{"id":533,"date":"2020-12-22T14:32:00","date_gmt":"2020-12-22T14:32:00","guid":{"rendered":"http:\/\/forms.mhamichiana.org\/?page_id=533"},"modified":"2021-01-13T20:59:05","modified_gmt":"2021-01-13T20:59:05","slug":"post-therapy-outcomes-questionnaire-client","status":"publish","type":"page","link":"https:\/\/forms.mhamichiana.org\/es\/post-therapy-outcomes-questionnaire-client\/","title":{"rendered":"Post Therapy Outcomes Questionnaire (Client)"},"content":{"rendered":"<div data-elementor-type=\"wp-page\" data-elementor-id=\"533\" class=\"elementor elementor-533\" data-elementor-post-type=\"page\">\n\t\t\t\t\t\t<section class=\"elementor-section elementor-top-section elementor-element elementor-element-51bba0d elementor-section-boxed elementor-section-height-default elementor-section-height-default\" data-id=\"51bba0d\" 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-6061836\" data-id=\"6061836\" 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-2f9c4d1 elementor-widget elementor-widget-heading\" data-id=\"2f9c4d1\" 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<h1 class=\"elementor-heading-title elementor-size-default\">Post Therapy Outcomes Questionnaire (Client)<\/h1>\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t<div class=\"elementor-element elementor-element-96cc27c pp-gravity-form-button-custom pp-gravity-form-pagination-buttons-auto elementor-widget elementor-widget-pp-gravity-forms\" data-id=\"96cc27c\" data-element_type=\"widget\" data-e-type=\"widget\" data-widget_type=\"pp-gravity-forms.default\">\n\t\t\t\t<div class=\"elementor-widget-container\">\n\t\t\t\t\t\t\t\t\t<div class=\"pp-contact-form pp-gravity-form\">\n\t\t\t\t\t\t\t\t\t\t<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 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 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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_13' >\n                        <div class='gform_heading'>\n                            <p class='gform_description'><\/p>\n                        <\/div><form method='post' enctype='multipart\/form-data'  id='gform_13'  action='\/es\/post-therapy-outcomes-questionnaire-client\/' data-formid='13' novalidate data-trp-original-action=\"\/post-therapy-outcomes-questionnaire-client\/\">\n                        <div class='gform-body gform_body'><ul id='gform_fields_13' class='gform_fields top_label form_sublabel_below description_below validation_below'><li id=\"field_13_1\" class=\"gfield gfield--type-text hipaa_forms_first_name field_sublabel_below gfield--has-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_13_1'>Client First Name:<\/label><div class='ginput_container ginput_container_text'><input name='input_1' id='input_13_1' type='text' value='' class='medium'  aria-describedby=\"gfield_description_13_1\"    aria-invalid=\"false\"   \/><\/div><div class='gfield_description' id='gfield_description_13_1'>(or Prefer to remain anonymous) <\/div><\/li><li id=\"field_13_23\" class=\"gfield gfield--type-text hipaa_forms_last_name field_sublabel_below gfield--has-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_13_23'>Client Last Name:<\/label><div class='ginput_container ginput_container_text'><input name='input_23' id='input_13_23' type='text' value='' class='medium'  aria-describedby=\"gfield_description_13_23\"    aria-invalid=\"false\"   \/><\/div><div class='gfield_description' id='gfield_description_13_23'>(or Prefer to remain anonymous) <\/div><\/li><li id=\"field_13_2\" class=\"gfield gfield--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_13_2'>Today\u2019s date:<\/label><div class='ginput_container ginput_container_date'>\n                            <input name='input_2' id='input_13_2' type='text' value='' class='datepicker gform-datepicker mdy datepicker_with_icon gdatepicker_with_icon'   placeholder='mm\/dd\/yyyy' aria-describedby=\"input_13_2_date_format\" aria-invalid=\"false\" \/>\n                            <span id='input_13_2_date_format' class='screen-reader-text'>MM slash DD slash YYYY<\/span>\n                        <\/div>\n                        <input type='hidden' id='gforms_calendar_icon_input_13_2' class='gform_hidden' value='https:\/\/forms.mhamichiana.org\/wp-content\/plugins\/gravityforms\/images\/datepicker\/datepicker.svg'\/><\/li><li id=\"field_13_27\" class=\"gfield gfield--type-radio gfield--type-choice 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_13_27'>\n\t\t\t<li class='gchoice gchoice_13_27_0'>\n\t\t\t\t<input name='input_27' type='radio' value='0'  id='choice_13_27_0'    \/>\n\t\t\t\t<label for='choice_13_27_0' id='label_13_27_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_13_27_1'>\n\t\t\t\t<input name='input_27' type='radio' value='1'  id='choice_13_27_1'    \/>\n\t\t\t\t<label for='choice_13_27_1' id='label_13_27_1' class='gform-field-label gform-field-label--type-inline'>1<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_13_27_2'>\n\t\t\t\t<input name='input_27' type='radio' value='2 or more'  id='choice_13_27_2'    \/>\n\t\t\t\t<label for='choice_13_27_2' id='label_13_27_2' class='gform-field-label gform-field-label--type-inline'>2 or more<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_13_24\" class=\"gfield gfield--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_13_24'>Email<\/label><div class='ginput_container ginput_container_email'>\n                            <input name='input_24' id='input_13_24' type='email' value='' class='medium'     aria-invalid=\"false\"  \/>\n                        <\/div><\/li><li id=\"field_13_4\" class=\"gfield gfield--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_13_4'>Name of therapist:<\/label><div class='ginput_container ginput_container_text'><input name='input_4' id='input_13_4' type='text' value='' class='medium'      aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_13_25\" class=\"gfield gfield--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_13_25'>How do you identify?<\/label><div class='ginput_container ginput_container_select'><select name='input_25' id='input_13_25' class='medium gfield_select'     aria-invalid=\"false\" ><option value='Male' >Male<\/option><option value='Female' >Female<\/option><option value='Non binary' >Non binary<\/option><option value='Other' >Other<\/option><\/select><\/div><\/li><li id=\"field_13_26\" class=\"gfield gfield--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_13_26'>How do you identify?<\/label><div class='ginput_container ginput_container_select'><select name='input_26' id='input_13_26' class='medium gfield_select'     aria-invalid=\"false\" ><option value='Black\/African American' >Black\/African American<\/option><option value='White' >White<\/option><option value='Latinx' >Latinx<\/option><option value='Mixed' >Mixed<\/option><option value='Asian' >Asian<\/option><option value='Other' >Other<\/option><\/select><\/div><\/li><li id=\"field_13_5\" class=\"gfield gfield--type-radio gfield--type-choice field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' >I made progress toward my goals.<\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_13_5'>\n\t\t\t<li class='gchoice gchoice_13_5_0'>\n\t\t\t\t<input name='input_5' type='radio' value='Strongly agree (5)'  id='choice_13_5_0'    \/>\n\t\t\t\t<label for='choice_13_5_0' id='label_13_5_0' class='gform-field-label gform-field-label--type-inline'>Strongly agree (5)<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_13_5_1'>\n\t\t\t\t<input name='input_5' type='radio' value='Agree (4)'  id='choice_13_5_1'    \/>\n\t\t\t\t<label for='choice_13_5_1' id='label_13_5_1' class='gform-field-label gform-field-label--type-inline'>Agree (4)<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_13_5_2'>\n\t\t\t\t<input name='input_5' type='radio' value='Neutral (3)'  id='choice_13_5_2'    \/>\n\t\t\t\t<label for='choice_13_5_2' id='label_13_5_2' class='gform-field-label gform-field-label--type-inline'>Neutral (3)<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_13_5_3'>\n\t\t\t\t<input name='input_5' type='radio' value='Disagree (2)'  id='choice_13_5_3'    \/>\n\t\t\t\t<label for='choice_13_5_3' id='label_13_5_3' class='gform-field-label gform-field-label--type-inline'>Disagree (2)<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_13_5_4'>\n\t\t\t\t<input name='input_5' type='radio' value='Strongly disagree (1)'  id='choice_13_5_4'    \/>\n\t\t\t\t<label for='choice_13_5_4' id='label_13_5_4' class='gform-field-label gform-field-label--type-inline'>Strongly disagree (1)<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_13_6\" class=\"gfield gfield--type-radio gfield--type-choice field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' >I am satisfied with the progress I made.<\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_13_6'>\n\t\t\t<li class='gchoice gchoice_13_6_0'>\n\t\t\t\t<input name='input_6' type='radio' value='Strongly agree (5)'  id='choice_13_6_0'    \/>\n\t\t\t\t<label for='choice_13_6_0' id='label_13_6_0' class='gform-field-label gform-field-label--type-inline'>Strongly agree (5)<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_13_6_1'>\n\t\t\t\t<input name='input_6' type='radio' value='Agree (4)'  id='choice_13_6_1'    \/>\n\t\t\t\t<label for='choice_13_6_1' id='label_13_6_1' class='gform-field-label gform-field-label--type-inline'>Agree (4)<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_13_6_2'>\n\t\t\t\t<input name='input_6' type='radio' value='Neutral (3)'  id='choice_13_6_2'    \/>\n\t\t\t\t<label for='choice_13_6_2' id='label_13_6_2' class='gform-field-label