>Select 1.<\/div><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_87_152'>\n\t\t\t<div class='gchoice gchoice_87_152_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_152' type='radio' value='Text-based chat (typing)'  id='choice_87_152_0' onchange='gformToggleRadioOther( this )' aria-describedby=\"gfield_description_87_152\"   \/>\n\t\t\t\t\t<label for='choice_87_152_0' id='label_87_152_0' class='gform-field-label gform-field-label--type-inline'>Text-based chat (typing)<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_87_152_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_152' type='radio' value='Voice-based conversation (speaking\/listening)'  id='choice_87_152_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_87_152_1' id='label_87_152_1' class='gform-field-label gform-field-label--type-inline'>Voice-based conversation (speaking\/listening)<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_87_152_2'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_152' type='radio' value='Both equally'  id='choice_87_152_2' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_87_152_2' id='label_87_152_2' class='gform-field-label gform-field-label--type-inline'>Both equally<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_87_152_3'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_152' type='radio' value='Other...'  id='choice_87_152_3' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_87_152_3' id='label_87_152_3' class='gform-field-label gform-field-label--type-inline'>Other...<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_87_152_4'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_152' type='radio' value='I don&#039;t know \/ not sure'  id='choice_87_152_4' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_87_152_4' id='label_87_152_4' class='gform-field-label gform-field-label--type-inline'>I don't know \/ not sure<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_87_153\" 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_87_153'>What other way do you interact with AI tools most often?<\/label><div class='ginput_container ginput_container_text'><input name='input_153' id='input_87_153' type='text' value='' class='medium'    placeholder='Tell us more...'  aria-invalid=\"false\"   \/><\/div><\/div><fieldset id=\"field_87_154\" 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' >When you interact with AI tools using text-based chat, how natural or human-like does the interaction feel?<\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_87_154'>\n\t\t\t<div class='gchoice gchoice_87_154_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_154' type='radio' value='Not natural at all'  id='choice_87_154_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_87_154_0' id='label_87_154_0' class='gform-field-label gform-field-label--type-inline'>Not natural at all<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_87_154_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_154' type='radio' value='Somewhat natural'  id='choice_87_154_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_87_154_1' id='label_87_154_1' class='gform-field-label gform-field-label--type-inline'>Somewhat natural<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_87_154_2'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_154' type='radio' value='Very natural'  id='choice_87_154_2' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_87_154_2' id='label_87_154_2' class='gform-field-label gform-field-label--type-inline'>Very natural<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_87_155\" 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' >When you interact with AI tools using voice-based conversation, how natural or human-like does the interaction feel?<\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_87_155'>\n\t\t\t<div class='gchoice gchoice_87_155_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_155' type='radio' value='Not natural at all'  id='choice_87_155_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_87_155_0' id='label_87_155_0' class='gform-field-label gform-field-label--type-inline'>Not natural at all<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_87_155_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_155' type='radio' value='Somewhat natural'  id='choice_87_155_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_87_155_1' id='label_87_155_1' class='gform-field-label gform-field-label--type-inline'>Somewhat natural<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_87_155_2'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_155' type='radio' value='Very natural'  id='choice_87_155_2' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_87_155_2' id='label_87_155_2' class='gform-field-label gform-field-label--type-inline'>Very natural<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_87_151\" 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_87_129\" 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' >We sometimes run paid research studies on topics like AI and mental health. Would you like to hear about future opportunities?<\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_87_129'>\n\t\t\t<div class='gchoice gchoice_87_129_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_129' type='radio' value='Yes, I&#039;m interested!'  id='choice_87_129_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_87_129_0' id='label_87_129_0' class='gform-field-label gform-field-label--type-inline'>Yes, I'm interested!<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_87_129_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_129' type='radio' value='No, thank you.'  id='choice_87_129_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_87_129_1' id='label_87_129_1' class='gform-field-label gform-field-label--type-inline'>No, thank you.<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_87_131\" class=\"gfield gfield--type-html gfield--input-type-html gfield--width-full gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  >Great! Drop your email below so we can reach out when something comes up:<\/div><div id=\"field_87_130\" class=\"gfield gfield--type-email gfield--input-type-email 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_87_130'>Email<\/label><div class='ginput_container ginput_container_email'>\n                            <input name='input_130' id='input_87_130' type='email' value='' class='small'   placeholder='Enter your email address...'  aria-invalid=\"false\"  \/>\n                        <\/div><\/div><\/div>\n                    <\/div>\n                    <div class='gform-page-footer gform_page_footer top_label'>\n                         <input type='button' id='gform_next_button_87_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_87_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_87_2' class='gform_fields top_label form_sublabel_below description_above validation_below'><div id=\"field_87_53\" class=\"gfield gfield--type-html gfield--input-type-html section-title gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><h2>About You<\/h2><\/div><div id=\"field_87_54\" class=\"gfield gfield--type-select gfield--input-type-select optional taxonomy field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_87_54'>Age Range<\/label><div class='ginput_container ginput_container_select'><select name='input_54' id='input_87_54' class='medium gfield_select'     aria-invalid=\"false\" ><option value='' ><\/option><option value='8-10' >8-10<\/option><option value='11-13' >11-13<\/option><option value='14-15' >14-15<\/option><option value='16-17' >16-17<\/option><option value='18-24' >18-24<\/option><option value='25-34' >25-34<\/option><option value='35-44' >35-44<\/option><option value='45-54' >45-54<\/option><option value='55-64' >55-64<\/option><option value='65+' >65+<\/option><option value='Prefer not to answer' >Prefer not to answer<\/option><\/select><\/div><\/div><fieldset id=\"field_87_55\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio optional mb-2 short 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_87_55'>\n\t\t\t<div class='gchoice gchoice_87_55_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_55' type='radio' value='Female'  id='choice_87_55_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_87_55_0' id='label_87_55_0' class='gform-field-label gform-field-label--type-inline'>Female<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_87_55_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_55' type='radio' value='Male'  id='choice_87_55_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_87_55_1' id='label_87_55_1' class='gform-field-label gform-field-label--type-inline'>Male<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_87_55_2'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_55' type='radio' value='Non-Binary'  id='choice_87_55_2' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_87_55_2' id='label_87_55_2' class='gform-field-label gform-field-label--type-inline'>Non-Binary<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_87_55_3'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_55' type='radio' value='Prefer not to answer'  id='choice_87_55_3' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_87_55_3' id='label_87_55_3' class='gform-field-label gform-field-label--type-inline'>Prefer not to answer<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_87_156\" 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_87_156'>\n\t\t\t<div class='gchoice gchoice_87_156_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_156' type='radio' value='Yes'  id='choice_87_156_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_87_156_0' id='label_87_156_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_87_156_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_156' type='radio' value='No'  id='choice_87_156_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_87_156_1' id='label_87_156_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_87_135\" 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_87_135'>How would you describe your gender?<\/label><div class='ginput_container ginput_container_text'><input name='input_135' id='input_87_135' type='text' value='' class='medium'      aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_87_58\" class=\"gfield gfield--type-select gfield--input-type-select optional field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_87_58'>Race\/Ethnicity<\/label><div class='ginput_container ginput_container_select'><select name='input_58' id='input_87_58' class='medium gfield_select'     aria-invalid=\"false\" ><option value='' ><\/option><option value='American Indian or Alaska Native' >American Indian or Alaska Native<\/option><option value='Asian' >Asian<\/option><option value='Black or African American (non-Hispanic)' >Black or African American (non-Hispanic)<\/option><option value='Hispanic or Latino' >Hispanic or Latino<\/option><option value='Middle Eastern or North African' >Middle Eastern or North African<\/option><option value='Native Hawaiian or other Pacific Islander' >Native Hawaiian or other Pacific Islander<\/option><option value='White (non-Hispanic)' >White (non-Hispanic)<\/option><option value='More than one of the above' >More than one of the above<\/option><option value='Other...' >Other...<\/option><\/select><\/div><\/div><div id=\"field_87_134\" 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_87_134'>How would you describe your race\/ethnicity?<\/label><div class='ginput_container ginput_container_text'><input name='input_134' id='input_87_134' type='text' value='' class='medium'      aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_87_59\" class=\"gfield gfield--type-select gfield--input-type-select optional field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_87_59'>Household Income<\/label><div class='ginput_container ginput_container_select'><select name='input_59' id='input_87_59' class='medium gfield_select'     aria-invalid=\"false\" ><option value='' ><\/option><option value='Less than $20,000' >Less than $20,000<\/option><option value='$20,000 - $39,999' >$20,000 - $39,999<\/option><option value='$40,000 - $59,999' >$40,000 - $59,999<\/option><option value='$60,000 - $79,999' >$60,000 - $79,999<\/option><option value='$80,000 - $99,999' >$80,000 - $99,999<\/option><option value='$100,000 - $149,999' >$100,000 - $149,999<\/option><option value='$150,000+' >$150,000+<\/option><\/select><\/div><\/div><fieldset id=\"field_87_87\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-full field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >Do you live in the United States or another country?<\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_87_87'>\n\t\t\t<div class='gchoice gchoice_87_87_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_87' type='radio' value='I live in the United States'  id='choice_87_87_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_87_87_0' id='label_87_87_0' class='gform-field-label gform-field-label--type-inline'>I live in the United States<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_87_87_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_87' type='radio' value='I live in another country'  id='choice_87_87_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_87_87_1' id='label_87_87_1' class='gform-field-label gform-field-label--type-inline'>I live in another country<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_87_78\" class=\"gfield gfield--type-select gfield--input-type-select gfield--width-full optional field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_87_78'>State<\/label><div class='ginput_container ginput_container_select'><select name='input_78' id='input_87_78' class='medium gfield_select'     aria-invalid=\"false\" ><option value='' ><\/option><option value='Alabama' >Alabama<\/option><option value='Alaska' >Alaska<\/option><option value='Arizona' >Arizona<\/option><option value='Arkansas' >Arkansas<\/option><option value='California' >California<\/option><option value='Colorado' >Colorado<\/option><option value='Connecticut' >Connecticut<\/option><option value='Delaware' >Delaware<\/option><option value='District of Columbia' >District of Columbia<\/option><option value='Florida' >Florida<\/option><option value='Georgia' >Georgia<\/option><option value='Hawaii' >Hawaii<\/option><option value='Idaho' >Idaho<\/option><option value='Illinois' >Illinois<\/option><option value='Indiana' >Indiana<\/option><option value='Iowa' >Iowa<\/option><option value='Kansas' >Kansas<\/option><option value='Kentucky' >Kentucky<\/option><option value='Louisiana' >Louisiana<\/option><option value='Maine' >Maine<\/option><option value='Maryland' >Maryland<\/option><option value='Massachusetts' >Massachusetts<\/option><option value='Michigan' >Michigan<\/option><option value='Minnesota' >Minnesota<\/option><option value='Mississippi' >Mississippi<\/option><option value='Missouri' >Missouri<\/option><option value='Montana' >Montana<\/option><option value='Nebraska' >Nebraska<\/option><option value='Nevada' >Nevada<\/option><option value='New Hampshire' >New Hampshire<\/option><option value='New Jersey' >New Jersey<\/option><option value='New Mexico' >New Mexico<\/option><option value='New York' >New York<\/option><option value='North Carolina' >North Carolina<\/option><option value='North Dakota' >North Dakota<\/option><option value='Ohio' >Ohio<\/option><option value='Oklahoma' >Oklahoma<\/option><option value='Oregon' >Oregon<\/option><option value='Pennsylvania' >Pennsylvania<\/option><option value='Rhode Island' >Rhode Island<\/option><option value='South Carolina' >South Carolina<\/option><option value='South Dakota' >South Dakota<\/option><option value='Tennessee' >Tennessee<\/option><option value='Texas' >Texas<\/option><option value='Utah' >Utah<\/option><option value='Vermont' >Vermont<\/option><option value='Virginia' >Virginia<\/option><option value='Washington' >Washington<\/option><option value='West Virginia' >West Virginia<\/option><option value='Wisconsin' >Wisconsin<\/option><option value='Wyoming' >Wyoming<\/option><option value='I live in a U.S. Territory' >I live in a U.S. Territory<\/option><\/select><\/div><\/div><div id=\"field_87_80\" class=\"gfield gfield--type-select gfield--input-type-select gfield--width-full optional field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_87_80'>What country do you live in?<\/label><div class='ginput_container ginput_container_select'><select name='input_80' id='input_87_80' class='medium gfield_select'     aria-invalid=\"false\" ><option value='' ><\/option><option value='Afghanistan' >Afghanistan<\/option><option value='Albania' >Albania<\/option><option value='Algeria' >Algeria<\/option><option value='American Samoa' >American Samoa<\/option><option value='Andorra' >Andorra<\/option><option value='Angola' >Angola<\/option><option value='Anguilla' >Anguilla<\/option><option value='Antarctica' >Antarctica<\/option><option value='Antigua and Barbuda' >Antigua and Barbuda<\/option><option value='Argentina' >Argentina<\/option><option value='Armenia' >Armenia<\/option><option value='Aruba' >Aruba<\/option><option value='Australia' >Australia<\/option><option value='Austria' >Austria<\/option><option value='Azerbaijan' >Azerbaijan<\/option><option value='Bahamas' >Bahamas<\/option><option value='Bahrain' >Bahrain<\/option><option value='Bangladesh' >Bangladesh<\/option><option value='Barbados' >Barbados<\/option><option value='Belarus' >Belarus<\/option><option value='Belgium' >Belgium<\/option><option value='Belize' >Belize<\/option><option value='Benin' >Benin<\/option><option value='Bermuda' >Bermuda<\/option><option value='Bhutan' >Bhutan<\/option><option value='Bolivia' >Bolivia<\/option><option value='Bonaire, Sint Eustatius and Saba' >Bonaire, Sint Eustatius and Saba<\/option><option value='Bosnia and Herzegovina' >Bosnia and Herzegovina<\/option><option value='Botswana' >Botswana<\/option><option value='Bouvet Island' >Bouvet Island<\/option><option value='Brazil' >Brazil<\/option><option value='British Indian Ocean Territory' >British Indian Ocean Territory<\/option><option value='Brunei Darussalam' >Brunei Darussalam<\/option><option value='Bulgaria' >Bulgaria<\/option><option value='Burkina Faso' >Burkina Faso<\/option><option value='Burundi' >Burundi<\/option><option value='Cambodia' >Cambodia<\/option><option value='Cameroon' >Cameroon<\/option><option value='Canada' >Canada<\/option><option value='Cape Verde' >Cape Verde<\/option><option value='Cayman Islands' >Cayman Islands<\/option><option value='Central African Republic' >Central African Republic<\/option><option value='Chad' >Chad<\/option><option value='Chile' >Chile<\/option><option value='China' >China<\/option><option value='Christmas Island' >Christmas Island<\/option><option value='Cocos Islands' >Cocos Islands<\/option><option value='Colombia' >Colombia<\/option><option value='Comoros' >Comoros<\/option><option value='Congo, Democratic Republic of the' >Congo, Democratic Republic of the<\/option><option value='Congo, Republic of the' >Congo, Republic of the<\/option><option value='Cook Islands' >Cook Islands<\/option><option value='Costa Rica' >Costa Rica<\/option><option value='Croatia' >Croatia<\/option><option value='Cuba' >Cuba<\/option><option value='Cura\u00e7ao' >Cura\u00e7ao<\/option><option value='Cyprus' >Cyprus<\/option><option value='Czech Republic' >Czech Republic<\/option><option value='C\u00f4te d&#039;Ivoire' >C\u00f4te d&#039;Ivoire<\/option><option value='Denmark' >Denmark<\/option><option value='Djibouti' >Djibouti<\/option><option value='Dominica' >Dominica<\/option><option value='Dominican Republic' >Dominican Republic<\/option><option value='Ecuador' >Ecuador<\/option><option value='Egypt' >Egypt<\/option><option value='El Salvador' >El Salvador<\/option><option value='Equatorial Guinea' >Equatorial Guinea<\/option><option value='Eritrea' >Eritrea<\/option><option value='Estonia' >Estonia<\/option><option value='Eswatini (Swaziland)' >Eswatini (Swaziland)<\/option><option value='Ethiopia' >Ethiopia<\/option><option value='Falkland Islands' >Falkland Islands<\/option><option value='Faroe Islands' >Faroe Islands<\/option><option value='Fiji' >Fiji<\/option><option value='Finland' >Finland<\/option><option value='France' >France<\/option><option value='French Guiana' >French Guiana<\/option><option value='French Polynesia' >French Polynesia<\/option><option value='French Southern Territories' >French Southern Territories<\/option><option value='Gabon' >Gabon<\/option><option value='Gambia' >Gambia<\/option><option value='Georgia' >Georgia<\/option><option value='Germany' >Germany<\/option><option value='Ghana' >Ghana<\/option><option value='Gibraltar' >Gibraltar<\/option><option value='Greece' >Greece<\/option><option value='Greenland' >Greenland<\/option><option value='Grenada' >Grenada<\/option><option value='Guadeloupe' >Guadeloupe<\/option><option value='Guam' >Guam<\/option><option value='Guatemala' >Guatemala<\/option><option value='Guernsey' >Guernsey<\/option><option value='Guinea' >Guinea<\/option><option value='Guinea-Bissau' >Guinea-Bissau<\/option><option value='Guyana' >Guyana<\/option><option value='Haiti' >Haiti<\/option><option value='Heard and McDonald Islands' >Heard and McDonald Islands<\/option><option value='Holy See' >Holy See<\/option><option value='Honduras' >Honduras<\/option><option value='Hong Kong' >Hong Kong<\/option><option value='Hungary' >Hungary<\/option><option value='Iceland' >Iceland<\/option><option value='India' >India<\/option><option value='Indonesia' >Indonesia<\/option><option value='Iran' >Iran<\/option><option value='Iraq' >Iraq<\/option><option value='Ireland' >Ireland<\/option><option value='Isle of Man' >Isle of Man<\/option><option value='Israel' >Israel<\/option><option value='Italy' >Italy<\/option><option value='Jamaica' >Jamaica<\/option><option value='Japan' >Japan<\/option><option value='Jersey' >Jersey<\/option><option value='Jordan' >Jordan<\/option><option value='Kazakhstan' >Kazakhstan<\/option><option value='Kenya' >Kenya<\/option><option value='Kiribati' >Kiribati<\/option><option value='Kuwait' >Kuwait<\/option><option value='Kyrgyzstan' >Kyrgyzstan<\/option><option value='Lao People&#039;s Democratic Republic' >Lao People&#039;s Democratic Republic<\/option><option value='Latvia' >Latvia<\/option><option value='Lebanon' >Lebanon<\/option><option value='Lesotho' >Lesotho<\/option><option value='Liberia' >Liberia<\/option><option value='Libya' >Libya<\/option><option value='Liechtenstein' >Liechtenstein<\/option><option value='Lithuania' >Lithuania<\/option><option value='Luxembourg' >Luxembourg<\/option><option value='Macau' >Macau<\/option><option value='Macedonia' >Macedonia<\/option><option value='Madagascar' >Madagascar<\/option><option value='Malawi' >Malawi<\/option><option value='Malaysia' >Malaysia<\/option><option value='Maldives' >Maldives<\/option><option value='Mali' >Mali<\/option><option value='Malta' >Malta<\/option><option value='Marshall Islands' >Marshall Islands<\/option><option value='Martinique' >Martinique<\/option><option value='Mauritania' >Mauritania<\/option><option value='Mauritius' >Mauritius<\/option><option value='Mayotte' >Mayotte<\/option><option value='Mexico' >Mexico<\/option><option value='Micronesia' >Micronesia<\/option><option value='Moldova' >Moldova<\/option><option value='Monaco' >Monaco<\/option><option value='Mongolia' >Mongolia<\/option><option value='Montenegro' >Montenegro<\/option><option value='Montserrat' >Montserrat<\/option><option value='Morocco' >Morocco<\/option><option value='Mozambique' >Mozambique<\/option><option value='Myanmar' >Myanmar<\/option><option value='Namibia' >Namibia<\/option><option value='Nauru' >Nauru<\/option><option value='Nepal' >Nepal<\/option><option value='Netherlands' >Netherlands<\/option><option value='New Caledonia' >New Caledonia<\/option><option value='New Zealand' >New Zealand<\/option><option value='Nicaragua' >Nicaragua<\/option><option value='Niger' >Niger<\/option><option value='Nigeria' >Nigeria<\/option><option value='Niue' >Niue<\/option><option value='Norfolk Island' >Norfolk Island<\/option><option value='North Korea' >North Korea<\/option><option value='Northern Mariana Islands' >Northern Mariana Islands<\/option><option value='Norway' >Norway<\/option><option value='Oman' >Oman<\/option><option value='Pakistan' >Pakistan<\/option><option value='Palau' >Palau<\/option><option value='Palestine, State of' >Palestine, State of<\/option><option value='Panama' >Panama<\/option><option value='Papua New Guinea' >Papua New Guinea<\/option><option value='Paraguay' >Paraguay<\/option><option value='Peru' >Peru<\/option><option value='Philippines' >Philippines<\/option><option value='Pitcairn' >Pitcairn<\/option><option value='Poland' >Poland<\/option><option value='Portugal' >Portugal<\/option><option value='Puerto Rico' >Puerto Rico<\/option><option value='Qatar' >Qatar<\/option><option value='Romania' >Romania<\/option><option value='Russia' >Russia<\/option><option value='Rwanda' >Rwanda<\/option><option value='R\u00e9union' >R\u00e9union<\/option><option value='Saint Barth\u00e9lemy' >Saint Barth\u00e9lemy<\/option><option value='Saint Helena' >Saint Helena<\/option><option value='Saint Kitts and Nevis' >Saint Kitts and Nevis<\/option><option value='Saint Lucia' >Saint Lucia<\/option><option value='Saint Martin' >Saint Martin<\/option><option value='Saint Pierre and Miquelon' >Saint Pierre and Miquelon<\/option><option value='Saint Vincent and the Grenadines' >Saint Vincent and the Grenadines<\/option><option value='Samoa' >Samoa<\/option><option value='San Marino' >San Marino<\/option><option value='Sao Tome and Principe' >Sao Tome and Principe<\/option><option value='Saudi Arabia' >Saudi Arabia<\/option><option value='Senegal' >Senegal<\/option><option value='Serbia' >Serbia<\/option><option value='Seychelles' >Seychelles<\/option><option value='Sierra Leone' >Sierra Leone<\/option><option value='Singapore' >Singapore<\/option><option value='Sint Maarten' >Sint Maarten<\/option><option value='Slovakia' >Slovakia<\/option><option value='Slovenia' >Slovenia<\/option><option value='Solomon Islands' >Solomon Islands<\/option><option value='Somalia' >Somalia<\/option><option value='South Africa' >South Africa<\/option><option value='South Georgia' >South Georgia<\/option><option value='South Korea' >South Korea<\/option><option value='South Sudan' >South Sudan<\/option><option value='Spain' >Spain<\/option><option value='Sri Lanka' >Sri Lanka<\/option><option value='Sudan' >Sudan<\/option><option value='Suriname' >Suriname<\/option><option value='Svalbard and Jan Mayen Islands' >Svalbard and Jan Mayen Islands<\/option><option value='Sweden' >Sweden<\/option><option value='Switzerland' >Switzerland<\/option><option value='Syria' >Syria<\/option><option value='Taiwan' >Taiwan<\/option><option value='Tajikistan' >Tajikistan<\/option><option value='Tanzania' >Tanzania<\/option><option value='Thailand' >Thailand<\/option><option value='Timor-Leste' >Timor-Leste<\/option><option value='Togo' >Togo<\/option><option value='Tokelau' >Tokelau<\/option><option value='Tonga' >Tonga<\/option><option value='Trinidad and Tobago' >Trinidad and Tobago<\/option><option value='Tunisia' >Tunisia<\/option><option value='Turkey' >Turkey<\/option><option value='Turkmenistan' >Turkmenistan<\/option><option value='Turks and Caicos Islands' >Turks and Caicos Islands<\/option><option value='Tuvalu' >Tuvalu<\/option><option value='US Minor Outlying Islands' >US Minor Outlying Islands<\/option><option value='Uganda' >Uganda<\/option><option value='Ukraine' >Ukraine<\/option><option value='United Arab Emirates' >United Arab Emirates<\/option><option value='United Kingdom' >United Kingdom<\/option><option value='Uruguay' >Uruguay<\/option><option value='Uzbekistan' >Uzbekistan<\/option><option value='Vanuatu' >Vanuatu<\/option><option value='Venezuela' >Venezuela<\/option><option value='Vietnam' >Vietnam<\/option><option value='Virgin Islands, British' >Virgin Islands, British<\/option><option value='Virgin Islands, U.S.' >Virgin Islands, U.S.