{"id":538,"date":"2020-12-22T14:33:02","date_gmt":"2020-12-22T14:33:02","guid":{"rendered":"http:\/\/forms.mhamichiana.org\/?page_id=538"},"modified":"2021-01-12T19:53:35","modified_gmt":"2021-01-12T19:53:35","slug":"post-therapy-outcomes-questionnaire-therapist","status":"publish","type":"page","link":"https:\/\/forms.mhamichiana.org\/es\/post-therapy-outcomes-questionnaire-therapist\/","title":{"rendered":"Post Therapy Outcomes Questionnaire (Therapist)"},"content":{"rendered":"<div data-elementor-type=\"wp-page\" data-elementor-id=\"538\" class=\"elementor elementor-538\" data-elementor-post-type=\"page\">\n\t\t\t\t\t\t<section class=\"elementor-section elementor-top-section elementor-element elementor-element-96fe5e5 elementor-section-boxed elementor-section-height-default elementor-section-height-default\" data-id=\"96fe5e5\" 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-eca783e\" data-id=\"eca783e\" 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-af2ab57 elementor-widget elementor-widget-heading\" data-id=\"af2ab57\" 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 (for Therapists)<\/h1>\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t<div class=\"elementor-element elementor-element-8b1087e elementor-widget elementor-widget-shortcode\" data-id=\"8b1087e\" 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 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\/* ]]> *\/\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_12' ><div id='gf_12' class='gform_anchor' tabindex='-1'><\/div><form method='post' enctype='multipart\/form-data' target='gform_ajax_frame_12' id='gform_12'  action='\/es\/wp-json\/wp\/v2\/pages\/538#gf_12' data-formid='12' novalidate data-trp-original-action=\"\/es\/wp-json\/wp\/v2\/pages\/538#gf_12\">\n                        <div class='gform-body gform_body'><ul id='gform_fields_12' class='gform_fields top_label form_sublabel_below description_below validation_below'><li id=\"field_12_1\" class=\"gfield gfield--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_12_1'>Client First Name:<\/label><div class='ginput_container ginput_container_text'><input name='input_1' id='input_12_1' type='text' value='' class='medium'   tabindex='49'   aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_12_20\" class=\"gfield gfield--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_12_20'>Client Last Name:<\/label><div class='ginput_container ginput_container_text'><input name='input_20' id='input_12_20' type='text' value='' class='medium'   tabindex='50'   aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_12_21\" 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_12_21'>Email<\/label><div class='ginput_container ginput_container_email'>\n                            <input name='input_21' id='input_12_21' type='email' value='' class='medium' tabindex='51'    aria-invalid=\"false\"  \/>\n                        <\/div><\/li><li id=\"field_12_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_12_2'>Today\u2019s date:<\/label><div class='ginput_container ginput_container_date'>\n                            <input name='input_2' id='input_12_2' type='text' value='' class='datepicker gform-datepicker mdy datepicker_with_icon gdatepicker_with_icon' tabindex='52'  placeholder='mm\/dd\/yyyy' aria-describedby=\"input_12_2_date_format\" aria-invalid=\"false\" \/>\n                            <span id='input_12_2_date_format' class='screen-reader-text'>MM slash DD slash YYYY<\/span>\n                        <\/div>\n                        <input type='hidden' id='gforms_calendar_icon_input_12_2' class='gform_hidden' value='https:\/\/forms.mhamichiana.org\/wp-content\/plugins\/gravityforms\/images\/datepicker\/datepicker.svg'\/><\/li><li id=\"field_12_22\" 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_12_22'>Date of first therapy appointment<\/label><div class='ginput_container ginput_container_date'>\n                            <input name='input_22' id='input_12_22' type='text' value='' class='datepicker gform-datepicker mdy datepicker_with_icon gdatepicker_with_icon' tabindex='53'  