{"id":528,"date":"2020-12-22T14:29:43","date_gmt":"2020-12-22T14:29:43","guid":{"rendered":"http:\/\/forms.mhamichiana.org\/?page_id=528"},"modified":"2026-05-01T09:16:56","modified_gmt":"2026-05-01T13:16:56","slug":"pro-bono-application","status":"publish","type":"page","link":"https:\/\/forms.mhamichiana.org\/es\/","title":{"rendered":"Pro Bono Application (Client)"},"content":{"rendered":"<div data-elementor-type=\"wp-page\" data-elementor-id=\"528\" class=\"elementor elementor-528\" data-elementor-post-type=\"page\">\n\t\t\t\t\t\t<section class=\"elementor-section elementor-top-section elementor-element elementor-element-3aa5d2b elementor-section-boxed elementor-section-height-default elementor-section-height-default\" data-id=\"3aa5d2b\" data-element_type=\"section\" data-e-type=\"section\" data-settings=\"{&quot;background_background&quot;:&quot;classic&quot;}\">\n\t\t\t\t\t\t<div class=\"elementor-container elementor-column-gap-default\">\n\t\t\t\t\t<div class=\"elementor-column elementor-col-100 elementor-top-column elementor-element elementor-element-a506258\" data-id=\"a506258\" data-element_type=\"column\" data-e-type=\"column\" data-settings=\"{&quot;background_background&quot;:&quot;classic&quot;}\">\n\t\t\t<div class=\"elementor-widget-wrap elementor-element-populated\">\n\t\t\t\t\t\t<div class=\"elementor-element elementor-element-057ac91 elementor-widget elementor-widget-heading\" data-id=\"057ac91\" data-element_type=\"widget\" data-e-type=\"widget\" data-widget_type=\"heading.default\">\n\t\t\t\t<div class=\"elementor-widget-container\">\n\t\t\t\t\t<h2 class=\"elementor-heading-title elementor-size-default\">Pro Bono Counseling Project Application<\/h2>\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t<div class=\"elementor-element elementor-element-5ee1ba7 elementor-widget elementor-widget-text-editor\" data-id=\"5ee1ba7\" data-element_type=\"widget\" data-e-type=\"widget\" data-widget_type=\"text-editor.default\">\n\t\t\t\t<div class=\"elementor-widget-container\">\n\t\t\t\t\t\t\t\t\t<p>In order to qualify for the Pro Bono Counseling Project services, you must apply by filling out the application below.\u00a0<\/p>\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t<div class=\"elementor-element elementor-element-0ca7fb9 elementor-widget elementor-widget-button\" data-id=\"0ca7fb9\" data-element_type=\"widget\" data-e-type=\"widget\" data-widget_type=\"button.default\">\n\t\t\t\t<div class=\"elementor-widget-container\">\n\t\t\t\t\t\t\t\t\t<div class=\"elementor-button-wrapper\">\n\t\t\t\t\t<a class=\"elementor-button elementor-button-link elementor-size-sm\" href=\"https:\/\/mhamichiana.org\/pro-bono-counseling-project\/\" target=\"_blank\">\n\t\t\t\t\t\t<span class=\"elementor-button-content-wrapper\">\n\t\t\t\t\t\t<span class=\"elementor-button-icon\">\n\t\t\t\t<i aria-hidden=\"true\" class=\"fas fa-long-arrow-alt-left\"><\/i>\t\t\t<\/span>\n\t\t\t\t\t\t\t\t\t<span class=\"elementor-button-text\">Learn More About the PBCP Program<\/span>\n\t\t\t\t\t<\/span>\n\t\t\t\t\t<\/a>\n\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t<div class=\"elementor-element elementor-element-64c1b13 elementor-widget elementor-widget-shortcode\" data-id=\"64c1b13\" data-element_type=\"widget\" data-e-type=\"widget\" data-widget_type=\"shortcode.default\">\n\t\t\t\t<div class=\"elementor-widget-container\">\n\t\t\t\t\t\t\t<div class=\"elementor-shortcode\"><script type=\"text\/javascript\">\n\/* <![CDATA[ *\/\nvar gform;gform||(document.addEventListener(\"gform_main_scripts_loaded\",function(){gform.scriptsLoaded=!0}),document.addEventListener(\"gform\/theme\/scripts_loaded\",function(){gform.themeScriptsLoaded=!0}),window.addEventListener(\"DOMContentLoaded\",function(){gform.domLoaded=!0}),gform={domLoaded:!1,scriptsLoaded:!1,themeScriptsLoaded:!1,isFormEditor:()=>\"function\"==typeof 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gform.doHook(\"filter\",o,arguments)},removeAction:function(o,r){gform.removeHook(\"action\",o,r)},removeFilter:function(o,r,e){gform.removeHook(\"filter\",o,r,e)},addHook:function(o,r,e,t,n){null==gform.hooks[o][r]&&(gform.hooks[o][r]=[]);var d=gform.hooks[o][r];null==n&&(n=r+\"_\"+d.length),gform.hooks[o][r].push({tag:n,callable:e,priority:t=null==t?10:t})},doHook:function(r,o,e){var t;if(e=Array.prototype.slice.call(e,1),null!=gform.hooks[r][o]&&((o=gform.hooks[r][o]).sort(function(o,r){return o.priority-r.priority}),o.forEach(function(o){\"function\"!=typeof(t=o.callable)&&(t=window[t]),\"action\"==r?t.apply(null,e):e[0]=t.apply(null,e)})),\"filter\"==r)return e[0]},removeHook:function(o,r,t,n){var e;null!=gform.hooks[o][r]&&(e=(e=gform.hooks[o][r]).filter(function(o,r,e){return!!(null!=n&&n!=o.tag||null!=t&&t!