<\/option><option value='Wallis and Futuna' >Wallis and Futuna<\/option><option value='Western Sahara' >Western Sahara<\/option><option value='Yemen' >Yemen<\/option><option value='Zambia' >Zambia<\/option><option value='Zimbabwe' >Zimbabwe<\/option><option value='\u00c5land Islands' >\u00c5land Islands<\/option><\/select><\/div><\/div><fieldset id=\"field_87_109\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield--input-type-checkbox gfield--width-full traditional gfield_contains_required field_sublabel_below gfield--has-description field_description_above field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Do you live with any of the following disabilities or conditions?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class='gfield_description' id='gfield_description_87_109'>Select all that apply.<\/div><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox ' id='input_87_109'><div class='gchoice gchoice_87_109_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_109.1' type='checkbox'  value='Blind\/Low vision'  id='choice_87_109_1'   aria-describedby=\"gfield_description_87_109\"\/>\n\t\t\t\t\t\t\t\t<label for='choice_87_109_1' id='label_87_109_1' class='gform-field-label gform-field-label--type-inline'>Blind\/Low vision<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_87_109_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_109.2' type='checkbox'  value='Hearing impairment'  id='choice_87_109_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_87_109_2' id='label_87_109_2' class='gform-field-label gform-field-label--type-inline'>Hearing impairment<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_87_109_3'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_109.3' type='checkbox'  value='Limited Mobility'  id='choice_87_109_3'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_87_109_3' id='label_87_109_3' class='gform-field-label gform-field-label--type-inline'>Limited Mobility<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_87_109_4'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_109.4' type='checkbox'  value='Arthritis or other chronic pain'  id='choice_87_109_4'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_87_109_4' id='label_87_109_4' 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_87_109_5'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_109.5' type='checkbox'  value='Anxiety'  id='choice_87_109_5'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_87_109_5' id='label_87_109_5' class='gform-field-label gform-field-label--type-inline'>Anxiety<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_87_109_6'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_109.6' type='checkbox'  value='Mood conditions: depression or bipolar'  id='choice_87_109_6'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_87_109_6' id='label_87_109_6' class='gform-field-label gform-field-label--type-inline'>Mood conditions: depression or bipolar<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_87_109_7'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_109.7' type='checkbox'  value='Autism spectrum and\/or ADHD'  id='choice_87_109_7'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_87_109_7' id='label_87_109_7' class='gform-field-label gform-field-label--type-inline'>Autism spectrum and\/or ADHD<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_87_109_8'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_109.8' type='checkbox'  value='Intellectual or learning disability'  id='choice_87_109_8'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_87_109_8' id='label_87_109_8' class='gform-field-label gform-field-label--type-inline'>Intellectual or learning disability<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_87_109_9'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_109.9' type='checkbox'  value='Neurological condition (epilepsy, etc.) or traumatic brain injury (TBI)'  id='choice_87_109_9'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_87_109_9' id='label_87_109_9' class='gform-field-label gform-field-label--type-inline'>Neurological condition (epilepsy, etc.) or traumatic brain injury (TBI)<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_87_109_11'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_109.11' type='checkbox'  value='None of the above'  id='choice_87_109_11'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_87_109_11' id='label_87_109_11' class='gform-field-label gform-field-label--type-inline'>None of the above<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_87_109_12'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_109.12' type='checkbox'  value='Other mental health condition...'  id='choice_87_109_12'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_87_109_12' id='label_87_109_12' class='gform-field-label gform-field-label--type-inline'>Other mental health condition...<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_87_109_13'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_109.13' type='checkbox'  value='Other...'  id='choice_87_109_13'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_87_109_13' id='label_87_109_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_87_111\" 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_87_111'>What other mental health conditions do you have?<\/label><div class='ginput_container ginput_container_text'><input name='input_111' id='input_87_111' type='text' value='' class='medium'    placeholder='Tell us more...'  aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_87_112\" 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_87_112'>What other disabilities or conditions do you 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de TOC"},"content":{"rendered":"\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_84' style='display:none'>\n                        <div class='gform_heading'>\n                            <h2 class=\"gform_title\">OCD Test<\/h2>\n                            <p class='gform_description'><\/p>\n\t\t\t\t\t\t\t<p class='gform_required_legend'>&quot;<span class=\"gfield_required gfield_required_asterisk\">*<\/span>&quot; indicates required fields<\/p>\n                        <\/div><form method='post' enctype='multipart\/form-data'  id='gform_84'  class='clearfix' action='\/es\/wp-json\/wp\/v2\/screen' data-formid='84' 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_84_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_84' class='gform_fields top_label form_sublabel_below description_above validation_below'><div id=\"field_84_139\" 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_84_139'>URL<\/label><div class='gfield_description' id='gfield_description_84_139'>This field is for validation purposes and should be left unchanged.<\/div><div class='ginput_container'><input name='input_139' id='input_84_139' type='text' value='' autocomplete='new-password'\/><\/div><\/div><div id=\"field_84_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_84_38' type='hidden' class='gform_hidden'  aria-invalid=\"false\" value='' \/><\/div><\/div><div id=\"field_84_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_84_39\" type=\"hidden\" class=\"gform_hidden\" aria-invalid=\"false\" value=\"245905\"><\/div><div id=\"field_84_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_84_40\" type=\"hidden\" class=\"gform_hidden\" aria-invalid=\"false\" value=\"34c0972926eed1ef42815dc87b83c969\"><\/div><div id=\"field_84_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_84_41' type='hidden' class='gform_hidden'  aria-invalid=\"false\" value='' \/><\/div><\/div><div id=\"field_84_47\" 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_47' id='input_84_47' type='hidden' class='gform_hidden'  aria-invalid=\"false\" value='http:\/\/screening.mhanational.org\/es\/wp-json\/wp\/v2\/screen' \/><\/div><\/div><div id=\"field_84_58\" 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_58' id='input_84_58' type='hidden' class='gform_hidden'  aria-invalid=\"false\" value='' \/><\/div><\/div><div id=\"field_84_59\" 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_59' id='input_84_59' type='hidden' class='gform_hidden'  aria-invalid=\"false\" value='' \/><\/div><\/div><div id=\"field_84_60\" 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_60' id='input_84_60' type='hidden' class='gform_hidden'  aria-invalid=\"false\" value='' \/><\/div><\/div><div id=\"field_84_73\" 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_73' id='input_84_73' type='hidden' class='gform_hidden'  aria-invalid=\"false\" value='' \/><\/div><\/div><div id=\"field_84_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_84_99' type='hidden' class='gform_hidden'  aria-invalid=\"false\" value='https:\/\/screening.mhanational.org\/es\/wp-json\/wp\/v2\/screen' \/><\/div><\/div><div id=\"field_84_136\" 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_136' id='input_84_136' type='hidden' class='gform_hidden'  aria-invalid=\"false\" value='lang--es' \/><\/div><\/div><div id=\"field_84_104\" class=\"gfield gfield--type-html gfield--input-type-html gfield--width-full gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><p>Some people have times when one thought or idea comes into their mind over and over again. When people have these thoughts they usually get upset because the thoughts are strange. No matter how hard they try, the thoughts keep coming back.<\/p>\n<p>Now we're going to ask you if you have had thoughts like these in the last three months.<\/p>\n<\/div><div id=\"field_84_105\" class=\"gfield gfield--type-html gfield--input-type-html gfield--width-full 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>In the last 3 months...<\/h2>\n<\/div><fieldset id=\"field_84_101\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >Have you had to count things over and over again or make yourself do things a certain number of times?<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_84_101'>\n\t\t\t<div class='gchoice gchoice_84_101_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_101' type='radio' value='1'  id='choice_84_101_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_84_101_0' id='label_84_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_84_101_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_101' type='radio' value='0'  id='choice_84_101_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_84_101_1' id='label_84_101_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_84_106\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >Was there a time when you washed your hands or body over and over again or changed your clothes many times each day because you thought they were dirty?<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_84_106'>\n\t\t\t<div class='gchoice gchoice_84_106_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_106' type='radio' value='1'  id='choice_84_106_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_84_106_0' id='label_84_106_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_84_106_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_106' type='radio' value='0'  id='choice_84_106_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_84_106_1' id='label_84_106_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_84_107\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >Have you often felt you should check on things over and over again?  For example, checking that the front door is locked, or the stove is turned off, or that something else was done even though you knew it had been done?<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_84_107'>\n\t\t\t<div class='gchoice gchoice_84_107_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_107' type='radio' value='1'  id='choice_84_107_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_84_107_0' id='label_84_107_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_84_107_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_107' type='radio' value='0'  id='choice_84_107_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_84_107_1' id='label_84_107_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_84_108\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >Have you often worried over and over again that things you touch are dirty or have germs?<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_84_108'>\n\t\t\t<div class='gchoice gchoice_84_108_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_108' type='radio' value='1'  id='choice_84_108_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_84_108_0' id='label_84_108_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_84_108_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_108' type='radio' value='0'  id='choice_84_108_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_84_108_1' id='label_84_108_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_84_109\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >Have you had any other thoughts that kept coming into your mind over and over again that you couldn&#039;t get rid of?<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_84_109'>\n\t\t\t<div class='gchoice gchoice_84_109_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_109' type='radio' value='1'  id='choice_84_109_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_84_109_0' id='label_84_109_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_84_109_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_109' type='radio' value='0'  id='choice_84_109_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_84_109_1' id='label_84_109_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_84_138\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >Have you done things like counting, checking, washing, over and over again because you like to do these 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_84_138'>\n\t\t\t<div class='gchoice gchoice_84_138_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_138' type='radio' value='1'  id='choice_84_138_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_84_138_0' id='label_84_138_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_84_138_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_138' type='radio' value='0'  id='choice_84_138_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_84_138_1' id='label_84_138_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_84_113\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >Have you done things like counting, checking, washing, over and over again, only because you&#039;ve been told by someone else to make sure that you&#039;ve done them right?<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_84_113'>\n\t\t\t<div class='gchoice gchoice_84_113_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_113' type='radio' value='1'  id='choice_84_113_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_84_113_0' id='label_84_113_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_84_113_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_113' type='radio' value='0'  id='choice_84_113_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_84_113_1' id='label_84_113_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_84_115\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >Have you wished you could stop yourself from doing things like counting, checking or washing over and over again?<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_84_115'>\n\t\t\t<div class='gchoice gchoice_84_115_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_115' type='radio' value='1'  id='choice_84_115_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_84_115_0' id='label_84_115_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_84_115_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_115' type='radio' value='0'  id='choice_84_115_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_84_115_1' id='label_84_115_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_84_116\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >Have you spent a lot of time each day doing things like counting, checking or washing over and over again ... say, for as long as an hour?<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_84_116'>\n\t\t\t<div class='gchoice gchoice_84_116_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_116' type='radio' value='1'  id='choice_84_116_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_84_116_0' id='label_84_116_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_84_116_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_116' type='radio' value='0'  id='choice_84_116_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_84_116_1' id='label_84_116_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_84_94\" class=\"gfield gfield--type-html gfield--input-type-html gfield--width-full 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\"  ><hr class=\"layout-action show-actions_b\" \/>\n\n<p>The following statements refer to experiences that many people have in their everyday lives. Select the option that best describes <strong>how much that experience has distressed or bothered you<\/strong> during the past month.<\/p>\n\n<h2>During the past month...<\/h2><\/div><fieldset id=\"field_84_5\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio question 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' >1. I have saved up so many things that they get in the way.<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_84_5'>\n\t\t\t<div class='gchoice gchoice_84_5_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_5' type='radio' value='0'  id='choice_84_5_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_84_5_0' id='label_84_5_0' class='gform-field-label gform-field-label--type-inline'>Not at all<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_84_5_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_5' type='radio' value='1'  id='choice_84_5_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_84_5_1' id='label_84_5_1' class='gform-field-label gform-field-label--type-inline'>A little<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_84_5_2'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_5' type='radio' value='2'  id='choice_84_5_2' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_84_5_2' id='label_84_5_2' class='gform-field-label gform-field-label--type-inline'>Moderately<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_84_5_3'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_5' type='radio' value='3'  id='choice_84_5_3' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_84_5_3' id='label_84_5_3' class='gform-field-label gform-field-label--type-inline'>A lot<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_84_5_4'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_5' type='radio' value='4'  id='choice_84_5_4' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_84_5_4' id='label_84_5_4' class='gform-field-label gform-field-label--type-inline'>Extremely<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_84_75\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-full 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' >2. I check things more often than necessary.<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_84_75'>\n\t\t\t<div class='gchoice gchoice_84_75_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_75' type='radio' value='0'  id='choice_84_75_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_84_75_0' id='label_84_75_0' class='gform-field-label gform-field-label--type-inline'>Not at all<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_84_75_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_75' type='radio' value='1'  id='choice_84_75_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_84_75_1' id='label_84_75_1' class='gform-field-label gform-field-label--type-inline'>A little<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_84_75_2'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_75' type='radio' value='2'  id='choice_84_75_2' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_84_75_2' id='label_84_75_2' class='gform-field-label gform-field-label--type-inline'>Moderately<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_84_75_3'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_75' type='radio' value='3'  id='choice_84_75_3' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_84_75_3' id='label_84_75_3' class='gform-field-label gform-field-label--type-inline'>A lot<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_84_75_4'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_75' type='radio' value='4'  id='choice_84_75_4' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_84_75_4' id='label_84_75_4' class='gform-field-label gform-field-label--type-inline'>Extremely<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_84_76\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-full 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 get upset if objects are not arranged properly.