{"id":84275,"date":"2022-08-05T13:05:47","date_gmt":"2022-08-05T17:05:47","guid":{"rendered":"https:\/\/screening.mhanational.org\/?post_type=screen&#038;p=84275"},"modified":"2025-08-26T14:27:30","modified_gmt":"2025-08-26T18:27:30","slug":"self-injury-survey","status":"publish","type":"screen","link":"https:\/\/screening.mhanational.org\/es\/screening-tools\/self-injury-survey\/","title":{"rendered":"Encuesta sobre autolesiones"},"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_65' 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_65' class='full-pager' class='clearfix' action='\/es\/wp-json\/wp\/v2\/screen\/84275' data-formid='65' 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_65_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_65' class='gform_fields top_label form_sublabel_below description_above validation_below'><div id=\"field_65_155\" 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_65_155'>Name<\/label><div class='gfield_description' id='gfield_description_65_155'>This field is for validation purposes and should be left unchanged.<\/div><div class='ginput_container'><input name='input_155' id='input_65_155' type='text' value='' autocomplete='new-password'\/><\/div><\/div><div id=\"field_65_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>The self-injury survey explores times when you\u2019ve <strong>hurt yourself on purpose without wanting to die<\/strong>, doing something that causes immediate pain or physical injury like cutting, burning, or scratching your skin.<\/p>\n\n<p style=\"display:none;\"><em><strong>Please note:<\/strong> This test is experimental for self-harm. Your responses will help us improve the test for other people like you.<\/em><\/p><\/div><fieldset id=\"field_65_96\" 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 ever hurt yourself (engaged in self-injury) on purpose?<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_65_96'>\n\t\t\t<div class='gchoice gchoice_65_96_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_96' type='radio' value='Yes'  id='choice_65_96_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_65_96_0' id='label_65_96_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_65_96_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_96' type='radio' value='No'  id='choice_65_96_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_65_96_1' id='label_65_96_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_65_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_65_38' type='hidden' class='gform_hidden'  aria-invalid=\"false\" value='' \/><\/div><\/div><div id=\"field_65_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_65_39\" type=\"hidden\" class=\"gform_hidden\" aria-invalid=\"false\" value=\"84275\"><\/div><div id=\"field_65_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_65_40\" type=\"hidden\" class=\"gform_hidden\" aria-invalid=\"false\" value=\"1065b15f1fb646497a4b06db21f9fba2\"><\/div><div id=\"field_65_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_65_41' type='hidden' class='gform_hidden'  aria-invalid=\"false\" value='' \/><\/div><\/div><div id=\"field_65_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_65_53' type='hidden' class='gform_hidden'  aria-invalid=\"false\" value='' \/><\/div><\/div><div id=\"field_65_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_65_83' type='hidden' class='gform_hidden'  aria-invalid=\"false\" value='' \/><\/div><\/div><div id=\"field_65_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_65_84' type='hidden' class='gform_hidden'  aria-invalid=\"false\" value='' \/><\/div><\/div><div id=\"field_65_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_65_85' type='hidden' class='gform_hidden'  aria-invalid=\"false\" value='' \/><\/div><\/div><div id=\"field_65_154\" 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_154' id='input_65_154' type='hidden' class='gform_hidden'  aria-invalid=\"false\" value='lang--es' \/><\/div><\/div><div id=\"field_65_99\" 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>Your history with self-injury<\/h2><\/div><fieldset id=\"field_65_100\" 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' >How old were you when you <strong>first<\/strong> engaged in self-injury?<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_65_100'>\n\t\t\t<div class='gchoice gchoice_65_100_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_100' type='radio' value='Less than 10 years old'  id='choice_65_100_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_65_100_0' id='label_65_100_0' class='gform-field-label gform-field-label--type-inline'>Less than 10 years old<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_65_100_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_100' type='radio' value='10-12 years old'  id='choice_65_100_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_65_100_1' id='label_65_100_1' class='gform-field-label gform-field-label--type-inline'>10-12 years old<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_65_100_2'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_100' type='radio' value='13-15 years old'  id='choice_65_100_2' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_65_100_2' id='label_65_100_2' class='gform-field-label gform-field-label--type-inline'>13-15 years old<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_65_100_3'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_100' type='radio' value='16-17 years old'  id='choice_65_100_3' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_65_100_3' id='label_65_100_3' class='gform-field-label gform-field-label--type-inline'>16-17 years old<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_65_100_4'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_100' type='radio' value='18 years or older'  id='choice_65_100_4' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_65_100_4' id='label_65_100_4' class='gform-field-label gform-field-label--type-inline'>18 years or older<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_65_112\" 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' >If you had to estimate, <strong>how often<\/strong> would you say that your injuries resulted in permanent scars?<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_65_112'>\n\t\t\t<div class='gchoice gchoice_65_112_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_112' type='radio' value='Never'  id='choice_65_112_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_65_112_0' id='label_65_112_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_65_112_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_112' type='radio' value='Sometimes'  id='choice_65_112_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_65_112_1' id='label_65_112_1' class='gform-field-label gform-field-label--type-inline'>Sometimes<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_65_112_2'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_112' type='radio' value='About half the time'  id='choice_65_112_2' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_65_112_2' id='label_65_112_2' class='gform-field-label gform-field-label--type-inline'>About half the time<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_65_112_3'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_112' type='radio' value='Most times'  id='choice_65_112_3' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_65_112_3' id='label_65_112_3' class='gform-field-label gform-field-label--type-inline'>Most times<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_65_112_4'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_112' type='radio' value='Always'  id='choice_65_112_4' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_65_112_4' id='label_65_112_4' class='gform-field-label gform-field-label--type-inline'>Always<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_65_148\" 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' >In the last year, have you engaged in self-injury on 5 or more days?