{"id":621,"date":"2021-01-13T20:58:25","date_gmt":"2021-01-13T20:58:25","guid":{"rendered":"http:\/\/forms.mhamichiana.org\/?page_id=621"},"modified":"2025-10-08T16:03:39","modified_gmt":"2025-10-08T20:03:39","slug":"counselor-volunteer-form","status":"publish","type":"page","link":"https:\/\/forms.mhamichiana.org\/es\/counselor-volunteer-form\/","title":{"rendered":"Counselor Volunteer Form"},"content":{"rendered":"<div data-elementor-type=\"wp-page\" data-elementor-id=\"621\" class=\"elementor elementor-621\" data-elementor-post-type=\"page\">\n\t\t\t\t\t\t<section class=\"elementor-section elementor-top-section elementor-element elementor-element-a99b317 elementor-section-boxed elementor-section-height-default elementor-section-height-default\" data-id=\"a99b317\" 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-a6df548\" data-id=\"a6df548\" 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-409c0c9 elementor-widget elementor-widget-heading\" data-id=\"409c0c9\" 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\">Volunteer Counselor Form<\/h1>\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t<div class=\"elementor-element elementor-element-7594bc7 elementor-widget elementor-widget-shortcode\" data-id=\"7594bc7\" 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_16' style='display:none'><div id='gf_16' class='gform_anchor' tabindex='-1'><\/div>\n                        <div class='gform_heading'>\n                            <p class='gform_description'>to be used for counselors who would like to volunteer for MHAM<\/p>\n                        <\/div><form method='post' enctype='multipart\/form-data' target='gform_ajax_frame_16' id='gform_16'  action='\/es\/wp-json\/wp\/v2\/pages\/621#gf_16' data-formid='16' novalidate data-trp-original-action=\"\/es\/wp-json\/wp\/v2\/pages\/621#gf_16\">\n                        <div class='gform-body gform_body'><ul id='gform_fields_16' class='gform_fields top_label form_sublabel_below description_below validation_below'><li id=\"field_16_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_16_1'>First Name<\/label><div class='ginput_container ginput_container_text'><input name='input_1' id='input_16_1' type='text' value='' class='medium'      aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_16_2\" 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_16_2'>Last Name<\/label><div class='ginput_container ginput_container_text'><input name='input_2' id='input_16_2' type='text' value='' class='medium'      aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_16_3\" 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_16_3'>Email<\/label><div class='ginput_container ginput_container_email'>\n                            <input name='input_3' id='input_16_3' type='email' value='' class='medium'     aria-invalid=\"false\"  \/>\n                        <\/div><\/li><li id=\"field_16_4\" class=\"gfield gfield--type-phone field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_16_4'>Phone<\/label><div class='ginput_container ginput_container_phone'><input name='input_4' id='input_16_4' type='tel' value='' class='medium'    aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_16_5\" class=\"gfield gfield--type-address 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' >Mailing Address<\/label>    \n                    <div class='ginput_complex ginput_container has_street has_street2 has_city has_state has_zip has_country ginput_container_address gform-grid-row' id='input_16_5' >\n                         <span class='ginput_full address_line_1 ginput_address_line_1 gform-grid-col' id='input_16_5_1_container' >\n                                        <input type='text' name='input_5.1' id='input_16_5_1' value=''    aria-required='false'    \/>\n                                        <label for='input_16_5_1' id='input_16_5_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_16_5_2_container' >\n                                        <input type='text' name='input_5.2' id='input_16_5_2' value=''     aria-required='false'   \/>\n                                        <label for='input_16_5_2' id='input_16_5_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_16_5_3_container' >\n                                    <input type='text' name='input_5.3' id='input_16_5_3' value=''    aria-required='false'    \/>\n                                    <label for='input_16_5_3' id='input_16_5_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_16_5_4_container' >\n                                        <input type='text' name='input_5.4' id='input_16_5_4' value=''      aria-required='false'    \/>\n                                        <label for='input_16_5_4' id='input_16_5_4_label' class='gform-field-label gform-field-label--type-sub'>State \/ Province \/ Region<\/label>\n                                      <\/span><span class='ginput_left address_zip ginput_address_zip gform-grid-col' id='input_16_5_5_container' >\n                                    <input type='text' name='input_5.5' id='input_16_5_5' value=''    aria-required='false'    \/>\n                                    <label for='input_16_5_5' id='input_16_5_5_label' class='gform-field-label gform-field-label--type-sub'>ZIP \/ Postal Code<\/label>\n                                <\/span><span class='ginput_right address_country ginput_address_country gform-grid-col' id='input_16_5_6_container' >\n                                        <select name='input_5.6' id='input_16_5_6'   aria-required='false'    ><option value='' selected='selected'><\/option><option value='Afghanistan' >Afghanistan<\/option><option value='Albania' >Albania<\/option><option value='Algeria' >Algeria<\/option><option value='American Samoa' >American Samoa<\/option><option value='Andorra' >Andorra<\/option><option value='Angola' >Angola<\/option><option value='Anguilla' >Anguilla<\/option><option value='Antarctica' >Antarctica<\/option><option value='Antigua and Barbuda' >Antigua and Barbuda<\/option><option value='Argentina' >Argentina<\/option><option value='Armenia' >Armenia<\/option><option value='Aruba' >Aruba<\/option><option value='Australia' >Australia<\/option><option value='Austria' >Austria<\/option><option value='Azerbaijan' >Azerbaijan<\/option><option value='Bahamas' >Bahamas<\/option><option value='Bahrain' >Bahrain<\/option><option value='Bangladesh' >Bangladesh<\/option><option value='Barbados' >Barbados<\/option><option value='Belarus' >Belarus<\/option><option value='Belgium' >Belgium<\/option><option value='Belize' >Belize<\/option><option value='Benin' >Benin<\/option><option value='Bermuda' >Bermuda<\/option><option value='Bhutan' >Bhutan<\/option><option value='Bolivia' >Bolivia<\/option><option value='Bonaire, Sint Eustatius and Saba' >Bonaire, Sint Eustatius and Saba<\/option><option value='Bosnia and Herzegovina' >Bosnia and Herzegovina<\/option><option value='Botswana' >Botswana<\/option><option value='Bouvet Island' >Bouvet Island<\/option><option value='Brazil' >Brazil<\/option><option value='British Indian Ocean Territory' >British Indian Ocean Territory<\/option><option value='Brunei Darussalam' >Brunei Darussalam<\/option><option value='Bulgaria' >Bulgaria<\/option><option value='Burkina Faso' >Burkina Faso<\/option><option value='Burundi' >Burundi<\/option><option value='Cabo Verde' >Cabo Verde<\/option><option value='Cambodia' >Cambodia<\/option><option value='Cameroon' >Cameroon<\/option><option value='Canada' >Canada<\/option><option value='Cayman Islands' >Cayman Islands<\/option><option value='Central African Republic' >Central African Republic<\/option><option value='Chad' >Chad<\/option><option value='Chile' >Chile<\/option><option value='China' >China<\/option><option value='Christmas Island' >Christmas Island<\/option><option value='Cocos Islands' >Cocos Islands<\/option><option value='Colombia' >Colombia<\/option><option value='Comoros' >Comoros<\/option><option value='Congo' >Congo<\/option><option value='Congo, Democratic Republic of the' >Congo, Democratic Republic of the<\/option><option value='Cook Islands' >Cook Islands<\/option><option value='Costa Rica' >Costa Rica<\/option><option value='Croatia' >Croatia<\/option><option value='Cuba' >Cuba<\/option><option value='Cura\u00e7ao' >Cura\u00e7ao<\/option><option value='Cyprus' >Cyprus<\/option><option value='Czechia' >Czechia<\/option><option value='C\u00f4te d&#039;Ivoire' >C\u00f4te d&#039;Ivoire<\/option><option value='Denmark' >Denmark<\/option><option value='Djibouti' >Djibouti<\/option><option value='Dominica' >Dominica<\/option><option value='Dominican Republic' >Dominican Republic<\/option><option value='Ecuador' >Ecuador<\/option><option value='Egypt' >Egypt<\/option><option value='El Salvador' >El Salvador<\/option><option value='Equatorial Guinea' >Equatorial Guinea<\/option><option value='Eritrea' >Eritrea<\/option><option value='Estonia' >Estonia<\/option><option value='Eswatini' >Eswatini<\/option><option value='Ethiopia' >Ethiopia<\/option><option value='Falkland Islands' >Falkland Islands<\/option><option value='Faroe Islands' >Faroe Islands<\/option><option value='Fiji' >Fiji<\/option><option value='Finland' >Finland<\/option><option value='France' >France<\/option><option value='French Guiana' >French Guiana<\/option><option value='French Polynesia' >French Polynesia<\/option><option value='French Southern Territories' >French Southern Territories<\/option><option value='Gabon' >Gabon<\/option><option value='Gambia' >Gambia<\/option><option value='Georgia' >Georgia<\/option><option value='Germany' >Germany<\/option><option value='Ghana' >Ghana<\/option><option value='Gibraltar' >Gibraltar<\/option><option value='Greece' >Greece<\/option><option value='Greenland' >Greenland<\/option><option value='Grenada' >Grenada<\/option><option value='Guadeloupe' >Guadeloupe<\/option><option value='Guam' >Guam<\/option><option value='Guatemala' >Guatemala<\/option><option value='Guernsey' >Guernsey<\/option><option value='Guinea' >Guinea<\/option><option value='Guinea-Bissau' >Guinea-Bissau<\/option><option value='Guyana' >Guyana<\/option><option value='Haiti' >Haiti<\/option><option value='Heard Island and McDonald Islands' >Heard Island and McDonald Islands<\/option><option value='Holy See' >Holy See<\/option><option value='Honduras' >Honduras<\/option><option value='Hong Kong' >Hong Kong<\/option><option value='Hungary' >Hungary<\/option><option value='Iceland' >Iceland<\/option><option value='India' >India<\/option><option value='Indonesia' >Indonesia<\/option><option value='Iran' >Iran<\/option><option value='Iraq' >Iraq<\/option><option value='Ireland' >Ireland<\/option><option value='Isle of Man' >Isle of Man<\/option><option value='Israel' >Israel<\/option><option value='Italy' >Italy<\/option><option value='Jamaica' >Jamaica<\/option><option value='Japan' >Japan<\/option><option value='Jersey' >Jersey<\/option><option value='Jordan' >Jordan<\/option><option value='Kazakhstan' >Kazakhstan<\/option><option value='Kenya' >Kenya<\/option><option value='Kiribati' >Kiribati<\/option><option value='Korea, Democratic People&#039;s Republic of' >Korea, Democratic People&#039;s Republic of<\/option><option value='Korea, Republic of' >Korea, Republic of<\/option><option value='Kuwait' >Kuwait<\/option><option value='Kyrgyzstan' >Kyrgyzstan<\/option><option value='Lao People&#039;s Democratic Republic' >Lao People&#039;s Democratic Republic<\/option><option value='Latvia' >Latvia<\/option><option value='Lebanon' >Lebanon<\/option><option value='Lesotho' >Lesotho<\/option><option value='Liberia' >Liberia<\/option><option value='Libya' >Libya<\/option><option value='Liechtenstein' >Liechtenstein<\/option><option value='Lithuania' >Lithuania<\/option><option value='Luxembourg' >Luxembourg<\/option><option value='Macao' >Macao<\/option><option value='Madagascar' >Madagascar<\/option><option value='Malawi' >Malawi<\/option><option value='Malaysia' >Malaysia<\/option><option value='Maldives' >Maldives<\/option><option value='Mali' >Mali<\/option><option value='Malta' >Malta<\/option><option value='Marshall Islands' >Marshall Islands<\/option><option value='Martinique' >Martinique<\/option><option value='Mauritania' >Mauritania<\/option><option value='Mauritius' >Mauritius<\/option><option value='Mayotte' >Mayotte<\/option><option value='Mexico' >Mexico<\/option><option value='Micronesia' >Micronesia<\/option><option value='Moldova' >Moldova<\/option><option value='Monaco' >Monaco<\/option><option value='Mongolia' >Mongolia<\/option><option value='Montenegro' >Montenegro<\/option><option