<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_84_76'>\n\t\t\t<div class='gchoice gchoice_84_76_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_76' type='radio' value='0'  id='choice_84_76_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_84_76_0' id='label_84_76_0' class='gform-field-label gform-field-label--type-inline'>Not at all<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_84_76_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_76' type='radio' value='1'  id='choice_84_76_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_84_76_1' id='label_84_76_1' class='gform-field-label gform-field-label--type-inline'>A little<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_84_76_2'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_76' type='radio' value='2'  id='choice_84_76_2' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_84_76_2' id='label_84_76_2' class='gform-field-label gform-field-label--type-inline'>Moderately<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_84_76_3'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_76' type='radio' value='3'  id='choice_84_76_3' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_84_76_3' id='label_84_76_3' class='gform-field-label gform-field-label--type-inline'>A lot<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_84_76_4'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_76' type='radio' value='4'  id='choice_84_76_4' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_84_76_4' id='label_84_76_4' class='gform-field-label gform-field-label--type-inline'>Extremely<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_84_77\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-full 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 feel compelled to count while I am doing 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_84_77'>\n\t\t\t<div class='gchoice gchoice_84_77_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_77' type='radio' value='0'  id='choice_84_77_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_84_77_0' id='label_84_77_0' class='gform-field-label gform-field-label--type-inline'>Not at all<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_84_77_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_77' type='radio' value='1'  id='choice_84_77_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_84_77_1' id='label_84_77_1' class='gform-field-label gform-field-label--type-inline'>A little<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_84_77_2'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_77' type='radio' value='2'  id='choice_84_77_2' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_84_77_2' id='label_84_77_2' class='gform-field-label gform-field-label--type-inline'>Moderately<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_84_77_3'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_77' type='radio' value='3'  id='choice_84_77_3' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_84_77_3' id='label_84_77_3' class='gform-field-label gform-field-label--type-inline'>A lot<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_84_77_4'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_77' type='radio' value='4'  id='choice_84_77_4' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_84_77_4' id='label_84_77_4' class='gform-field-label gform-field-label--type-inline'>Extremely<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_84_78\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-full 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 find it difficult to touch an object when I know it has been touched by strangers or certain people.<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_84_78'>\n\t\t\t<div class='gchoice gchoice_84_78_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_78' type='radio' value='0'  id='choice_84_78_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_84_78_0' id='label_84_78_0' class='gform-field-label gform-field-label--type-inline'>Not at all<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_84_78_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_78' type='radio' value='1'  id='choice_84_78_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_84_78_1' id='label_84_78_1' class='gform-field-label gform-field-label--type-inline'>A little<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_84_78_2'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_78' type='radio' value='2'  id='choice_84_78_2' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_84_78_2' id='label_84_78_2' class='gform-field-label gform-field-label--type-inline'>Moderately<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_84_78_3'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_78' type='radio' value='3'  id='choice_84_78_3' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_84_78_3' id='label_84_78_3' class='gform-field-label gform-field-label--type-inline'>A lot<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_84_78_4'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_78' type='radio' value='4'  id='choice_84_78_4' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_84_78_4' id='label_84_78_4' class='gform-field-label gform-field-label--type-inline'>Extremely<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_84_79\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-full 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' >6. I find it difficult to control my own thoughts.<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_84_79'>\n\t\t\t<div class='gchoice gchoice_84_79_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_79' type='radio' value='0'  id='choice_84_79_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_84_79_0' id='label_84_79_0' class='gform-field-label gform-field-label--type-inline'>Not at all<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_84_79_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_79' type='radio' value='1'  id='choice_84_79_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_84_79_1' id='label_84_79_1' class='gform-field-label gform-field-label--type-inline'>A little<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_84_79_2'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_79' type='radio' value='2'  id='choice_84_79_2' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_84_79_2' id='label_84_79_2' class='gform-field-label gform-field-label--type-inline'>Moderately<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_84_79_3'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_79' type='radio' value='3'  id='choice_84_79_3' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_84_79_3' id='label_84_79_3' class='gform-field-label gform-field-label--type-inline'>A lot<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_84_79_4'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_79' type='radio' value='4'  id='choice_84_79_4' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_84_79_4' id='label_84_79_4' class='gform-field-label gform-field-label--type-inline'>Extremely<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_84_80\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-full question 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' >7. I collect things I don\u2019t need.<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_84_80'>\n\t\t\t<div class='gchoice gchoice_84_80_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_80' type='radio' value='0'  id='choice_84_80_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_84_80_0' id='label_84_80_0' class='gform-field-label gform-field-label--type-inline'>Not at all<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_84_80_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_80' type='radio' value='1'  id='choice_84_80_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_84_80_1' id='label_84_80_1' class='gform-field-label gform-field-label--type-inline'>A little<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_84_80_2'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_80' type='radio' value='2'  id='choice_84_80_2' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_84_80_2' id='label_84_80_2' class='gform-field-label gform-field-label--type-inline'>Moderately<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_84_80_3'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_80' type='radio' value='3'  id='choice_84_80_3' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_84_80_3' id='label_84_80_3' class='gform-field-label gform-field-label--type-inline'>A lot<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_84_80_4'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_80' type='radio' value='4'  id='choice_84_80_4' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_84_80_4' id='label_84_80_4' class='gform-field-label gform-field-label--type-inline'>Extremely<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_84_81\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-full 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 repeatedly check doors, windows, drawers, etc.<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_84_81'>\n\t\t\t<div class='gchoice gchoice_84_81_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_81' type='radio' value='0'  id='choice_84_81_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_84_81_0' id='label_84_81_0' class='gform-field-label gform-field-label--type-inline'>Not at all<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_84_81_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_81' type='radio' value='1'  id='choice_84_81_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_84_81_1' id='label_84_81_1' class='gform-field-label gform-field-label--type-inline'>A little<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_84_81_2'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_81' type='radio' value='2'  id='choice_84_81_2' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_84_81_2' id='label_84_81_2' class='gform-field-label gform-field-label--type-inline'>Moderately<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_84_81_3'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_81' type='radio' value='3'  id='choice_84_81_3' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_84_81_3' id='label_84_81_3' class='gform-field-label gform-field-label--type-inline'>A lot<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_84_81_4'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_81' type='radio' value='4'  id='choice_84_81_4' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_84_81_4' id='label_84_81_4' class='gform-field-label gform-field-label--type-inline'>Extremely<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_84_82\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-full 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 get upset if others change the way I have arranged 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_84_82'>\n\t\t\t<div class='gchoice gchoice_84_82_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_82' type='radio' value='0'  id='choice_84_82_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_84_82_0' id='label_84_82_0' class='gform-field-label gform-field-label--type-inline'>Not at all<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_84_82_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_82' type='radio' value='1'  id='choice_84_82_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_84_82_1' id='label_84_82_1' class='gform-field-label gform-field-label--type-inline'>A little<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_84_82_2'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_82' type='radio' value='2'  id='choice_84_82_2' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_84_82_2' id='label_84_82_2' class='gform-field-label gform-field-label--type-inline'>Moderately<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_84_82_3'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_82' type='radio' value='3'  id='choice_84_82_3' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_84_82_3' id='label_84_82_3' class='gform-field-label gform-field-label--type-inline'>A lot<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_84_82_4'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_82' type='radio' value='4'  id='choice_84_82_4' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_84_82_4' id='label_84_82_4' class='gform-field-label gform-field-label--type-inline'>Extremely<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_84_83\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-full 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' >10. I feel I have to repeat certain numbers.<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_84_83'>\n\t\t\t<div class='gchoice gchoice_84_83_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_83' type='radio' value='0'  id='choice_84_83_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_84_83_0' id='label_84_83_0' class='gform-field-label gform-field-label--type-inline'>Not at all<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_84_83_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_83' type='radio' value='1'  id='choice_84_83_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_84_83_1' id='label_84_83_1' class='gform-field-label gform-field-label--type-inline'>A little<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_84_83_2'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_83' type='radio' value='2'  id='choice_84_83_2' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_84_83_2' id='label_84_83_2' class='gform-field-label gform-field-label--type-inline'>Moderately<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_84_83_3'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_83' type='radio' value='3'  id='choice_84_83_3' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_84_83_3' id='label_84_83_3' class='gform-field-label gform-field-label--type-inline'>A lot<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_84_83_4'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_83' type='radio' value='4'  id='choice_84_83_4' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_84_83_4' id='label_84_83_4' class='gform-field-label gform-field-label--type-inline'>Extremely<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_84_84\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-full 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' >11. I sometimes have to wash or clean myself simply because I feel contaminated.<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_84_84'>\n\t\t\t<div class='gchoice gchoice_84_84_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_84' type='radio' value='0'  id='choice_84_84_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_84_84_0' id='label_84_84_0' class='gform-field-label gform-field-label--type-inline'>Not at all<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_84_84_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_84' type='radio' value='1'  id='choice_84_84_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_84_84_1' id='label_84_84_1' class='gform-field-label gform-field-label--type-inline'>A little<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_84_84_2'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_84' type='radio' value='2'  id='choice_84_84_2' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_84_84_2' id='label_84_84_2' class='gform-field-label gform-field-label--type-inline'>Moderately<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_84_84_3'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_84' type='radio' value='3'  id='choice_84_84_3' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_84_84_3' id='label_84_84_3' class='gform-field-label gform-field-label--type-inline'>A lot<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_84_84_4'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_84' type='radio' value='4'  id='choice_84_84_4' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_84_84_4' id='label_84_84_4' class='gform-field-label gform-field-label--type-inline'>Extremely<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_84_85\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-full 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' >12. I am upset by unpleasant thoughts that come into my mind against my will.<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_84_85'>\n\t\t\t<div class='gchoice gchoice_84_85_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_85' type='radio' value='0'  id='choice_84_85_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_84_85_0' id='label_84_85_0' class='gform-field-label gform-field-label--type-inline'>Not at all<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_84_85_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_85' type='radio' value='1'  id='choice_84_85_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_84_85_1' id='label_84_85_1' class='gform-field-label gform-field-label--type-inline'>A little<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_84_85_2'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_85' type='radio' value='2'  id='choice_84_85_2' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_84_85_2' id='label_84_85_2' class='gform-field-label gform-field-label--type-inline'>Moderately<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_84_85_3'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_85' type='radio' value='3'  id='choice_84_85_3' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_84_85_3' id='label_84_85_3' class='gform-field-label gform-field-label--type-inline'>A lot<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_84_85_4'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_85' type='radio' value='4'  id='choice_84_85_4' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_84_85_4' id='label_84_85_4' class='gform-field-label gform-field-label--type-inline'>Extremely<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_84_86\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-full question 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' >13. I avoid throwing things away because I am afraid I might need them later.<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_84_86'>\n\t\t\t<div class='gchoice gchoice_84_86_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_86' type='radio' value='0'  id='choice_84_86_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_84_86_0' id='label_84_86_0' class='gform-field-label gform-field-label--type-inline'>Not at all<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_84_86_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_86' type='radio' value='1'  id='choice_84_86_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_84_86_1' id='label_84_86_1' class='gform-field-label gform-field-label--type-inline'>A little<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_84_86_2'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_86' type='radio' value='2'  id='choice_84_86_2' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_84_86_2' id='label_84_86_2' class='gform-field-label gform-field-label--type-inline'>Moderately<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_84_86_3'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_86' type='radio' value='3'  id='choice_84_86_3' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_84_86_3' id='label_84_86_3' class='gform-field-label gform-field-label--type-inline'>A lot<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_84_86_4'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_86' type='radio' value='4'  id='choice_84_86_4' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_84_86_4' id='label_84_86_4' class='gform-field-label gform-field-label--type-inline'>Extremely<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_84_87\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-full 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' >14. I repeatedly check gas and water taps and light switches after turning them off.<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_84_87'>\n\t\t\t<div class='gchoice gchoice_84_87_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_87' type='radio' value='0'  id='choice_84_87_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_84_87_0' id='label_84_87_0' class='gform-field-label gform-field-label--type-inline'>Not at all<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_84_87_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_87' type='radio' value='1'  id='choice_84_87_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_84_87_1' id='label_84_87_1' class='gform-field-label gform-field-label--type-inline'>A little<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_84_87_2'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_87' type='radio' value='2'  id='choice_84_87_2' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_84_87_2' id='label_84_87_2' class='gform-field-label gform-field-label--type-inline'>Moderately<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_84_87_3'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_87' type='radio' value='3'  id='choice_84_87_3' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_84_87_3' id='label_84_87_3' class='gform-field-label gform-field-label--type-inline'>A lot<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_84_87_4'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_87' type='radio' value='4'  id='choice_84_87_4' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_84_87_4' id='label_84_87_4' class='gform-field-label gform-field-label--type-inline'>Extremely<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_84_88\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-full 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' >15. I need things to be arranged in a particular way.<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_84_88'>\n\t\t\t<div class='gchoice gchoice_84_88_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_88' type='radio' value='0'  id='choice_84_88_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_84_88_0' id='label_84_88_0' class='gform-field-label gform-field-label--type-inline'>Not at all<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_84_88_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_88' type='radio' value='1'  id='choice_84_88_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_84_88_1' id='label_84_88_1' class='gform-field-label gform-field-label--type-inline'>A little<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_84_88_2'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_88' type='radio' value='2'  id='choice_84_88_2' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_84_88_2' id='label_84_88_2' class='gform-field-label gform-field-label--type-inline'>Moderately<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_84_88_3'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_88' type='radio' value='3'  id='choice_84_88_3' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_84_88_3' id='label_84_88_3' class='gform-field-label gform-field-label--type-inline'>A lot<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_84_88_4'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_88' type='radio' value='4'  id='choice_84_88_4' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_84_88_4' id='label_84_88_4' class='gform-field-label gform-field-label--type-inline'>Extremely<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_84_89\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-full 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' >16. I feel that there are good and bad numbers.<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_84_89'>\n\t\t\t<div class='gchoice gchoice_84_89_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_89' type='radio' value='0'  id='choice_84_89_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_84_89_0' id='label_84_89_0' class='gform-field-label gform-field-label--type-inline'>Not at all<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_84_89_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_89' type='radio' value='1'  id='choice_84_89_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_84_89_1' id='label_84_89_1' class='gform-field-label gform-field-label--type-inline'>A little<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_84_89_2'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_89' type='radio' value='2'  id='choice_84_89_2' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_84_89_2' id='label_84_89_2' class='gform-field-label gform-field-label--type-inline'>Moderately<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_84_89_3'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_89' type='radio' value='3'  id='choice_84_89_3' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_84_89_3' id='label_84_89_3' class='gform-field-label gform-field-label--type-inline'>A lot<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_84_89_4'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_89' type='radio' value='4'  id='choice_84_89_4' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_84_89_4' id='label_84_89_4' class='gform-field-label gform-field-label--type-inline'>Extremely<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_84_90\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-full 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' >17. I wash my hands more often and longer than necessary.