<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_65_148'>\n\t\t\t<div class='gchoice gchoice_65_148_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_148' type='radio' value='Yes'  id='choice_65_148_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_65_148_0' id='label_65_148_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_65_148_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_148' type='radio' value='No'  id='choice_65_148_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_65_148_1' id='label_65_148_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_65_109\" class=\"gfield gfield--type-html gfield--input-type-html gfield--width-full section-title question 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\nIn the following questions, please think about your self-injury behaviors in the <strong>past month<\/strong> (30 days).\n\n<br \/>\n&nbsp;<\/div><div id=\"field_65_119\" class=\"gfield gfield--type-number gfield--input-type-number gfield--width-full rounded-number number-stepper question gfield_contains_required field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_65_119'>In the past month (30 days), on how many <strong>days<\/strong> have you engaged in self-injury?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_number'><div class=\"step-buttons\"><button type=\"button\" class=\"step-down\" title=\"Increase by 1\" aria-label=\"Increase by 1\">-<\/button><button type=\"button\" class=\"step-up\" aria-label=\"Decrease by 1\" title=\"Decrease by 1\">+<\/button><\/div><input name='input_119' id='input_65_119' type='number' step='1'  pattern='\\d*'  min='0' max='30' value='' class='small'     aria-required=\"true\" aria-invalid=\"false\" aria-describedby=\"gfield_instruction_65_119\" \/><div class='gfield_description instruction ' id='gfield_instruction_65_119'>Please enter a number from <strong>0<\/strong> to <strong>30<\/strong>.<\/div><\/div><\/div><fieldset id=\"field_65_114\" 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' >In the past month, how often have you had an <strong>urge (or a strong desire)<\/strong> to injure yourself?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_65_114'>\n\t\t\t<div class='gchoice gchoice_65_114_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_114' type='radio' value='Never'  id='choice_65_114_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_65_114_0' id='label_65_114_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_65_114_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_114' type='radio' value='Once or twice during the past 30 days'  id='choice_65_114_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_65_114_1' id='label_65_114_1' class='gform-field-label gform-field-label--type-inline'>Once or twice during the past 30 days<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_65_114_2'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_114' type='radio' value='Around once a week'  id='choice_65_114_2' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_65_114_2' id='label_65_114_2' class='gform-field-label gform-field-label--type-inline'>Around once a week<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_65_114_3'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_114' type='radio' value='Several times a week'  id='choice_65_114_3' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_65_114_3' id='label_65_114_3' class='gform-field-label gform-field-label--type-inline'>Several times a week<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_65_114_4'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_114' type='radio' value='Several times a day'  id='choice_65_114_4' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_65_114_4' id='label_65_114_4' class='gform-field-label gform-field-label--type-inline'>Several times a day<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_65_114_5'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_114' type='radio' value='Prefer not to answer'  id='choice_65_114_5' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_65_114_5' id='label_65_114_5' 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_65_115\" 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' >In the past month, how often have you injured yourself so badly you weren\u2019t sure you could care for your wounds without help?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_65_115'>\n\t\t\t<div class='gchoice gchoice_65_115_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_115' type='radio' value='Never'  id='choice_65_115_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_65_115_0' id='label_65_115_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_65_115_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_115' type='radio' value='Sometimes'  id='choice_65_115_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_65_115_1' id='label_65_115_1' class='gform-field-label gform-field-label--type-inline'>Sometimes<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_65_115_2'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_115' type='radio' value='About half the time'  id='choice_65_115_2' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_65_115_2' id='label_65_115_2' class='gform-field-label gform-field-label--type-inline'>About half the time<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_65_115_3'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_115' type='radio' value='Most times'  id='choice_65_115_3' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_65_115_3' id='label_65_115_3' class='gform-field-label gform-field-label--type-inline'>Most times<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_65_115_4'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_115' type='radio' value='Always'  id='choice_65_115_4' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_65_115_4' id='label_65_115_4' class='gform-field-label gform-field-label--type-inline'>Always<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_65_115_5'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_115' type='radio' value='Prefer not to answer'  id='choice_65_115_5' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_65_115_5' id='label_65_115_5' 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_65_126\" 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' >In the past month, how often did you have negative feelings or thoughts (anger, sadness, self-criticism, etc.) <strong>before injuring yourself<\/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_65_126'>\n\t\t\t<div class='gchoice gchoice_65_126_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_126' type='radio' value='Never'  id='choice_65_126_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_65_126_0' id='label_65_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_65_126_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_126' type='radio' value='Sometimes'  id='choice_65_126_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_65_126_1' id='label_65_126_1' class='gform-field-label