value='Montserrat' >Montserrat<\/option><option value='Morocco' >Morocco<\/option><option value='Mozambique' >Mozambique<\/option><option value='Myanmar' >Myanmar<\/option><option value='Namibia' >Namibia<\/option><option value='Nauru' >Nauru<\/option><option value='Nepal' >Nepal<\/option><option value='Netherlands' >Netherlands<\/option><option value='New Caledonia' >New Caledonia<\/option><option value='New Zealand' >New Zealand<\/option><option value='Nicaragua' >Nicaragua<\/option><option value='Niger' >Niger<\/option><option value='Nigeria' >Nigeria<\/option><option value='Niue' >Niue<\/option><option value='Norfolk Island' >Norfolk Island<\/option><option value='North Macedonia' >North Macedonia<\/option><option value='Northern Mariana Islands' >Northern Mariana Islands<\/option><option value='Norway' >Norway<\/option><option value='Oman' >Oman<\/option><option value='Pakistan' >Pakistan<\/option><option value='Palau' >Palau<\/option><option value='Palestine, State of' >Palestine, State of<\/option><option value='Panama' >Panama<\/option><option value='Papua New Guinea' >Papua New Guinea<\/option><option value='Paraguay' >Paraguay<\/option><option value='Peru' >Peru<\/option><option value='Philippines' >Philippines<\/option><option value='Pitcairn' >Pitcairn<\/option><option value='Poland' >Poland<\/option><option value='Portugal' >Portugal<\/option><option value='Puerto Rico' >Puerto Rico<\/option><option value='Qatar' >Qatar<\/option><option value='Romania' >Romania<\/option><option value='Russian Federation' >Russian Federation<\/option><option value='Rwanda' >Rwanda<\/option><option value='R\u00e9union' >R\u00e9union<\/option><option value='Saint Barth\u00e9lemy' >Saint Barth\u00e9lemy<\/option><option value='Saint Helena, Ascension and Tristan da Cunha' >Saint Helena, Ascension and Tristan da Cunha<\/option><option value='Saint Kitts and Nevis' >Saint Kitts and Nevis<\/option><option value='Saint Lucia' >Saint Lucia<\/option><option value='Saint Martin' >Saint Martin<\/option><option value='Saint Pierre and Miquelon' >Saint Pierre and Miquelon<\/option><option value='Saint Vincent and the Grenadines' >Saint Vincent and the Grenadines<\/option><option value='Samoa' >Samoa<\/option><option value='San Marino' >San Marino<\/option><option value='Sao Tome and Principe' >Sao Tome and Principe<\/option><option value='Saudi Arabia' >Saudi Arabia<\/option><option value='Senegal' >Senegal<\/option><option value='Serbia' >Serbia<\/option><option value='Seychelles' >Seychelles<\/option><option value='Sierra Leone' >Sierra Leone<\/option><option value='Singapore' >Singapore<\/option><option value='Sint Maarten' >Sint Maarten<\/option><option value='Slovakia' >Slovakia<\/option><option value='Slovenia' >Slovenia<\/option><option value='Solomon Islands' >Solomon Islands<\/option><option value='Somalia' >Somalia<\/option><option value='South Africa' >South Africa<\/option><option value='South Georgia and the South Sandwich Islands' >South Georgia and the South Sandwich Islands<\/option><option value='South Sudan' >South Sudan<\/option><option value='Spain' >Spain<\/option><option value='Sri Lanka' >Sri Lanka<\/option><option value='Sudan' >Sudan<\/option><option value='Suriname' >Suriname<\/option><option value='Svalbard and Jan Mayen' >Svalbard and Jan Mayen<\/option><option value='Sweden' >Sweden<\/option><option value='Switzerland' >Switzerland<\/option><option value='Syria Arab Republic' >Syria Arab Republic<\/option><option value='Taiwan' >Taiwan<\/option><option value='Tajikistan' >Tajikistan<\/option><option value='Tanzania, the United Republic of' >Tanzania, the United Republic of<\/option><option value='Thailand' >Thailand<\/option><option value='Timor-Leste' >Timor-Leste<\/option><option value='Togo' >Togo<\/option><option value='Tokelau' >Tokelau<\/option><option value='Tonga' >Tonga<\/option><option value='Trinidad and Tobago' >Trinidad and Tobago<\/option><option value='Tunisia' >Tunisia<\/option><option value='Turkmenistan' >Turkmenistan<\/option><option value='Turks and Caicos Islands' >Turks and Caicos Islands<\/option><option value='Tuvalu' >Tuvalu<\/option><option value='T\u00fcrkiye' >T\u00fcrkiye<\/option><option value='US Minor Outlying Islands' >US Minor Outlying Islands<\/option><option value='Uganda' >Uganda<\/option><option value='Ukraine' >Ukraine<\/option><option value='United Arab Emirates' >United Arab Emirates<\/option><option value='United Kingdom' >United Kingdom<\/option><option value='United States' >United States<\/option><option value='Uruguay' >Uruguay<\/option><option value='Uzbekistan' >Uzbekistan<\/option><option value='Vanuatu' >Vanuatu<\/option><option value='Venezuela' >Venezuela<\/option><option value='Viet Nam' >Viet Nam<\/option><option value='Virgin Islands, British' >Virgin Islands, British<\/option><option value='Virgin Islands, U.S.' >Virgin Islands, U.S.<\/option><option value='Wallis and Futuna' >Wallis and Futuna<\/option><option value='Western Sahara' >Western Sahara<\/option><option value='Yemen' >Yemen<\/option><option value='Zambia' >Zambia<\/option><option value='Zimbabwe' >Zimbabwe<\/option><option value='\u00c5land Islands' >\u00c5land Islands<\/option><\/select>\n                                        <label for='input_16_5_6' id='input_16_5_6_label' class='gform-field-label gform-field-label--type-sub'>Country<\/label>\n                                    <\/span>\n                    <div class='gf_clear gf_clear_complex'><\/div>\n                <\/div><\/li><li id=\"field_16_12\" 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' >License Type<\/label><div class='ginput_container ginput_container_checkbox'><ul class='gfield_checkbox' id='input_16_12'><li class='gchoice gchoice_16_12_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_12.1' type='checkbox'  value='LCSW'  id='choice_16_12_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_16_12_1' id='label_16_12_1' class='gform-field-label gform-field-label--type-inline'>LCSW<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_16_12_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_12.2' type='checkbox'  value='LMHC'  id='choice_16_12_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_16_12_2' id='label_16_12_2' class='gform-field-label gform-field-label--type-inline'>LMHC<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_16_12_3'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_12.3' type='checkbox'  value='PhD'  id='choice_16_12_3'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_16_12_3' id='label_16_12_3' class='gform-field-label gform-field-label--type-inline'>PhD<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_16_12_4'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_12.4' type='checkbox'  value='LMFT'  id='choice_16_12_4'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_16_12_4' id='label_16_12_4' class='gform-field-label gform-field-label--type-inline'>LMFT<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_16_12_5'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_12.5' type='checkbox'  value='LSW'  id='choice_16_12_5'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_16_12_5' id='label_16_12_5' class='gform-field-label gform-field-label--type-inline'>LSW<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_16_12_6'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_12.6' type='checkbox'  value='Other'  id='choice_16_12_6'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_16_12_6' id='label_16_12_6' 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_16_13\" 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_16_13'>Other:<\/label><div class='ginput_container ginput_container_text'><input name='input_13' id='input_16_13' type='text' value='' class='medium'      aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_16_28\" class=\"gfield gfield--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_16_28'>How did you hear about the Pro Bono Counseling Project?<\/label><div class='ginput_container ginput_container_text'><input name='input_28' id='input_16_28' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_16_24\" 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' >In the past year, has there been a complaint filed against you with the licensing board?<\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_16_24'>\n\t\t\t<li class='gchoice gchoice_16_24_0'>\n\t\t\t\t<input name='input_24' type='radio' value='Yes'  id='choice_16_24_0'    \/>\n\t\t\t\t<label for='choice_16_24_0' id='label_16_24_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_16_24_1'>\n\t\t\t\t<input name='input_24' type='radio' value='No'  id='choice_16_24_1'    \/>\n\t\t\t\t<label for='choice_16_24_1' id='label_16_24_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_16_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' >Years in clinical practice<\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_16_10'>\n\t\t\t<li class='gchoice gchoice_16_10_0'>\n\t\t\t\t<input name='input_10' type='radio' value='0-2 years'  id='choice_16_10_0'    \/>\n\t\t\t\t<label for='choice_16_10_0' id='label_16_10_0' class='gform-field-label gform-field-label--type-inline'>0-2 years<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_16_10_1'>\n\t\t\t\t<input name='input_10' type='radio' value='2-5 years'  id='choice_16_10_1'    \/>\n\t\t\t\t<label for='choice_16_10_1' id='label_16_10_1' class='gform-field-label gform-field-label--type-inline'>2-5 years<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_16_10_2'>\n\t\t\t\t<input name='input_10' type='radio' value='5-10 years'  id='choice_16_10_2'    \/>\n\t\t\t\t<label for='choice_16_10_2' id='label_16_10_2' class='gform-field-label gform-field-label--type-inline'>5-10 years<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_16_10_3'>\n\t\t\t\t<input name='input_10' type='radio' value='10+ years'  id='choice_16_10_3'    \/>\n\t\t\t\t<label for='choice_16_10_3' id='label_16_10_3' class='gform-field-label gform-field-label--type-inline'>10+ years<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_16_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' >Practice Location<\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_16_11'>\n\t\t\t<li class='gchoice gchoice_16_11_0'>\n\t\t\t\t<input name='input_11' type='radio' value='Private practice'  id='choice_16_11_0'    \/>\n\t\t\t\t<label for='choice_16_11_0' id='label_16_11_0' class='gform-field-label gform-field-label--type-inline'>Private practice<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_16_11_1'>\n\t\t\t\t<input name='input_11' type='radio' value='Group practice'  id='choice_16_11_1'    \/>\n\t\t\t\t<label for='choice_16_11_1' id='label_16_11_1' class='gform-field-label gform-field-label--type-inline'>Group practice<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_16_11_2'>\n\t\t\t\t<input name='input_11' type='radio' value='Community Organization'  id='choice_16_11_2'    \/>\n\t\t\t\t<label for='choice_16_11_2' id='label_16_11_2' class='gform-field-label gform-field-label--type-inline'>Community Organization<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_16_11_3'>\n\t\t\t\t<input name='input_11' type='radio' value='Church'  id='choice_16_11_3'    \/>\n\t\t\t\t<label for='choice_16_11_3' id='label_16_11_3' class='gform-field-label gform-field-label--type-inline'>Church<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_16_11_4'>\n\t\t\t\t<input name='input_11' type='radio' value='School'  id='choice_16_11_4'    \/>\n\t\t\t\t<label for='choice_16_11_4' id='label_16_11_4' class='gform-field-label gform-field-label--type-inline'>School<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_16_11_5'>\n\t\t\t\t<input name='input_11' type='radio' value='Hospital'  id='choice_16_11_5'    \/>\n\t\t\t\t<label for='choice_16_11_5' id='label_16_11_5' class='gform-field-label gform-field-label--type-inline'>Hospital<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_16_11_6'>\n\t\t\t\t<input name='input_11' type='radio' value='gf_other_choice'  id='choice_16_11_6'   onfocus=\"jQuery(this).next('input').focus();\" \/>\n\t\t\t\t<input class='small' id='input_16_11_other' name='input_11_other' type='text' value='Other' aria-label='Other' onfocus='jQuery(this).prev(\"input\")[0].click(); if(jQuery(this).val() == \"Other\") { jQuery(this).val(\"\"); }' onblur='if(jQuery(this).val().replace(\" \", \"\") == \"\") { jQuery(this).val(\"Other\"); }'   \/>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_16_14\" 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_16_14'>Name of