placeholder='mm\/dd\/yyyy' aria-describedby=\"input_12_22_date_format\" aria-invalid=\"false\" \/>\n                            <span id='input_12_22_date_format' class='screen-reader-text'>MM slash DD slash YYYY<\/span>\n                        <\/div>\n                        <input type='hidden' id='gforms_calendar_icon_input_12_22' class='gform_hidden' value='https:\/\/forms.mhamichiana.org\/wp-content\/plugins\/gravityforms\/images\/datepicker\/datepicker.svg'\/><\/li><li id=\"field_12_23\" class=\"gfield gfield--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_12_23'>Date of final therapy appointment<\/label><div class='ginput_container ginput_container_date'>\n                            <input name='input_23' id='input_12_23' type='text' value='' class='datepicker gform-datepicker mdy datepicker_no_icon gdatepicker-no-icon' tabindex='54'  placeholder='mm\/dd\/yyyy' aria-describedby=\"input_12_23_date_format\" aria-invalid=\"false\" \/>\n                            <span id='input_12_23_date_format' class='screen-reader-text'>MM slash DD slash YYYY<\/span>\n                        <\/div>\n                        <input type='hidden' id='gforms_calendar_icon_input_12_23' class='gform_hidden' value='https:\/\/forms.mhamichiana.org\/wp-content\/plugins\/gravityforms\/images\/datepicker\/datepicker.svg'\/><\/li><li id=\"field_12_3\" class=\"gfield gfield--type-number field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_12_3'>Number of sessions provided:<\/label><div class='ginput_container ginput_container_number'><input name='input_3' id='input_12_3' type='number' step='any'   value='' class='medium' tabindex='55'     aria-invalid=\"false\"  \/><\/div><\/li><li id=\"field_12_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_12_4'>Name of therapist:<\/label><div class='ginput_container ginput_container_text'><input name='input_4' id='input_12_4' type='text' value='' class='medium'   tabindex='56'   aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_12_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' >The client made progress toward their goals.<\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_12_5'>\n\t\t\t<li class='gchoice gchoice_12_5_0'>\n\t\t\t\t<input name='input_5' type='radio' value='Strongly agree (5)'  id='choice_12_5_0' tabindex='57'   \/>\n\t\t\t\t<label for='choice_12_5_0' id='label_12_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_12_5_1'>\n\t\t\t\t<input name='input_5' type='radio' value='Agree (4)'  id='choice_12_5_1' tabindex='58'   \/>\n\t\t\t\t<label for='choice_12_5_1' id='label_12_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_12_5_2'>\n\t\t\t\t<input name='input_5' type='radio' value='Neutral (3)'  id='choice_12_5_2' tabindex='59'   \/>\n\t\t\t\t<label for='choice_12_5_2' id='label_12_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_12_5_3'>\n\t\t\t\t<input name='input_5' type='radio' value='Disagree (2)'  id='choice_12_5_3' tabindex='60'   \/>\n\t\t\t\t<label for='choice_12_5_3' id='label_12_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_12_5_4'>\n\t\t\t\t<input name='input_5' type='radio' value='Strongly disagree (1)'  id='choice_12_5_4' tabindex='61'   \/>\n\t\t\t\t<label for='choice_12_5_4' id='label_12_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_12_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' >The client was satisfied with the progress made.<\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_12_6'>\n\t\t\t<li class='gchoice gchoice_12_6_0'>\n\t\t\t\t<input name='input_6' type='radio' value='Strongly agree (5)'  id='choice_12_6_0' tabindex='62'   \/>\n\t\t\t\t<label for='choice_12_6_0' id='label_12_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_12_6_1'>\n\t\t\t\t<input name='input_6' type='radio' value='Agree (4)'  id='choice_12_6_1' tabindex='63'   \/>\n\t\t\t\t<label for='choice_12_6_1' id='label_12_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_12_6_2'>\n\t\t\t\t<input name='input_6' type='radio' value='Neutral (3)'  id='choice_12_6_2' tabindex='64'   \/>\n\t\t\t\t<label for='choice_12_6_2' id='label_12_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_12_6_3'>\n\t\t\t\t<input name='input_6' type='radio' value='Disagree (2)'  id='choice_12_6_3' tabindex='65'   \/>\n\t\t\t\t<label for='choice_12_6_3' id='label_12_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_12_6_4'>\n\t\t\t\t<input name='input_6' type='radio' value='Strongly disagree (1)'  id='choice_12_6_4' tabindex='66'   \/>\n\t\t\t\t<label for='choice_12_6_4' id='label_12_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_12_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' >The client was able to talk to friends  or family members about their mental health.