gform-field-label--type-inline'>Sometimes<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_65_126_2'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_126' type='radio' value='About half the time'  id='choice_65_126_2' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_65_126_2' id='label_65_126_2' class='gform-field-label gform-field-label--type-inline'>About half the time<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_65_126_3'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_126' type='radio' value='Most times'  id='choice_65_126_3' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_65_126_3' id='label_65_126_3' class='gform-field-label gform-field-label--type-inline'>Most times<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_65_126_4'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_126' type='radio' value='Always'  id='choice_65_126_4' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_65_126_4' id='label_65_126_4' class='gform-field-label gform-field-label--type-inline'>Always<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_65_126_5'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_126' type='radio' value='Prefer not to answer'  id='choice_65_126_5' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_65_126_5' id='label_65_126_5' 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_65_124\" 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' >In the past month, how often were you thinking or worrying about the idea of injuring yourself <strong>before injuring yourself<\/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_65_124'>\n\t\t\t<div class='gchoice gchoice_65_124_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_124' type='radio' value='Never'  id='choice_65_124_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_65_124_0' id='label_65_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_65_124_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_124' type='radio' value='Sometimes'  id='choice_65_124_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_65_124_1' id='label_65_124_1' class='gform-field-label gform-field-label--type-inline'>Sometimes<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_65_124_2'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_124' type='radio' value='About half the time'  id='choice_65_124_2' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_65_124_2' id='label_65_124_2' class='gform-field-label gform-field-label--type-inline'>About half the time<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_65_124_3'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_124' type='radio' value='Most times'  id='choice_65_124_3' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_65_124_3' id='label_65_124_3' class='gform-field-label gform-field-label--type-inline'>Most times<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_65_124_4'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_124' type='radio' value='Always'  id='choice_65_124_4' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_65_124_4' id='label_65_124_4' class='gform-field-label gform-field-label--type-inline'>Always<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_65_124_5'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_124' type='radio' value='Prefer not to answer'  id='choice_65_124_5' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_65_124_5' id='label_65_124_5' 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_65_125\" 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' >In the past month, how often have you experienced conflict or problems with other people <strong>before injuring yourself<\/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_65_125'>\n\t\t\t<div class='gchoice gchoice_65_125_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_125' type='radio' value='Never'  id='choice_65_125_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_65_125_0' id='label_65_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_65_125_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_125' type='radio' value='Sometimes'  id='choice_65_125_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_65_125_1' id='label_65_125_1' class='gform-field-label gform-field-label--type-inline'>Sometimes<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_65_125_2'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_125' type='radio' value='About half the time'  id='choice_65_125_2' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_65_125_2' id='label_65_125_2' class='gform-field-label gform-field-label--type-inline'>About half the time<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_65_125_3'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_125' type='radio' value='Most times'  id='choice_65_125_3' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_65_125_3' id='label_65_125_3' class='gform-field-label gform-field-label--type-inline'>Most times<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_65_125_4'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_125' type='radio' value='Always'  id='choice_65_125_4' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_65_125_4' id='label_65_125_4' class='gform-field-label gform-field-label--type-inline'>Always<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_65_125_5'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_125' type='radio' value='Prefer not to answer'  id='choice_65_125_5' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_65_125_5' id='label_65_125_5' 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_65_127\" 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' >In the past month, how often have you had thoughts of killing yourself or ending your life?<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_65_127'>\n\t\t\t<div class='gchoice gchoice_65_127_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_127' type='radio' value='Never'  id='choice_65_127_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_65_127_0' id='label_65_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_65_127_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_127' type='radio' value='Once or twice during the past 30 days'  id='choice_65_127_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_65_127_1' id='label_65_127_1' class='gform-field-label gform-field-label--type-inline'>Once or twice during the past 30 days<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_65_127_2'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_127' type='radio' value='Around once a week'  id='choice_65_127_2' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_65_127_2' id='label_65_127_2' class='gform-field-label gform-field-label--type-inline'>Around once a week<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_65_127_3'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_127' type='radio' value='Several times a week'  id='choice_65_127_3' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_65_127_3' id='label_65_127_3' class='gform-field-label gform-field-label--type-inline'>Several times a week<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_65_127_4'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_127' type='radio' value='Several times a day'  id='choice_65_127_4' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_65_127_4' id='label_65_127_4' class='gform-field-label gform-field-label--type-inline'>Several times a day<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_65_127_5'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_127' type='radio' value='Prefer not to answer'  id='choice_65_127_5' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_65_127_5' id='label_65_127_5' class='gform-field-label gform-field-label--type-inline'>Prefer not to answer<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_65_146\" class=\"gfield gfield--type-html gfield--input-type-html gfield--width-full warning gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  >If you need immediate help, you can reach the Suicide &amp; Crisis Lifeline by calling or texting <a href=\"tel:+1-988\">988<\/a> or using the chat box at <a href=\"http:\/\/988lifeline.org\/\">988lifeline.org<\/a>. You can also <a href=\"sms:+1-741-741?body=MHA\">text \u201cMHA\u201d to 741-741<\/a> to reach the Crisis Text Line. <a href=\"https:\/\/screening.mhanational.org\/content\/need-talk-someone-warmlines\/\">Warmlines<\/a> are an excellent place for non-crisis support.