=o.priority)}),gform.hooks[o][r]=e)}});\n\/* ]]> *\/\n<\/script>\n\n                <div class='gf_browser_gecko gform_wrapper gform_legacy_markup_wrapper gform-theme--no-framework' data-form-theme='legacy' data-form-index='0' id='gform_wrapper_14' style='display:none'><div id='gf_14' class='gform_anchor' tabindex='-1'><\/div><form method='post' enctype='multipart\/form-data' target='gform_ajax_frame_14' id='gform_14'  action='\/es\/wp-json\/wp\/v2\/pages\/528#gf_14' data-formid='14' novalidate data-trp-original-action=\"\/es\/wp-json\/wp\/v2\/pages\/528#gf_14\">\n                        <div class='gform-body gform_body'><ul id='gform_fields_14' class='gform_fields top_label form_sublabel_below description_below validation_below'><li id=\"field_14_1\" class=\"gfield gfield--type-text gfield--input-type-text hipaa_forms_first_name field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_14_1'>First Name:<\/label><div class='ginput_container ginput_container_text'><input name='input_1' id='input_14_1' type='text' value='' class='medium'   tabindex='49'   aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_14_21\" class=\"gfield gfield--type-text gfield--input-type-text hipaa_forms_last_name field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_14_21'>Last Name:<\/label><div class='ginput_container ginput_container_text'><input name='input_21' id='input_14_21' type='text' value='' class='medium'   tabindex='50'   aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_14_24\" class=\"gfield gfield--type-date gfield--input-type-date gfield--input-type-datepicker gfield--datepicker-no-icon field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_14_24'>Today&#039;s Date<\/label><div class='ginput_container ginput_container_date'>\n                            <input name='input_24' id='input_14_24' type='text' value='' class='datepicker gform-datepicker mdy datepicker_no_icon gdatepicker-no-icon' tabindex='51'  placeholder='mm\/dd\/yyyy' aria-describedby=\"input_14_24_date_format\" aria-invalid=\"false\" \/>\n                            <span id='input_14_24_date_format' class='screen-reader-text'>MM slash DD slash YYYY<\/span>\n                        <\/div>\n                        <input type='hidden' id='gforms_calendar_icon_input_14_24' class='gform_hidden' value='https:\/\/forms.mhamichiana.org\/wp-content\/plugins\/gravityforms\/images\/datepicker\/datepicker.svg'\/><\/li><li id=\"field_14_22\" class=\"gfield gfield--type-select gfield--input-type-select field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_14_22'>Preferred Pronoun (optional)<\/label><div class='ginput_container ginput_container_select'><select name='input_22' id='input_14_22' class='medium gfield_select' tabindex='52'    aria-invalid=\"false\" ><option value='' selected='selected'><\/option><option value='She\/Her\/Hers' >She\/Her\/Hers<\/option><option value='He\/Him\/His' >He\/Him\/His<\/option><option value='They\/Them\/Theirs' >They\/Them\/Theirs<\/option><\/select><\/div><\/li><li id=\"field_14_30\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-full field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' >Who is filling out this application?<\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_14_30'>\n\t\t\t<li class='gchoice gchoice_14_30_0'>\n\t\t\t\t<input name='input_30' type='radio' value='I am filling it out for myself.'  id='choice_14_30_0' tabindex='53'   \/>\n\t\t\t\t<label for='choice_14_30_0' id='label_14_30_0' class='gform-field-label gform-field-label--type-inline'>I am filling it out for myself.<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_14_30_1'>\n\t\t\t\t<input name='input_30' type='radio' value='I am filling it out on someone else&#039;s behalf.'  id='choice_14_30_1' tabindex='54'   \/>\n\t\t\t\t<label for='choice_14_30_1' id='label_14_30_1' class='gform-field-label gform-field-label--type-inline'>I am filling it out on someone else's behalf.<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_14_34\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-full field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' >I am interested in receiving Peer Support<\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_14_34'>\n\t\t\t<li class='gchoice gchoice_14_34_0'>\n\t\t\t\t<input name='input_34' type='radio' value='Yes'  id='choice_14_34_0' tabindex='55'   \/>\n\t\t\t\t<label for='choice_14_34_0' id='label_14_34_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_14_34_1'>\n\t\t\t\t<input name='input_34' type='radio' value='No'  id='choice_14_34_1' tabindex='56'   \/>\n\t\t\t\t<label for='choice_14_34_1' id='label_14_34_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_14_34_2'>\n\t\t\t\t<input name='input_34' type='radio' value='Maybe'  id='choice_14_34_2' tabindex='57'   \/>\n\t\t\t\t<label for='choice_14_34_2' id='label_14_34_2' class='gform-field-label