<\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_12_7'>\n\t\t\t<li class='gchoice gchoice_12_7_0'>\n\t\t\t\t<input name='input_7' type='radio' value='Strongly agree (5)'  id='choice_12_7_0' tabindex='67'   \/>\n\t\t\t\t<label for='choice_12_7_0' id='label_12_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_12_7_1'>\n\t\t\t\t<input name='input_7' type='radio' value='Agree (4)'  id='choice_12_7_1' tabindex='68'   \/>\n\t\t\t\t<label for='choice_12_7_1' id='label_12_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_12_7_2'>\n\t\t\t\t<input name='input_7' type='radio' value='Neutral (3)'  id='choice_12_7_2' tabindex='69'   \/>\n\t\t\t\t<label for='choice_12_7_2' id='label_12_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_12_7_3'>\n\t\t\t\t<input name='input_7' type='radio' value='Disagree (2)'  id='choice_12_7_3' tabindex='70'   \/>\n\t\t\t\t<label for='choice_12_7_3' id='label_12_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_12_7_4'>\n\t\t\t\t<input name='input_7' type='radio' value='Strongly disagree (1)'  id='choice_12_7_4' tabindex='71'   \/>\n\t\t\t\t<label for='choice_12_7_4' id='label_12_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_12_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' >The client\u2019s mental health improved because of therapy.<\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_12_8'>\n\t\t\t<li class='gchoice gchoice_12_8_0'>\n\t\t\t\t<input name='input_8' type='radio' value='Strongly agree (5)'  id='choice_12_8_0' tabindex='72'   \/>\n\t\t\t\t<label for='choice_12_8_0' id='label_12_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_12_8_1'>\n\t\t\t\t<input name='input_8' type='radio' value='Agree (4)'  id='choice_12_8_1' tabindex='73'   \/>\n\t\t\t\t<label for='choice_12_8_1' id='label_12_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_12_8_2'>\n\t\t\t\t<input name='input_8' type='radio' value='Neutral (3)'  id='choice_12_8_2' tabindex='74'   \/>\n\t\t\t\t<label for='choice_12_8_2' id='label_12_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_12_8_3'>\n\t\t\t\t<input name='input_8' type='radio' value='Disagree (2)'  id='choice_12_8_3' tabindex='75'   \/>\n\t\t\t\t<label for='choice_12_8_3' id='label_12_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_12_8_4'>\n\t\t\t\t<input name='input_8' type='radio' value='Strongly disagree (1)'  id='choice_12_8_4' tabindex='76'   \/>\n\t\t\t\t<label for='choice_12_8_4' id='label_12_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_12_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' >The client\u2019s mental health improved because of other reasons.<\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_12_9'>\n\t\t\t<li class='gchoice gchoice_12_9_0'>\n\t\t\t\t<input name='input_9' type='radio' value='Strongly agree (5)'  id='choice_12_9_0' tabindex='77'   \/>\n\t\t\t\t<label for='choice_12_9_0' id='label_12_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_12_9_1'>\n\t\t\t\t<input name='input_9' type='radio' value='Agree (4)'  id='choice_12_9_1' tabindex='78'   \/>\n\t\t\t\t<label for='choice_12_9_1' id='label_12_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_12_9_2'>\n\t\t\t\t<input name='input_9' type='radio' value='Neutral (3)'  id='choice_12_9_2' tabindex='79'   \/>\n\t\t\t\t<label for='choice_12_9_2' id='label_12_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_12_9_3'>\n\t\t\t\t<input name='input_9' type='radio' value='Disagree (2)'  id='choice_12_9_3' tabindex='80'   \/>\n\t\t\t\t<label for='choice_12_9_3' id='label_12_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_12_9_4'>\n\t\t\t\t<input