<\/div><div id=\"field_65_128\" 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 \/>\n\nWhen thinking about your self-injury in the <strong>past month<\/strong>, please rate how much you agree or disagree with these statements.\n\n<br \/>\n&nbsp;<\/div><div id=\"field_65_145\" 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 \/>\n\nPlease rate how much you agree or disagree with these statements.\n\n<br \/>\n&nbsp;<\/div><fieldset id=\"field_65_129\" 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' >When I injure myself, I <strong>expect it will<\/strong> stop or relieve bad feelings 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_65_129'>\n\t\t\t<div class='gchoice gchoice_65_129_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_129' type='radio' value='Strongly Agree'  id='choice_65_129_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_65_129_0' id='label_65_129_0' class='gform-field-label gform-field-label--type-inline'>Strongly Agree<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_65_129_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_129' type='radio' value='Agree'  id='choice_65_129_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_65_129_1' id='label_65_129_1' class='gform-field-label gform-field-label--type-inline'>Agree<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_65_129_2'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_129' type='radio' value='Unsure'  id='choice_65_129_2' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_65_129_2' id='label_65_129_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_65_129_3'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_129' type='radio' value='Disagree'  id='choice_65_129_3' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_65_129_3' id='label_65_129_3' class='gform-field-label gform-field-label--type-inline'>Disagree<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_65_129_4'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_129' type='radio' value='Strongly Disagree'  id='choice_65_129_4' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_65_129_4' id='label_65_129_4' class='gform-field-label gform-field-label--type-inline'>Strongly Disagree<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_65_130\" 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' >When I injure myself, I <strong>expect it will<\/strong> make me feel good, or better than I 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_65_130'>\n\t\t\t<div class='gchoice gchoice_65_130_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_130' type='radio' value='Strongly Agree'  id='choice_65_130_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_65_130_0' id='label_65_130_0' class='gform-field-label gform-field-label--type-inline'>Strongly Agree<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_65_130_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_130' type='radio' value='Agree'  id='choice_65_130_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_65_130_1' id='label_65_130_1' class='gform-field-label gform-field-label--type-inline'>Agree<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_65_130_2'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_130' type='radio' value='Unsure'  id='choice_65_130_2' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_65_130_2' id='label_65_130_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_65_130_3'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_130' type='radio' value='Disagree'  id='choice_65_130_3' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_65_130_3' id='label_65_130_3' class='gform-field-label gform-field-label--type-inline'>Disagree<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_65_130_4'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_130' type='radio' value='Strongly Disagree'  id='choice_65_130_4' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_65_130_4' id='label_65_130_4' class='gform-field-label gform-field-label--type-inline'>Strongly Disagree<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_65_131\" 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' >When I injure myself, I <strong>expect it will<\/strong> help me resolve problems with 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_65_131'>\n\t\t\t<div class='gchoice gchoice_65_131_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_131' type='radio' value='Strongly Agree'  id='choice_65_131_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_65_131_0' id='label_65_131_0' class='gform-field-label gform-field-label--type-inline'>Strongly Agree<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_65_131_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_131' type='radio' value='Agree'  id='choice_65_131_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_65_131_1' id='label_65_131_1' class='gform-field-label gform-field-label--type-inline'>Agree<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_65_131_2'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_131' type='radio' value='Unsure'  id='choice_65_131_2' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_65_131_2' id='label_65_131_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_65_131_3'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_131' type='radio' value='Disagree'  id='choice_65_131_3' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_65_131_3' id='label_65_131_3' class='gform-field-label gform-field-label--type-inline'>Disagree<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_65_131_4'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_131' type='radio' value='Strongly Disagree'  id='choice_65_131_4' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_65_131_4' id='label_65_131_4' class='gform-field-label gform-field-label--type-inline'>Strongly Disagree<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_65_134\" 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' >Over time, I have had to injure myself more deeply or in more places to get the same effect.