practice\/organization<\/label><div class='ginput_container ginput_container_text'><input name='input_14' id='input_16_14' type='text' value='' class='medium'      aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_16_15\" class=\"gfield gfield--type-address 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' >Practice Address<\/label>    \n                    <div class='ginput_complex ginput_container has_street has_street2 has_city has_state has_zip has_country ginput_container_address gform-grid-row' id='input_16_15' >\n                         <span class='ginput_full address_line_1 ginput_address_line_1 gform-grid-col' id='input_16_15_1_container' >\n                                        <input type='text' name='input_15.1' id='input_16_15_1' value=''    aria-required='false'    \/>\n                                        <label for='input_16_15_1' id='input_16_15_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_16_15_2_container' >\n                                        <input type='text' name='input_15.2' id='input_16_15_2' value=''     aria-required='false'   \/>\n                                        <label for='input_16_15_2' id='input_16_15_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_16_15_3_container' >\n                                    <input type='text' name='input_15.3' id='input_16_15_3' value=''    aria-required='false'    \/>\n                                    <label for='input_16_15_3' id='input_16_15_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_16_15_4_container' >\n                                        <input type='text' name='input_15.4' id='input_16_15_4' value=''      aria-required='false'    \/>\n                                        <label for='input_16_15_4' id='input_16_15_4_label' class='gform-field-label gform-field-label--type-sub'>State \/ Province \/ Region<\/label>\n                                      <\/span><span class='ginput_left address_zip ginput_address_zip gform-grid-col' id='input_16_15_5_container' >\n                                    <input type='text' name='input_15.5' id='input_16_15_5' value=''    aria-required='false'    \/>\n                                    <label for='input_16_15_5' id='input_16_15_5_label' class='gform-field-label gform-field-label--type-sub'>ZIP \/ Postal Code<\/label>\n                                <\/span><span class='ginput_right address_country ginput_address_country gform-grid-col' id='input_16_15_6_container' >\n                                        <select name='input_15.6' id='input_16_15_6'   aria-required='false'    ><option value='' selected='selected'><\/option><option value='Afghanistan' >Afghanistan<\/option><option value='Albania' >Albania<\/option><option value='Algeria' >Algeria<\/option><option value='American Samoa' >American Samoa<\/option><option value='Andorra' >Andorra<\/option><option value='Angola' >Angola<\/option><option value='Anguilla' >Anguilla<\/option><option value='Antarctica' >Antarctica<\/option><option value='Antigua and Barbuda' >Antigua and Barbuda<\/option><option value='Argentina' >Argentina<\/option><option value='Armenia' >Armenia<\/option><option value='Aruba' >Aruba<\/option><option value='Australia' >Australia<\/option><option value='Austria' >Austria<\/option><option value='Azerbaijan' >Azerbaijan<\/option><option value='Bahamas' >Bahamas<\/option><option value='Bahrain' >Bahrain<\/option><option value='Bangladesh' >Bangladesh<\/option><option value='Barbados' >Barbados<\/option><option value='Belarus' >Belarus<\/option><option value='Belgium' >Belgium<\/option><option value='Belize' >Belize<\/option><option value='Benin' >Benin<\/option><option value='Bermuda' >Bermuda<\/option><option value='Bhutan' >Bhutan<\/option><option value='Bolivia' >Bolivia<\/option><option value='Bonaire, Sint Eustatius and Saba' >Bonaire, Sint Eustatius and Saba<\/option><option value='Bosnia and Herzegovina' >Bosnia and Herzegovina<\/option><option value='Botswana' >Botswana<\/option><option value='Bouvet Island' >Bouvet Island<\/option><option value='Brazil' >Brazil<\/option><option value='British Indian Ocean Territory' >British Indian Ocean Territory<\/option><option value='Brunei Darussalam' >Brunei Darussalam<\/option><option value='Bulgaria' >Bulgaria<\/option><option value='Burkina Faso' >Burkina Faso<\/option><option value='Burundi' >Burundi<\/option><option value='Cabo Verde' >Cabo Verde<\/option><option value='Cambodia' >Cambodia<\/option><option value='Cameroon' >Cameroon<\/option><option value='Canada' >Canada<\/option><option value='Cayman Islands' >Cayman Islands<\/option><option value='Central African Republic' >Central African Republic<\/option><option value='Chad' >Chad<\/option><option value='Chile' >Chile<\/option><option value='China' >China<\/option><option value='Christmas Island' >Christmas Island<\/option><option value='Cocos Islands' >Cocos Islands<\/option><option value='Colombia' >Colombia<\/option><option value='Comoros' >Comoros<\/option><option value='Congo' >Congo<\/option><option value='Congo, Democratic Republic of the' >Congo, Democratic Republic of the<\/option><option value='Cook Islands' >Cook Islands<\/option><option value='Costa Rica' >Costa Rica<\/option><option value='Croatia' >Croatia<\/option><option value='Cuba' >Cuba<\/option><option value='Cura\u00e7ao' >Cura\u00e7ao<\/option><option value='Cyprus' >Cyprus<\/option><option value='Czechia' >Czechia<\/option><option value='C\u00f4te d&#039;Ivoire' >C\u00f4te d&#039;Ivoire<\/option><option value='Denmark' >Denmark<\/option><option value='Djibouti' >Djibouti<\/option><option value='Dominica' >Dominica<\/option><option value='Dominican Republic' >Dominican Republic<\/option><option value='Ecuador' >Ecuador<\/option><option value='Egypt' >Egypt<\/option><option value='El Salvador' >El Salvador<\/option><option value='Equatorial Guinea' >Equatorial Guinea<\/option><option value='Eritrea' >Eritrea<\/option><option value='Estonia' >Estonia<\/option><option value='Eswatini' >Eswatini<\/option><option value='Ethiopia' >Ethiopia<\/option><option value='Falkland Islands' >Falkland Islands<\/option><option value='Faroe Islands' >Faroe Islands<\/option><option value='Fiji' >Fiji<\/option><option value='Finland' >Finland<\/option><option value='France' >France<\/option><option value='French Guiana' >French Guiana<\/option><option value='French Polynesia' >French Polynesia<\/option><option value='French Southern Territories' >French Southern Territories<\/option><option value='Gabon' >Gabon<\/option><option value='Gambia' >Gambia<\/option><option value='Georgia' >Georgia<\/option><option value='Germany' >Germany<\/option><option value='Ghana' >Ghana<\/option><option value='Gibraltar' >Gibraltar<\/option><option value='Greece' >Greece<\/option><option value='Greenland' >Greenland<\/option><option value='Grenada' >Grenada<\/option><option value='Guadeloupe' >Guadeloupe<\/option><option value='Guam' >Guam<\/option><option value='Guatemala' >Guatemala<\/option><option value='Guernsey' >Guernsey<\/option><option value='Guinea' >Guinea<\/option><option value='Guinea-Bissau' >Guinea-Bissau<\/option><option value='Guyana' >Guyana<\/option><option value='Haiti' >Haiti<\/option><option value='Heard Island and McDonald Islands' >Heard Island and McDonald Islands<\/option><option value='Holy See' >Holy See<\/option><option value='Honduras' >Honduras<\/option><option value='Hong Kong' >Hong Kong<\/option><option value='Hungary' >Hungary<\/option><option value='Iceland' >Iceland<\/option><option value='India' >India<\/option><option value='Indonesia' >Indonesia<\/option><option value='Iran' >Iran<\/option><option value='Iraq' >Iraq<\/option><option value='Ireland' >Ireland<\/option><option value='Isle of Man' >Isle of Man<\/option><option value='Israel' >Israel<\/option><option value='Italy' >Italy<\/option><option value='Jamaica' >Jamaica<\/option><option value='Japan' >Japan<\/option><option value='Jersey' >Jersey<\/option><option value='Jordan' >Jordan<\/option><option value='Kazakhstan' >Kazakhstan<\/option><option value='Kenya' >Kenya<\/option><option value='Kiribati' >Kiribati<\/option><option value='Korea, Democratic People&#039;s Republic of' >Korea, Democratic People&#039;s Republic of<\/option><option value='Korea, Republic of' >Korea, Republic of<\/option><option value='Kuwait' >Kuwait<\/option><option value='Kyrgyzstan' >Kyrgyzstan<\/option><option value='Lao People&#039;s Democratic Republic' >Lao People&#039;s Democratic Republic<\/option><option value='Latvia' >Latvia<\/option><option value='Lebanon' >Lebanon<\/option><option value='Lesotho' >Lesotho<\/option><option value='Liberia' >Liberia<\/option><option value='Libya' >Libya<\/option><option value='Liechtenstein' >Liechtenstein<\/option><option value='Lithuania' >Lithuania<\/option><option value='Luxembourg' >Luxembourg<\/option><option value='Macao' >Macao<\/option><option value='Madagascar' >Madagascar<\/option><option value='Malawi' >Malawi<\/option><option value='Malaysia' >Malaysia<\/option><option value='Maldives' >Maldives<\/option><option value='Mali' >Mali<\/option><option value='Malta' >Malta<\/option><option value='Marshall Islands' >Marshall Islands<\/option><option value='Martinique' >Martinique<\/option><option value='Mauritania' >Mauritania<\/option><option value='Mauritius' >Mauritius<\/option><option value='Mayotte' >Mayotte<\/option><option value='Mexico' >Mexico<\/option><option value='Micronesia' >Micronesia<\/option><option value='Moldova' >Moldova<\/option><option value='Monaco' >Monaco<\/option><option value='Mongolia' >Mongolia<\/option><option value='Montenegro' >Montenegro<\/option><option value='Montserrat' >Montserrat<\/option><option value='Morocco' >Morocco<\/option><option value='Mozambique' >Mozambique<\/option><option value='Myanmar' >Myanmar<\/option><option value='Namibia' >Namibia<\/option><option value='Nauru' >Nauru<\/option><option value='Nepal' >Nepal<\/option><option value='Netherlands' >Netherlands<\/option><option value='New Caledonia' >New Caledonia<\/option><option value='New Zealand' >New Zealand<\/option><option value='Nicaragua' >Nicaragua<\/option><option value='Niger' >Niger<\/option><option value='Nigeria' >Nigeria<\/option><option value='Niue' >Niue<\/option><option value='Norfolk Island' >Norfolk Island<\/option><option value='North Macedonia' >North Macedonia<\/option><option value='Northern Mariana Islands' >Northern Mariana Islands<\/option><option value='Norway' >Norway<\/option><option value='Oman' >Oman<\/option><option value='Pakistan' >Pakistan<\/option><option value='Palau' >Palau<\/option><option value='Palestine, State of' >Palestine, State of<\/option><option value='Panama' >Panama<\/option><option value='Papua New Guinea' >Papua New Guinea<\/option><option value='Paraguay' >Paraguay<\/option><option value='Peru' >Peru<\/option><option value='Philippines' >Philippines<\/option><option value='Pitcairn' >Pitcairn<\/option><option value='Poland' >Poland<\/option><option value='Portugal' >Portugal<\/option><option value='Puerto Rico' >Puerto Rico<\/option><option value='Qatar' >Qatar<\/option><option value='Romania' >Romania<\/option><option value='Russian Federation' >Russian Federation<\/option><option value='Rwanda' >Rwanda<\/option><option value='R\u00e9union' >R\u00e9union<\/option><option value='Saint Barth\u00e9lemy' >Saint Barth\u00e9lemy<\/option><option value='Saint Helena, Ascension and Tristan da Cunha' >Saint Helena, Ascension and Tristan da Cunha<\/option><option value='Saint Kitts and Nevis' >Saint Kitts and Nevis<\/option><option value='Saint Lucia' >Saint Lucia<\/option><option value='Saint Martin' >Saint Martin<\/option><option value='Saint Pierre and Miquelon' >Saint Pierre and Miquelon<\/option><option value='Saint Vincent and the Grenadines' >Saint Vincent and the Grenadines<\/option><option value='Samoa' >Samoa<\/option><option value='San Marino' >San Marino<\/option><option value='Sao Tome and Principe' >Sao Tome and Principe<\/option><option value='Saudi Arabia' >Saudi Arabia<\/option><option value='Senegal' >Senegal<\/option><option value='Serbia' >Serbia<\/option><option value='Seychelles' >Seychelles<\/option><option value='Sierra Leone' >Sierra Leone<\/option><option value='Singapore' >Singapore<\/option><option value='Sint Maarten' >Sint Maarten<\/option><option value='Slovakia' >Slovakia<\/option><option value='Slovenia' >Slovenia<\/option><option value='Solomon Islands' >Solomon Islands<\/option><option value='Somalia' >Somalia<\/option><option value='South Africa' >South Africa<\/option><option