gform-field-label--type-inline'>Neutral (3)<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_13_6_3'>\n\t\t\t\t<input name='input_6' type='radio' value='Disagree (2)'  id='choice_13_6_3'    \/>\n\t\t\t\t<label for='choice_13_6_3' id='label_13_6_3' class='gform-field-label gform-field-label--type-inline'>Disagree (2)<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_13_6_4'>\n\t\t\t\t<input name='input_6' type='radio' value='Strongly disagree (1)'  id='choice_13_6_4'    \/>\n\t\t\t\t<label for='choice_13_6_4' id='label_13_6_4' class='gform-field-label gform-field-label--type-inline'>Strongly disagree (1)<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_13_7\" class=\"gfield gfield--type-radio gfield--type-choice field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' >I can talk to friends or family members about my mental health.<\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_13_7'>\n\t\t\t<li class='gchoice gchoice_13_7_0'>\n\t\t\t\t<input name='input_7' type='radio' value='Strongly agree (5)'  id='choice_13_7_0'    \/>\n\t\t\t\t<label for='choice_13_7_0' id='label_13_7_0' class='gform-field-label gform-field-label--type-inline'>Strongly agree (5)<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_13_7_1'>\n\t\t\t\t<input name='input_7' type='radio' value='Agree (4)'  id='choice_13_7_1'    \/>\n\t\t\t\t<label for='choice_13_7_1' id='label_13_7_1' class='gform-field-label gform-field-label--type-inline'>Agree (4)<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_13_7_2'>\n\t\t\t\t<input name='input_7' type='radio' value='Neutral (3)'  id='choice_13_7_2'    \/>\n\t\t\t\t<label for='choice_13_7_2' id='label_13_7_2' class='gform-field-label gform-field-label--type-inline'>Neutral (3)<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_13_7_3'>\n\t\t\t\t<input name='input_7' type='radio' value='Disagree (2)'  id='choice_13_7_3'    \/>\n\t\t\t\t<label for='choice_13_7_3' id='label_13_7_3' class='gform-field-label gform-field-label--type-inline'>Disagree (2)<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_13_7_4'>\n\t\t\t\t<input name='input_7' type='radio' value='Strongly disagree (1)'  id='choice_13_7_4'    \/>\n\t\t\t\t<label for='choice_13_7_4' id='label_13_7_4' class='gform-field-label gform-field-label--type-inline'>Strongly disagree (1)<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_13_8\" class=\"gfield gfield--type-radio gfield--type-choice field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' >My mental health improved because of therapy.<\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_13_8'>\n\t\t\t<li class='gchoice gchoice_13_8_0'>\n\t\t\t\t<input name='input_8' type='radio' value='Strongly agree (5)'  id='choice_13_8_0'    \/>\n\t\t\t\t<label for='choice_13_8_0' id='label_13_8_0' class='gform-field-label gform-field-label--type-inline'>Strongly agree (5)<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_13_8_1'>\n\t\t\t\t<input name='input_8' type='radio' value='Agree (4)'  id='choice_13_8_1'    \/>\n\t\t\t\t<label for='choice_13_8_1' id='label_13_8_1' class='gform-field-label gform-field-label--type-inline'>Agree (4)<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_13_8_2'>\n\t\t\t\t<input name='input_8' type='radio' value='Neutral (3)'  id='choice_13_8_2'    \/>\n\t\t\t\t<label for='choice_13_8_2' id='label_13_8_2' class='gform-field-label gform-field-label--type-inline'>Neutral (3)<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_13_8_3'>\n\t\t\t\t<input name='input_8' type='radio' value='Disagree (2)'  id='choice_13_8_3'    \/>\n\t\t\t\t<label for='choice_13_8_3' id='label_13_8_3' class='gform-field-label gform-field-label--type-inline'>Disagree (2)<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_13_8_4'>\n\t\t\t\t<input name='input_8' type='radio' value='Strongly disagree (1)'  id='choice_13_8_4'    \/>\n\t\t\t\t<label for='choice_13_8_4' id='label_13_8_4' class='gform-field-label gform-field-label--type-inline'>Strongly disagree (1)<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_13_9\" class=\"gfield gfield--type-radio gfield--type-choice field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' >My mental health improved because of other reasons.