<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_65_134'>\n\t\t\t<div class='gchoice gchoice_65_134_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_134' type='radio' value='Strongly Agree'  id='choice_65_134_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_65_134_0' id='label_65_134_0' class='gform-field-label gform-field-label--type-inline'>Strongly Agree<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_65_134_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_134' type='radio' value='Agree'  id='choice_65_134_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_65_134_1' id='label_65_134_1' class='gform-field-label gform-field-label--type-inline'>Agree<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_65_134_2'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_134' type='radio' value='Unsure'  id='choice_65_134_2' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_65_134_2' id='label_65_134_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_65_134_3'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_134' type='radio' value='Disagree'  id='choice_65_134_3' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_65_134_3' id='label_65_134_3' class='gform-field-label gform-field-label--type-inline'>Disagree<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_65_134_4'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_134' type='radio' value='Strongly Disagree'  id='choice_65_134_4' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_65_134_4' id='label_65_134_4' class='gform-field-label gform-field-label--type-inline'>Strongly Disagree<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_65_138\" 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' >Self-injury has affected relationships that are important to me.<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_65_138'>\n\t\t\t<div class='gchoice gchoice_65_138_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_138' type='radio' value='Strongly Agree'  id='choice_65_138_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_65_138_0' id='label_65_138_0' class='gform-field-label gform-field-label--type-inline'>Strongly Agree<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_65_138_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_138' type='radio' value='Agree'  id='choice_65_138_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_65_138_1' id='label_65_138_1' class='gform-field-label gform-field-label--type-inline'>Agree<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_65_138_2'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_138' type='radio' value='Unsure'  id='choice_65_138_2' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_65_138_2' id='label_65_138_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_65_138_3'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_138' type='radio' value='Disagree'  id='choice_65_138_3' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_65_138_3' id='label_65_138_3' class='gform-field-label gform-field-label--type-inline'>Disagree<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_65_138_4'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_138' type='radio' value='Strongly Disagree'  id='choice_65_138_4' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_65_138_4' id='label_65_138_4' class='gform-field-label gform-field-label--type-inline'>Strongly Disagree<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_65_139\" 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' >Self-injury has affected my ability to do school work or finish work tasks.<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_65_139'>\n\t\t\t<div class='gchoice gchoice_65_139_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_139' type='radio' value='Strongly Agree'  id='choice_65_139_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_65_139_0' id='label_65_139_0' class='gform-field-label gform-field-label--type-inline'>Strongly Agree<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_65_139_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_139' type='radio' value='Agree'  id='choice_65_139_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_65_139_1' id='label_65_139_1' class='gform-field-label gform-field-label--type-inline'>Agree<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_65_139_2'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_139' type='radio' value='Unsure'  id='choice_65_139_2' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_65_139_2' id='label_65_139_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_65_139_3'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_139' type='radio' value='Disagree'  id='choice_65_139_3' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_65_139_3' id='label_65_139_3' class='gform-field-label gform-field-label--type-inline'>Disagree<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_65_139_4'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_139' type='radio' value='Strongly Disagree'  id='choice_65_139_4' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_65_139_4' id='label_65_139_4' class='gform-field-label gform-field-label--type-inline'>Strongly Disagree<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_65_140\" 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' >Self-injury has affected my ability to take care of myself.<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_65_140'>\n\t\t\t<div class='gchoice gchoice_65_140_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_140' type='radio' value='Strongly Agree'  id='choice_65_140_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_65_140_0' id='label_65_140_0' class='gform-field-label gform-field-label--type-inline'>Strongly Agree<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_65_140_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_140' type='radio' value='Agree'  id='choice_65_140_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_65_140_1' id='label_65_140_1' class='gform-field-label gform-field-label--type-inline'>Agree<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_65_140_2'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_140' type='radio' value='Unsure'  id='choice_65_140_2' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_65_140_2' id='label_65_140_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_65_140_3'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_140' type='radio' value='Disagree'  id='choice_65_140_3' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_65_140_3' id='label_65_140_3' class='gform-field-label gform-field-label--type-inline'>Disagree<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_65_140_4'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_140' type='radio' value='Strongly Disagree'  id='choice_65_140_4' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_65_140_4' id='label_65_140_4' class='gform-field-label gform-field-label--type-inline'>Strongly Disagree<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_65_141\" 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' >Self-injury has affected my ability to do things that I like.