gform-field-label--type-inline'>Maybe<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_14_4\" class=\"gfield gfield--type-email gfield--input-type-email hipaa_forms_email field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_14_4'>Email:<\/label><div class='ginput_container ginput_container_email'>\n                            <input name='input_4' id='input_14_4' type='email' value='' class='medium' tabindex='58'    aria-invalid=\"false\"  \/>\n                        <\/div><\/li><li id=\"field_14_2\" class=\"gfield gfield--type-date gfield--input-type-date gfield--input-type-datepicker gfield--datepicker-default-icon field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_14_2'>Date of birth:<\/label><div class='ginput_container ginput_container_date'>\n                            <input name='input_2' id='input_14_2' type='text' value='' class='datepicker gform-datepicker mdy datepicker_with_icon gdatepicker_with_icon' tabindex='59'  placeholder='mm\/dd\/yyyy' aria-describedby=\"input_14_2_date_format\" aria-invalid=\"false\" \/>\n                            <span id='input_14_2_date_format' class='screen-reader-text'>MM slash DD slash YYYY<\/span>\n                        <\/div>\n                        <input type='hidden' id='gforms_calendar_icon_input_14_2' class='gform_hidden' value='https:\/\/forms.mhamichiana.org\/wp-content\/plugins\/gravityforms\/images\/datepicker\/datepicker.svg'\/><\/li><li id=\"field_14_3\" class=\"gfield gfield--type-phone gfield--input-type-phone field_sublabel_below gfield--has-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_14_3'>Phone:<\/label><div class='ginput_container ginput_container_phone'><input name='input_3' id='input_14_3' type='tel' value='' class='medium' tabindex='60' placeholder='555-555-5555'  aria-invalid=\"false\" aria-describedby=\"gfield_description_14_3\"  \/><\/div><div class='gfield_description' id='gfield_description_14_3'>Please enter your 10-digit phone number without the country code (e.g., 123-456-7890). Do not include a leading '1'.<\/div><\/li><li id=\"field_14_27\" class=\"gfield gfield--type-address gfield--input-type-address gfield--width-full field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label gfield_label_before_complex' >Address<\/label>    \n                    <div class='ginput_complex ginput_container has_street has_street2 has_city has_state has_zip ginput_container_address gform-grid-row' id='input_14_27' >\n                         <span class='ginput_full address_line_1 ginput_address_line_1 gform-grid-col' id='input_14_27_1_container' >\n                                        <input type='text' name='input_27.1' id='input_14_27_1' value='' tabindex='61'   aria-required='false'    \/>\n                                        <label for='input_14_27_1' id='input_14_27_1_label' class='gform-field-label gform-field-label--type-sub'>Street Address<\/label>\n                                    <\/span><span class='ginput_full address_line_2 ginput_address_line_2 gform-grid-col' id='input_14_27_2_container' >\n                                        <input type='text' name='input_27.2' id='input_14_27_2' value='' tabindex='62'    aria-required='false'   \/>\n                                        <label for='input_14_27_2' id='input_14_27_2_label' class='gform-field-label gform-field-label--type-sub'>Address Line 2<\/label>\n                                    <\/span><span class='ginput_left address_city ginput_address_city gform-grid-col' id='input_14_27_3_container' >\n                                    <input type='text' name='input_27.3' id='input_14_27_3' value='' tabindex='63'   aria-required='false'    \/>\n                                    <label for='input_14_27_3' id='input_14_27_3_label' class='gform-field-label gform-field-label--type-sub'>City<\/label>\n                                 <\/span><span class='ginput_right address_state ginput_address_state gform-grid-col' id='input_14_27_4_container' >\n                                        <select name='input_27.4' id='input_14_27_4' tabindex='64'    aria-required='false'    ><option value='' selected='selected'><\/option><option value='Alabama' >Alabama<\/option><option value='Alaska' >Alaska<\/option><option value='American Samoa' >American Samoa<\/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='Guam' >Guam<\/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='Northern Mariana Islands' >Northern Mariana Islands<\/option><option value='Ohio' >Ohio<\/option><option value='Oklahoma' >Oklahoma<\/option><option value='Oregon' >Oregon<\/option><option value='Pennsylvania' >Pennsylvania<\/option><option value='Puerto Rico' >Puerto Rico<\/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='U.S. Virgin Islands' >U.S. Virgin Islands<\/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='Armed Forces Americas' >Armed