<\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_13_9'>\n\t\t\t<li class='gchoice gchoice_13_9_0'>\n\t\t\t\t<input name='input_9' type='radio' value='Strongly agree (5)'  id='choice_13_9_0'    \/>\n\t\t\t\t<label for='choice_13_9_0' id='label_13_9_0' class='gform-field-label gform-field-label--type-inline'>Strongly agree (5)<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_13_9_1'>\n\t\t\t\t<input name='input_9' type='radio' value='Agree (4)'  id='choice_13_9_1'    \/>\n\t\t\t\t<label for='choice_13_9_1' id='label_13_9_1' class='gform-field-label gform-field-label--type-inline'>Agree (4)<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_13_9_2'>\n\t\t\t\t<input name='input_9' type='radio' value='Neutral (3)'  id='choice_13_9_2'    \/>\n\t\t\t\t<label for='choice_13_9_2' id='label_13_9_2' class='gform-field-label gform-field-label--type-inline'>Neutral (3)<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_13_9_3'>\n\t\t\t\t<input name='input_9' type='radio' value='Disagree (2)'  id='choice_13_9_3'    \/>\n\t\t\t\t<label for='choice_13_9_3' id='label_13_9_3' class='gform-field-label gform-field-label--type-inline'>Disagree (2)<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_13_9_4'>\n\t\t\t\t<input name='input_9' type='radio' value='Strongly disagree (1)'  id='choice_13_9_4'    \/>\n\t\t\t\t<label for='choice_13_9_4' id='label_13_9_4' class='gform-field-label gform-field-label--type-inline'>Strongly disagree (1)<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_13_10\" class=\"gfield gfield--type-radio gfield--type-choice field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' >My work situation improved (new job,  better job, better hours, better pay or benefits, better attendance)<\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_13_10'>\n\t\t\t<li class='gchoice gchoice_13_10_0'>\n\t\t\t\t<input name='input_10' type='radio' value='Strongly agree (5)'  id='choice_13_10_0'    \/>\n\t\t\t\t<label for='choice_13_10_0' id='label_13_10_0' class='gform-field-label gform-field-label--type-inline'>Strongly agree (5)<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_13_10_1'>\n\t\t\t\t<input name='input_10' type='radio' value='Agree (4)'  id='choice_13_10_1'    \/>\n\t\t\t\t<label for='choice_13_10_1' id='label_13_10_1' class='gform-field-label gform-field-label--type-inline'>Agree (4)<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_13_10_2'>\n\t\t\t\t<input name='input_10' type='radio' value='Neutral (3)'  id='choice_13_10_2'    \/>\n\t\t\t\t<label for='choice_13_10_2' id='label_13_10_2' class='gform-field-label gform-field-label--type-inline'>Neutral (3)<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_13_10_3'>\n\t\t\t\t<input name='input_10' type='radio' value='Disagree (2)'  id='choice_13_10_3'    \/>\n\t\t\t\t<label for='choice_13_10_3' id='label_13_10_3' class='gform-field-label gform-field-label--type-inline'>Disagree (2)<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_13_10_4'>\n\t\t\t\t<input name='input_10' type='radio' value='Strongly disagree (1)'  id='choice_13_10_4'    \/>\n\t\t\t\t<label for='choice_13_10_4' id='label_13_10_4' class='gform-field-label gform-field-label--type-inline'>Strongly disagree (1)<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_13_11\" class=\"gfield gfield--type-radio gfield--type-choice field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' >My education improved (went back to  school, stayed in school, better attendance)<\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_13_11'>\n\t\t\t<li class='gchoice gchoice_13_11_0'>\n\t\t\t\t<input name='input_11' type='radio' value='Strongly agree (5)'  id='choice_13_11_0'    \/>\n\t\t\t\t<label for='choice_13_11_0' id='label_13_11_0' class='gform-field-label gform-field-label--type-inline'>Strongly agree (5)<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_13_11_1'>\n\t\t\t\t<input name='input_11' type='radio' value='Agree (4)'  id='choice_13_11_1'    \/>\n\t\t\t\t<label for='choice_13_11_1' id='label_13_11_1' class='gform-field-label gform-field-label--type-inline'>Agree (4)<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_13_11_2'>\n\t\t\t\t<input name='input_11' type='radio' value='Neutral (3)'  id='choice_13_11_2'    \/>\n\t\t\t\t<label for='choice_13_11_2' id='label_13_11_2' class='gform-field-label gform-field-label--type-inline'>Neutral (3)<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_13_11_3'>\n\t\t\t\t<input name='input_11' type='radio' value='Disagree (2)'  id='choice_13_11_3'    \/>\n\t\t\t\t<label for='choice_13_11_3' id='label_13_11_3' class='gform-field-label gform-field-label--type-inline'>Disagree (2)<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_13_11_4'>\n\t\t\t\t<input name='input_11' type='radio' value='Strongly disagree (1)'  id='choice_13_11_4'    \/>\n\t\t\t\t<label for='choice_13_11_4' id='label_13_11_4' class='gform-field-label gform-field-label--type-inline'>Strongly disagree (1)<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_13_12\" class=\"gfield gfield--type-radio gfield--type-choice field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' >My overall well-being improved (general sense of well-being, life satisfaction).