<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_84_90'>\n\t\t\t<div class='gchoice gchoice_84_90_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_90' type='radio' value='0'  id='choice_84_90_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_84_90_0' id='label_84_90_0' class='gform-field-label gform-field-label--type-inline'>Not at all<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_84_90_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_90' type='radio' value='1'  id='choice_84_90_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_84_90_1' id='label_84_90_1' class='gform-field-label gform-field-label--type-inline'>A little<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_84_90_2'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_90' type='radio' value='2'  id='choice_84_90_2' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_84_90_2' id='label_84_90_2' class='gform-field-label gform-field-label--type-inline'>Moderately<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_84_90_3'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_90' type='radio' value='3'  id='choice_84_90_3' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_84_90_3' id='label_84_90_3' class='gform-field-label gform-field-label--type-inline'>A lot<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_84_90_4'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_90' type='radio' value='4'  id='choice_84_90_4' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_84_90_4' id='label_84_90_4' class='gform-field-label gform-field-label--type-inline'>Extremely<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_84_91\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-full 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' >18. I frequently get nasty thoughts and have difficulty in getting rid of them.<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_84_91'>\n\t\t\t<div class='gchoice gchoice_84_91_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_91' type='radio' value='0'  id='choice_84_91_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_84_91_0' id='label_84_91_0' class='gform-field-label gform-field-label--type-inline'>Not at all<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_84_91_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_91' type='radio' value='1'  id='choice_84_91_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_84_91_1' id='label_84_91_1' class='gform-field-label gform-field-label--type-inline'>A little<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_84_91_2'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_91' type='radio' value='2'  id='choice_84_91_2' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_84_91_2' id='label_84_91_2' class='gform-field-label gform-field-label--type-inline'>Moderately<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_84_91_3'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_91' type='radio' value='3'  id='choice_84_91_3' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_84_91_3' id='label_84_91_3' class='gform-field-label gform-field-label--type-inline'>A lot<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_84_91_4'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_91' type='radio' value='4'  id='choice_84_91_4' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_84_91_4' id='label_84_91_4' class='gform-field-label gform-field-label--type-inline'>Extremely<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_84_117\" 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 \/>\n<p>Some people have times when one thought or idea comes into their mind over and over again. When people have these thoughts they usually get upset because the thoughts are strange. No matter how hard they try, the thoughts keep coming back.<\/p>\n<p>Now we're going to ask you if you have had thoughts like these in the last three months.<\/p>\n<\/div><div id=\"field_84_119\" class=\"gfield gfield--type-html gfield--input-type-html gfield--width-full 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>In the last 3 months...<\/h2>\n<\/div><fieldset id=\"field_84_120\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >Have you had to count things over and over again or make yourself do things a certain number of times?<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_84_120'>\n\t\t\t<div class='gchoice gchoice_84_120_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_120' type='radio' value='1'  id='choice_84_120_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_84_120_0' id='label_84_120_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_84_120_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_120' type='radio' value='0'  id='choice_84_120_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_84_120_1' id='label_84_120_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_84_121\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >Was there a time when you washed your hands or body over and over again or changed your clothes many times each day because you thought they were dirty?<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_84_121'>\n\t\t\t<div class='gchoice gchoice_84_121_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_121' type='radio' value='1'  id='choice_84_121_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_84_121_0' id='label_84_121_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_84_121_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_121' type='radio' value='0'  id='choice_84_121_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_84_121_1' id='label_84_121_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_84_122\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >Have you often felt you should check on things over and over again?  For example, checking that the front door is locked, or the stove is turned off, or that something else was done even though you knew it had been done?<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_84_122'>\n\t\t\t<div class='gchoice gchoice_84_122_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_122' type='radio' value='1'  id='choice_84_122_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_84_122_0' id='label_84_122_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_84_122_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_122' type='radio' value='0'  id='choice_84_122_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_84_122_1' id='label_84_122_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_84_123\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >Have you often worried over and over again that things you touch are dirty or have germs?<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_84_123'>\n\t\t\t<div class='gchoice gchoice_84_123_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_123' type='radio' value='1'  id='choice_84_123_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_84_123_0' id='label_84_123_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_84_123_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_123' type='radio' value='0'  id='choice_84_123_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_84_123_1' id='label_84_123_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_84_124\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >Have you had any other thoughts that kept coming into your mind over and over again that you couldn&#039;t get rid of?<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_84_124'>\n\t\t\t<div class='gchoice gchoice_84_124_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_124' type='radio' value='1'  id='choice_84_124_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_84_124_0' id='label_84_124_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_84_124_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_124' type='radio' value='0'  id='choice_84_124_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_84_124_1' id='label_84_124_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_84_137\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >Have you done things like counting, checking, washing, over and over again because you like to do these 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_84_137'>\n\t\t\t<div class='gchoice gchoice_84_137_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_137' type='radio' value='1'  id='choice_84_137_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_84_137_0' id='label_84_137_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_84_137_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_137' type='radio' value='0'  id='choice_84_137_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_84_137_1' id='label_84_137_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_84_127\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >Have you done things like counting, checking, washing, over and over again, only because you&#039;ve been told by someone else to make sure that you&#039;ve done them right?<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_84_127'>\n\t\t\t<div class='gchoice gchoice_84_127_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_127' type='radio' value='1'  id='choice_84_127_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_84_127_0' id='label_84_127_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_84_127_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_127' type='radio' value='0'  id='choice_84_127_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_84_127_1' id='label_84_127_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_84_128\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >Have you wished you could stop yourself from doing things like counting, checking or washing over and over again?<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_84_128'>\n\t\t\t<div class='gchoice gchoice_84_128_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_128' type='radio' value='1'  id='choice_84_128_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_84_128_0' id='label_84_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_84_128_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_128' type='radio' value='0'  id='choice_84_128_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_84_128_1' id='label_84_128_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_84_129\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >Have you spent a lot of time each day doing things like counting, checking or washing over and over again ... say, for as long as an hour?<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_84_129'>\n\t\t\t<div class='gchoice gchoice_84_129_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_129' type='radio' value='1'  id='choice_84_129_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_84_129_0' id='label_84_129_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_84_129_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_129' type='radio' value='0'  id='choice_84_129_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_84_129_1' id='label_84_129_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_84_130\" class=\"gfield gfield--type-html gfield--input-type-html gfield--width-full gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><hr \/><\/div><div id=\"field_84_92\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-full field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_84_92'>Optional: What is most distressing to you about the OCD symptoms you&#039;ve been experiencing?<\/label><div class='ginput_container ginput_container_text'><input name='input_92' id='input_84_92' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/div><\/div>\n                    <\/div>\n                    <div class='gform-page-footer gform_page_footer top_label'>\n                         <input type='button' id='gform_next_button_84_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_84_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_84_2' class='gform_fields top_label form_sublabel_below description_above validation_below'><div id=\"field_84_18\" 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_84_61\" 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_84_69\" 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' >What is the main thing you want to do after taking this mental health test? (Select one)<\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_84_69'>\n\t\t\t<div class='gchoice gchoice_84_69_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_69' type='radio' value='Take another mental health test'  id='choice_84_69_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_84_69_0' id='label_84_69_0' class='gform-field-label gform-field-label--type-inline'>Take another mental health test<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_84_69_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_69' type='radio' value='Understand what OCD is like (reading articles)'  id='choice_84_69_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_84_69_1' id='label_84_69_1' class='gform-field-label gform-field-label--type-inline'>Understand what OCD is like (reading articles)<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_84_69_2'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_69' type='radio' value='Understand and manage self-harm or suicidal thoughts'  id='choice_84_69_2' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_84_69_2' id='label_84_69_2' class='gform-field-label gform-field-label--type-inline'>Understand and manage self-harm or suicidal thoughts<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_84_69_3'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_69' type='radio' value='Tips for managing OCD (reading articles)'  id='choice_84_69_3' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_84_69_3' id='label_84_69_3' class='gform-field-label gform-field-label--type-inline'>Tips for managing OCD (reading articles)<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_84_69_4'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_69' type='radio' value='Learn and practice skills for how to manage depression (try a free self-help tool)'  id='choice_84_69_4' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_84_69_4' id='label_84_69_4' class='gform-field-label gform-field-label--type-inline'>Learn and practice skills for how to manage depression (try a free self-help tool)<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_84_69_5'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_69' type='radio' value='Learn about what therapy\/treatment is like (reading articles)'  id='choice_84_69_5' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_84_69_5' id='label_84_69_5' class='gform-field-label gform-field-label--type-inline'>Learn about what therapy\/treatment is like (reading articles)<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_84_69_6'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_69' type='radio' value='Find a treatment provider near you'  id='choice_84_69_6' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_84_69_6' id='label_84_69_6' class='gform-field-label gform-field-label--type-inline'>Find a treatment provider near you<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_84_69_7'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_69' type='radio' value='Find a forum or support group for people with OCD'  id='choice_84_69_7' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_84_69_7' id='label_84_69_7' class='gform-field-label gform-field-label--type-inline'>Find a forum or support group for people with OCD<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_84_69_8'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_69' type='radio' value='Other...'  id='choice_84_69_8' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_84_69_8' id='label_84_69_8' class='gform-field-label gform-field-label--type-inline'>Other...<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_84_69_9'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_69' type='radio' value='I don\u2019t want to do anything'  id='choice_84_69_9' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_84_69_9' id='label_84_69_9' class='gform-field-label gform-field-label--type-inline'>I don\u2019t want to do anything<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_84_70\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-full field_sublabel_below gfield--no-description field_description_above hidden_label field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_84_70'>Next Steps - Other<\/label><div class='ginput_container ginput_container_text'><input name='input_70' id='input_84_70' type='text' value='' class='medium'    placeholder='Enter other...'  aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_84_72\" class=\"gfield gfield--type-html gfield--input-type-html gfield--width-full layout-action show-actions_b 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_84_62\" 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_84_62'>\n\t\t\t<div class='gchoice gchoice_84_62_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_62' type='radio' value='For myself'  id='choice_84_62_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_84_62_0' id='label_84_62_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_84_62_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_62' type='radio' value='For someone else'  id='choice_84_62_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_84_62_1' id='label_84_62_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_84_63\" 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_84_42\" 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_84_19\" 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_84_19'>Age Range<\/label><div class='ginput_container ginput_container_select'><select name='input_19' id='input_84_19' 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_84_46\" 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_84_46'>\n\t\t\t<div class='gchoice gchoice_84_46_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_46' type='radio' value='Female'  id='choice_84_46_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_84_46_0' id='label_84_46_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_84_46_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_46' type='radio' value='Male'  id='choice_84_46_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_84_46_1' id='label_84_46_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_84_46_2'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_46' type='radio' value='Non-Binary'  id='choice_84_46_2' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_84_46_2' id='label_84_46_2' class='gform-field-label gform-field-label--type-inline'>Non-Binary<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_84_133\" 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_84_133'>\n\t\t\t<div class='gchoice gchoice_84_133_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_133' type='radio' value='Yes'  id='choice_84_133_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_84_133_0' id='label_84_133_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_84_133_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_133' type='radio' value='No'  id='choice_84_133_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_84_133_1' id='label_84_133_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_84_48\" 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_84_48'>How would you describe your gender?<\/label><div class='ginput_container ginput_container_text'><input name='input_48' id='input_84_48' type='text' value='' class='small'    placeholder='Enter gender...'  aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_84_22\" 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_84_22'>Race\/Ethnicity<\/label><div class='ginput_container ginput_container_select'><select name='input_22' id='input_84_22' 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_84_23\" 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_84_23'>Household Income<\/label><div class='ginput_container ginput_container_select'><select name='input_23' id='input_84_23' 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_84_64\" 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_84_64'>\n\t\t\t<div class='gchoice gchoice_84_64_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_64' type='radio' value='I live in the United States'  id='choice_84_64_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_84_64_0' id='label_84_64_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_84_64_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_64' type='radio' value='I live in another country'  id='choice_84_64_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_84_64_1' id='label_84_64_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_84_32\" 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_84_32'>State<\/label><div class='ginput_container ginput_container_select'><select name='input_32' id='input_84_32' 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_84_36\" 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_84_36'>What country do you live in?<\/label><div class='ginput_container ginput_container_select'><select name='input_36' id='input_84_36' 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_84_34\" 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_84_34'>Zip\/Postal Code<\/label><div class='ginput_container ginput_container_text'><input name='input_34' id='input_84_34' type='text' value='' class='small'      aria-invalid=\"false\"   \/><\/div><\/div><fieldset id=\"field_84_28\" 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_84_28'>Select all that apply.<\/div><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox ' id='input_84_28'><div class='gchoice gchoice_84_28_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_28.1' type='checkbox'  value='Veteran or active-duty military'  id='choice_84_28_1'   aria-describedby=\"gfield_description_84_28\"\/>\n\t\t\t\t\t\t\t\t<label for='choice_84_28_1' id='label_84_28_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_84_28_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_28.2' type='checkbox'  value='Caregiver of someone living with emotional or physical illness'  id='choice_84_28_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_84_28_2' id='label_84_28_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_84_28_3'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_28.3' type='checkbox'  value='LGBTQ+'  id='choice_84_28_3'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_84_28_3' id='label_84_28_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_84_28_4'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_28.4' type='checkbox'  value='Student'  id='choice_84_28_4'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_84_28_4' id='label_84_28_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_84_28_5'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_28.5' type='checkbox'  value='Trauma survivor'  id='choice_84_28_5'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_84_28_5' id='label_84_28_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_84_28_6'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_28.6' type='checkbox'  value='New or expecting parent'  id='choice_84_28_6'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_84_28_6' id='label_84_28_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_84_28_7'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_28.7' type='checkbox'  value='Healthcare worker'  id='choice_84_28_7'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_84_28_7' id='label_84_28_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_84_65\" 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_84_65'>\n\t\t\t<div class='gchoice gchoice_84_65_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_65' type='radio' value='Mental health condition'  id='choice_84_65_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_84_65_0' id='label_84_65_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_84_65_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_65' type='radio' value='Physical health condition'  id='choice_84_65_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_84_65_1' id='label_84_65_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_84_65_2'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_65' type='radio' value='Both mental and physical health conditions'  id='choice_84_65_2' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_84_65_2' id='label_84_65_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_84_66\" 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_84_66'>Which of the following best describes your sexual orientation?<\/label><div class='ginput_container ginput_container_select'><select name='input_66' id='input_84_66' 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_84_50\" 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_84_50'>What is your sexual orientation?