<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_65_141'>\n\t\t\t<div class='gchoice gchoice_65_141_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_141' type='radio' value='Strongly Agree'  id='choice_65_141_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_65_141_0' id='label_65_141_0' class='gform-field-label gform-field-label--type-inline'>Strongly Agree<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_65_141_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_141' type='radio' value='Agree'  id='choice_65_141_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_65_141_1' id='label_65_141_1' class='gform-field-label gform-field-label--type-inline'>Agree<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_65_141_2'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_141' type='radio' value='Unsure'  id='choice_65_141_2' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_65_141_2' id='label_65_141_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_65_141_3'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_141' type='radio' value='Disagree'  id='choice_65_141_3' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_65_141_3' id='label_65_141_3' class='gform-field-label gform-field-label--type-inline'>Disagree<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_65_141_4'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_141' type='radio' value='Strongly Disagree'  id='choice_65_141_4' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_65_141_4' id='label_65_141_4' class='gform-field-label gform-field-label--type-inline'>Strongly Disagree<\/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_65_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_65_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_65_2' class='gform_fields top_label form_sublabel_below description_above validation_below'><div id=\"field_65_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_65_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_65_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_65_87'>\n\t\t\t<div class='gchoice gchoice_65_87_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_87' type='radio' value='For myself'  id='choice_65_87_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_65_87_0' id='label_65_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_65_87_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_87' type='radio' value='For someone else'  id='choice_65_87_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_65_87_1' id='label_65_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_65_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_65_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_65_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_65_56'>Age Range<\/label><div class='ginput_container ginput_container_select'><select name='input_56' id='input_65_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_65_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_65_57'>\n\t\t\t<div class='gchoice gchoice_65_57_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_57' type='radio' value='Female'  id='choice_65_57_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_65_57_0' id='label_65_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_65_57_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_57' type='radio' value='Male'  id='choice_65_57_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_65_57_1' id='label_65_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_65_57_2'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_57' type='radio' value='Non-Binary'  id='choice_65_57_2' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_65_57_2' id='label_65_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_65_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_65_151'>\n\t\t\t<div class='gchoice gchoice_65_151_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_151' type='radio' value='Yes'  id='choice_65_151_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_65_151_0' id='label_65_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_65_151_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_151' type='radio' value='No'  id='choice_65_151_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_65_151_1' id='label_65_151_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_65_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_65_58'>How would you describe your gender?<\/label><div class='ginput_container ginput_container_text'><input name='input_58' id='input_65_58' type='text' value='' class='small'    placeholder='Enter gender...'  aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_65_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_65_60'>Race\/Ethnicity<\/label><div class='ginput_container ginput_container_select'><select name='input_60' id='input_65_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_65_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_65_61'>Household Income<\/label><div class='ginput_container ginput_container_select'><select name='input_61' id='input_65_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_65_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_65_91'>\n\t\t\t<div class='gchoice gchoice_65_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_65_91_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_65_91_0' id='label_65_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_65_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_65_91_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_65_91_1' id='label_65_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_65_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_65_80'>State<\/label><div class='ginput_container ginput_container_select'><select name='input_80' id='input_65_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_65_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_65_82'>What country do you live in?<\/label><div class='ginput_container ginput_container_select'><select name='input_82' id='input_65_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_65_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_65_81'>Zip\/Postal Code<\/label><div class='ginput_container ginput_container_text'><input name='input_81' id='input_65_81' type='text' value='' class='small'      aria-invalid=\"false\"   \/><\/div><\/div><fieldset id=\"field_65_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_65_62'>Select all that apply.<\/div><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox ' id='input_65_62'><div class='gchoice gchoice_65_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_65_62_1'   aria-describedby=\"gfield_description_65_62\"\/>\n\t\t\t\t\t\t\t\t<label for='choice_65_62_1' id='label_65_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_65_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_65_62_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_65_62_2' id='label_65_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_65_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_65_62_3'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_65_62_3' id='label_65_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_65_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_65_62_4'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_65_62_4' id='label_65_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_65_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_65_62_5'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_65_62_5' id='label_65_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_65_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_65_62_6'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_65_62_6' id='label_65_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_65_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_65_62_7'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_65_62_7' id='label_65_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_65_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_65_92'>\n\t\t\t<div class='gchoice gchoice_65_92_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_92' type='radio' value='Mental health condition'  id='choice_65_92_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_65_92_0' id='label_65_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_65_92_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_92' type='radio' value='Physical health condition'  id='choice_65_92_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_65_92_1' id='label_65_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_65_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_65_92_2' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_65_92_2' id='label_65_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_65_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_65_93'>Which of the following best describes your sexual orientation?