Forces Americas<\/option><option value='Armed Forces Europe' >Armed Forces Europe<\/option><option value='Armed Forces Pacific' >Armed Forces Pacific<\/option><\/select>\n                                        <label for='input_14_27_4' id='input_14_27_4_label' class='gform-field-label gform-field-label--type-sub'>State<\/label>\n                                      <\/span><span class='ginput_left address_zip ginput_address_zip gform-grid-col' id='input_14_27_5_container' >\n                                    <input type='text' name='input_27.5' id='input_14_27_5' value='' tabindex='66'   aria-required='false'    \/>\n                                    <label for='input_14_27_5' id='input_14_27_5_label' class='gform-field-label gform-field-label--type-sub'>ZIP Code<\/label>\n                                <\/span><input type='hidden' class='gform_hidden' name='input_27.6' id='input_14_27_6' value='United States' \/>\n                    <div class='gf_clear gf_clear_complex'><\/div>\n                <\/div><\/li><li id=\"field_14_31\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-full field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_14_31'>What is your preferred language?<\/label><div class='ginput_container ginput_container_text'><input name='input_31' id='input_14_31' type='text' value='' class='large'   tabindex='67'   aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_14_25\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-full field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_14_25'>How did you hear about the Pro Bono Counseling Project?<\/label><div class='ginput_container ginput_container_text'><input name='input_25' id='input_14_25' type='text' value='' class='large'   tabindex='68'   aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_14_6\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' >What is your employment status?<\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_14_6'>\n\t\t\t<li class='gchoice gchoice_14_6_0'>\n\t\t\t\t<input name='input_6' type='radio' value='Work Full Time'  id='choice_14_6_0' tabindex='69'   \/>\n\t\t\t\t<label for='choice_14_6_0' id='label_14_6_0' class='gform-field-label gform-field-label--type-inline'>Work Full Time<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_14_6_1'>\n\t\t\t\t<input name='input_6' type='radio' value='Work Part Time'  id='choice_14_6_1' tabindex='70'   \/>\n\t\t\t\t<label for='choice_14_6_1' id='label_14_6_1' class='gform-field-label gform-field-label--type-inline'>Work Part Time<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_14_6_2'>\n\t\t\t\t<input name='input_6' type='radio' value='Unemployed'  id='choice_14_6_2' tabindex='71'   \/>\n\t\t\t\t<label for='choice_14_6_2' id='label_14_6_2' class='gform-field-label gform-field-label--type-inline'>Unemployed<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_14_6_3'>\n\t\t\t\t<input name='input_6' type='radio' value='Caregiver of a child or family member'  id='choice_14_6_3' tabindex='72'   \/>\n\t\t\t\t<label for='choice_14_6_3' id='label_14_6_3' class='gform-field-label gform-field-label--type-inline'>Caregiver of a child or family member<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_14_6_4'>\n\t\t\t\t<input name='input_6' type='radio' value='Other'  id='choice_14_6_4' tabindex='73'   \/>\n\t\t\t\t<label for='choice_14_6_4' id='label_14_6_4' class='gform-field-label gform-field-label--type-inline'>Other<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_14_7\" class=\"gfield gfield--type-text gfield--input-type-text field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_14_7'>How many people are you financially responsible for?<\/label><div class='ginput_container ginput_container_text'><input name='input_7' id='input_14_7' type='text' value='' class='medium'   tabindex='74'   aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_14_8\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' >Does someone else in the home assist financially with household costs?<\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_14_8'>\n\t\t\t<li class='gchoice gchoice_14_8_0'>\n\t\t\t\t<input name='input_8' type='radio' value='Yes'  id='choice_14_8_0' tabindex='75'   \/>\n\t\t\t\t<label for='choice_14_8_0' id='label_14_8_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_14_8_1'>\n\t\t\t\t<input name='input_8' type='radio' value='No'  id='choice_14_8_1' tabindex='76'   \/>\n\t\t\t\t<label for='choice_14_8_1' id='label_14_8_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_14_9\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' >Choose the one that best fits your situation:<\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_14_9'>\n\t\t\t<li class='gchoice gchoice_14_9_0'>\n\t\t\t\t<input name='input_9' type='radio' value='I have insurance through my