<\/label><div class='ginput_container ginput_container_text'><input name='input_50' id='input_84_50' type='text' value='' class='small'    placeholder='Enter sexual orientation...'  aria-invalid=\"false\"   \/><\/div><\/div><fieldset id=\"field_84_67\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield--input-type-checkbox gfield--width-full traditional field_sublabel_below gfield--no-description field_description_above 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='ginput_container ginput_container_checkbox'><div class='gfield_checkbox ' id='input_84_67'><div class='gchoice gchoice_84_67_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_67.1' type='checkbox'  value='Child abuse\/violence'  id='choice_84_67_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_84_67_1' id='label_84_67_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_84_67_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_67.2' type='checkbox'  value='Intimate partner violence'  id='choice_84_67_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_84_67_2' id='label_84_67_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_84_67_3'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_67.3' type='checkbox'  value='Sexual assault\/violence'  id='choice_84_67_3'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_84_67_3' id='label_84_67_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_84_67_4'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_67.4' type='checkbox'  value='Serious illness\/injury\/assault'  id='choice_84_67_4'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_84_67_4' id='label_84_67_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_84_67_5'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_67.5' type='checkbox'  value='Family conflict (identity acceptance\/separation\/divorce)'  id='choice_84_67_5'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_84_67_5' id='label_84_67_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_84_67_6'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_67.6' type='checkbox'  value='Traumatic event (natural disaster, accident, witnessing violence, etc.)'  id='choice_84_67_6'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_84_67_6' id='label_84_67_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_84_67_7'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_67.7' type='checkbox'  value='Death of a loved one'  id='choice_84_67_7'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_84_67_7' id='label_84_67_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_84_67_8'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_67.8' type='checkbox'  value='Other and\/or tell us more about your trauma'  id='choice_84_67_8'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_84_67_8' id='label_84_67_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_84_68\" 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_84_68'>Please tell us more about your experience of trauma:<\/label><div class='ginput_container ginput_container_text'><input name='input_68' id='input_84_68' type='text' value='' class='medium'    placeholder='Tell us more...'  aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_84_43\" 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_84_25\" 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_84_25'>\n\t\t\t<div class='gchoice gchoice_84_25_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_25' type='radio' value='Yes'  id='choice_84_25_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_84_25_0' id='label_84_25_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_84_25_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_25' type='radio' value='No'  id='choice_84_25_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_84_25_1' id='label_84_25_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_84_57\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-full 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_84_57'>\n\t\t\t<div class='gchoice gchoice_84_57_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_57' type='radio' value='Yes'  id='choice_84_57_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_84_57_0' id='label_84_57_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_84_57_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_57' type='radio' value='No'  id='choice_84_57_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_84_57_1' id='label_84_57_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_84_134\" 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_84_134'>Choose up to 3.<\/div><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox ' id='input_84_134'><div class='gchoice gchoice_84_134_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_134.1' type='checkbox'  value='I wanted to handle my mental health on my own'  id='choice_84_134_1'   aria-describedby=\"gfield_description_84_134\"\/>\n\t\t\t\t\t\t\t\t<label for='choice_84_134_1' id='label_84_134_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_84_134_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_134.2' type='checkbox'  value='I didn\u2019t know how or where to start'  id='choice_84_134_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_84_134_2' id='label_84_134_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_84_134_3'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_134.3' type='checkbox'  value='I thought it would cost too much'  id='choice_84_134_3'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_84_134_3' id='label_84_134_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_84_134_4'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_134.4' type='checkbox'  value='I didn\u2019t have time'  id='choice_84_134_4'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_84_134_4' id='label_84_134_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_84_134_5'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_134.5' type='checkbox'  value='I didn\u2019t think it would help me'  id='choice_84_134_5'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_84_134_5' id='label_84_134_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_84_134_6'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_134.6' type='checkbox'  value='I didn&#039;t feel ready to start treatment'  id='choice_84_134_6'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_84_134_6' id='label_84_134_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_84_134_7'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_134.7' type='checkbox'  value='I was worried about what people would think or say if I got treatment'  id='choice_84_134_7'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_84_134_7' id='label_84_134_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_84_134_8'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_134.8' type='checkbox'  value='I was afraid of being forced into a hospital or forced to take medication'  id='choice_84_134_8'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_84_134_8' id='label_84_134_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_84_134_9'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_134.9' type='checkbox'  value='I tried, but couldn\u2019t find available treatment (no openings, wouldn\u2019t take insurance, etc.)'  id='choice_84_134_9'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_84_134_9' id='label_84_134_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_84_134_11'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_134.11' type='checkbox'  value='My parent(s) or guardian wouldn&#039;t let me, or I didn&#039;t want to ask'  id='choice_84_134_11'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_84_134_11' id='label_84_134_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_84_134_12'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_134.12' type='checkbox'  value='Other...'  id='choice_84_134_12'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_84_134_12' id='label_84_134_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_84_135\" 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_84_135'>What else has prevented you from seeking treatment in the past?<\/label><div class='ginput_container ginput_container_text'><input name='input_135' id='input_84_135' type='text' value='' class='medium'    placeholder='Tell us more...'  aria-invalid=\"false\"   \/><\/div><\/div><fieldset id=\"field_84_26\" 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_84_26'>Choose up to 3.<\/div><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox ' id='input_84_26'><div class='gchoice gchoice_84_26_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_26.1' type='checkbox'  value='Abuse or violence'  id='choice_84_26_1'   aria-describedby=\"gfield_description_84_26\"\/>\n\t\t\t\t\t\t\t\t<label for='choice_84_26_1' id='label_84_26_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_84_26_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_26.2' type='checkbox'  value='Relationship problems (friends, family, or significant other)'  id='choice_84_26_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_84_26_2' id='label_84_26_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_84_26_3'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_26.3' type='checkbox'  value='Body image'  id='choice_84_26_3'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_84_26_3' id='label_84_26_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_84_26_4'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_26.4' type='checkbox'  value='Low self-esteem or self-image'  id='choice_84_26_4'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_84_26_4' id='label_84_26_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_84_26_5'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_26.5' type='checkbox'  value='School or work problems'  id='choice_84_26_5'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_84_26_5' id='label_84_26_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_84_26_6'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_26.6' type='checkbox'  value='Financial problems'  id='choice_84_26_6'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_84_26_6' id='label_84_26_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_84_26_7'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_26.7' type='checkbox'  value='Loneliness or isolation'  id='choice_84_26_7'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_84_26_7' id='label_84_26_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_84_26_8'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_26.8' type='checkbox'  value='Grief or loss of someone or something'  id='choice_84_26_8'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_84_26_8' id='label_84_26_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_84_26_9'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_26.9' type='checkbox'  value='Experiencing hate\/bullying (including racism, homophobia, transphobia, or discrimination)'  id='choice_84_26_9'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_84_26_9' id='label_84_26_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_84_26_11'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_26.11' type='checkbox'  value='State of the world (war, climate, politics, immigration)'  id='choice_84_26_11'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_84_26_11' id='label_84_26_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_84_26_12'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_26.12' type='checkbox'  value='I don\u2019t know (something just feels wrong)'  id='choice_84_26_12'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_84_26_12' id='label_84_26_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_84_26_13'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_26.13' type='checkbox'  value='Other...'  id='choice_84_26_13'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_84_26_13' id='label_84_26_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_84_27\" 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_84_27'>What else is contributing to your mental health problems right now?<\/label><div class='ginput_container ginput_container_text'><input name='input_27' id='input_84_27' type='text' value='' class='medium'    placeholder='Tell us more...'  aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_84_74\" 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_84_74'>What about the state of the world is affecting you the most?<\/label><div class='ginput_container ginput_container_text'><input name='input_74' id='input_84_74' type='text' value='' class='medium'    placeholder='Tell us more...'  aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_84_44\" 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_84_29\" 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_84_29'>\n\t\t\t<div class='gchoice gchoice_84_29_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_29' type='radio' value='Yes'  id='choice_84_29_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_84_29_0' id='label_84_29_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_84_29_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_29' type='radio' value='No'  id='choice_84_29_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_84_29_1' id='label_84_29_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_84_29_2'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_29' type='radio' value='I don&#039;t know'  id='choice_84_29_2' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_84_29_2' id='label_84_29_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_84_30\" 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_84_30'>Select all that apply.<\/div><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox ' id='input_84_30'><div class='gchoice gchoice_84_30_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_30.1' type='checkbox'  value='Heart disease'  id='choice_84_30_1'   aria-describedby=\"gfield_description_84_30\"\/>\n\t\t\t\t\t\t\t\t<label for='choice_84_30_1' id='label_84_30_1' class='gform-field-label gform-field-label--type-inline'>Heart disease<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_84_30_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_30.2' type='checkbox'  value='Reproductive health concerns (PCOS, endometriosis, infertility, etc.)'  id='choice_84_30_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_84_30_2' id='label_84_30_2' class='gform-field-label gform-field-label--type-inline'>Reproductive health concerns (PCOS, endometriosis, infertility, etc.)<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_84_30_3'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_30.3' type='checkbox'  value='Diabetes'  id='choice_84_30_3'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_84_30_3' id='label_84_30_3' class='gform-field-label gform-field-label--type-inline'>Diabetes<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_84_30_4'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_30.4' type='checkbox'  value='Cancer'  id='choice_84_30_4'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_84_30_4' id='label_84_30_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_84_30_5'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_30.5' type='checkbox'  value='Arthritis or other chronic pain'  id='choice_84_30_5'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_84_30_5' id='label_84_30_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_84_30_6'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_30.6' type='checkbox'  value='Asthma, COPD or other lung conditions'  id='choice_84_30_6'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_84_30_6' id='label_84_30_6' class='gform-field-label gform-field-label--type-inline'>Asthma, COPD or other lung conditions<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_84_30_7'>\n\t\t\t\t\t\t\t\t<input 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(2002). The Obsessive-Complusive Inventory: Development and validation of a short version. <em>Psychological Assessment 14<\/em>(4), pp. 485\u2013495. Retrieved from <a href=\"https:\/\/doi.org\/10.1037\/\/1040-3590.14.4.485\">https:\/\/doi.org\/10.1037\/\/1040-3590.14.4.485<\/a><\/p>\n<p><a href=\"https:\/\/screening.mhanational.org\/about-our-mental-health-tests\/\" target=\"_blank\" rel=\"noopener\">For more information about our screening tools, please click here.<\/a><\/p>\n<p><strong><em>Please note:<\/em><\/strong><em> Online screening tools are not diagnostic instruments. You are encouraged to share your results with a physician or healthcare provider. Mental Health America Inc., sponsors, partners, and advertisers disclaim any liability, loss, or risk incurred as a consequence, directly or indirectly, from the use and application of these screens.<\/em><\/p>\n<\/div>\n","protected":false},"excerpt":{"rendered":"<p>Para personas cuyos pensamientos y comportamientos repetitivos interfieren en su vida cotidiana. Tambi\u00e9n eval\u00faa el trastorno de acumulaci\u00f3n compulsiva.<\/p>","protected":false},"template":"","tags":[],"age_group":[],"condition":[109],"class_list":["post-245905","screen","type-screen","status-publish","hentry","condition-ocd"],"acf":[],"yoast_head":"<title>OCD Test &#8211; Obsessive-Compulsive Disorder &#8211; Mental Health America<\/title>\n<meta name=\"description\" content=\"Getting stuck in obsessive thoughts and behaviors? Our online OCD test is free, quick, confidential, and scientifically validated.\" \/>\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\/ocd\/\" \/>\n<meta property=\"og:locale\" content=\"es_MX\" \/>\n<meta property=\"og:type\" content=\"article\" \/>\n<meta property=\"og:title\" content=\"OCD Test &#8211; Mental Health America\" \/>\n<meta property=\"og:description\" content=\"Getting stuck in obsessive thoughts and behaviors? Our online OCD test is free, quick, confidential, and scientifically validated.\" \/>\n<meta property=\"og:url\" content=\"https:\/\/screening.mhanational.org\/es\/screening-tools\/ocd\/\" \/>\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=\"2026-05-15T19:37:49+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=\"OCD Test &#8211; Mental Health America\" \/>\n<meta name=\"twitter:description\" content=\"Getting stuck in obsessive thoughts and behaviors? 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Nuestra prueba de TOC en l\u00ednea es gratuita, r\u00e1pida, confidencial y est\u00e1 validada cient\u00edficamente.","robots":{"index":"index","follow":"follow","max-snippet":"max-snippet:-1","max-image-preview":"max-image-preview:large","max-video-preview":"max-video-preview:-1"},"canonical":"https:\/\/screening.mhanational.org\/es\/screening-tools\/ocd\/","og_locale":"es_MX","og_type":"article","og_title":"OCD Test &#8211; Mental Health America","og_description":"Getting stuck in obsessive thoughts and behaviors? 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Our online OCD test is free, quick, confidential, and scientifically validated.","twitter_site":"@mentalhealtham","twitter_misc":{"Est. reading time":"3 minutos"},"schema":{"@context":"https:\/\/schema.org","@graph":[{"@type":"WebPage","@id":"https:\/\/screening.mhanational.org\/screening-tools\/ocd\/","url":"https:\/\/screening.mhanational.org\/screening-tools\/ocd\/","name":"OCD Test &#8211; Obsessive-Compulsive Disorder &#8211; Mental Health America","isPartOf":{"@id":"https:\/\/screening.mhanational.org\/#website"},"datePublished":"2025-08-14T18:18:22+00:00","dateModified":"2026-05-15T19:37:49+00:00","description":"Getting stuck in obsessive thoughts and behaviors? 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de adicci\u00f3n al juego"},"content":{"rendered":"\n                <div class='gf_browser_gecko gform_wrapper gravity-theme gform-theme--no-framework full-pager_wrapper' data-form-theme='gravity-theme' data-form-index='0' id='gform_wrapper_82' 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_82' class='full-pager' class='clearfix' action='\/es\/wp-json\/wp\/v2\/screen' data-formid='82' novalidate><ol class=\"full-progress-bar clearfix step-1-of-3\"><li class=\"step-1 active\"><span>Test Questions<\/span><\/li><li class=\"step-2 empty\"><span>Optional Questions<\/span><\/li><\/ol>\n                        <div class='gform-body gform_body'><div id='gform_page_82_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_82' class='gform_fields top_label form_sublabel_below description_above validation_below'><div id=\"field_82_303\" 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_82_303'>Email<\/label><div class='gfield_description' id='gfield_description_82_303'>This field is for validation purposes and should be left unchanged.<\/div><div class='ginput_container'><input name='input_303' id='input_82_303' type='text' value='' autocomplete='new-password'\/><\/div><\/div><div id=\"field_82_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\"  >When answering the following questions, think about your gambling activity over the <strong>past 12 months<\/strong>.<\/div><div id=\"field_82_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_82_38' type='hidden' class='gform_hidden'  aria-invalid=\"false\" value='' \/><\/div><\/div><div id=\"field_82_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_82_39\" type=\"hidden\" class=\"gform_hidden\" aria-invalid=\"false\" value=\"245618\"><\/div><div id=\"field_82_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_82_40\" type=\"hidden\" class=\"gform_hidden\" aria-invalid=\"false\" value=\"34c0972926eed1ef42815dc87b83c969\"><\/div><div id=\"field_82_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_82_41' type='hidden' class='gform_hidden'  aria-invalid=\"false\" value='' \/><\/div><\/div><div id=\"field_82_53\" 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_53' id='input_82_53' type='hidden' class='gform_hidden'  aria-invalid=\"false\" value='http:\/\/screening.mhanational.org\/es\/wp-json\/wp\/v2\/screen' \/><\/div><\/div><div id=\"field_82_83\" class=\"gfield gfield--type-hidden gfield--input-type-hidden gform_hidden field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><div class='ginput_container ginput_container_text'><input name='input_83' id='input_82_83' type='hidden' class='gform_hidden'  aria-invalid=\"false\" value='' \/><\/div><\/div><div id=\"field_82_84\" 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_84' id='input_82_84' type='hidden' class='gform_hidden'  aria-invalid=\"false\" value='' \/><\/div><\/div><div id=\"field_82_85\" 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_85' id='input_82_85' type='hidden' class='gform_hidden'  aria-invalid=\"false\" value='' \/><\/div><\/div><div id=\"field_82_97\" 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_97' id='input_82_97' type='hidden' class='gform_hidden'  aria-invalid=\"false\" value='' \/><\/div><\/div><div id=\"field_82_169\" 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_169' id='input_82_169' type='hidden' class='gform_hidden'  aria-invalid=\"false\" value='https:\/\/screening.mhanational.org\/es\/wp-json\/wp\/v2\/screen' \/><\/div><\/div><div id=\"field_82_302\" 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_302' id='input_82_302' type='hidden' class='gform_hidden'  aria-invalid=\"false\" value='lang--es' \/><\/div><\/div><div id=\"field_82_293\" class=\"gfield gfield--type-html gfield--input-type-html gfield--width-full 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>In the last 12 months...<\/h2><\/div><fieldset id=\"field_82_149\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-full short gfield_contains_required field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >Did you have strong desires or cravings for gambling?<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_82_149'>\n\t\t\t<div class='gchoice gchoice_82_149_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_149' type='radio' value='1'  id='choice_82_149_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_82_149_0' id='label_82_149_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_82_149_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_149' type='radio' value='0'  id='choice_82_149_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_82_149_1' id='label_82_149_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_82_137\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-full short gfield_contains_required field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >Did you want to cut back or stop gambling, but couldn&#039;t?