value='South Georgia and the South Sandwich Islands' >South Georgia and the South Sandwich Islands<\/option><option value='South Sudan' >South Sudan<\/option><option value='Spain' >Spain<\/option><option value='Sri Lanka' >Sri Lanka<\/option><option value='Sudan' >Sudan<\/option><option value='Suriname' >Suriname<\/option><option value='Svalbard and Jan Mayen' >Svalbard and Jan Mayen<\/option><option value='Sweden' >Sweden<\/option><option value='Switzerland' >Switzerland<\/option><option value='Syria Arab Republic' >Syria Arab Republic<\/option><option value='Taiwan' >Taiwan<\/option><option value='Tajikistan' >Tajikistan<\/option><option value='Tanzania, the United Republic of' >Tanzania, the United Republic of<\/option><option value='Thailand' >Thailand<\/option><option value='Timor-Leste' >Timor-Leste<\/option><option value='Togo' >Togo<\/option><option value='Tokelau' >Tokelau<\/option><option value='Tonga' >Tonga<\/option><option value='Trinidad and Tobago' >Trinidad and Tobago<\/option><option value='Tunisia' >Tunisia<\/option><option value='Turkmenistan' >Turkmenistan<\/option><option value='Turks and Caicos Islands' >Turks and Caicos Islands<\/option><option value='Tuvalu' >Tuvalu<\/option><option value='T\u00fcrkiye' >T\u00fcrkiye<\/option><option value='US Minor Outlying Islands' >US Minor Outlying Islands<\/option><option value='Uganda' >Uganda<\/option><option value='Ukraine' >Ukraine<\/option><option value='United Arab Emirates' >United Arab Emirates<\/option><option value='United Kingdom' >United Kingdom<\/option><option value='United States' >United States<\/option><option value='Uruguay' >Uruguay<\/option><option value='Uzbekistan' >Uzbekistan<\/option><option value='Vanuatu' >Vanuatu<\/option><option value='Venezuela' >Venezuela<\/option><option value='Viet Nam' >Viet Nam<\/option><option value='Virgin Islands, British' >Virgin Islands, British<\/option><option value='Virgin Islands, U.S.' >Virgin Islands, U.S.<\/option><option value='Wallis and Futuna' >Wallis and Futuna<\/option><option value='Western Sahara' >Western Sahara<\/option><option value='Yemen' >Yemen<\/option><option value='Zambia' >Zambia<\/option><option value='Zimbabwe' >Zimbabwe<\/option><option value='\u00c5land Islands' >\u00c5land Islands<\/option><\/select>\n                                        <label for='input_16_15_6' id='input_16_15_6_label' class='gform-field-label gform-field-label--type-sub'>Country<\/label>\n                                    <\/span>\n                    <div class='gf_clear gf_clear_complex'><\/div>\n                <\/div><\/li><li id=\"field_16_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' >Are you able to see clients in person or virtually?<\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_16_16'>\n\t\t\t<li class='gchoice gchoice_16_16_0'>\n\t\t\t\t<input name='input_16' type='radio' value='In person'  id='choice_16_16_0'    \/>\n\t\t\t\t<label for='choice_16_16_0' id='label_16_16_0' class='gform-field-label gform-field-label--type-inline'>In person<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_16_16_1'>\n\t\t\t\t<input name='input_16' type='radio' value='Virtually'  id='choice_16_16_1'    \/>\n\t\t\t\t<label for='choice_16_16_1' id='label_16_16_1' class='gform-field-label gform-field-label--type-inline'>Virtually<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_16_16_2'>\n\t\t\t\t<input name='input_16' type='radio' value='Either'  id='choice_16_16_2'    \/>\n\t\t\t\t<label for='choice_16_16_2' id='label_16_16_2' class='gform-field-label gform-field-label--type-inline'>Either<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_16_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' >Do you carry your own malpractice insurance?<\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_16_17'>\n\t\t\t<li class='gchoice gchoice_16_17_0'>\n\t\t\t\t<input name='input_17' type='radio' value='Yes'  id='choice_16_17_0'    \/>\n\t\t\t\t<label for='choice_16_17_0' id='label_16_17_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_16_17_1'>\n\t\t\t\t<input name='input_17' type='radio' value='No'  id='choice_16_17_1'    \/>\n\t\t\t\t<label for='choice_16_17_1' id='label_16_17_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_16_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' >Do you speak another language, other than English?<\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_16_18'>\n\t\t\t<li class='gchoice gchoice_16_18_0'>\n\t\t\t\t<input name='input_18' type='radio' value='Yes'  id='choice_16_18_0'    \/>\n\t\t\t\t<label for='choice_16_18_0' id='label_16_18_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_16_18_1'>\n\t\t\t\t<input name='input_18' type='radio' value='No'  id='choice_16_18_1'    \/>\n\t\t\t\t<label for='choice_16_18_1' id='label_16_18_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_16_18_2'>\n\t\t\t\t<input name='input_18' type='radio' value='gf_other_choice'  id='choice_16_18_2'   onfocus=\"jQuery(this).next('input').focus();\" \/>\n\t\t\t\t<input class='small' id='input_16_18_other' name='input_18_other' type='text' value='Other' aria-label='Other' onfocus='jQuery(this).prev(\"input\")[0].click(); if(jQuery(this).val() == \"Other\") { jQuery(this).val(\"\"); }' onblur='if(jQuery(this).val().replace(\" \", \"\") == \"\") { jQuery(this).val(\"Other\"); }'   \/>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_16_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' >Have you had cultural competence training in the past 3 years?<\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_16_19'>\n\t\t\t<li class='gchoice gchoice_16_19_0'>\n\t\t\t\t<input name='input_19' type='radio' value='Yes'  id='choice_16_19_0'    \/>\n\t\t\t\t<label for='choice_16_19_0' id='label_16_19_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_16_19_1'>\n\t\t\t\t<input name='input_19' type='radio' value='No'  id='choice_16_19_1'    \/>\n\t\t\t\t<label for='choice_16_19_1' id='label_16_19_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_16_25\" 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' >Have you had training on HIPAA compliance with Telehealth?<\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_16_25'>\n\t\t\t<li class='gchoice gchoice_16_25_0'>\n\t\t\t\t<input name='input_25' type='radio' value='Yes'  id='choice_16_25_0'    \/>\n\t\t\t\t<label for='choice_16_25_0' id='label_16_25_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_16_25_1'>\n\t\t\t\t<input name='input_25' type='radio' value='No'  id='choice_16_25_1'    \/>\n\t\t\t\t<label for='choice_16_25_1' id='label_16_25_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_16_20\" 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' >Please check all modalities that apply to your practice<\/label><div class='ginput_container ginput_container_checkbox'><ul class='gfield_checkbox' id='input_16_20'><li class='gchoice gchoice_16_20_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_20.1' type='checkbox'  value='Individual'  id='choice_16_20_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_16_20_1' id='label_16_20_1' class='gform-field-label gform-field-label--type-inline'>Individual<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_16_20_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_20.2' type='checkbox'  value='Family'  id='choice_16_20_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_16_20_2' id='label_16_20_2' class='gform-field-label gform-field-label--type-inline'>Family<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_16_20_3'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_20.3' type='checkbox'  value='Couples'  id='choice_16_20_3'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_16_20_3' id='label_16_20_3' class='gform-field-label gform-field-label--type-inline'>Couples<\/label>\n\t\t\t\t\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_16_21\" 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_16_21'>Please note practice specialties<\/label><div class='ginput_container ginput_container_text'><input name='input_21' id='input_16_21' type='text' value='' class='medium'      aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_16_22\" 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' >Do you currently offer sliding scale or pro bono services?<\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_16_22'>\n\t\t\t<li class='gchoice gchoice_16_22_0'>\n\t\t\t\t<input name='input_22' type='radio' value='Sliding scale'  id='choice_16_22_0'    \/>\n\t\t\t\t<label for='choice_16_22_0' id='label_16_22_0' class='gform-field-label gform-field-label--type-inline'>Sliding scale<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_16_22_1'>\n\t\t\t\t<input name='input_22' type='radio' value='Pro bono'  id='choice_16_22_1'    \/>\n\t\t\t\t<label for='choice_16_22_1' id='label_16_22_1' class='gform-field-label gform-field-label--type-inline'>Pro bono<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_16_22_2'>\n\t\t\t\t<input name='input_22' type='radio' value='Neither at this time'  id='choice_16_22_2'    \/>\n\t\t\t\t<label for='choice_16_22_2' id='label_16_22_2' class='gform-field-label gform-field-label--type-inline'>Neither at this time<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_16_22_3'>\n\t\t\t\t<input name='input_22' type='radio' value='Both'  id='choice_16_22_3'    \/>\n\t\t\t\t<label for='choice_16_22_3' id='label_16_22_3' class='gform-field-label gform-field-label--type-inline'>Both<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_16_26\" 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' >Were you referred by a current therapist volunteer?<\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_16_26'>\n\t\t\t<li class='gchoice gchoice_16_26_0'>\n\t\t\t\t<input name='input_26' type='radio' value='Yes'  id='choice_16_26_0'    \/>\n\t\t\t\t<label for='choice_16_26_0' id='label_16_26_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_16_26_1'>\n\t\t\t\t<input name='input_26' type='radio' value='No'  id='choice_16_26_1'    \/>\n\t\t\t\t<label for='choice_16_26_1' id='label_16_26_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_16_27\" 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_16_27'>If yes, who?<\/label><div class='ginput_container ginput_container_text'><input name='input_27' id='input_16_27' type='text' value='' class='medium'      aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_16_29\" class=\"gfield gfield--type-section gsection field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><h2 class=\"gsection_title\">Supervision<\/h2><\/li><li id=\"field_16_30\" 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' >Are you interested in providing clinical supervision to other PBCP volunteer therapists?<\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_16_30'>\n\t\t\t<li class='gchoice gchoice_16_30_0'>\n\t\t\t\t<input name='input_30' type='radio' value='Yes'  id='choice_16_30_0'    \/>\n\t\t\t\t<label for='choice_16_30_0' id='label_16_30_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_16_30_1'>\n\t\t\t\t<input name='input_30' type='radio' value='No'  id='choice_16_30_1'    \/>\n\t\t\t\t<label for='choice_16_30_1' id='label_16_30_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_16_30_2'>\n\t\t\t\t<input name='input_30' type='radio' value='Maybe, but need more information'  id='choice_16_30_2'    \/>\n\t\t\t\t<label for='choice_16_30_2' id='label_16_30_2' class='gform-field-label gform-field-label--type-inline'>Maybe, but need more information<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_16_31\" 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' >Have you received training or do you have experience providing clinical supervision?<\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_16_31'>\n\t\t\t<li class='gchoice gchoice_16_31_0'>\n\t\t\t\t<input name='input_31' type='radio' value='Yes'  id='choice_16_31_0'    \/>\n\t\t\t\t<label for='choice_16_31_0' id='label_16_31_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_16_31_1'>\n\t\t\t\t<input name='input_31' type='radio' value='No'  id='choice_16_31_1'    \/>\n\t\t\t\t<label for='choice_16_31_1' id='label_16_31_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_16_32\" class=\"gfield gfield--type-textarea 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_16_32'>Please explain:<\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_32' id='input_16_32' class='textarea large'      aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/li><li id=\"field_16_33\" 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' >Are you interested in being trained to provide clinical supervision?