<\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_13_12'>\n\t\t\t<li class='gchoice gchoice_13_12_0'>\n\t\t\t\t<input name='input_12' type='radio' value='Strongly agree (5)'  id='choice_13_12_0'    \/>\n\t\t\t\t<label for='choice_13_12_0' id='label_13_12_0' class='gform-field-label gform-field-label--type-inline'>Strongly agree (5)<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_13_12_1'>\n\t\t\t\t<input name='input_12' type='radio' value='Agree (4)'  id='choice_13_12_1'    \/>\n\t\t\t\t<label for='choice_13_12_1' id='label_13_12_1' class='gform-field-label gform-field-label--type-inline'>Agree (4)<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_13_12_2'>\n\t\t\t\t<input name='input_12' type='radio' value='Neutral (3)'  id='choice_13_12_2'    \/>\n\t\t\t\t<label for='choice_13_12_2' id='label_13_12_2' class='gform-field-label gform-field-label--type-inline'>Neutral (3)<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_13_12_3'>\n\t\t\t\t<input name='input_12' type='radio' value='Disagree (2)'  id='choice_13_12_3'    \/>\n\t\t\t\t<label for='choice_13_12_3' id='label_13_12_3' class='gform-field-label gform-field-label--type-inline'>Disagree (2)<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_13_12_4'>\n\t\t\t\t<input name='input_12' type='radio' value='Strongly disagree (1)'  id='choice_13_12_4'    \/>\n\t\t\t\t<label for='choice_13_12_4' id='label_13_12_4' class='gform-field-label gform-field-label--type-inline'>Strongly disagree (1)<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_13_13\" class=\"gfield gfield--type-radio gfield--type-choice field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' >My close relationships improved (better communication, less conflict).<\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_13_13'>\n\t\t\t<li class='gchoice gchoice_13_13_0'>\n\t\t\t\t<input name='input_13' type='radio' value='Strongly agree (5)'  id='choice_13_13_0'    \/>\n\t\t\t\t<label for='choice_13_13_0' id='label_13_13_0' class='gform-field-label gform-field-label--type-inline'>Strongly agree (5)<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_13_13_1'>\n\t\t\t\t<input name='input_13' type='radio' value='Agree (4)'  id='choice_13_13_1'    \/>\n\t\t\t\t<label for='choice_13_13_1' id='label_13_13_1' class='gform-field-label gform-field-label--type-inline'>Agree (4)<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_13_13_2'>\n\t\t\t\t<input name='input_13' type='radio' value='Neutral (3)'  id='choice_13_13_2'    \/>\n\t\t\t\t<label for='choice_13_13_2' id='label_13_13_2' class='gform-field-label gform-field-label--type-inline'>Neutral (3)<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_13_13_3'>\n\t\t\t\t<input name='input_13' type='radio' value='Disagree (2)'  id='choice_13_13_3'    \/>\n\t\t\t\t<label for='choice_13_13_3' id='label_13_13_3' class='gform-field-label gform-field-label--type-inline'>Disagree (2)<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_13_13_4'>\n\t\t\t\t<input name='input_13' type='radio' value='Strongly disagree (1)'  id='choice_13_13_4'    \/>\n\t\t\t\t<label for='choice_13_13_4' id='label_13_13_4' class='gform-field-label gform-field-label--type-inline'>Strongly disagree (1)<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_13_14\" class=\"gfield gfield--type-radio gfield--type-choice field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' >Other relationships improved (work, school, friends)<\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_13_14'>\n\t\t\t<li class='gchoice gchoice_13_14_0'>\n\t\t\t\t<input name='input_14' type='radio' value='Strongly agree (5)'  id='choice_13_14_0'    \/>\n\t\t\t\t<label for='choice_13_14_0' id='label_13_14_0' class='gform-field-label gform-field-label--type-inline'>Strongly agree (5)<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_13_14_1'>\n\t\t\t\t<input name='input_14' type='radio' value='Agree (4)'  id='choice_13_14_1'    \/>\n\t\t\t\t<label for='choice_13_14_1' id='label_13_14_1' class='gform-field-label gform-field-label--type-inline'>Agree (4)<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_13_14_2'>\n\t\t\t\t<input name='input_14' type='radio' value='Neutral (3)'  id='choice_13_14_2'    \/>\n\t\t\t\t<label for='choice_13_14_2' id='label_13_14_2' class='gform-field-label gform-field-label--type-inline'>Neutral (3)<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_13_14_3'>\n\t\t\t\t<input name='input_14' type='radio' value='Disagree (2)'  id='choice_13_14_3'    \/>\n\t\t\t\t<label for='choice_13_14_3' id='label_13_14_3' class='gform-field-label gform-field-label--type-inline'>Disagree (2)<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_13_14_4'>\n\t\t\t\t<input name='input_14' type='radio' value='Strongly disagree (1)'  id='choice_13_14_4'    \/>\n\t\t\t\t<label for='choice_13_14_4' id='label_13_14_4' class='gform-field-label gform-field-label--type-inline'>Strongly disagree (1)<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_13_15\" class=\"gfield gfield--type-radio gfield--type-choice field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' >My finances improved (more stable, better decision making).