employer'  id='choice_14_9_0' tabindex='77'   \/>\n\t\t\t\t<label for='choice_14_9_0' id='label_14_9_0' class='gform-field-label gform-field-label--type-inline'>I have insurance through my employer<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_14_9_1'>\n\t\t\t\t<input name='input_9' type='radio' value='I have Medicaid'  id='choice_14_9_1' tabindex='78'   \/>\n\t\t\t\t<label for='choice_14_9_1' id='label_14_9_1' class='gform-field-label gform-field-label--type-inline'>I have Medicaid<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_14_9_2'>\n\t\t\t\t<input name='input_9' type='radio' value='I don\u2019t have insurance'  id='choice_14_9_2' tabindex='79'   \/>\n\t\t\t\t<label for='choice_14_9_2' id='label_14_9_2' class='gform-field-label gform-field-label--type-inline'>I don\u2019t have insurance<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_14_9_3'>\n\t\t\t\t<input name='input_9' type='radio' value='I have insurance through the Affordable Care Act'  id='choice_14_9_3' tabindex='80'   \/>\n\t\t\t\t<label for='choice_14_9_3' id='label_14_9_3' class='gform-field-label gform-field-label--type-inline'>I have insurance through the Affordable Care Act<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_14_9_4'>\n\t\t\t\t<input name='input_9' type='radio' value='I have Medicare'  id='choice_14_9_4' tabindex='81'   \/>\n\t\t\t\t<label for='choice_14_9_4' id='label_14_9_4' class='gform-field-label gform-field-label--type-inline'>I have Medicare<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_14_10\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' >I have enough money to pay my  household bills.<\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_14_10'>\n\t\t\t<li class='gchoice gchoice_14_10_0'>\n\t\t\t\t<input name='input_10' type='radio' value='Strongly agree'  id='choice_14_10_0' tabindex='82'   \/>\n\t\t\t\t<label for='choice_14_10_0' id='label_14_10_0' class='gform-field-label gform-field-label--type-inline'>Strongly agree<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_14_10_1'>\n\t\t\t\t<input name='input_10' type='radio' value='Agree'  id='choice_14_10_1' tabindex='83'   \/>\n\t\t\t\t<label for='choice_14_10_1' id='label_14_10_1' class='gform-field-label gform-field-label--type-inline'>Agree<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_14_10_2'>\n\t\t\t\t<input name='input_10' type='radio' value='Neutral'  id='choice_14_10_2' tabindex='84'   \/>\n\t\t\t\t<label for='choice_14_10_2' id='label_14_10_2' class='gform-field-label gform-field-label--type-inline'>Neutral<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_14_10_3'>\n\t\t\t\t<input name='input_10' type='radio' value='Disagree'  id='choice_14_10_3' tabindex='85'   \/>\n\t\t\t\t<label for='choice_14_10_3' id='label_14_10_3' class='gform-field-label gform-field-label--type-inline'>Disagree<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_14_10_4'>\n\t\t\t\t<input name='input_10' type='radio' value='Strongly Disagree'  id='choice_14_10_4' tabindex='86'   \/>\n\t\t\t\t<label for='choice_14_10_4' id='label_14_10_4' class='gform-field-label gform-field-label--type-inline'>Strongly Disagree<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_14_11\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' >I have enough money to afford the kind of clothes I need.<\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_14_11'>\n\t\t\t<li class='gchoice gchoice_14_11_0'>\n\t\t\t\t<input name='input_11' type='radio' value='Strongly agree'  id='choice_14_11_0' tabindex='87'   \/>\n\t\t\t\t<label for='choice_14_11_0' id='label_14_11_0' class='gform-field-label gform-field-label--type-inline'>Strongly agree<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_14_11_1'>\n\t\t\t\t<input name='input_11' type='radio' value='Agree'  id='choice_14_11_1' tabindex='88'   \/>\n\t\t\t\t<label for='choice_14_11_1' id='label_14_11_1' class='gform-field-label gform-field-label--type-inline'>Agree<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_14_11_2'>\n\t\t\t\t<input name='input_11' type='radio' value='Neutral'  id='choice_14_11_2' tabindex='89'   \/>\n\t\t\t\t<label for='choice_14_11_2' id='label_14_11_2' class='gform-field-label gform-field-label--type-inline'>Neutral<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_14_11_3'>\n\t\t\t\t<input name='input_11' type='radio' value='Disagree'  id='choice_14_11_3' tabindex='90'   \/>\n\t\t\t\t<label for='choice_14_11_3' id='label_14_11_3' class='gform-field-label gform-field-label--type-inline'>Disagree<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_14_11_4'>\n\t\t\t\t<input name='input_11' type='radio' value='Strongly Disagree'  id='choice_14_11_4' tabindex='91'   \/>\n\t\t\t\t<label for='choice_14_11_4' id='label_14_11_4' class='gform-field-label gform-field-label--type-inline'>Strongly Disagree<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_14_12\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' >I have enough money to pay my medical bills.