name='input_9' type='radio' value='Strongly disagree (1)'  id='choice_12_9_4' tabindex='81'   \/>\n\t\t\t\t<label for='choice_12_9_4' id='label_12_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_12_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' >The client\u2019s 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_12_10'>\n\t\t\t<li class='gchoice gchoice_12_10_0'>\n\t\t\t\t<input name='input_10' type='radio' value='Strongly agree (5)'  id='choice_12_10_0' tabindex='82'   \/>\n\t\t\t\t<label for='choice_12_10_0' id='label_12_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_12_10_1'>\n\t\t\t\t<input name='input_10' type='radio' value='Agree (4)'  id='choice_12_10_1' tabindex='83'   \/>\n\t\t\t\t<label for='choice_12_10_1' id='label_12_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_12_10_2'>\n\t\t\t\t<input name='input_10' type='radio' value='Neutral (3)'  id='choice_12_10_2' tabindex='84'   \/>\n\t\t\t\t<label for='choice_12_10_2' id='label_12_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_12_10_3'>\n\t\t\t\t<input name='input_10' type='radio' value='Disagree (2)'  id='choice_12_10_3' tabindex='85'   \/>\n\t\t\t\t<label for='choice_12_10_3' id='label_12_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_12_10_4'>\n\t\t\t\t<input name='input_10' type='radio' value='Strongly disagree (1)'  id='choice_12_10_4' tabindex='86'   \/>\n\t\t\t\t<label for='choice_12_10_4' id='label_12_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_12_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' >The client\u2019s 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_12_11'>\n\t\t\t<li class='gchoice gchoice_12_11_0'>\n\t\t\t\t<input name='input_11' type='radio' value='Strongly agree (5)'  id='choice_12_11_0' tabindex='87'   \/>\n\t\t\t\t<label for='choice_12_11_0' id='label_12_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_12_11_1'>\n\t\t\t\t<input name='input_11' type='radio' value='Agree (4)'  id='choice_12_11_1' tabindex='88'   \/>\n\t\t\t\t<label for='choice_12_11_1' id='label_12_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_12_11_2'>\n\t\t\t\t<input name='input_11' type='radio' value='Neutral (3)'  id='choice_12_11_2' tabindex='89'   \/>\n\t\t\t\t<label for='choice_12_11_2' id='label_12_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_12_11_3'>\n\t\t\t\t<input name='input_11' type='radio' value='Disagree (2)'  id='choice_12_11_3' tabindex='90'   \/>\n\t\t\t\t<label for='choice_12_11_3' id='label_12_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_12_11_4'>\n\t\t\t\t<input name='input_11' type='radio' value='Strongly disagree (1)'  id='choice_12_11_4' tabindex='91'   \/>\n\t\t\t\t<label for='choice_12_11_4' id='label_12_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_12_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' >The client\u2019s 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_12_12'>\n\t\t\t<li class='gchoice gchoice_12_12_0'>\n\t\t\t\t<input name='input_12' type='radio' value='Strongly agree (5)'  id='choice_12_12_0' tabindex='92'   \/>\n\t\t\t\t<label for='choice_12_12_0' id='label_12_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_12_12_1'>\n\t\t\t\t<input name='input_12' type='radio' value='Agree (4)'  id='choice_12_12_1' tabindex='93'   \/>\n\t\t\t\t<label for='choice_12_12_1' id='label_12_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_12_12_2'>\n\t\t\t\t<input name='input_12' type='radio' value='Neutral (3)'  id='choice_12_12_2' tabindex='94'   \/>\n\t\t\t\t<label for='choice_12_12_2' id='label_12_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_12_12_3'>\n\t\t\t\t<input name='input_12' type='radio' value='Disagree (2)'  id='choice_12_12_3' tabindex='95'   \/>\n\t\t\t\t<label for='choice_12_12_3' id='label_12_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_12_12_4'>\n\t\t\t\t<input name='input_12' type='radio' value='Strongly disagree (1)'  id='choice_12_12_4' tabindex='96'   \/>\n\t\t\t\t<label for='choice_12_12_4' id='label_12_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_12_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' >The client\u2019s close relationships improved (better communication, less conflict).