<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_82_137'>\n\t\t\t<div class='gchoice gchoice_82_137_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_137' type='radio' value='1'  id='choice_82_137_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_82_137_0' id='label_82_137_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_82_137_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_137' type='radio' value='0'  id='choice_82_137_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_82_137_1' id='label_82_137_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_82_139\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-full short gfield_contains_required field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >Did you spend a lot of time preparing to gamble, gambling, or recovering from gambling?<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_82_139'>\n\t\t\t<div class='gchoice gchoice_82_139_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_139' type='radio' value='1'  id='choice_82_139_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_82_139_0' id='label_82_139_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_82_139_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_139' type='radio' value='0'  id='choice_82_139_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_82_139_1' id='label_82_139_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_82_135\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-full short gfield_contains_required field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >Did you have times when you gambled more or for longer than you wanted to?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_82_135'>\n\t\t\t<div class='gchoice gchoice_82_135_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_135' type='radio' value='1'  id='choice_82_135_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_82_135_0' id='label_82_135_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_82_135_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_135' type='radio' value='0'  id='choice_82_135_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_82_135_1' id='label_82_135_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_82_131\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-full short gfield_contains_required field_sublabel_below gfield--has-description field_description_above field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >Did gambling have less effect than it used to? Or did you have to gamble more to feel the effect you wanted?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class='gfield_description' id='gfield_description_82_131'>Please answer \u201cyes\u201d if either question is true for you.<\/div><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_82_131'>\n\t\t\t<div class='gchoice gchoice_82_131_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_131' type='radio' value='1'  id='choice_82_131_0' onchange='gformToggleRadioOther( this )' aria-describedby=\"gfield_description_82_131\"   \/>\n\t\t\t\t\t<label for='choice_82_131_0' id='label_82_131_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_82_131_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_131' type='radio' value='0'  id='choice_82_131_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_82_131_1' id='label_82_131_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_82_133\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-full short gfield_contains_required field_sublabel_below gfield--has-description field_description_above field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >Did you feel restless or irritable when you weren&#039;t gambling? Or did you gamble to avoid feeling restless or irritable?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class='gfield_description' id='gfield_description_82_133'>Please answer \u201cyes\u201d if either question is true for you.<\/div><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_82_133'>\n\t\t\t<div class='gchoice gchoice_82_133_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_133' type='radio' value='1'  id='choice_82_133_0' onchange='gformToggleRadioOther( this )' aria-describedby=\"gfield_description_82_133\"   \/>\n\t\t\t\t\t<label for='choice_82_133_0' id='label_82_133_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_82_133_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_133' type='radio' value='0'  id='choice_82_133_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_82_133_1' id='label_82_133_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_82_141\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-full short gfield_contains_required field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >Did you continue gambling even though you thought it might be causing mental or physical problems \u2014 or making them worse?<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_82_141'>\n\t\t\t<div class='gchoice gchoice_82_141_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_141' type='radio' value='1'  id='choice_82_141_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_82_141_0' id='label_82_141_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_82_141_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_141' type='radio' value='0'  id='choice_82_141_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_82_141_1' id='label_82_141_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_82_147\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-full short gfield_contains_required field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >Did you gamble even though you thought it might be causing problems with your family or other people?<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_82_147'>\n\t\t\t<div class='gchoice gchoice_82_147_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_147' type='radio' value='1'  id='choice_82_147_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_82_147_0' id='label_82_147_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_82_147_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_147' type='radio' value='0'  id='choice_82_147_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_82_147_1' id='label_82_147_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_82_143\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-full short gfield_contains_required field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >Did gambling make it harder for you to keep up with your responsibilities at work, school, or home?<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_82_143'>\n\t\t\t<div class='gchoice gchoice_82_143_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_143' type='radio' value='1'  id='choice_82_143_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_82_143_0' id='label_82_143_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_82_143_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_143' type='radio' value='0'  id='choice_82_143_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_82_143_1' id='label_82_143_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_82_151\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-full short gfield_contains_required field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >Did you spend less time working, enjoying hobbies, or being with others because of gambling?<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_82_151'>\n\t\t\t<div class='gchoice gchoice_82_151_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_151' type='radio' value='1'  id='choice_82_151_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_82_151_0' id='label_82_151_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_82_151_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_151' type='radio' value='0'  id='choice_82_151_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_82_151_1' id='label_82_151_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_82_145\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-full short gfield_contains_required field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >Did you end up in a risky situation more than once because of gambling \u2014 like where you or someone else could be hurt\/harmed?<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_82_145'>\n\t\t\t<div class='gchoice gchoice_82_145_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_145' type='radio' value='1'  id='choice_82_145_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_82_145_0' id='label_82_145_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_82_145_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_145' type='radio' value='0'  id='choice_82_145_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_82_145_1' id='label_82_145_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_82_238\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-full short gfield_contains_required field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >Have there been any periods lasting two weeks or longer when you spent a lot of time thinking about your gambling experiences or planning future gambling ventures or bets?<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_82_238'>\n\t\t\t<div class='gchoice gchoice_82_238_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_238' type='radio' value='1'  id='choice_82_238_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_82_238_0' id='label_82_238_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_82_238_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_238' type='radio' value='0'  id='choice_82_238_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_82_238_1' id='label_82_238_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_82_240\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-full short gfield_contains_required field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >Have there been periods lasting two weeks or longer when you spent a lot of time thinking about ways of getting money to gamble with?<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_82_240'>\n\t\t\t<div class='gchoice gchoice_82_240_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_240' type='radio' value='1'  id='choice_82_240_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_82_240_0' id='label_82_240_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_82_240_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_240' type='radio' value='0'  id='choice_82_240_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_82_240_1' id='label_82_240_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_82_241\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-full question short gfield_contains_required field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >Have there been periods when you needed to gamble with increasing amounts of money or with larger bets than before in order to get the same feeling of excitement?<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_82_241'>\n\t\t\t<div class='gchoice gchoice_82_241_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_241' type='radio' value='1'  id='choice_82_241_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_82_241_0' id='label_82_241_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_82_241_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_241' type='radio' value='0'  id='choice_82_241_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_82_241_1' id='label_82_241_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_82_242\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-full question short gfield_contains_required field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >Have you tried to stop, cut down, or control your gambling?<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_82_242'>\n\t\t\t<div class='gchoice gchoice_82_242_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_242' type='radio' value='Yes'  id='choice_82_242_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_82_242_0' id='label_82_242_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_82_242_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_242' type='radio' value='No'  id='choice_82_242_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_82_242_1' id='label_82_242_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_82_244\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-full question indent short gfield_contains_required field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >On one or more of the times when you tried to stop, cut down, or control your gambling, were you restless or irritable?<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_82_244'>\n\t\t\t<div class='gchoice gchoice_82_244_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_244' type='radio' value='1'  id='choice_82_244_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_82_244_0' id='label_82_244_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_82_244_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_244' type='radio' value='0'  id='choice_82_244_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_82_244_1' id='label_82_244_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_82_243\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-full question short gfield_contains_required field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >Have you tried but not succeeded in stopping, cutting down, or controlling your gambling?<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_82_243'>\n\t\t\t<div class='gchoice gchoice_82_243_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_243' type='radio' value='Yes'  id='choice_82_243_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_82_243_0' id='label_82_243_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_82_243_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_243' type='radio' value='No'  id='choice_82_243_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_82_243_1' id='label_82_243_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_82_246\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-full question indent short gfield_contains_required field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >Has this happened three or more times?<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_82_246'>\n\t\t\t<div class='gchoice gchoice_82_246_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_246' type='radio' value='1'  id='choice_82_246_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_82_246_0' id='label_82_246_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_82_246_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_246' type='radio' value='0'  id='choice_82_246_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_82_246_1' id='label_82_246_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_82_245\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-full short gfield_contains_required field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >Have you gambled as a way to escape from personal problems?<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_82_245'>\n\t\t\t<div class='gchoice gchoice_82_245_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_245' type='radio' value='1'  id='choice_82_245_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_82_245_0' id='label_82_245_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_82_245_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_245' type='radio' value='0'  id='choice_82_245_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_82_245_1' id='label_82_245_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_82_247\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-full short gfield_contains_required field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >Have you gambled to relieve uncomfortable feelings such as guilt, anxiety, helplessness, or depression?<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_82_247'>\n\t\t\t<div class='gchoice gchoice_82_247_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_247' type='radio' value='1'  id='choice_82_247_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_82_247_0' id='label_82_247_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_82_247_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_247' type='radio' value='0'  id='choice_82_247_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_82_247_1' id='label_82_247_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_82_248\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-full question short gfield_contains_required field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >Has there ever been a period when, if you lost money gambling on one day, you would often return another day to get even?<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_82_248'>\n\t\t\t<div class='gchoice gchoice_82_248_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_248' type='radio' value='1'  id='choice_82_248_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_82_248_0' id='label_82_248_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_82_248_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_248' type='radio' value='0'  id='choice_82_248_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_82_248_1' id='label_82_248_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_82_249\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-full question short gfield_contains_required field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >Have you more than once lied to family members, friends, or others about how much you gamble or how much money you lost on gambling?<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_82_249'>\n\t\t\t<div class='gchoice gchoice_82_249_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_249' type='radio' value='Yes'  id='choice_82_249_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_82_249_0' id='label_82_249_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_82_249_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_249' type='radio' value='No'  id='choice_82_249_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_82_249_1' id='label_82_249_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_82_250\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-full question indent short gfield_contains_required field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >Has this happened three or more times?<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_82_250'>\n\t\t\t<div class='gchoice gchoice_82_250_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_250' type='radio' value='1'  id='choice_82_250_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_82_250_0' id='label_82_250_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_82_250_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_250' type='radio' value='0'  id='choice_82_250_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_82_250_1' id='label_82_250_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_82_251\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-full short gfield_contains_required field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >Has your gambling caused serious or repeated problems in your relationships with any of your family members or 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_82_251'>\n\t\t\t<div class='gchoice gchoice_82_251_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_251' type='radio' value='1'  id='choice_82_251_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_82_251_0' id='label_82_251_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_82_251_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_251' type='radio' value='0'  id='choice_82_251_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_82_251_1' id='label_82_251_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_82_254\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-full short gfield_contains_required field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >Has your gambling caused you any problems in school, such as missing classes or days of school or getting worse grades?<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_82_254'>\n\t\t\t<div class='gchoice gchoice_82_254_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_254' type='radio' value='1'  id='choice_82_254_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_82_254_0' id='label_82_254_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_82_254_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_254' type='radio' value='0'  id='choice_82_254_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_82_254_1' id='label_82_254_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_82_252\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-full short gfield_contains_required field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >Has your gambling caused you to lose a job, have trouble with your job, or miss out on an important job or career opportunity?<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_82_252'>\n\t\t\t<div class='gchoice gchoice_82_252_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_252' type='radio' value='1'  id='choice_82_252_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_82_252_0' id='label_82_252_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_82_252_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_252' type='radio' value='0'  id='choice_82_252_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_82_252_1' id='label_82_252_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_82_253\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-full question short gfield_contains_required field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >Have you needed to ask family members or anyone else to loan you money or otherwise bail you out of a desperate money situation that was largely caused by your gambling?<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_82_253'>\n\t\t\t<div class='gchoice gchoice_82_253_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_253' type='radio' value='1'  id='choice_82_253_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_82_253_0' id='label_82_253_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_82_253_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_253' type='radio' value='0'  id='choice_82_253_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_82_253_1' id='label_82_253_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_82_278\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-full short gfield_contains_required field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >Did you have strong desires or cravings for gambling?<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_82_278'>\n\t\t\t<div class='gchoice gchoice_82_278_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_278' type='radio' value='1'  id='choice_82_278_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_82_278_0' id='label_82_278_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_82_278_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_278' type='radio' value='0'  id='choice_82_278_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_82_278_1' id='label_82_278_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_82_279\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-full short gfield_contains_required field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >Did you want to cut back or stop gambling, but couldn&#039;t?<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_82_279'>\n\t\t\t<div class='gchoice gchoice_82_279_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_279' type='radio' value='1'  id='choice_82_279_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_82_279_0' id='label_82_279_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_82_279_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_279' type='radio' value='0'  id='choice_82_279_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_82_279_1' id='label_82_279_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_82_280\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-full short gfield_contains_required field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >Did you spend a lot of time preparing to gamble, gambling, or recovering from gambling?<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_82_280'>\n\t\t\t<div class='gchoice gchoice_82_280_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_280' type='radio' value='1'  id='choice_82_280_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_82_280_0' id='label_82_280_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_82_280_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_280' type='radio' value='0'  id='choice_82_280_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_82_280_1' id='label_82_280_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_82_281\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-full short gfield_contains_required field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >Did you have times when you gambled more or for longer than you wanted to?