<\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_14_12'>\n\t\t\t<li class='gchoice gchoice_14_12_0'>\n\t\t\t\t<input name='input_12' type='radio' value='Strongly agree'  id='choice_14_12_0' tabindex='92'   \/>\n\t\t\t\t<label for='choice_14_12_0' id='label_14_12_0' class='gform-field-label gform-field-label--type-inline'>Strongly agree<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_14_12_1'>\n\t\t\t\t<input name='input_12' type='radio' value='Agree'  id='choice_14_12_1' tabindex='93'   \/>\n\t\t\t\t<label for='choice_14_12_1' id='label_14_12_1' class='gform-field-label gform-field-label--type-inline'>Agree<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_14_12_2'>\n\t\t\t\t<input name='input_12' type='radio' value='Neutral'  id='choice_14_12_2' tabindex='94'   \/>\n\t\t\t\t<label for='choice_14_12_2' id='label_14_12_2' class='gform-field-label gform-field-label--type-inline'>Neutral<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_14_12_3'>\n\t\t\t\t<input name='input_12' type='radio' value='Disagree'  id='choice_14_12_3' tabindex='95'   \/>\n\t\t\t\t<label for='choice_14_12_3' id='label_14_12_3' class='gform-field-label gform-field-label--type-inline'>Disagree<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_14_12_4'>\n\t\t\t\t<input name='input_12' type='radio' value='Strongly Disagree'  id='choice_14_12_4' tabindex='96'   \/>\n\t\t\t\t<label for='choice_14_12_4' id='label_14_12_4' class='gform-field-label gform-field-label--type-inline'>Strongly Disagree<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_14_13\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' >I have enough money to afford leisure\/ fun activities.<\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_14_13'>\n\t\t\t<li class='gchoice gchoice_14_13_0'>\n\t\t\t\t<input name='input_13' type='radio' value='Strongly agree'  id='choice_14_13_0' tabindex='97'   \/>\n\t\t\t\t<label for='choice_14_13_0' id='label_14_13_0' class='gform-field-label gform-field-label--type-inline'>Strongly agree<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_14_13_1'>\n\t\t\t\t<input name='input_13' type='radio' value='Agree'  id='choice_14_13_1' tabindex='98'   \/>\n\t\t\t\t<label for='choice_14_13_1' id='label_14_13_1' class='gform-field-label gform-field-label--type-inline'>Agree<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_14_13_2'>\n\t\t\t\t<input name='input_13' type='radio' value='Neutral'  id='choice_14_13_2' tabindex='99'   \/>\n\t\t\t\t<label for='choice_14_13_2' id='label_14_13_2' class='gform-field-label gform-field-label--type-inline'>Neutral<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_14_13_3'>\n\t\t\t\t<input name='input_13' type='radio' value='Disagree'  id='choice_14_13_3' tabindex='100'   \/>\n\t\t\t\t<label for='choice_14_13_3' id='label_14_13_3' class='gform-field-label gform-field-label--type-inline'>Disagree<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_14_13_4'>\n\t\t\t\t<input name='input_13' type='radio' value='Strongly Disagree'  id='choice_14_13_4' tabindex='101'   \/>\n\t\t\t\t<label for='choice_14_13_4' id='label_14_13_4' class='gform-field-label gform-field-label--type-inline'>Strongly Disagree<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_14_14\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' >I have enough money to afford the kind of food I need.<\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_14_14'>\n\t\t\t<li class='gchoice gchoice_14_14_0'>\n\t\t\t\t<input name='input_14' type='radio' value='Strongly agree'  id='choice_14_14_0' tabindex='102'   \/>\n\t\t\t\t<label for='choice_14_14_0' id='label_14_14_0' class='gform-field-label gform-field-label--type-inline'>Strongly agree<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_14_14_1'>\n\t\t\t\t<input name='input_14' type='radio' value='Agree'  id='choice_14_14_1' tabindex='103'   \/>\n\t\t\t\t<label for='choice_14_14_1' id='label_14_14_1' class='gform-field-label gform-field-label--type-inline'>Agree<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_14_14_2'>\n\t\t\t\t<input name='input_14' type='radio' value='Neutral'  id='choice_14_14_2' tabindex='104'   \/>\n\t\t\t\t<label for='choice_14_14_2' id='label_14_14_2' class='gform-field-label gform-field-label--type-inline'>Neutral<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_14_14_3'>\n\t\t\t\t<input name='input_14' type='radio' value='Disagree'  id='choice_14_14_3' tabindex='105'   \/>\n\t\t\t\t<label for='choice_14_14_3' id='label_14_14_3' class='gform-field-label gform-field-label--type-inline'>Disagree<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_14_14_4'>\n\t\t\t\t<input name='input_14' type='radio' value='Strongly Disagree'  id='choice_14_14_4' tabindex='106'   \/>\n\t\t\t\t<label for='choice_14_14_4' id='label_14_14_4' class='gform-field-label gform-field-label--type-inline'>Strongly Disagree<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_14_15\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' >At the end of the month, I have enough money to pay my bills.