<\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_13_15'>\n\t\t\t<li class='gchoice gchoice_13_15_0'>\n\t\t\t\t<input name='input_15' type='radio' value='Strongly agree (5)'  id='choice_13_15_0'    \/>\n\t\t\t\t<label for='choice_13_15_0' id='label_13_15_0' class='gform-field-label gform-field-label--type-inline'>Strongly agree (5)<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_13_15_1'>\n\t\t\t\t<input name='input_15' type='radio' value='Agree (4)'  id='choice_13_15_1'    \/>\n\t\t\t\t<label for='choice_13_15_1' id='label_13_15_1' class='gform-field-label gform-field-label--type-inline'>Agree (4)<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_13_15_2'>\n\t\t\t\t<input name='input_15' type='radio' value='Neutral (3)'  id='choice_13_15_2'    \/>\n\t\t\t\t<label for='choice_13_15_2' id='label_13_15_2' class='gform-field-label gform-field-label--type-inline'>Neutral (3)<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_13_15_3'>\n\t\t\t\t<input name='input_15' type='radio' value='Disagree (2)'  id='choice_13_15_3'    \/>\n\t\t\t\t<label for='choice_13_15_3' id='label_13_15_3' class='gform-field-label gform-field-label--type-inline'>Disagree (2)<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_13_15_4'>\n\t\t\t\t<input name='input_15' type='radio' value='Strongly disagree (1)'  id='choice_13_15_4'    \/>\n\t\t\t\t<label for='choice_13_15_4' id='label_13_15_4' class='gform-field-label gform-field-label--type-inline'>Strongly disagree (1)<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_13_16\" class=\"gfield gfield--type-radio gfield--type-choice field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' >My therapist respected my culture, spiritual beliefs, and\/ or sexuality.<\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_13_16'>\n\t\t\t<li class='gchoice gchoice_13_16_0'>\n\t\t\t\t<input name='input_16' type='radio' value='Strongly agree (5)'  id='choice_13_16_0'    \/>\n\t\t\t\t<label for='choice_13_16_0' id='label_13_16_0' class='gform-field-label gform-field-label--type-inline'>Strongly agree (5)<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_13_16_1'>\n\t\t\t\t<input name='input_16' type='radio' value='Agree (4)'  id='choice_13_16_1'    \/>\n\t\t\t\t<label for='choice_13_16_1' id='label_13_16_1' class='gform-field-label gform-field-label--type-inline'>Agree (4)<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_13_16_2'>\n\t\t\t\t<input name='input_16' type='radio' value='Neutral (3)'  id='choice_13_16_2'    \/>\n\t\t\t\t<label for='choice_13_16_2' id='label_13_16_2' class='gform-field-label gform-field-label--type-inline'>Neutral (3)<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_13_16_3'>\n\t\t\t\t<input name='input_16' type='radio' value='Disagree (2)'  id='choice_13_16_3'    \/>\n\t\t\t\t<label for='choice_13_16_3' id='label_13_16_3' class='gform-field-label gform-field-label--type-inline'>Disagree (2)<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_13_16_4'>\n\t\t\t\t<input name='input_16' type='radio' value='Strongly disagree (1)'  id='choice_13_16_4'    \/>\n\t\t\t\t<label for='choice_13_16_4' id='label_13_16_4' class='gform-field-label gform-field-label--type-inline'>Strongly disagree (1)<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_13_17\" class=\"gfield gfield--type-radio gfield--type-choice field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' >I was matched with a clinician who met my needs.<\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_13_17'>\n\t\t\t<li class='gchoice gchoice_13_17_0'>\n\t\t\t\t<input name='input_17' type='radio' value='Strongly agree (5)'  id='choice_13_17_0'    \/>\n\t\t\t\t<label for='choice_13_17_0' id='label_13_17_0' class='gform-field-label gform-field-label--type-inline'>Strongly agree (5)<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_13_17_1'>\n\t\t\t\t<input name='input_17' type='radio' value='Agree (4)'  id='choice_13_17_1'    \/>\n\t\t\t\t<label for='choice_13_17_1' id='label_13_17_1' class='gform-field-label gform-field-label--type-inline'>Agree (4)<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_13_17_2'>\n\t\t\t\t<input name='input_17' type='radio' value='Neutral (3)'  id='choice_13_17_2'    \/>\n\t\t\t\t<label for='choice_13_17_2' id='label_13_17_2' class='gform-field-label gform-field-label--type-inline'>Neutral (3)<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_13_17_3'>\n\t\t\t\t<input name='input_17' type='radio' value='Disagree (2)'  id='choice_13_17_3'    \/>\n\t\t\t\t<label for='choice_13_17_3' id='label_13_17_3' class='gform-field-label gform-field-label--type-inline'>Disagree (2)<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_13_17_4'>\n\t\t\t\t<input name='input_17' type='radio' value='Strongly disagree (1)'  id='choice_13_17_4'    \/>\n\t\t\t\t<label for='choice_13_17_4' id='label_13_17_4' class='gform-field-label gform-field-label--type-inline'>Strongly disagree (1)<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_13_18\" class=\"gfield gfield--type-radio gfield--type-choice field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' >I would recommend this service to a friend\/ family.