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_82_281'>\n\t\t\t<div class='gchoice gchoice_82_281_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_281' type='radio' value='1'  id='choice_82_281_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_82_281_0' id='label_82_281_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_82_281_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_281' type='radio' value='0'  id='choice_82_281_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_82_281_1' id='label_82_281_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_82_282\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-full short gfield_contains_required field_sublabel_below gfield--has-description field_description_above field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >Did gambling have less effect than it used to? Or did you have to gamble more to feel the effect you wanted?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class='gfield_description' id='gfield_description_82_282'>Please answer \u201cyes\u201d if either question is true for you.<\/div><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_82_282'>\n\t\t\t<div class='gchoice gchoice_82_282_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_282' type='radio' value='1'  id='choice_82_282_0' onchange='gformToggleRadioOther( this )' aria-describedby=\"gfield_description_82_282\"   \/>\n\t\t\t\t\t<label for='choice_82_282_0' id='label_82_282_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_82_282_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_282' type='radio' value='0'  id='choice_82_282_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_82_282_1' id='label_82_282_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_82_283\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-full short gfield_contains_required field_sublabel_below gfield--has-description field_description_above field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >Did you feel restless or irritable when you weren&#039;t gambling? Or did you gamble to avoid feeling restless or irritable?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class='gfield_description' id='gfield_description_82_283'>Please answer \u201cyes\u201d if either question is true for you.<\/div><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_82_283'>\n\t\t\t<div class='gchoice gchoice_82_283_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_283' type='radio' value='1'  id='choice_82_283_0' onchange='gformToggleRadioOther( this )' aria-describedby=\"gfield_description_82_283\"   \/>\n\t\t\t\t\t<label for='choice_82_283_0' id='label_82_283_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_82_283_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_283' type='radio' value='0'  id='choice_82_283_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_82_283_1' id='label_82_283_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_82_284\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-full short gfield_contains_required field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >Did you continue gambling even though you thought it might be causing mental or physical problems \u2014 or making them worse?<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_82_284'>\n\t\t\t<div class='gchoice gchoice_82_284_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_284' type='radio' value='1'  id='choice_82_284_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_82_284_0' id='label_82_284_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_82_284_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_284' type='radio' value='0'  id='choice_82_284_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_82_284_1' id='label_82_284_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_82_285\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-full short gfield_contains_required field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >Did you gamble even though you thought it might be causing problems with your family or other people?<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_82_285'>\n\t\t\t<div class='gchoice gchoice_82_285_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_285' type='radio' value='1'  id='choice_82_285_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_82_285_0' id='label_82_285_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_82_285_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_285' type='radio' value='0'  id='choice_82_285_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_82_285_1' id='label_82_285_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_82_286\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-full short gfield_contains_required field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >Did gambling make it harder for you to keep up with your responsibilities at work, school, or home?<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_82_286'>\n\t\t\t<div class='gchoice gchoice_82_286_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_286' type='radio' value='1'  id='choice_82_286_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_82_286_0' id='label_82_286_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_82_286_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_286' type='radio' value='0'  id='choice_82_286_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_82_286_1' id='label_82_286_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_82_287\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-full short gfield_contains_required field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >Did you spend less time working, enjoying hobbies, or being with others because of gambling?<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_82_287'>\n\t\t\t<div class='gchoice gchoice_82_287_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_287' type='radio' value='1'  id='choice_82_287_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_82_287_0' id='label_82_287_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_82_287_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_287' type='radio' value='0'  id='choice_82_287_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_82_287_1' id='label_82_287_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_82_288\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-full short gfield_contains_required field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >Did you end up in a risky situation more than once because of gambling \u2014 like where you or someone else could be hurt\/harmed?<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_82_288'>\n\t\t\t<div class='gchoice gchoice_82_288_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_288' type='radio' value='1'  id='choice_82_288_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_82_288_0' id='label_82_288_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_82_288_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_288' type='radio' value='0'  id='choice_82_288_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_82_288_1' id='label_82_288_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_82_274\" class=\"gfield gfield--type-section gfield--input-type-section gsection field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><h3 class=\"gsection_title\"><\/h3><\/div><div id=\"field_82_166\" 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 \/>\n\nThe following <strong>optional<\/strong> questions will help us understand the experiences of people struggling with gambling.<\/div><div id=\"field_82_296\" 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_82_296'>What is most distressing to you about your gambling?<\/label><div class='ginput_container ginput_container_text'><input name='input_296' id='input_82_296' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/div><fieldset id=\"field_82_163\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-full question-optional field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >How often have you gambled in the past 12 months?<\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_82_163'>\n\t\t\t<div class='gchoice gchoice_82_163_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_163' type='radio' value='More than once a day'  id='choice_82_163_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_82_163_0' id='label_82_163_0' class='gform-field-label gform-field-label--type-inline'>More than once a day<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_82_163_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_163' type='radio' value='More than once a week'  id='choice_82_163_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_82_163_1' id='label_82_163_1' class='gform-field-label gform-field-label--type-inline'>More than once a week<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_82_163_2'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_163' type='radio' value='More than once a month'  id='choice_82_163_2' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_82_163_2' id='label_82_163_2' class='gform-field-label gform-field-label--type-inline'>More than once a month<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_82_163_3'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_163' type='radio' value='Once a month or less'  id='choice_82_163_3' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_82_163_3' id='label_82_163_3' class='gform-field-label gform-field-label--type-inline'>Once a month or less<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_82_207\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-full question-optional field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >How strongly do you agree with this statement: &quot;I believe gambling is morally wrong or sinful.&quot;<\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_82_207'>\n\t\t\t<div class='gchoice gchoice_82_207_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_207' type='radio' value='Strongly Disagree'  id='choice_82_207_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_82_207_0' id='label_82_207_0' class='gform-field-label gform-field-label--type-inline'>Strongly Disagree<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_82_207_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_207' type='radio' value='Disagree'  id='choice_82_207_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_82_207_1' id='label_82_207_1' class='gform-field-label gform-field-label--type-inline'>Disagree<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_82_207_2'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_207' type='radio' value='Agree'  id='choice_82_207_2' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_82_207_2' id='label_82_207_2' class='gform-field-label gform-field-label--type-inline'>Agree<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_82_207_3'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_207' type='radio' value='Strongly Agree'  id='choice_82_207_3' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_82_207_3' id='label_82_207_3' class='gform-field-label gform-field-label--type-inline'>Strongly Agree<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_82_165\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-full question-optional field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >How strongly do you agree with this statement: &quot;I believe I am addicted to gambling.&quot;<\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_82_165'>\n\t\t\t<div class='gchoice gchoice_82_165_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_165' type='radio' value='Strongly Disagree'  id='choice_82_165_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_82_165_0' id='label_82_165_0' class='gform-field-label gform-field-label--type-inline'>Strongly Disagree<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_82_165_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_165' type='radio' value='Disagree'  id='choice_82_165_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_82_165_1' id='label_82_165_1' class='gform-field-label gform-field-label--type-inline'>Disagree<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_82_165_2'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_165' type='radio' value='Agree'  id='choice_82_165_2' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_82_165_2' id='label_82_165_2' class='gform-field-label gform-field-label--type-inline'>Agree<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_82_165_3'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_165' type='radio' value='Strongly Agree'  id='choice_82_165_3' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_82_165_3' id='label_82_165_3' class='gform-field-label gform-field-label--type-inline'>Strongly Agree<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_82_295\" 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' >Besides gambling, are you concerned that you may be addicted to any other behaviors?<\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_82_295'>\n\t\t\t<div class='gchoice gchoice_82_295_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_295' type='radio' value='Yes'  id='choice_82_295_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_82_295_0' id='label_82_295_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_82_295_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_295' type='radio' value='No'  id='choice_82_295_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_82_295_1' id='label_82_295_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_82_218\" 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 behaviors are you concerned about?<\/legend><div class='gfield_description' id='gfield_description_82_218'>Select all that apply.<\/div><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox ' id='input_82_218'><div class='gchoice gchoice_82_218_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_218.1' type='checkbox'  value='Self-injury (cutting, burning, hitting, etc.)'  id='choice_82_218_1'   aria-describedby=\"gfield_description_82_218\"\/>\n\t\t\t\t\t\t\t\t<label for='choice_82_218_1' id='label_82_218_1' class='gform-field-label gform-field-label--type-inline'>Self-injury (cutting, burning, hitting, etc.)<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_82_218_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_218.2' type='checkbox'  value='Pornography'  id='choice_82_218_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_82_218_2' id='label_82_218_2' class='gform-field-label gform-field-label--type-inline'>Pornography<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_82_218_3'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_218.3' type='checkbox'  value='Sex'  id='choice_82_218_3'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_82_218_3' id='label_82_218_3' class='gform-field-label gform-field-label--type-inline'>Sex<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_82_218_4'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_218.4' type='checkbox'  value='Internet (social media, videos, doomscrolling, etc.)'  id='choice_82_218_4'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_82_218_4' id='label_82_218_4' class='gform-field-label gform-field-label--type-inline'>Internet (social media, videos, doomscrolling, etc.)<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_82_218_5'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_218.5' type='checkbox'  value='Food (junk food, binge eating, etc.)'  id='choice_82_218_5'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_82_218_5' id='label_82_218_5' class='gform-field-label gform-field-label--type-inline'>Food (junk food, binge eating, etc.)<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_82_218_6'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_218.6' type='checkbox'  value='Masturbation'  id='choice_82_218_6'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_82_218_6' id='label_82_218_6' class='gform-field-label gform-field-label--type-inline'>Masturbation<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_82_218_7'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_218.7' type='checkbox'  value='Shopping'  id='choice_82_218_7'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_82_218_7' id='label_82_218_7' class='gform-field-label gform-field-label--type-inline'>Shopping<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_82_218_8'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_218.8' type='checkbox'  value='Video games'  id='choice_82_218_8'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_82_218_8' id='label_82_218_8' class='gform-field-label gform-field-label--type-inline'>Video games<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_82_218_9'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_218.9' type='checkbox'  value='Substances (nicotine\/vaping, alcohol, drugs, etc.)'  id='choice_82_218_9'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_82_218_9' id='label_82_218_9' class='gform-field-label gform-field-label--type-inline'>Substances (nicotine\/vaping, alcohol, drugs, etc.)<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_82_218_11'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_218.11' type='checkbox'  value='Other...'  id='choice_82_218_11'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_82_218_11' id='label_82_218_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_82_227\" 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_82_227'>What substance are you most concerned about?<\/label><div class='ginput_container ginput_container_text'><input name='input_227' id='input_82_227' type='text' value='' class='medium'    placeholder='Enter other...'  aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_82_220\" 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_82_220'>What other behavior are you concerned about?<\/label><div class='ginput_container ginput_container_text'><input name='input_220' id='input_82_220' type='text' value='' class='medium'    placeholder='Enter other...'  aria-invalid=\"false\"   \/><\/div><\/div><\/div>\n                    <\/div>\n                    <div class='gform-page-footer gform_page_footer top_label'>\n                         <input type='button' id='gform_next_button_82_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_82_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_82_2' class='gform_fields top_label form_sublabel_below description_above validation_below'><div id=\"field_82_54\" 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_82_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_82_167\" 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' >What is the main thing you want to do after taking this mental health test? (Select one)<\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_82_167'>\n\t\t\t<div class='gchoice gchoice_82_167_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_167' type='radio' value='Take another mental health test'  id='choice_82_167_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_82_167_0' id='label_82_167_0' class='gform-field-label gform-field-label--type-inline'>Take another mental health test<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_82_167_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_167' type='radio' value='Understand what addiction is like (reading articles)'  id='choice_82_167_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_82_167_1' id='label_82_167_1' class='gform-field-label gform-field-label--type-inline'>Understand what addiction is like (reading articles)<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_82_167_2'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_167' type='radio' value='Understand and manage self-harm or suicidal thoughts'  id='choice_82_167_2' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_82_167_2' id='label_82_167_2' class='gform-field-label gform-field-label--type-inline'>Understand and manage self-harm or suicidal thoughts<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_82_167_3'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_167' type='radio' value='Tips for managing addiction (reading articles)'  id='choice_82_167_3' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_82_167_3' id='label_82_167_3' class='gform-field-label gform-field-label--type-inline'>Tips for managing addiction (reading articles)<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_82_167_4'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_167' type='radio' value='Learn and practice skills for how to manage addiction (try a free self-help tool)'  id='choice_82_167_4' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_82_167_4' id='label_82_167_4' class='gform-field-label gform-field-label--type-inline'>Learn and practice skills for how to manage addiction (try a free self-help tool)<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_82_167_5'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_167' type='radio' value='Learn about what therapy\/treatment is like (reading articles)'  id='choice_82_167_5' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_82_167_5' id='label_82_167_5' class='gform-field-label gform-field-label--type-inline'>Learn about what therapy\/treatment is like (reading articles)<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_82_167_6'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_167' type='radio' value='Find a treatment provider near you'  id='choice_82_167_6' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_82_167_6' id='label_82_167_6' class='gform-field-label gform-field-label--type-inline'>Find a treatment provider near you<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_82_167_7'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_167' type='radio' value='Find a forum or support group for people with addiction'  id='choice_82_167_7' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_82_167_7' id='label_82_167_7' class='gform-field-label gform-field-label--type-inline'>Find a forum or support group for people with addiction<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_82_167_8'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_167' type='radio' value='Other...'  id='choice_82_167_8' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_82_167_8' id='label_82_167_8' class='gform-field-label gform-field-label--type-inline'>Other...<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_82_167_9'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_167' type='radio' value='I don\u2019t want to do anything'  id='choice_82_167_9' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_82_167_9' id='label_82_167_9' class='gform-field-label gform-field-label--type-inline'>I don\u2019t want to do anything<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_82_168\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-full field_sublabel_below gfield--no-description field_description_above hidden_label field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_82_168'>Next Steps - Other<\/label><div class='ginput_container ginput_container_text'><input name='input_168' id='input_82_168' type='text' value='' class='medium'    placeholder='Enter other...'  aria-invalid=\"false\"   \/><\/div><\/div><fieldset id=\"field_82_87\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-full field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >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_82_87'>\n\t\t\t<div class='gchoice gchoice_82_87_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_87' type='radio' value='For myself'  id='choice_82_87_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_82_87_0' id='label_82_87_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_82_87_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_87' type='radio' value='For someone else'  id='choice_82_87_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_82_87_1' id='label_82_87_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_82_88\" 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_82_55\" class=\"gfield gfield--type-html gfield--input-type-html gfield--width-full 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_82_56\" 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_82_56'>Age Range<\/label><div class='ginput_container ginput_container_select'><select name='input_56' id='input_82_56' 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_82_57\" 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_82_57'>\n\t\t\t<div class='gchoice gchoice_82_57_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_57' type='radio' value='Female'  id='choice_82_57_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_82_57_0' id='label_82_57_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_82_57_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_57' type='radio' value='Male'  id='choice_82_57_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_82_57_1' id='label_82_57_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_82_57_2'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_57' type='radio' value='Non-Binary'  id='choice_82_57_2' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_82_57_2' id='label_82_57_2' class='gform-field-label gform-field-label--type-inline'>Non-Binary<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_82_299\" 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_82_299'>\n\t\t\t<div class='gchoice gchoice_82_299_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_299' type='radio' value='Yes'  id='choice_82_299_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_82_299_0' id='label_82_299_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_82_299_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_299' type='radio' value='No'  id='choice_82_299_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_82_299_1' id='label_82_299_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_82_58\" 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_82_58'>How would you describe your gender?