<\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_16_33'>\n\t\t\t<li class='gchoice gchoice_16_33_0'>\n\t\t\t\t<input name='input_33' type='radio' value='Yes'  id='choice_16_33_0'    \/>\n\t\t\t\t<label for='choice_16_33_0' id='label_16_33_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_16_33_1'>\n\t\t\t\t<input name='input_33' type='radio' value='No'  id='choice_16_33_1'    \/>\n\t\t\t\t<label for='choice_16_33_1' id='label_16_33_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_16_33_2'>\n\t\t\t\t<input name='input_33' type='radio' value='Not sure'  id='choice_16_33_2'    \/>\n\t\t\t\t<label for='choice_16_33_2' id='label_16_33_2' class='gform-field-label gform-field-label--type-inline'>Not sure<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_16_34\" 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' >Are you interested in receiving clinical supervision, either one on one or as part of a group?<\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_16_34'>\n\t\t\t<li class='gchoice gchoice_16_34_0'>\n\t\t\t\t<input name='input_34' type='radio' value='Yes'  id='choice_16_34_0'    \/>\n\t\t\t\t<label for='choice_16_34_0' id='label_16_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_16_34_1'>\n\t\t\t\t<input name='input_34' type='radio' value='No'  id='choice_16_34_1'    \/>\n\t\t\t\t<label for='choice_16_34_1' id='label_16_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_16_34_2'>\n\t\t\t\t<input name='input_34' type='radio' value='Maybe'  id='choice_16_34_2'    \/>\n\t\t\t\t<label for='choice_16_34_2' id='label_16_34_2' class='gform-field-label gform-field-label--type-inline'>Maybe<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_16_23\" 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_16_23'>Please tell us why you would like to participate in this project. Thank you!<\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_23' id='input_16_23' class='textarea medium'      aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/li><\/ul><\/div>\n        <div class='gform-footer gform_footer top_label'>  <input type='hidden' name='gform_ajax' value='form_id=16&amp;title=&amp;description=1&amp;tabindex=0&amp;theme=legacy&amp;styles=[]&amp;hash=75b85c1af7c6a436506a26a7f01ed153' \/>\n            <input type='hidden' class='gform_hidden' name='gform_submission_method' data-js='gform_submission_method_16' value='iframe' \/>\n            <input type='hidden' class='gform_hidden' name='gform_theme' data-js='gform_theme_16' id='gform_theme_16' value='legacy' \/>\n            <input type='hidden' class='gform_hidden' name='gform_style_settings' data-js='gform_style_settings_16' id='gform_style_settings_16' value='[]' \/>\n            <input type='hidden' class='gform_hidden' name='is_submit_16' value='1' \/>\n            <input type='hidden' class='gform_hidden' name='gform_submit' value='16' \/>\n            \n            <input type='hidden' class='gform_hidden' name='gform_currency' data-currency='USD' value='ExSYDYOT3SWeWwoT4yoi+Hlaoe3xOhix1ryuKkRKDlbuUDw6tdaJf\/s\/cP75xU4WGEP+gpR81I6qNPfoS\/wZ6Wfwb5uBsjLvD5\/9GjBGLNuFnPA=' \/>\n            <input type='hidden' class='gform_hidden' name='gform_unique_id' value='' \/>\n            <input type='hidden' class='gform_hidden' name='state_16' value='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' \/>\n            <input type='hidden' autocomplete='off' class='gform_hidden' name='gform_target_page_number_16' id='gform_target_page_number_16' value='0' \/>\n            <input type='hidden' autocomplete='off' class='gform_hidden' name='gform_source_page_number_16' id='gform_source_page_number_16' value='1' \/>\n            <input type='hidden' name='gform_field_values' value='' \/>\n            \n        <\/div>\n                        <input type=\"hidden\" name=\"trp-form-language\" value=\"es\"\/><\/form>\n                        <\/div>\n\t\t                <iframe style='display:none;width:0px;height:0px;' src='about:blank' name='gform_ajax_frame_16' id='gform_ajax_frame_16' title='This iframe contains the logic required to handle Ajax powered Gravity Forms.'><\/iframe>\n\t\t                <script type=\"text\/javascript\">\n\/* <![CDATA[ *\/\n gform.initializeOnLoaded( function() {gformInitSpinner( 16, 'https:\/\/forms.mhamichiana.org\/wp-content\/plugins\/gravityforms\/images\/spinner.svg', true );jQuery('#gform_ajax_frame_16').on('load',function(){var contents = jQuery(this).contents().find('*').html();var is_postback = contents.indexOf('GF_AJAX_POSTBACK') >= 0;if(!is_postback){return;}var form_content = jQuery(this).contents().find('#gform_wrapper_16');var is_confirmation = jQuery(this).contents().find('#gform_confirmation_wrapper_16').length > 0;var is_redirect = contents.indexOf('gformRedirect(){') >= 0;var is_form = form_content.length > 0 && ! is_redirect && ! is_confirmation;var mt = parseInt(jQuery('html').css('margin-top'), 10) + parseInt(jQuery('body').css('margin-top'), 10) + 100;if(is_form){form_content.find('form').css('opacity', 0);jQuery('#gform_wrapper_16').html(form_content.html());if(form_content.hasClass('gform_validation_error')){jQuery('#gform_wrapper_16').addClass('gform_validation_error');} else {jQuery('#gform_wrapper_16').removeClass('gform_validation_error');}setTimeout( function() { \/* delay the scroll by 50 milliseconds to fix a bug in chrome *\/ jQuery(document).scrollTop(jQuery('#gform_wrapper_16').offset().top - mt); }, 50 );if(window['gformInitDatepicker']) {gformInitDatepicker();}if(window['gformInitPriceFields']) {gformInitPriceFields();}var current_page = jQuery('#gform_source_page_number_16').val();gformInitSpinner( 16, 'https:\/\/forms.mhamichiana.org\/wp-content\/plugins\/gravityforms\/images\/spinner.svg', true );jQuery(document).trigger('gform_page_loaded', [16, current_page]);window['gf_submitting_16'] = false;}else if(!is_redirect){var confirmation_content = jQuery(this).contents().find('.GF_AJAX_POSTBACK').html();if(!confirmation_content){confirmation_content = contents;}jQuery('#gform_wrapper_16').replaceWith(confirmation_content);jQuery(document).scrollTop(jQuery('#gf_16').offset().top - mt);jQuery(document).trigger('gform_confirmation_loaded', [16]);window['gf_submitting_16'] = false;wp.a11y.speak(jQuery('#gform_confirmation_message_16').text());}else{jQuery('#gform_16').append(contents);if(window['gformRedirect']) {gformRedirect();}}jQuery(document).trigger(\"gform_pre_post_render\", [{ formId: \"16\", currentPage: \"current_page\", abort: function() { this.preventDefault(); } }]);        if (event && event.defaultPrevented) {                return;        }        const gformWrapperDiv = document.getElementById( \"gform_wrapper_16\" );        if ( gformWrapperDiv ) {            const visibilitySpan = document.createElement( \"span\" );            visibilitySpan.id = \"gform_visibility_test_16\";            gformWrapperDiv.insertAdjacentElement( \"afterend\", visibilitySpan );        }        const visibilityTestDiv = document.getElementById( \"gform_visibility_test_16\" );        let postRenderFired = false;        function triggerPostRender() {            if ( postRenderFired ) {                return;            }            postRenderFired = true;            gform.core.triggerPostRenderEvents( 16, current_page );            if ( visibilityTestDiv ) {                visibilityTestDiv.parentNode.removeChild( visibilityTestDiv );            }        }        function debounce( func, wait, immediate ) {            var timeout;            return function() {                var context = this, args = arguments;                var later = function() {                    timeout = null;                    if ( !immediate ) func.apply( context, args );                };                var callNow = immediate && !timeout;                clearTimeout( timeout );                timeout = setTimeout( later, wait );                if ( callNow ) func.apply( context, args );            };        }        const debouncedTriggerPostRender = debounce( function() {            triggerPostRender();        }, 200 );        if ( visibilityTestDiv && visibilityTestDiv.offsetParent === null ) {            const observer = new MutationObserver( ( mutations ) => {                mutations.forEach( ( mutation ) => {                    if ( mutation.type === 'attributes' && visibilityTestDiv.offsetParent !== null ) {                        debouncedTriggerPostRender();                        observer.disconnect();                    }                });            });            observer.observe( document.body, {                attributes: true,                childList: false,                subtree: true,                attributeFilter: [ 'style', 'class' ],            });        } else {            triggerPostRender();        }    } );} ); \n\/* ]]> *\/\n<\/script>\n<\/div>\n\t\t\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t<div class=\"elementor-element elementor-element-665c110 pp-gravity-form-button-custom pp-gravity-form-pagination-buttons-auto elementor-widget elementor-widget-pp-gravity-forms\" data-id=\"665c110\" 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\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_16' style='display:none'><form method='post' enctype='multipart\/form-data'  id='gform_16'  action='\/es\/counselor-volunteer-form\/' data-formid='16' novalidate data-trp-original-action=\"\/es\/counselor-volunteer-form\/\">\n                        <div class='gform-body gform_body'><ul id='gform_fields_16' class='gform_fields top_label form_sublabel_below description_below validation_below'><li id=\"field_16_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_16_1'>First Name<\/label><div class='ginput_container ginput_container_text'><input name='input_1' id='input_16_1' type='text' value='' class='medium'      aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_16_2\" 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_16_2'>Last Name<\/label><div class='ginput_container ginput_container_text'><input name='input_2' id='input_16_2' type='text' value='' class='medium'      aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_16_3\" 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_16_3'>Email<\/label><div class='ginput_container ginput_container_email'>\n                            <input name='input_3' id='input_16_3' type='email' value='' class='medium'     aria-invalid=\"false\"  \/>\n                        <\/div><\/li><li id=\"field_16_4\" class=\"gfield gfield--type-phone field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_16_4'>Phone<\/label><div class='ginput_container ginput_container_phone'><input name='input_4' id='input_16_4' type='tel' value='' class='medium'    aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_16_5\" class=\"gfield gfield--type-address 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' >Mailing Address<\/label>    \n                    <div class='ginput_complex ginput_container has_street has_street2 has_city has_state has_zip has_country ginput_container_address gform-grid-row' id='input_16_5' >\n                         <span class='ginput_full address_line_1 ginput_address_line_1 gform-grid-col' id='input_16_5_1_container' >\n                                        <input type='text' name='input_5.1' id='input_16_5_1' value=''    aria-required='false'    \/>\n                                        <label for='input_16_5_1' id='input_16_5_1_label' class='gform-field-label gform-field-label--type-sub' data-no-translation=\"\" data-trp-gettext=\"\">Street Address<\/label>\n                                    <\/span><span class='ginput_full address_line_2 ginput_address_line_2 gform-grid-col' id='input_16_5_2_container' >\n                                        <input type='text' name='input_5.2' id='input_16_5_2' value=''     aria-required='false'   \/>\n                                        <label for='input_16_5_2' id='input_16_5_2_label' class='gform-field-label gform-field-label--type-sub' data-no-translation=\"\" data-trp-gettext=\"\">Address Line 2<\/label>\n                                    <\/span><span class='ginput_left address_city ginput_address_city gform-grid-col' id='input_16_5_3_container' >\n                                    <input type='text' name='input_5.3' id='input_16_5_3' value=''    aria-required='false'    \/>\n                                    <label for='input_16_5_3' id='input_16_5_3_label' class='gform-field-label gform-field-label--type-sub' data-no-translation=\"\" data-trp-gettext=\"\">City<\/label>\n                                 <\/span><span class='ginput_right address_state ginput_address_state gform-grid-col' id='input_16_5_4_container' >\n                                        <input type='text' name='input_5.4' id='input_16_5_4' value=''      aria-required='false'    \/>\n                                        <label for='input_16_5_4' id='input_16_5_4_label' class='gform-field-label gform-field-label--type-sub' data-no-translation=\"\" data-trp-gettext=\"\">State \/ Province \/ Region<\/label>\n                                      <\/span><span class='ginput_left address_zip ginput_address_zip gform-grid-col' id='input_16_5_5_container' >\n                                    <input type='text' name='input_5.5' id='input_16_5_5' value=''    aria-required='false'    \/>\n                                    <label for='input_16_5_5' id='input_16_5_5_label' class='gform-field-label gform-field-label--type-sub' data-no-translation=\"\" data-trp-gettext=\"\">ZIP \/ Postal Code<\/label>\n                                <\/span><span class='ginput_right address_country ginput_address_country gform-grid-col' id='input_16_5_6_container' >\n                                        <select name='input_5.6' id='input_16_5_6'   aria-required='false'    ><option value='' selected='selected'><\/option><option value='United States' data-no-translation=\"\" data-trp-gettext=\"\" data-no-translation-value=\"\" >United States<\/option><option value='American Samoa' data-no-translation=\"\" data-trp-gettext=\"\" data-no-translation-value=\"\" >American Samoa<\/option><option value='Guam' data-no-translation=\"\" data-trp-gettext=\"\" data-no-translation-value=\"\" >Guam<\/option><option value='Northern Mariana Islands' data-no-translation=\"\" data-trp-gettext=\"\" data-no-translation-value=\"\" >Northern Mariana Islands<\/option><option value='Puerto Rico' data-no-translation=\"\" data-trp-gettext=\"\" data-no-translation-value=\"\" >Puerto Rico<\/option><option value='Afghanistan' data-no-translation=\"\" data-trp-gettext=\"\" data-no-translation-value=\"\" >Afghanistan<\/option><option value='\u00c5land Islands' data-no-translation=\"\" data-trp-gettext=\"\" data-no-translation-value=\"\" >\u00c5land Islands<\/option><option value='Albania' data-no-translation=\"\" data-trp-gettext=\"\" data-no-translation-value=\"\" >Albania<\/option><option value='Algeria' data-no-translation=\"\" data-trp-gettext=\"\" data-no-translation-value=\"\" >Algeria<\/option><option value='Andorra' data-no-translation=\"\" data-trp-gettext=\"\" data-no-translation-value=\"\" >Andorra<\/option><option value='Angola' data-no-translation=\"\" data-trp-gettext=\"\" data-no-translation-value=\"\" >Angola<\/option><option value='Anguilla' data-no-translation=\"\" data-trp-gettext=\"\" data-no-translation-value=\"\" >Anguilla<\/option><option value='Antarctica' data-no-translation=\"\" data-trp-gettext=\"\" data-no-translation-value=\"\" >Antarctica<\/option><option value='Antigua and Barbuda' data-no-translation=\"\" data-trp-gettext=\"\" data-no-translation-value=\"\" >Antigua and Barbuda<\/option><option value='Argentina' data-no-translation=\"\" data-trp-gettext=\"\" data-no-translation-value=\"\" >Argentina<\/option><option value='Armenia' data-no-translation=\"\" data-trp-gettext=\"\" data-no-translation-value=\"\" >Armenia<\/option><option value='Aruba' data-no-translation=\"\" data-trp-gettext=\"\" data-no-translation-value=\"\" >Aruba<\/option><option value='Australia' data-no-translation=\"\" data-trp-gettext=\"\" data-no-translation-value=\"\" >Australia<\/option><option value='Austria' data-no-translation=\"\" data-trp-gettext=\"\" data-no-translation-value=\"\" >Austria<\/option><option value='Azerbaijan' data-no-translation=\"\" data-trp-gettext=\"\" data-no-translation-value=\"\" >Azerbaijan<\/option><option value='Bahamas' data-no-translation=\"\" data-trp-gettext=\"\" data-no-translation-value=\"\" >Bahamas<\/option><option value='Bahrain' data-no-translation=\"\" data-trp-gettext=\"\" data-no-translation-value=\"\" >Bahrain<\/option><option value='Bangladesh' data-no-translation=\"\" data-trp-gettext=\"\" data-no-translation-value=\"\" >Bangladesh<\/option><option value='Barbados' data-no-translation=\"\" data-trp-gettext=\"\" data-no-translation-value=\"\" >Barbados<\/option><option value='Belarus' data-no-translation=\"\" data-trp-gettext=\"\" data-no-translation-value=\"\" >Belarus<\/option><option value='Belgium' data-no-translation=\"\" data-trp-gettext=\"\" data-no-translation-value=\"\" >Belgium<\/option><option value='Belize' data-no-translation=\"\" data-trp-gettext=\"\" data-no-translation-value=\"\" >Belize<\/option><option value='Benin' data-no-translation=\"\" data-trp-gettext=\"\" data-no-translation-value=\"\" >Benin<\/option><option value='Bermuda' data-no-translation=\"\" data-trp-gettext=\"\" data-no-translation-value=\"\" >Bermuda<\/option><option value='Bhutan' data-no-translation=\"\" data-trp-gettext=\"\" data-no-translation-value=\"\" >Bhutan<\/option><option value='Bolivia' data-no-translation=\"\" data-trp-gettext=\"\" data-no-translation-value=\"\" >Bolivia<\/option><option value='Bonaire, Sint Eustatius and Saba' data-no-translation=\"\" data-trp-gettext=\"\" data-no-translation-value=\"\" >Bonaire, Sint Eustatius and Saba<\/option><option value='Bosnia and Herzegovina' data-no-translation=\"\" data-trp-gettext=\"\" data-no-translation-value=\"\" >Bosnia and Herzegovina<\/option><option value='Botswana' data-no-translation=\"\" data-trp-gettext=\"\" data-no-translation-value=\"\" >Botswana<\/option><option value='Bouvet Island' data-no-translation=\"\" data-trp-gettext=\"\" data-no-translation-value=\"\" >Bouvet Island<\/option><option value='Brazil' data-no-translation=\"\" data-trp-gettext=\"\" data-no-translation-value=\"\" >Brazil<\/option><option value='British Indian Ocean Territory' data-no-translation=\"\" data-trp-gettext=\"\" data-no-translation-value=\"\" >British Indian Ocean Territory<\/option><option value='Brunei Darussalam' data-no-translation=\"\" data-trp-gettext=\"\" data-no-translation-value=\"\" >Brunei Darussalam<\/option><option value='Bulgaria' data-no-translation=\"\" data-trp-gettext=\"\" data-no-translation-value=\"\" >Bulgaria<\/option><option value='Burkina Faso' data-no-translation=\"\" data-trp-gettext=\"\" data-no-translation-value=\"\" >Burkina Faso<\/option><option value='Burundi' data-no-translation=\"\" data-trp-gettext=\"\" data-no-translation-value=\"\" >Burundi<\/option><option value='Cabo Verde' data-no-translation=\"\" data-trp-gettext=\"\" data-no-translation-value=\"\" >Cabo Verde<\/option><option value='Cambodia' data-no-translation=\"\" data-trp-gettext=\"\" data-no-translation-value=\"\" >Cambodia<\/option><option value='Cameroon' data-no-translation=\"\" data-trp-gettext=\"\" data-no-translation-value=\"\" >Cameroon<\/option><option value='Canada' data-no-translation=\"\" data-trp-gettext=\"\" data-no-translation-value=\"\" >Canada<\/option><option value='Cayman Islands' data-no-translation=\"\" data-trp-gettext=\"\" data-no-translation-value=\"\" >Cayman Islands<\/option><option value='Central African Republic' data-no-translation=\"\" data-trp-gettext=\"\" data-no-translation-value=\"\" >Central African Republic<\/option><option value='Chad' data-no-translation=\"\" data-trp-gettext=\"\" data-no-translation-value=\"\" >Chad<\/option><option value='Chile' data-no-translation=\"\" data-trp-gettext=\"\" data-no-translation-value=\"\" >Chile<\/option><option value='China' data-no-translation=\"\" data-trp-gettext=\"\" data-no-translation-value=\"\" >China<\/option><option value='Christmas Island' data-no-translation=\"\" data-trp-gettext=\"\" data-no-translation-value=\"\" >Christmas Island<\/option><option value='Cocos Islands' data-no-translation=\"\" data-trp-gettext=\"\" data-no-translation-value=\"\" >Cocos Islands<\/option><option value='Colombia' data-no-translation=\"\" data-trp-gettext=\"\" data-no-translation-value=\"\" >Colombia<\/option><option value='Comoros' data-no-translation=\"\" data-trp-gettext=\"\" data-no-translation-value=\"\" >Comoros<\/option><option value='Congo, Democratic Republic of the' data-no-translation=\"\" data-trp-gettext=\"\" data-no-translation-value=\"\" >Congo, Democratic Republic of the<\/option><option value='Congo' data-no-translation=\"\" data-trp-gettext=\"\" data-no-translation-value=\"\" >Congo<\/option><option value='Cook Islands' data-no-translation=\"\" data-trp-gettext=\"\" data-no-translation-value=\"\" >Cook Islands<\/option><option value='Costa Rica' data-no-translation=\"\" data-trp-gettext=\"\" data-no-translation-value=\"\" >Costa Rica<\/option><option value='C\u00f4te d&#039;Ivoire' data-no-translation=\"\" data-trp-gettext=\"\" data-no-translation-value=\"\" >C\u00f4te d&#039;Ivoire<\/option><option value='Croatia' data-no-translation=\"\" data-trp-gettext=\"\" data-no-translation-value=\"\" >Croatia<\/option><option value='Cuba' data-no-translation=\"\" data-trp-gettext=\"\" data-no-translation-value=\"\" >Cuba<\/option><option value='Cura\u00e7ao' data-no-translation=\"\" data-trp-gettext=\"\" data-no-translation-value=\"\" >Cura\u00e7ao<\/option><option value='Cyprus' data-no-translation=\"\" data-trp-gettext=\"\" data-no-translation-value=\"\" >Cyprus<\/option><option value='Czechia' data-no-translation=\"\" data-trp-gettext=\"\" data-no-translation-value=\"\" >Czechia<\/option><option value='Denmark' data-no-translation=\"\" data-trp-gettext=\"\" data-no-translation-value=\"\" >Denmark<\/option><option value='Djibouti' data-no-translation=\"\" data-trp-gettext=\"\" data-no-translation-value=\"\" >Djibouti<\/option><option value='Dominica' data-no-translation=\"\" data-trp-gettext=\"\" data-no-translation-value=\"\" >Dominica<\/option><option value='Dominican Republic' data-no-translation=\"\" data-trp-gettext=\"\" data-no-translation-value=\"\" >Dominican Republic<\/option><option value='Ecuador' data-no-translation=\"\" data-trp-gettext=\"\" data-no-translation-value=\"\" >Ecuador<\/option><option value='Egypt' data-no-translation=\"\" data-trp-gettext=\"\" data-no-translation-value=\"\" >Egypt<\/option><option value='El Salvador' data-no-translation=\"\" data-trp-gettext=\"\" data-no-translation-value=\"\" >El Salvador<\/option><option value='Equatorial Guinea' data-no-translation=\"\" data-trp-gettext=\"\" data-no-translation-value=\"\" >Equatorial Guinea<\/option><option value='Eritrea' data-no-translation=\"\" data-trp-gettext=\"\" data-no-translation-value=\"\" >Eritrea<\/option><option value='Estonia' data-no-translation=\"\" data-trp-gettext=\"\" data-no-translation-value=\"\" >Estonia<\/option><option value='Eswatini' data-no-translation=\"\" data-trp-gettext=\"\" data-no-translation-value=\"\" >Eswatini<\/option><option value='Ethiopia' data-no-translation=\"\" data-trp-gettext=\"\" data-no-translation-value=\"\" >Ethiopia<\/option><option value='Falkland Islands' data-no-translation=\"\" data-trp-gettext=\"\" data-no-translation-value=\"\" >Falkland Islands<\/option><option value='Faroe Islands' data-no-translation=\"\" data-trp-gettext=\"\" data-no-translation-value=\"\" >Faroe Islands<\/option><option value='Fiji' data-no-translation=\"\" data-trp-gettext=\"\" data-no-translation-value=\"\" >Fiji<\/option><option value='Finland' data-no-translation=\"\" data-trp-gettext=\"\" data-no-translation-value=\"\" >Finland<\/option><option value='France' data-no-translation=\"\" data-trp-gettext=\"\" data-no-translation-value=\"\" >France<\/option><option value='French Guiana' data-no-translation=\"\" data-trp-gettext=\"\" data-no-translation-value=\"\" >French Guiana<\/option><option value='French Polynesia' data-no-translation=\"\" data-trp-gettext=\"\" data-no-translation-value=\"\" >French Polynesia<\/option><option value='French Southern Territories' data-no-translation=\"\" data-trp-gettext=\"\" data-no-translation-value=\"\" >French Southern Territories<\/option><option value='Gabon' data-no-translation=\"\" data-trp-gettext=\"\" data-no-translation-value=\"\" >Gabon<\/option><option value='Gambia' data-no-translation=\"\" data-trp-gettext=\"\" data-no-translation-value=\"\" >Gambia<\/option><option value='Georgia' data-no-translation=\"\" data-trp-gettext=\"\" data-no-translation-value=\"\" >Georgia<\/option><option value='Germany' data-no-translation=\"\" data-trp-gettext=\"\" data-no-translation-value=\"\" >Germany<\/option><option value='Ghana' data-no-translation=\"\" data-trp-gettext=\"\" data-no-translation-value=\"\" >Ghana<\/option><option