<\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_13_18'>\n\t\t\t<li class='gchoice gchoice_13_18_0'>\n\t\t\t\t<input name='input_18' type='radio' value='Strongly agree (5)'  id='choice_13_18_0'    \/>\n\t\t\t\t<label for='choice_13_18_0' id='label_13_18_0' class='gform-field-label gform-field-label--type-inline'>Strongly agree (5)<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_13_18_1'>\n\t\t\t\t<input name='input_18' type='radio' value='Agree (4)'  id='choice_13_18_1'    \/>\n\t\t\t\t<label for='choice_13_18_1' id='label_13_18_1' class='gform-field-label gform-field-label--type-inline'>Agree (4)<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_13_18_2'>\n\t\t\t\t<input name='input_18' type='radio' value='Neutral (3)'  id='choice_13_18_2'    \/>\n\t\t\t\t<label for='choice_13_18_2' id='label_13_18_2' class='gform-field-label gform-field-label--type-inline'>Neutral (3)<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_13_18_3'>\n\t\t\t\t<input name='input_18' type='radio' value='Disagree (2)'  id='choice_13_18_3'    \/>\n\t\t\t\t<label for='choice_13_18_3' id='label_13_18_3' class='gform-field-label gform-field-label--type-inline'>Disagree (2)<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_13_18_4'>\n\t\t\t\t<input name='input_18' type='radio' value='Strongly disagree (1)'  id='choice_13_18_4'    \/>\n\t\t\t\t<label for='choice_13_18_4' id='label_13_18_4' class='gform-field-label gform-field-label--type-inline'>Strongly disagree (1)<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_13_19\" class=\"gfield gfield--type-radio gfield--type-choice field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' >How many sessions did you complete (to the best of your memory)?<\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_13_19'>\n\t\t\t<li class='gchoice gchoice_13_19_0'>\n\t\t\t\t<input name='input_19' type='radio' value='0'  id='choice_13_19_0'    \/>\n\t\t\t\t<label for='choice_13_19_0' id='label_13_19_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_13_19_1'>\n\t\t\t\t<input name='input_19' type='radio' value='1'  id='choice_13_19_1'    \/>\n\t\t\t\t<label for='choice_13_19_1' id='label_13_19_1' class='gform-field-label gform-field-label--type-inline'>1<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_13_19_2'>\n\t\t\t\t<input name='input_19' type='radio' value='2'  id='choice_13_19_2'    \/>\n\t\t\t\t<label for='choice_13_19_2' id='label_13_19_2' class='gform-field-label gform-field-label--type-inline'>2<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_13_19_3'>\n\t\t\t\t<input name='input_19' type='radio' value='3'  id='choice_13_19_3'    \/>\n\t\t\t\t<label for='choice_13_19_3' id='label_13_19_3' class='gform-field-label gform-field-label--type-inline'>3<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_13_19_4'>\n\t\t\t\t<input name='input_19' type='radio' value='4'  id='choice_13_19_4'    \/>\n\t\t\t\t<label for='choice_13_19_4' id='label_13_19_4' class='gform-field-label gform-field-label--type-inline'>4<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_13_19_5'>\n\t\t\t\t<input name='input_19' type='radio' value='5'  id='choice_13_19_5'    \/>\n\t\t\t\t<label for='choice_13_19_5' id='label_13_19_5' class='gform-field-label gform-field-label--type-inline'>5<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_13_19_6'>\n\t\t\t\t<input name='input_19' type='radio' value='6'  id='choice_13_19_6'    \/>\n\t\t\t\t<label for='choice_13_19_6' id='label_13_19_6' class='gform-field-label gform-field-label--type-inline'>6<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_13_19_7'>\n\t\t\t\t<input name='input_19' type='radio' value='7'  id='choice_13_19_7'    \/>\n\t\t\t\t<label for='choice_13_19_7' id='label_13_19_7' class='gform-field-label gform-field-label--type-inline'>7<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_13_19_8'>\n\t\t\t\t<input name='input_19' type='radio' value='8'  id='choice_13_19_8'    \/>\n\t\t\t\t<label for='choice_13_19_8' id='label_13_19_8' class='gform-field-label gform-field-label--type-inline'>8<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_13_19_9'>\n\t\t\t\t<input name='input_19' type='radio' value='9'  