<\/label><div class='ginput_container ginput_container_select'><select name='input_93' id='input_65_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_65_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_65_68'>What is your sexual orientation?<\/label><div class='ginput_container ginput_container_text'><input name='input_68' id='input_65_68' type='text' value='' class='small'    placeholder='Enter sexual orientation...'  aria-invalid=\"false\"   \/><\/div><\/div><fieldset id=\"field_65_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_65_94'>Select all that apply.<\/div><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox ' id='input_65_94'><div class='gchoice gchoice_65_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_65_94_1'   aria-describedby=\"gfield_description_65_94\"\/>\n\t\t\t\t\t\t\t\t<label for='choice_65_94_1' id='label_65_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_65_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_65_94_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_65_94_2' id='label_65_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_65_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_65_94_3'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_65_94_3' id='label_65_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_65_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_65_94_4'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_65_94_4' id='label_65_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_65_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_65_94_5'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_65_94_5' id='label_65_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_65_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_65_94_6'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_65_94_6' id='label_65_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_65_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_65_94_7'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_65_94_7' id='label_65_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_65_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_65_94_8'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_65_94_8' id='label_65_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_65_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_65_95'>Please tell us more about your experience of trauma:<\/label><div class='ginput_container ginput_container_text'><input name='input_95' id='input_65_95' type='text' value='' class='medium'    placeholder='Tell us more...'  aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_65_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_65_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_65_71'>\n\t\t\t<div class='gchoice gchoice_65_71_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_71' type='radio' value='Yes'  id='choice_65_71_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_65_71_0' id='label_65_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_65_71_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_71' type='radio' value='No'  id='choice_65_71_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_65_71_1' id='label_65_71_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_65_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_65_72'>\n\t\t\t<div class='gchoice gchoice_65_72_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_72' type='radio' value='Yes'  id='choice_65_72_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_65_72_0' id='label_65_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_65_72_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_72' type='radio' value='No'  id='choice_65_72_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_65_72_1' id='label_65_72_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_65_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_65_152'>Choose up to 3.<\/div><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox ' id='input_65_152'><div class='gchoice gchoice_65_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_65_152_1'   aria-describedby=\"gfield_description_65_152\"\/>\n\t\t\t\t\t\t\t\t<label for='choice_65_152_1' id='label_65_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_65_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_65_152_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_65_152_2' id='label_65_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_65_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_65_152_3'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_65_152_3' id='label_65_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_65_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_65_152_4'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_65_152_4' id='label_65_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_65_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_65_152_5'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_65_152_5' id='label_65_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_65_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_65_152_6'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_65_152_6' id='label_65_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_65_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_65_152_7'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_65_152_7' id='label_65_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_65_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_65_152_8'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_65_152_8' id='label_65_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_65_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_65_152_9'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_65_152_9' id='label_65_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_65_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_65_152_11'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_65_152_11' id='label_65_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_65_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_65_152_12'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_65_152_12' id='label_65_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_65_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_65_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_65_153' type='text' value='' class='medium'    placeholder='Tell us more...'  aria-invalid=\"false\"   \/><\/div><\/div><fieldset id=\"field_65_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_65_73'>Choose up to 3.