<\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_12_13'>\n\t\t\t<li class='gchoice gchoice_12_13_0'>\n\t\t\t\t<input name='input_13' type='radio' value='Strongly agree (5)'  id='choice_12_13_0' tabindex='97'   \/>\n\t\t\t\t<label for='choice_12_13_0' id='label_12_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_12_13_1'>\n\t\t\t\t<input name='input_13' type='radio' value='Agree (4)'  id='choice_12_13_1' tabindex='98'   \/>\n\t\t\t\t<label for='choice_12_13_1' id='label_12_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_12_13_2'>\n\t\t\t\t<input name='input_13' type='radio' value='Neutral (3)'  id='choice_12_13_2' tabindex='99'   \/>\n\t\t\t\t<label for='choice_12_13_2' id='label_12_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_12_13_3'>\n\t\t\t\t<input name='input_13' type='radio' value='Disagree (2)'  id='choice_12_13_3' tabindex='100'   \/>\n\t\t\t\t<label for='choice_12_13_3' id='label_12_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_12_13_4'>\n\t\t\t\t<input name='input_13' type='radio' value='Strongly disagree (1)'  id='choice_12_13_4' tabindex='101'   \/>\n\t\t\t\t<label for='choice_12_13_4' id='label_12_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_12_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' >The client\u2019s other relationships improved (work, school, friends)<\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_12_14'>\n\t\t\t<li class='gchoice gchoice_12_14_0'>\n\t\t\t\t<input name='input_14' type='radio' value='Strongly agree (5)'  id='choice_12_14_0' tabindex='102'   \/>\n\t\t\t\t<label for='choice_12_14_0' id='label_12_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_12_14_1'>\n\t\t\t\t<input name='input_14' type='radio' value='Agree (4)'  id='choice_12_14_1' tabindex='103'   \/>\n\t\t\t\t<label for='choice_12_14_1' id='label_12_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_12_14_2'>\n\t\t\t\t<input name='input_14' type='radio' value='Neutral (3)'  id='choice_12_14_2' tabindex='104'   \/>\n\t\t\t\t<label for='choice_12_14_2' id='label_12_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_12_14_3'>\n\t\t\t\t<input name='input_14' type='radio' value='Disagree (2)'  id='choice_12_14_3' tabindex='105'   \/>\n\t\t\t\t<label for='choice_12_14_3' id='label_12_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_12_14_4'>\n\t\t\t\t<input name='input_14' type='radio' value='Strongly disagree (1)'  id='choice_12_14_4' tabindex='106'   \/>\n\t\t\t\t<label for='choice_12_14_4' id='label_12_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_12_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' >The client\u2019s finances improved (more stable, better decision making).<\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_12_15'>\n\t\t\t<li class='gchoice gchoice_12_15_0'>\n\t\t\t\t<input name='input_15' type='radio' value='Strongly agree (5)'  id='choice_12_15_0' tabindex='107'   \/>\n\t\t\t\t<label for='choice_12_15_0' id='label_12_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_12_15_1'>\n\t\t\t\t<input name='input_15' type='radio' value='Agree (4)'  id='choice_12_15_1' tabindex='108'   \/>\n\t\t\t\t<label for='choice_12_15_1' id='label_12_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_12_15_2'>\n\t\t\t\t<input name='input_15' type='radio' value='Neutral (3)'  id='choice_12_15_2' tabindex='109'   \/>\n\t\t\t\t<label for='choice_12_15_2' id='label_12_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_12_15_3'>\n\t\t\t\t<input name='input_15' type='radio' value='Disagree (2)'  id='choice_12_15_3' tabindex='110'   \/>\n\t\t\t\t<label for='choice_12_15_3' id='label_12_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_12_15_4'>\n\t\t\t\t<input name='input_15' type='radio' value='Strongly disagree (1)'  id='choice_12_15_4' tabindex='111'   \/>\n\t\t\t\t<label for='choice_12_15_4' id='label_12_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_12_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' >I was matched with a client who was appropriate to the level of care I could provide in short term counseling.