value='Gibraltar' data-no-translation=\"\" data-trp-gettext=\"\" data-no-translation-value=\"\" >Gibraltar<\/option><option value='Greece' data-no-translation=\"\" data-trp-gettext=\"\" data-no-translation-value=\"\" >Greece<\/option><option value='Greenland' data-no-translation=\"\" data-trp-gettext=\"\" data-no-translation-value=\"\" >Greenland<\/option><option value='Grenada' data-no-translation=\"\" data-trp-gettext=\"\" data-no-translation-value=\"\" >Grenada<\/option><option value='Guadeloupe' data-no-translation=\"\" data-trp-gettext=\"\" data-no-translation-value=\"\" >Guadeloupe<\/option><option value='Guatemala' data-no-translation=\"\" data-trp-gettext=\"\" data-no-translation-value=\"\" >Guatemala<\/option><option value='Guernsey' data-no-translation=\"\" data-trp-gettext=\"\" data-no-translation-value=\"\" >Guernsey<\/option><option value='Guinea' data-no-translation=\"\" data-trp-gettext=\"\" data-no-translation-value=\"\" >Guinea<\/option><option value='Guinea-Bissau' data-no-translation=\"\" data-trp-gettext=\"\" data-no-translation-value=\"\" >Guinea-Bissau<\/option><option value='Guyana' data-no-translation=\"\" data-trp-gettext=\"\" data-no-translation-value=\"\" >Guyana<\/option><option value='Haiti' data-no-translation=\"\" data-trp-gettext=\"\" data-no-translation-value=\"\" >Haiti<\/option><option value='Heard Island and McDonald Islands' data-no-translation=\"\" data-trp-gettext=\"\" data-no-translation-value=\"\" >Heard Island and McDonald Islands<\/option><option value='Holy See' data-no-translation=\"\" data-trp-gettext=\"\" data-no-translation-value=\"\" >Holy See<\/option><option value='Honduras' data-no-translation=\"\" data-trp-gettext=\"\" data-no-translation-value=\"\" >Honduras<\/option><option value='Hong Kong' data-no-translation=\"\" data-trp-gettext=\"\" data-no-translation-value=\"\" >Hong Kong<\/option><option value='Hungary' data-no-translation=\"\" data-trp-gettext=\"\" data-no-translation-value=\"\" >Hungary<\/option><option value='Iceland' data-no-translation=\"\" data-trp-gettext=\"\" data-no-translation-value=\"\" >Iceland<\/option><option value='India' data-no-translation=\"\" data-trp-gettext=\"\" data-no-translation-value=\"\" >India<\/option><option value='Indonesia' data-no-translation=\"\" data-trp-gettext=\"\" data-no-translation-value=\"\" >Indonesia<\/option><option value='Iran' data-no-translation=\"\" data-trp-gettext=\"\" data-no-translation-value=\"\" >Iran<\/option><option value='Iraq' data-no-translation=\"\" data-trp-gettext=\"\" data-no-translation-value=\"\" >Iraq<\/option><option value='Ireland' data-no-translation=\"\" data-trp-gettext=\"\" data-no-translation-value=\"\" >Ireland<\/option><option value='Isle of Man' data-no-translation=\"\" data-trp-gettext=\"\" data-no-translation-value=\"\" >Isle of Man<\/option><option value='Israel' data-no-translation=\"\" data-trp-gettext=\"\" data-no-translation-value=\"\" >Israel<\/option><option value='Italy' data-no-translation=\"\" data-trp-gettext=\"\" data-no-translation-value=\"\" >Italy<\/option><option value='Jamaica' data-no-translation=\"\" data-trp-gettext=\"\" data-no-translation-value=\"\" >Jamaica<\/option><option value='Japan' data-no-translation=\"\" data-trp-gettext=\"\" data-no-translation-value=\"\" >Japan<\/option><option value='Jersey' data-no-translation=\"\" data-trp-gettext=\"\" data-no-translation-value=\"\" >Jersey<\/option><option value='Jordan' data-no-translation=\"\" data-trp-gettext=\"\" data-no-translation-value=\"\" >Jordan<\/option><option value='Kazakhstan' data-no-translation=\"\" data-trp-gettext=\"\" data-no-translation-value=\"\" >Kazakhstan<\/option><option value='Kenya' data-no-translation=\"\" data-trp-gettext=\"\" data-no-translation-value=\"\" >Kenya<\/option><option value='Kiribati' data-no-translation=\"\" data-trp-gettext=\"\" data-no-translation-value=\"\" >Kiribati<\/option><option value='Korea, Democratic People&#039;s Republic of' data-no-translation=\"\" data-trp-gettext=\"\" data-no-translation-value=\"\" >Korea, Democratic People&#039;s Republic of<\/option><option value='Korea, Republic of' data-no-translation=\"\" data-trp-gettext=\"\" data-no-translation-value=\"\" >Korea, Republic of<\/option><option value='Kuwait' data-no-translation=\"\" data-trp-gettext=\"\" data-no-translation-value=\"\" >Kuwait<\/option><option value='Kyrgyzstan' data-no-translation=\"\" data-trp-gettext=\"\" data-no-translation-value=\"\" >Kyrgyzstan<\/option><option value='Lao People&#039;s Democratic Republic' data-no-translation=\"\" data-trp-gettext=\"\" data-no-translation-value=\"\" >Lao People&#039;s Democratic Republic<\/option><option value='Latvia' data-no-translation=\"\" data-trp-gettext=\"\" data-no-translation-value=\"\" >Latvia<\/option><option value='Lebanon' data-no-translation=\"\" data-trp-gettext=\"\" data-no-translation-value=\"\" >Lebanon<\/option><option value='Lesotho' data-no-translation=\"\" data-trp-gettext=\"\" data-no-translation-value=\"\" >Lesotho<\/option><option value='Liberia' data-no-translation=\"\" data-trp-gettext=\"\" data-no-translation-value=\"\" >Liberia<\/option><option value='Libya' data-no-translation=\"\" data-trp-gettext=\"\" data-no-translation-value=\"\" >Libya<\/option><option value='Liechtenstein' data-no-translation=\"\" data-trp-gettext=\"\" data-no-translation-value=\"\" >Liechtenstein<\/option><option value='Lithuania' data-no-translation=\"\" data-trp-gettext=\"\" data-no-translation-value=\"\" >Lithuania<\/option><option value='Luxembourg' data-no-translation=\"\" data-trp-gettext=\"\" data-no-translation-value=\"\" >Luxembourg<\/option><option value='Macao' data-no-translation=\"\" data-trp-gettext=\"\" data-no-translation-value=\"\" >Macao<\/option><option value='Madagascar' data-no-translation=\"\" data-trp-gettext=\"\" data-no-translation-value=\"\" >Madagascar<\/option><option value='Malawi' data-no-translation=\"\" data-trp-gettext=\"\" data-no-translation-value=\"\" >Malawi<\/option><option value='Malaysia' data-no-translation=\"\" data-trp-gettext=\"\" data-no-translation-value=\"\" >Malaysia<\/option><option value='Maldives' data-no-translation=\"\" data-trp-gettext=\"\" data-no-translation-value=\"\" >Maldives<\/option><option value='Mali' data-no-translation=\"\" data-trp-gettext=\"\" data-no-translation-value=\"\" >Mali<\/option><option value='Malta' data-no-translation=\"\" data-trp-gettext=\"\" data-no-translation-value=\"\" >Malta<\/option><option value='Marshall Islands' data-no-translation=\"\" data-trp-gettext=\"\" data-no-translation-value=\"\" >Marshall Islands<\/option><option value='Martinique' data-no-translation=\"\" data-trp-gettext=\"\" data-no-translation-value=\"\" >Martinique<\/option><option value='Mauritania' data-no-translation=\"\" data-trp-gettext=\"\" data-no-translation-value=\"\" >Mauritania<\/option><option value='Mauritius' data-no-translation=\"\" data-trp-gettext=\"\" data-no-translation-value=\"\" >Mauritius<\/option><option value='Mayotte' data-no-translation=\"\" data-trp-gettext=\"\" data-no-translation-value=\"\" >Mayotte<\/option><option value='Mexico' data-no-translation=\"\" data-trp-gettext=\"\" data-no-translation-value=\"\" >Mexico<\/option><option value='Micronesia' data-no-translation=\"\" data-trp-gettext=\"\" data-no-translation-value=\"\" >Micronesia<\/option><option value='Moldova' data-no-translation=\"\" data-trp-gettext=\"\" data-no-translation-value=\"\" >Moldova<\/option><option value='Monaco' data-no-translation=\"\" data-trp-gettext=\"\" data-no-translation-value=\"\" >Monaco<\/option><option value='Mongolia' data-no-translation=\"\" data-trp-gettext=\"\" data-no-translation-value=\"\" >Mongolia<\/option><option value='Montenegro' data-no-translation=\"\" data-trp-gettext=\"\" data-no-translation-value=\"\" >Montenegro<\/option><option value='Montserrat' data-no-translation=\"\" data-trp-gettext=\"\" data-no-translation-value=\"\" >Montserrat<\/option><option value='Morocco' data-no-translation=\"\" data-trp-gettext=\"\" data-no-translation-value=\"\" >Morocco<\/option><option value='Mozambique' data-no-translation=\"\" data-trp-gettext=\"\" data-no-translation-value=\"\" >Mozambique<\/option><option value='Myanmar' data-no-translation=\"\" data-trp-gettext=\"\" data-no-translation-value=\"\" >Myanmar<\/option><option value='Namibia' data-no-translation=\"\" data-trp-gettext=\"\" data-no-translation-value=\"\" >Namibia<\/option><option value='Nauru' data-no-translation=\"\" data-trp-gettext=\"\" data-no-translation-value=\"\" >Nauru<\/option><option value='Nepal' data-no-translation=\"\" data-trp-gettext=\"\" data-no-translation-value=\"\" >Nepal<\/option><option value='Netherlands' data-no-translation=\"\" data-trp-gettext=\"\" data-no-translation-value=\"\" >Netherlands<\/option><option value='New Caledonia' data-no-translation=\"\" data-trp-gettext=\"\" data-no-translation-value=\"\" >New Caledonia<\/option><option value='New Zealand' data-no-translation=\"\" data-trp-gettext=\"\" data-no-translation-value=\"\" >New Zealand<\/option><option value='Nicaragua' data-no-translation=\"\" data-trp-gettext=\"\" data-no-translation-value=\"\" >Nicaragua<\/option><option value='Niger' data-no-translation=\"\" data-trp-gettext=\"\" data-no-translation-value=\"\" >Niger<\/option><option value='Nigeria' data-no-translation=\"\" data-trp-gettext=\"\" data-no-translation-value=\"\" >Nigeria<\/option><option value='Niue' data-no-translation=\"\" data-trp-gettext=\"\" data-no-translation-value=\"\" >Niue<\/option><option value='Norfolk Island' data-no-translation=\"\" data-trp-gettext=\"\" data-no-translation-value=\"\" >Norfolk Island<\/option><option value='North Macedonia' data-no-translation=\"\" data-trp-gettext=\"\" data-no-translation-value=\"\" >North Macedonia<\/option><option value='Norway' data-no-translation=\"\" data-trp-gettext=\"\" data-no-translation-value=\"\" >Norway<\/option><option value='Oman' data-no-translation=\"\" data-trp-gettext=\"\" data-no-translation-value=\"\" >Oman<\/option><option value='Pakistan' data-no-translation=\"\" data-trp-gettext=\"\" data-no-translation-value=\"\" >Pakistan<\/option><option value='Palau' data-no-translation=\"\" data-trp-gettext=\"\" data-no-translation-value=\"\" >Palau<\/option><option value='Palestine, State of' data-no-translation=\"\" data-trp-gettext=\"\" data-no-translation-value=\"\" >Palestine, State of<\/option><option value='Panama' data-no-translation=\"\" data-trp-gettext=\"\" data-no-translation-value=\"\" >Panama<\/option><option value='Papua New Guinea' data-no-translation=\"\" data-trp-gettext=\"\" data-no-translation-value=\"\" >Papua New Guinea<\/option><option value='Paraguay' data-no-translation=\"\" data-trp-gettext=\"\" data-no-translation-value=\"\" >Paraguay<\/option><option value='Peru' data-no-translation=\"\" data-trp-gettext=\"\" data-no-translation-value=\"\" >Peru<\/option><option value='Philippines' data-no-translation=\"\" data-trp-gettext=\"\" data-no-translation-value=\"\" >Philippines<\/option><option value='Pitcairn' data-no-translation=\"\" data-trp-gettext=\"\" data-no-translation-value=\"\" >Pitcairn<\/option><option value='Poland' data-no-translation=\"\" data-trp-gettext=\"\" data-no-translation-value=\"\" >Poland<\/option><option value='Portugal' data-no-translation=\"\" data-trp-gettext=\"\" data-no-translation-value=\"\" >Portugal<\/option><option value='Qatar' data-no-translation=\"\" data-trp-gettext=\"\" data-no-translation-value=\"\" >Qatar<\/option><option value='R\u00e9union' data-no-translation=\"\" data-trp-gettext=\"\" data-no-translation-value=\"\" >R\u00e9union<\/option><option value='Romania' data-no-translation=\"\" data-trp-gettext=\"\" data-no-translation-value=\"\" >Romania<\/option><option value='Russian Federation' data-no-translation=\"\" data-trp-gettext=\"\" data-no-translation-value=\"\" >Russian Federation<\/option><option value='Rwanda' data-no-translation=\"\" data-trp-gettext=\"\" data-no-translation-value=\"\" >Rwanda<\/option><option value='Saint Barth\u00e9lemy' data-no-translation=\"\" data-trp-gettext=\"\" data-no-translation-value=\"\" >Saint Barth\u00e9lemy<\/option><option value='Saint Helena, Ascension and Tristan da Cunha' data-no-translation=\"\" data-trp-gettext=\"\" data-no-translation-value=\"\" >Saint Helena, Ascension and Tristan da Cunha<\/option><option value='Saint Kitts and Nevis' data-no-translation=\"\" data-trp-gettext=\"\" data-no-translation-value=\"\" >Saint Kitts and Nevis<\/option><option value='Saint