<\/div><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox ' id='input_65_73'><div class='gchoice gchoice_65_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_65_73_1'   aria-describedby=\"gfield_description_65_73\"\/>\n\t\t\t\t\t\t\t\t<label for='choice_65_73_1' id='label_65_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_65_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_65_73_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_65_73_2' id='label_65_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_65_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_65_73_3'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_65_73_3' id='label_65_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_65_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_65_73_4'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_65_73_4' id='label_65_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_65_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_65_73_5'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_65_73_5' id='label_65_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_65_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_65_73_6'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_65_73_6' id='label_65_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_65_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_65_73_7'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_65_73_7' id='label_65_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_65_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_65_73_8'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_65_73_8' id='label_65_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_65_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_65_73_9'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_65_73_9' id='label_65_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_65_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_65_73_11'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_65_73_11' id='label_65_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_65_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_65_73_12'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_65_73_12' id='label_65_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_65_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_65_73_13'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_65_73_13' id='label_65_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_65_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_65_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_65_74' type='text' value='' class='medium'    placeholder='Tell us more...'  aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_65_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_65_147'>What about the state of the world is affecting you the most?<\/label><div class='ginput_container ginput_container_text'><input name='input_147' id='input_65_147' type='text' value='' class='large'    placeholder='Tell us more...'  aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_65_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_65_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_65_76'>\n\t\t\t<div class='gchoice gchoice_65_76_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_76' type='radio' value='Yes'  id='choice_65_76_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_65_76_0' id='label_65_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_65_76_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_76' type='radio' value='No'  id='choice_65_76_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_65_76_1' id='label_65_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_65_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_65_76_2' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_65_76_2' id='label_65_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_65_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_65_77'>Select all that apply.<\/div><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox ' id='input_65_77'><div class='gchoice gchoice_65_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_65_77_1'   aria-describedby=\"gfield_description_65_77\"\/>\n\t\t\t\t\t\t\t\t<label for='choice_65_77_1' id='label_65_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_65_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_65_77_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_65_77_2' id='label_65_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_65_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_65_77_3'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_65_77_3' id='label_65_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_65_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_65_77_4'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_65_77_4' id='label_65_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_65_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_65_77_5'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_65_77_5' id='label_65_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_65_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_65_77_6'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_65_77_6' id='label_65_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_65_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_65_77_7'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_65_77_7' id='label_65_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_65_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_65_77_8'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_65_77_8' id='label_65_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_65_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 (TBI)'  id='choice_65_77_9'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_65_77_9' id='label_65_77_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_65_77_11'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_77.11' type='checkbox'  value='Other...'  id='choice_65_77_11'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_65_77_11' id='label_65_77_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_65_78\" class=\"gfield gfield--type-text gfield--input-type-text optional field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_65_78'>What other physical health conditions do you have?<\/label><div class='ginput_container ginput_container_text'><input name='input_78' id='input_65_78' type='text' value='' class='medium'    placeholder='Tell us more...'  aria-invalid=\"false\"   \/><\/div><\/div><fieldset id=\"field_65_149\" 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_65_149'>\n\t\t\t<div class='gchoice gchoice_65_149_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_149' type='radio' value='Yes'  id='choice_65_149_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_65_149_0' id='label_65_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_65_149_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_149' type='radio' value='No'  id='choice_65_149_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_65_149_1' id='label_65_149_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_65_150\" 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_65_150'>\n\t\t\t<div class='gchoice gchoice_65_150_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_150' type='radio' value='Yes'  id='choice_65_150_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_65_150_0' id='label_65_150_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_65_150_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_150' type='radio' value='No'  id='choice_65_150_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_65_150_1' id='label_65_150_1' class='gform-field-label gform-field-label--type-inline'>No<\/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_65' 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_65' class='gform_button button' 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