id='choice_13_19_9'    \/>\n\t\t\t\t<label for='choice_13_19_9' id='label_13_19_9' class='gform-field-label gform-field-label--type-inline'>9<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_13_19_10'>\n\t\t\t\t<input name='input_19' type='radio' value='10'  id='choice_13_19_10'    \/>\n\t\t\t\t<label for='choice_13_19_10' id='label_13_19_10' class='gform-field-label gform-field-label--type-inline'>10<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_13_19_11'>\n\t\t\t\t<input name='input_19' type='radio' value='11'  id='choice_13_19_11'    \/>\n\t\t\t\t<label for='choice_13_19_11' id='label_13_19_11' class='gform-field-label gform-field-label--type-inline'>11<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_13_19_12'>\n\t\t\t\t<input name='input_19' type='radio' value='12'  id='choice_13_19_12'    \/>\n\t\t\t\t<label for='choice_13_19_12' id='label_13_19_12' class='gform-field-label gform-field-label--type-inline'>12<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_13_19_13'>\n\t\t\t\t<input name='input_19' type='radio' value='more than 12'  id='choice_13_19_13'    \/>\n\t\t\t\t<label for='choice_13_19_13' id='label_13_19_13' class='gform-field-label gform-field-label--type-inline'>more than 12<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_13_20\" class=\"gfield gfield--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_13_20'>How many days in the past month would you say your mental health was not good (difficulty coping)?<\/label><div class='ginput_container ginput_container_text'><input name='input_20' id='input_13_20' type='text' value='' class='medium'      aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_13_21\" class=\"gfield gfield--type-checkbox gfield--type-choice 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' >Reason therapy ended (check all that apply):<\/label><div class='ginput_container ginput_container_checkbox'><ul class='gfield_checkbox' id='input_13_21'><li class='gchoice gchoice_13_21_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_21.1' type='checkbox'  value='Met my goals'  id='choice_13_21_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_13_21_1' id='label_13_21_1' class='gform-field-label gform-field-label--type-inline'>Met my goals<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_13_21_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_21.2' type='checkbox'  value='Finished allotted number of sessions'  id='choice_13_21_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_13_21_2' id='label_13_21_2' class='gform-field-label gform-field-label--type-inline'>Finished allotted number of sessions<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_13_21_3'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_21.3' type='checkbox'  value='Bad fit with therapist'  id='choice_13_21_3'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_13_21_3' id='label_13_21_3' class='gform-field-label gform-field-label--type-inline'>Bad fit with therapist<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_13_21_4'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_21.4' type='checkbox'  value='Unable to continue therapy due to life circumstances (transportation, scheduling, other)'  id='choice_13_21_4'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_13_21_4' id='label_13_21_4' class='gform-field-label gform-field-label--type-inline'>Unable to continue therapy due to life circumstances (transportation, scheduling, other)<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_13_21_5'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_21.5' type='checkbox'  value='Obtained insurance (new benefit)'  id='choice_13_21_5'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_13_21_5' id='label_13_21_5' class='gform-field-label gform-field-label--type-inline'>Obtained insurance (new benefit)<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_13_21_6'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_21.6' type='checkbox'  value='Sought services elsewhere'  id='choice_13_21_6'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_13_21_6' id='label_13_21_6' class='gform-field-label gform-field-label--type-inline'>Sought services elsewhere<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_13_21_7'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_21.7' type='checkbox'  value='Other:'  id='choice_13_21_7'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_13_21_7' id='label_13_21_7' 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_13_22\" class=\"gfield gfield--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_13_22'>We welcome any other comments or feedback about your experience:<\/label><div class='ginput_container ginput_container_textarea'><textarea 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