<\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_12_16'>\n\t\t\t<li class='gchoice gchoice_12_16_0'>\n\t\t\t\t<input name='input_16' type='radio' value='Strongly agree (5)'  id='choice_12_16_0' tabindex='112'   \/>\n\t\t\t\t<label for='choice_12_16_0' id='label_12_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_12_16_1'>\n\t\t\t\t<input name='input_16' type='radio' value='Agree (4)'  id='choice_12_16_1' tabindex='113'   \/>\n\t\t\t\t<label for='choice_12_16_1' id='label_12_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_12_16_2'>\n\t\t\t\t<input name='input_16' type='radio' value='Neutral (3)'  id='choice_12_16_2' tabindex='114'   \/>\n\t\t\t\t<label for='choice_12_16_2' id='label_12_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_12_16_3'>\n\t\t\t\t<input name='input_16' type='radio' value='Disagree (2)'  id='choice_12_16_3' tabindex='115'   \/>\n\t\t\t\t<label for='choice_12_16_3' id='label_12_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_12_16_4'>\n\t\t\t\t<input name='input_16' type='radio' value='Strongly disagree (1)'  id='choice_12_16_4' tabindex='116'   \/>\n\t\t\t\t<label for='choice_12_16_4' id='label_12_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_12_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 would recommend this project to a colleague, a friend\/ family.<\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_12_17'>\n\t\t\t<li class='gchoice gchoice_12_17_0'>\n\t\t\t\t<input name='input_17' type='radio' value='Strongly agree (5)'  id='choice_12_17_0' tabindex='117'   \/>\n\t\t\t\t<label for='choice_12_17_0' id='label_12_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_12_17_1'>\n\t\t\t\t<input name='input_17' type='radio' value='Agree (4)'  id='choice_12_17_1' tabindex='118'   \/>\n\t\t\t\t<label for='choice_12_17_1' id='label_12_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_12_17_2'>\n\t\t\t\t<input name='input_17' type='radio' value='Neutral (3)'  id='choice_12_17_2' tabindex='119'   \/>\n\t\t\t\t<label for='choice_12_17_2' id='label_12_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_12_17_3'>\n\t\t\t\t<input name='input_17' type='radio' value='Disagree (2)'  id='choice_12_17_3' tabindex='120'   \/>\n\t\t\t\t<label for='choice_12_17_3' id='label_12_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_12_17_4'>\n\t\t\t\t<input name='input_17' type='radio' value='Strongly disagree (1)'  id='choice_12_17_4' tabindex='121'   \/>\n\t\t\t\t<label for='choice_12_17_4' id='label_12_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_12_18\" 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_12_18'><li class='gchoice gchoice_12_18_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_18.1' type='checkbox'  value='Goals Met'  id='choice_12_18_1' tabindex='122'  \/>\n\t\t\t\t\t\t\t\t<label for='choice_12_18_1' id='label_12_18_1' class='gform-field-label gform-field-label--type-inline'>Goals Met<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_12_18_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_18.2' type='checkbox'  value='Finished allotted number of sessions'  id='choice_12_18_2' tabindex='123'  \/>\n\t\t\t\t\t\t\t\t<label for='choice_12_18_2' id='label_12_18_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_12_18_3'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_18.3' type='checkbox'  value='Bad fit with therapist'  id='choice_12_18_3' tabindex='124'  \/>\n\t\t\t\t\t\t\t\t<label for='choice_12_18_3' id='label_12_18_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_12_18_4'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_18.4' type='checkbox'  value='Unable to continue therapy due to life circumstances (transportation, scheduling, other'  id='choice_12_18_4' tabindex='125'  \/>\n\t\t\t\t\t\t\t\t<label for='choice_12_18_4' id='label_12_18_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_12_18_5'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_18.5' type='checkbox'  value='Obtained insurance (new benefit)'  id='choice_12_18_5' tabindex='126'  \/>\n\t\t\t\t\t\t\t\t<label for='choice_12_18_5' id='label_12_18_5' 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