<\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_14_15'>\n\t\t\t<li class='gchoice gchoice_14_15_0'>\n\t\t\t\t<input name='input_15' type='radio' value='Strongly agree'  id='choice_14_15_0' tabindex='107'   \/>\n\t\t\t\t<label for='choice_14_15_0' id='label_14_15_0' class='gform-field-label gform-field-label--type-inline'>Strongly agree<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_14_15_1'>\n\t\t\t\t<input name='input_15' type='radio' value='Agree'  id='choice_14_15_1' tabindex='108'   \/>\n\t\t\t\t<label for='choice_14_15_1' id='label_14_15_1' class='gform-field-label gform-field-label--type-inline'>Agree<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_14_15_2'>\n\t\t\t\t<input name='input_15' type='radio' value='Neutral'  id='choice_14_15_2' tabindex='109'   \/>\n\t\t\t\t<label for='choice_14_15_2' id='label_14_15_2' class='gform-field-label gform-field-label--type-inline'>Neutral<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_14_15_3'>\n\t\t\t\t<input name='input_15' type='radio' value='Disagree'  id='choice_14_15_3' tabindex='110'   \/>\n\t\t\t\t<label for='choice_14_15_3' id='label_14_15_3' class='gform-field-label gform-field-label--type-inline'>Disagree<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_14_15_4'>\n\t\t\t\t<input name='input_15' type='radio' value='Strongly Disagree'  id='choice_14_15_4' tabindex='111'   \/>\n\t\t\t\t<label for='choice_14_15_4' id='label_14_15_4' class='gform-field-label gform-field-label--type-inline'>Strongly Disagree<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_14_32\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-full field_sublabel_below gfield--has-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' >Are you or are you a partner of someone who is:<\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_14_32'>\n\t\t\t<li class='gchoice gchoice_14_32_0'>\n\t\t\t\t<input name='input_32' type='radio' value='Yes'  id='choice_14_32_0' tabindex='112'   \/>\n\t\t\t\t<label for='choice_14_32_0' id='label_14_32_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_14_32_1'>\n\t\t\t\t<input name='input_32' type='radio' value='No'  id='choice_14_32_1' tabindex='113'   \/>\n\t\t\t\t<label for='choice_14_32_1' id='label_14_32_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/li><\/ul><\/div><div class='gfield_description' id='gfield_description_14_32'><ul><li>Pregnant; <\/li><li>Has a child less than 18 months old; <\/li><li>Been pregnant in the past 18 months?<\/li><\/ul><\/div><\/li><li id=\"field_14_16\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield--input-type-checkbox field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label gfield_label_before_complex' >Please tell us a little about what issues are going on in your life that are bringing you to therapy<\/label><div class='ginput_container ginput_container_checkbox'><ul class='gfield_checkbox' id='input_14_16'><li class='gchoice gchoice_14_16_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_16.1' type='checkbox'  value='Difficulty coping'  id='choice_14_16_1' tabindex='114'  \/>\n\t\t\t\t\t\t\t\t<label for='choice_14_16_1' id='label_14_16_1' class='gform-field-label gform-field-label--type-inline'>Difficulty coping<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_14_16_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_16.2' type='checkbox'  value='Relationship difficulties'  id='choice_14_16_2' tabindex='115'  \/>\n\t\t\t\t\t\t\t\t<label for='choice_14_16_2' id='label_14_16_2' class='gform-field-label gform-field-label--type-inline'>Relationship difficulties<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_14_16_3'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_16.3' type='checkbox'  value='Grief\/ loss'  id='choice_14_16_3' tabindex='116'  \/>\n\t\t\t\t\t\t\t\t<label for='choice_14_16_3' id='label_14_16_3' class='gform-field-label gform-field-label--type-inline'>Grief\/ loss<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_14_16_4'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_16.4' type='checkbox'  value='Life transition'  id='choice_14_16_4' tabindex='117'  \/>\n\t\t\t\t\t\t\t\t<label for='choice_14_16_4' id='label_14_16_4' class='gform-field-label gform-field-label--type-inline'>Life transition<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_14_16_5'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_16.5' type='checkbox'  value='Problems at Work'  id='choice_14_16_5' tabindex='118'  \/>\n\t\t\t\t\t\t\t\t<label for='choice_14_16_5' id='label_14_16_5' class='gform-field-label gform-field-label--type-inline'>Problems at Work<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_14_16_6'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_16.6' type='checkbox'  value='Problems at School'  id='choice_14_16_6' tabindex='119'  \/>\n\t\t\t\t\t\t\t\t<label for='choice_14_16_6' id='label_14_16_6' class='gform-field-label gform-field-label--type-inline'>Problems at School<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_14_16_7'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_16.7' type='checkbox'  value='Medical\/ sickness'  id='choice_14_16_7' tabindex='120'  \/>\n\t\t\t\t\t\t\t\t<label for='choice_14_16_7' id='label_14_16_7' class='gform-field-label gform-field-label--type-inline'>Medical\/ sickness<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_14_16_8'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_16.8' type='checkbox'  value='Financial stress'  id='choice_14_16_8' tabindex='121'  \/>\n\t\t\t\t\t\t\t\t<label for='choice_14_16_8' id='label_14_16_8' class='gform-field-label gform-field-label--type-inline'>Financial stress<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_14_16_9'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_16.9' type='checkbox'  value='Family issues'  id='choice_14_16_9' tabindex='122'  \/>\n\t\t\t\t\t\t\t\t<label for='choice_14_16_9' id='label_14_16_9' class='gform-field-label gform-field-label--type-inline'>Family issues<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_14_16_11'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_16.11' type='checkbox'  value='Mental Illness'  id='choice_14_16_11' tabindex='123'  \/>\n\t\t\t\t\t\t\t\t<label for='choice_14_16_11' id='label_14_16_11' class='gform-field-label gform-field-label--type-inline'>Mental Illness<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_14_16_12'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_16.12' type='checkbox'  value='Addictions'  id='choice_14_16_12' tabindex='124'  \/>\n\t\t\t\t\t\t\t\t<label for='choice_14_16_12' id='label_14_16_12' class='gform-field-label gform-field-label--type-inline'>Addictions<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_14_16_13'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_16.13' type='checkbox'  value='Other:'  id='choice_14_16_13' tabindex='125'  \/>\n\t\t\t\t\t\t\t\t<label for='choice_14_16_13' id='label_14_16_13' class='gform-field-label gform-field-label--type-inline'>Other:<\/label>\n\t\t\t\t\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_14_23\" class=\"gfield gfield--type-textarea gfield--input-type-textarea field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_14_23'>Please explain:<\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_23' id='input_14_23' class='textarea medium' tabindex='126'     aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/li><li id=\"field_14_17\" class=\"gfield gfield--type-text gfield--input-type-text field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_14_17'>Have you received counseling in the past? If so how long ago?<\/label><div class='ginput_container ginput_container_text'><input name='input_17' id='input_14_17' type='text' value='' class='medium'   tabindex='127'   aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_14_33\" class=\"gfield gfield--type-number gfield--input-type-number gfield--width-full field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_14_33'>How many days in the past 30 days would you say your mental health was not good (difficulty coping)?<\/label><div class='ginput_container ginput_container_number'><input name='input_33' id='input_14_33' type='number' step='any' min='0' max='30' value='' class='small' tabindex='128'     aria-invalid=\"false\" aria-describedby=\"gfield_instruction_14_33\" \/><div class='gfield_description instruction' id='gfield_instruction_14_33'>Please enter a number from <strong>0<\/strong> to <strong>30<\/strong>.<\/div><\/div><\/li><li id=\"field_14_26\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-full field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' >How many trusted adults do you have in your life who you can talk to about your mental health?<\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_14_26'>\n\t\t\t<li class='gchoice gchoice_14_26_0'>\n\t\t\t\t<input name='input_26' type='radio' value='0'  id='choice_14_26_0' tabindex='129'   \/>\n\t\t\t\t<label for='choice_14_26_0' id='label_14_26_0' class='gform-field-label gform-field-label--type-inline'>0<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_14_26_1'>\n\t\t\t\t<input name='input_26' type='radio' value='1'  id='choice_14_26_1' tabindex='130'   \/>\n\t\t\t\t<label for='choice_14_26_1' 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