<\/label><div class='ginput_container ginput_container_text'><input name='input_58' id='input_82_58' type='text' value='' class='small'    placeholder='Enter gender...'  aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_82_60\" 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_82_60'>Race\/Ethnicity<\/label><div class='ginput_container ginput_container_select'><select name='input_60' id='input_82_60' 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_82_61\" 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_82_61'>Household Income<\/label><div class='ginput_container ginput_container_select'><select name='input_61' id='input_82_61' 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_82_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' >Do you live in the United States or another country?<\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_82_91'>\n\t\t\t<div class='gchoice gchoice_82_91_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_91' type='radio' value='I live in the United States'  id='choice_82_91_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_82_91_0' id='label_82_91_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_82_91_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_91' type='radio' value='I live in another country'  id='choice_82_91_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_82_91_1' id='label_82_91_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_82_80\" class=\"gfield gfield--type-select gfield--input-type-select gfield--width-full optional field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_82_80'>State<\/label><div class='ginput_container ginput_container_select'><select name='input_80' id='input_82_80' 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_82_82\" 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_82_82'>What country do you live in?<\/label><div class='ginput_container ginput_container_select'><select name='input_82' id='input_82_82' 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_82_81\" 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_82_81'>Zip\/Postal Code<\/label><div class='ginput_container ginput_container_text'><input name='input_81' id='input_82_81' type='text' value='' class='small'      aria-invalid=\"false\"   \/><\/div><\/div><fieldset id=\"field_82_62\" 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_82_62'>Select all that apply.<\/div><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox ' id='input_82_62'><div class='gchoice gchoice_82_62_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_62.1' type='checkbox'  value='Veteran or active-duty military'  id='choice_82_62_1'   aria-describedby=\"gfield_description_82_62\"\/>\n\t\t\t\t\t\t\t\t<label for='choice_82_62_1' id='label_82_62_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_82_62_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_62.2' type='checkbox'  value='Caregiver of someone living with emotional or physical illness'  id='choice_82_62_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_82_62_2' id='label_82_62_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_82_62_3'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_62.3' type='checkbox'  value='LGBTQ+'  id='choice_82_62_3'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_82_62_3' id='label_82_62_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_82_62_4'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_62.4' type='checkbox'  value='Student'  id='choice_82_62_4'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_82_62_4' id='label_82_62_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_82_62_5'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_62.5' type='checkbox'  value='Trauma survivor'  id='choice_82_62_5'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_82_62_5' id='label_82_62_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_82_62_6'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_62.6' type='checkbox'  value='New or expecting parent'  id='choice_82_62_6'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_82_62_6' id='label_82_62_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_82_62_7'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_62.7' type='checkbox'  value='Healthcare worker'  id='choice_82_62_7'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_82_62_7' id='label_82_62_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_82_92\" 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_82_92'>\n\t\t\t<div class='gchoice gchoice_82_92_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_92' type='radio' value='Mental health condition'  id='choice_82_92_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_82_92_0' id='label_82_92_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_82_92_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_92' type='radio' value='Physical health condition'  id='choice_82_92_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_82_92_1' id='label_82_92_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_82_92_2'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_92' type='radio' value='Both mental and physical health conditions'  id='choice_82_92_2' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_82_92_2' id='label_82_92_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_82_93\" 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_82_93'>Which of the following best describes your sexual orientation?<\/label><div class='ginput_container ginput_container_select'><select name='input_93' id='input_82_93' 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_82_68\" 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_82_68'>What is your sexual orientation?<\/label><div class='ginput_container ginput_container_text'><input name='input_68' id='input_82_68' type='text' value='' class='small'    placeholder='Enter sexual orientation...'  aria-invalid=\"false\"   \/><\/div><\/div><fieldset id=\"field_82_94\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield--input-type-checkbox gfield--width-full 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 describe your experience of trauma?<\/legend><div class='gfield_description' id='gfield_description_82_94'>Select all that apply.<\/div><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox ' id='input_82_94'><div class='gchoice gchoice_82_94_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_94.1' type='checkbox'  value='Child abuse\/violence'  id='choice_82_94_1'   aria-describedby=\"gfield_description_82_94\"\/>\n\t\t\t\t\t\t\t\t<label for='choice_82_94_1' id='label_82_94_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_82_94_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_94.2' type='checkbox'  value='Intimate partner violence'  id='choice_82_94_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_82_94_2' id='label_82_94_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_82_94_3'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_94.3' type='checkbox'  value='Sexual assault\/violence'  id='choice_82_94_3'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_82_94_3' id='label_82_94_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_82_94_4'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_94.4' type='checkbox'  value='Serious illness\/injury\/assault'  id='choice_82_94_4'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_82_94_4' id='label_82_94_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_82_94_5'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_94.5' type='checkbox'  value='Family conflict (identity acceptance\/separation\/divorce)'  id='choice_82_94_5'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_82_94_5' id='label_82_94_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_82_94_6'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_94.6' type='checkbox'  value='Traumatic event (natural disaster, accident, witnessing violence, etc.)'  id='choice_82_94_6'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_82_94_6' id='label_82_94_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_82_94_7'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_94.7' type='checkbox'  value='Death of a loved one'  id='choice_82_94_7'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_82_94_7' id='label_82_94_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_82_94_8'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_94.8' type='checkbox'  value='Other and\/or tell us more about your trauma'  id='choice_82_94_8'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_82_94_8' id='label_82_94_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_82_95\" 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_82_95'>Please tell us more about your experience of trauma:<\/label><div class='ginput_container ginput_container_text'><input name='input_95' id='input_82_95' type='text' value='' class='medium'    placeholder='Tell us more...'  aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_82_69\" 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_82_71\" 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_82_71'>\n\t\t\t<div class='gchoice gchoice_82_71_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_71' type='radio' value='Yes'  id='choice_82_71_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_82_71_0' id='label_82_71_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_82_71_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_71' type='radio' value='No'  id='choice_82_71_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_82_71_1' id='label_82_71_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_82_72\" 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_82_72'>\n\t\t\t<div class='gchoice gchoice_82_72_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_72' type='radio' value='Yes'  id='choice_82_72_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_82_72_0' id='label_82_72_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_82_72_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_72' type='radio' value='No'  id='choice_82_72_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_82_72_1' id='label_82_72_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_82_300\" 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_82_300'>Choose up to 3.<\/div><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox ' id='input_82_300'><div class='gchoice gchoice_82_300_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_300.1' type='checkbox'  value='I wanted to handle my mental health on my own'  id='choice_82_300_1'   aria-describedby=\"gfield_description_82_300\"\/>\n\t\t\t\t\t\t\t\t<label for='choice_82_300_1' id='label_82_300_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_82_300_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_300.2' type='checkbox'  value='I didn\u2019t know how or where to start'  id='choice_82_300_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_82_300_2' id='label_82_300_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_82_300_3'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_300.3' type='checkbox'  value='I thought it would cost too much'  id='choice_82_300_3'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_82_300_3' id='label_82_300_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_82_300_4'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_300.4' type='checkbox'  value='I didn\u2019t have time'  id='choice_82_300_4'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_82_300_4' id='label_82_300_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_82_300_5'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_300.5' type='checkbox'  value='I didn\u2019t think it would help me'  id='choice_82_300_5'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_82_300_5' id='label_82_300_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_82_300_6'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_300.6' type='checkbox'  value='I didn&#039;t feel ready to start treatment'  id='choice_82_300_6'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_82_300_6' id='label_82_300_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_82_300_7'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_300.7' type='checkbox'  value='I was worried about what people would think or say if I got treatment'  id='choice_82_300_7'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_82_300_7' id='label_82_300_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_82_300_8'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_300.8' type='checkbox'  value='I was afraid of being forced into a hospital or forced to take medication'  id='choice_82_300_8'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_82_300_8' id='label_82_300_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_82_300_9'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_300.9' type='checkbox'  value='I tried, but couldn\u2019t find available treatment (no openings, wouldn\u2019t take insurance, etc.)'  id='choice_82_300_9'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_82_300_9' id='label_82_300_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_82_300_11'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_300.11' type='checkbox'  value='My parent(s) or guardian wouldn&#039;t let me, or I didn&#039;t want to ask'  id='choice_82_300_11'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_82_300_11' id='label_82_300_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_82_300_12'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_300.12' type='checkbox'  value='Other...'  id='choice_82_300_12'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_82_300_12' id='label_82_300_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_82_301\" 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_82_301'>What else has prevented you from seeking treatment in the past?<\/label><div class='ginput_container ginput_container_text'><input name='input_301' id='input_82_301' type='text' value='' class='medium'    placeholder='Tell us more...'  aria-invalid=\"false\"   \/><\/div><\/div><fieldset id=\"field_82_73\" 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_82_73'>Choose up to 3.<\/div><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox ' id='input_82_73'><div class='gchoice gchoice_82_73_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_73.1' type='checkbox'  value='Abuse or violence'  id='choice_82_73_1'   aria-describedby=\"gfield_description_82_73\"\/>\n\t\t\t\t\t\t\t\t<label for='choice_82_73_1' id='label_82_73_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_82_73_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_73.2' type='checkbox'  value='Relationship problems (friends, family, or significant other)'  id='choice_82_73_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_82_73_2' id='label_82_73_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_82_73_3'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_73.3' type='checkbox'  value='Body image'  id='choice_82_73_3'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_82_73_3' id='label_82_73_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_82_73_4'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_73.4' type='checkbox'  value='Low self-esteem or self-image'  id='choice_82_73_4'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_82_73_4' id='label_82_73_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_82_73_5'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_73.5' type='checkbox'  value='School or work problems'  id='choice_82_73_5'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_82_73_5' id='label_82_73_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_82_73_6'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_73.6' type='checkbox'  value='Financial problems'  id='choice_82_73_6'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_82_73_6' id='label_82_73_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_82_73_7'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_73.7' type='checkbox'  value='Loneliness or isolation'  id='choice_82_73_7'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_82_73_7' id='label_82_73_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_82_73_8'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_73.8' type='checkbox'  value='Grief or loss of someone or something'  id='choice_82_73_8'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_82_73_8' id='label_82_73_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_82_73_9'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_73.9' type='checkbox'  value='Experiencing hate\/bullying (including racism, homophobia, transphobia, or discrimination)'  id='choice_82_73_9'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_82_73_9' id='label_82_73_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_82_73_11'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_73.11' type='checkbox'  value='State of the world (war, climate, politics, immigration)'  id='choice_82_73_11'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_82_73_11' id='label_82_73_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_82_73_12'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_73.12' type='checkbox'  value='I don\u2019t know (something just feels wrong)'  id='choice_82_73_12'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_82_73_12' id='label_82_73_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_82_73_13'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_73.13' type='checkbox'  value='Other...'  id='choice_82_73_13'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_82_73_13' id='label_82_73_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_82_74\" 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_82_74'>What else is contributing to your mental health problems right now?<\/label><div class='ginput_container ginput_container_text'><input name='input_74' id='input_82_74' type='text' value='' class='medium'    placeholder='Tell us more...'  aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_82_96\" 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_82_96'>What about the state of the world is affecting you the most?<\/label><div class='ginput_container ginput_container_text'><input name='input_96' id='input_82_96' type='text' value='' class='medium'    placeholder='Tell us more...'  aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_82_75\" 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_82_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' >Do you currently have health insurance?<\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_82_76'>\n\t\t\t<div class='gchoice gchoice_82_76_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_76' type='radio' value='Yes'  id='choice_82_76_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_82_76_0' id='label_82_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_82_76_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_76' type='radio' value='No'  id='choice_82_76_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_82_76_1' id='label_82_76_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_82_76_2'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_76' type='radio' value='I don&#039;t know'  id='choice_82_76_2' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_82_76_2' id='label_82_76_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_82_77\" 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_82_77'>Select all that apply.<\/div><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox ' id='input_82_77'><div class='gchoice gchoice_82_77_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_77.1' type='checkbox'  value='Heart disease'  id='choice_82_77_1'   aria-describedby=\"gfield_description_82_77\"\/>\n\t\t\t\t\t\t\t\t<label for='choice_82_77_1' id='label_82_77_1' class='gform-field-label gform-field-label--type-inline'>Heart disease<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_82_77_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_77.2' type='checkbox'  value='Reproductive health concerns (PCOS, endometriosis, infertility, etc.)'  id='choice_82_77_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_82_77_2' id='label_82_77_2' class='gform-field-label gform-field-label--type-inline'>Reproductive health concerns (PCOS, endometriosis, infertility, etc.)<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_82_77_3'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_77.3' type='checkbox'  value='Diabetes'  id='choice_82_77_3'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_82_77_3' id='label_82_77_3' class='gform-field-label gform-field-label--type-inline'>Diabetes<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_82_77_4'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_77.4' type='checkbox'  value='Cancer'  id='choice_82_77_4'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_82_77_4' id='label_82_77_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_82_77_5'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_77.5' type='checkbox'  value='Arthritis or other chronic pain'  id='choice_82_77_5'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_82_77_5' id='label_82_77_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_82_77_6'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_77.6' type='checkbox'  value='Asthma, COPD or other lung conditions'  id='choice_82_77_6'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_82_77_6' id='label_82_77_6' class='gform-field-label gform-field-label--type-inline'>Asthma, COPD or other lung conditions<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_82_77_7'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_77.7' type='checkbox'  value='Movement Disorders (involuntary tics, tardive dyskinesia, etc.)'  id='choice_82_77_7'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_82_77_7' id='label_82_77_7' class='gform-field-label gform-field-label--type-inline'>Movement Disorders (involuntary tics, tardive dyskinesia, etc.)<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_82_77_8'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_77.8' type='checkbox'  value='Digestive problems (Crohn\u2019s, colitis, IBS, etc.)'  id='choice_82_77_8'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_82_77_8' id='label_82_77_8' class='gform-field-label gform-field-label--type-inline'>Digestive problems (Crohn\u2019s, colitis, IBS, etc.)<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_82_77_9'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_77.9' type='checkbox'  value='Neurological conditions (epilepsy, etc.) or traumatic brain injury 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(2022). Psychometric evaluation of the NORC diagnostic screen for gambling problems (NODS) for the assessment of DSM-5 gambling disorder. <em>Addictive Behaviors 130<\/em>, p. 107310. Retrieved from <a href=\"https:\/\/doi.org\/10.1016\/j.addbeh.2022.107310\">https:\/\/doi.org\/10.1016\/j.addbeh.2022.107310<\/a><\/p>\n<p>Original NODS:<\/p>\n<p>Wickwire Jr, E. M., Burke, R. S., Brown, S. A., Parker, J. D., &amp; May, R. K. (2008). Psychometric evaluation of the national opinion research center DSM-IV screen for gambling problems (NODS). <i>American Journal on Addictions<\/i>, <i>17<\/i>(5), 392-395.<\/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<\/div>\n","protected":false},"excerpt":{"rendered":"<p>Para personas preocupadas por su comportamiento con respecto al juego.<\/p>","protected":false},"template":"","tags":[123],"age_group":[],"condition":[],"class_list":["post-245618","screen","type-screen","status-publish","hentry","tag-addictive-compulsive-behaviors"],"acf":[],"yoast_head":"<title>Gambling Addiction Test &#8211; Mental Health America<\/title>\n<meta name=\"description\" content=\"Worried that you gamble too much? 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