Lucia' data-no-translation=\"\" data-trp-gettext=\"\" data-no-translation-value=\"\" >Saint Lucia<\/option><option value='Saint Martin' data-no-translation=\"\" data-trp-gettext=\"\" data-no-translation-value=\"\" >Saint Martin<\/option><option value='Saint Pierre and Miquelon' data-no-translation=\"\" data-trp-gettext=\"\" data-no-translation-value=\"\" >Saint Pierre and Miquelon<\/option><option value='Saint Vincent and the Grenadines' data-no-translation=\"\" data-trp-gettext=\"\" data-no-translation-value=\"\" >Saint Vincent and the Grenadines<\/option><option value='Samoa' data-no-translation=\"\" data-trp-gettext=\"\" data-no-translation-value=\"\" >Samoa<\/option><option value='San Marino' data-no-translation=\"\" data-trp-gettext=\"\" data-no-translation-value=\"\" >San Marino<\/option><option value='Sao Tome and Principe' data-no-translation=\"\" data-trp-gettext=\"\" data-no-translation-value=\"\" >Sao Tome and Principe<\/option><option value='Saudi Arabia' data-no-translation=\"\" data-trp-gettext=\"\" data-no-translation-value=\"\" >Saudi Arabia<\/option><option value='Senegal' data-no-translation=\"\" data-trp-gettext=\"\" data-no-translation-value=\"\" >Senegal<\/option><option value='Serbia' data-no-translation=\"\" data-trp-gettext=\"\" data-no-translation-value=\"\" >Serbia<\/option><option value='Seychelles' data-no-translation=\"\" data-trp-gettext=\"\" data-no-translation-value=\"\" >Seychelles<\/option><option value='Sierra Leone' data-no-translation=\"\" data-trp-gettext=\"\" data-no-translation-value=\"\" >Sierra Leone<\/option><option value='Singapore' data-no-translation=\"\" data-trp-gettext=\"\" data-no-translation-value=\"\" >Singapore<\/option><option value='Sint Maarten' data-no-translation=\"\" data-trp-gettext=\"\" data-no-translation-value=\"\" >Sint Maarten<\/option><option value='Slovakia' data-no-translation=\"\" data-trp-gettext=\"\" data-no-translation-value=\"\" >Slovakia<\/option><option value='Slovenia' data-no-translation=\"\" data-trp-gettext=\"\" data-no-translation-value=\"\" >Slovenia<\/option><option value='Solomon Islands' data-no-translation=\"\" data-trp-gettext=\"\" data-no-translation-value=\"\" >Solomon Islands<\/option><option value='Somalia' data-no-translation=\"\" data-trp-gettext=\"\" data-no-translation-value=\"\" >Somalia<\/option><option value='South Africa' data-no-translation=\"\" data-trp-gettext=\"\" data-no-translation-value=\"\" >South Africa<\/option><option value='South Georgia and the South Sandwich Islands' data-no-translation=\"\" data-trp-gettext=\"\" data-no-translation-value=\"\" >South Georgia and the South Sandwich Islands<\/option><option value='South Sudan' data-no-translation=\"\" data-trp-gettext=\"\" data-no-translation-value=\"\" >South Sudan<\/option><option value='Spain' data-no-translation=\"\" data-trp-gettext=\"\" data-no-translation-value=\"\" >Spain<\/option><option value='Sri Lanka' data-no-translation=\"\" data-trp-gettext=\"\" data-no-translation-value=\"\" >Sri Lanka<\/option><option value='Sudan' data-no-translation=\"\" data-trp-gettext=\"\" data-no-translation-value=\"\" >Sudan<\/option><option value='Suriname' data-no-translation=\"\" data-trp-gettext=\"\" data-no-translation-value=\"\" >Suriname<\/option><option value='Svalbard and Jan Mayen' data-no-translation=\"\" data-trp-gettext=\"\" data-no-translation-value=\"\" >Svalbard and Jan Mayen<\/option><option value='Sweden' data-no-translation=\"\" data-trp-gettext=\"\" data-no-translation-value=\"\" >Sweden<\/option><option value='Switzerland' data-no-translation=\"\" data-trp-gettext=\"\" data-no-translation-value=\"\" >Switzerland<\/option><option value='Syria Arab Republic' data-no-translation=\"\" data-trp-gettext=\"\" data-no-translation-value=\"\" >Syria Arab Republic<\/option><option value='Taiwan' data-no-translation=\"\" data-trp-gettext=\"\" data-no-translation-value=\"\" >Taiwan<\/option><option value='Tajikistan' data-no-translation=\"\" data-trp-gettext=\"\" data-no-translation-value=\"\" >Tajikistan<\/option><option value='Tanzania, the United Republic of' data-no-translation=\"\" data-trp-gettext=\"\" data-no-translation-value=\"\" >Tanzania, the United Republic of<\/option><option value='Thailand' data-no-translation=\"\" data-trp-gettext=\"\" data-no-translation-value=\"\" >Thailand<\/option><option value='Timor-Leste' data-no-translation=\"\" data-trp-gettext=\"\" data-no-translation-value=\"\" >Timor-Leste<\/option><option value='Togo' data-no-translation=\"\" data-trp-gettext=\"\" data-no-translation-value=\"\" >Togo<\/option><option value='Tokelau' data-no-translation=\"\" data-trp-gettext=\"\" data-no-translation-value=\"\" >Tokelau<\/option><option value='Tonga' data-no-translation=\"\" data-trp-gettext=\"\" data-no-translation-value=\"\" >Tonga<\/option><option value='Trinidad and Tobago' data-no-translation=\"\" data-trp-gettext=\"\" data-no-translation-value=\"\" >Trinidad and Tobago<\/option><option value='Tunisia' data-no-translation=\"\" data-trp-gettext=\"\" data-no-translation-value=\"\" >Tunisia<\/option><option value='T\u00fcrkiye' data-no-translation=\"\" data-trp-gettext=\"\" data-no-translation-value=\"\" >T\u00fcrkiye<\/option><option value='Turkmenistan' data-no-translation=\"\" data-trp-gettext=\"\" data-no-translation-value=\"\" >Turkmenistan<\/option><option value='Turks and Caicos Islands' data-no-translation=\"\" data-trp-gettext=\"\" data-no-translation-value=\"\" >Turks and Caicos Islands<\/option><option value='Tuvalu' data-no-translation=\"\" data-trp-gettext=\"\" data-no-translation-value=\"\" >Tuvalu<\/option><option value='Uganda' data-no-translation=\"\" data-trp-gettext=\"\" data-no-translation-value=\"\" >Uganda<\/option><option value='Ukraine' data-no-translation=\"\" data-trp-gettext=\"\" data-no-translation-value=\"\" >Ukraine<\/option><option value='United Arab Emirates' data-no-translation=\"\" data-trp-gettext=\"\" data-no-translation-value=\"\" >United Arab Emirates<\/option><option value='United Kingdom' data-no-translation=\"\" data-trp-gettext=\"\" data-no-translation-value=\"\" >United Kingdom<\/option><option value='Uruguay' data-no-translation=\"\" data-trp-gettext=\"\" data-no-translation-value=\"\" >Uruguay<\/option><option value='US Minor Outlying Islands' data-no-translation=\"\" data-trp-gettext=\"\" data-no-translation-value=\"\" >US Minor Outlying Islands<\/option><option value='Uzbekistan' data-no-translation=\"\" data-trp-gettext=\"\" data-no-translation-value=\"\" >Uzbekistan<\/option><option value='Vanuatu' data-no-translation=\"\" data-trp-gettext=\"\" data-no-translation-value=\"\" >Vanuatu<\/option><option value='Venezuela' data-no-translation=\"\" data-trp-gettext=\"\" data-no-translation-value=\"\" >Venezuela<\/option><option value='Viet Nam' data-no-translation=\"\" data-trp-gettext=\"\" data-no-translation-value=\"\" >Viet Nam<\/option><option value='Virgin Islands, British' data-no-translation=\"\" data-trp-gettext=\"\" data-no-translation-value=\"\" >Virgin Islands, British<\/option><option value='Virgin Islands, U.S.' data-no-translation=\"\" data-trp-gettext=\"\" data-no-translation-value=\"\" >Virgin Islands, U.S.<\/option><option value='Wallis and Futuna' data-no-translation=\"\" data-trp-gettext=\"\" data-no-translation-value=\"\" >Wallis and Futuna<\/option><option value='Western Sahara' data-no-translation=\"\" data-trp-gettext=\"\" data-no-translation-value=\"\" >Western Sahara<\/option><option value='Yemen' data-no-translation=\"\" data-trp-gettext=\"\" data-no-translation-value=\"\" >Yemen<\/option><option value='Zambia' data-no-translation=\"\" data-trp-gettext=\"\" data-no-translation-value=\"\" >Zambia<\/option><option value='Zimbabwe' data-no-translation=\"\" data-trp-gettext=\"\" data-no-translation-value=\"\" >Zimbabwe<\/option><\/select>\n                                        <label for='input_16_5_6' id='input_16_5_6_label' class='gform-field-label gform-field-label--type-sub' data-no-translation=\"\" data-trp-gettext=\"\">Country<\/label>\n                                    <\/span>\n                    <div class='gf_clear gf_clear_complex'><\/div>\n                <\/div><\/li><li id=\"field_16_12\" 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' >License Type<\/label><div class='ginput_container ginput_container_checkbox'><ul class='gfield_checkbox' id='input_16_12'><li class='gchoice gchoice_16_12_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_12.1' type='checkbox'  value='LCSW'  id='choice_16_12_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_16_12_1' id='label_16_12_1' class='gform-field-label gform-field-label--type-inline'>LCSW<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_16_12_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_12.2' type='checkbox'  value='LMHC'  id='choice_16_12_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_16_12_2' id='label_16_12_2' class='gform-field-label gform-field-label--type-inline'>LMHC<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_16_12_3'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_12.3' type='checkbox'  value='PhD'  id='choice_16_12_3'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_16_12_3' id='label_16_12_3' class='gform-field-label gform-field-label--type-inline'>PhD<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_16_12_4'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_12.4' type='checkbox'  value='LMFT'  id='choice_16_12_4'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_16_12_4' id='label_16_12_4' class='gform-field-label gform-field-label--type-inline'>LMFT<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_16_12_5'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_12.5' type='checkbox'  value='LSW'  id='choice_16_12_5'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_16_12_5' id='label_16_12_5' class='gform-field-label gform-field-label--type-inline'>LSW<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_16_12_6'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_12.6' type='checkbox'  value='Other'  id='choice_16_12_6'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_16_12_6' id='label_16_12_6' 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_16_13\" 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_16_13'>Other:<\/label><div class='ginput_container ginput_container_text'><input name='input_13' id='input_16_13' type='text' value='' class='medium'      aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_16_28\" class=\"gfield gfield--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_16_28'>How did you hear about the Pro Bono Counseling Project?<\/label><div class='ginput_container ginput_container_text'><input name='input_28' id='input_16_28' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_16_24\" 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' >In the past year, has there been a complaint filed against you with the licensing board?<\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_16_24'>\n\t\t\t<li class='gchoice gchoice_16_24_0'>\n\t\t\t\t<input name='input_24' type='radio' value='Yes'  id='choice_16_24_0'    \/>\n\t\t\t\t<label for='choice_16_24_0' id='label_16_24_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_16_24_1'>\n\t\t\t\t<input name='input_24' type='radio' value='No'  id='choice_16_24_1'    \/>\n\t\t\t\t<label for='choice_16_24_1' id='label_16_24_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_16_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' >Years in clinical practice<\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_16_10'>\n\t\t\t<li class='gchoice gchoice_16_10_0'>\n\t\t\t\t<input name='input_10' type='radio' value='0-2 years'  id='choice_16_10_0'    \/>\n\t\t\t\t<label for='choice_16_10_0' id='label_16_10_0' class='gform-field-label gform-field-label--type-inline'>0-2 years<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_16_10_1'>\n\t\t\t\t<input name='input_10' type='radio' value='2-5 years'  id='choice_16_10_1'    \/>\n\t\t\t\t<label for='choice_16_10_1' id='label_16_10_1' class='gform-field-label gform-field-label--type-inline'>2-5 years<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_16_10_2'>\n\t\t\t\t<input name='input_10' type='radio' value='5-10 years'  id='choice_16_10_2'    \/>\n\t\t\t\t<label for='choice_16_10_2' id='label_16_10_2' class='gform-field-label gform-field-label--type-inline'>5-10 years<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_16_10_3'>\n\t\t\t\t<input name='input_10' type='radio' value='10+ years'  id='choice_16_10_3'    \/>\n\t\t\t\t<label for='choice_16_10_3' id='label_16_10_3' class='gform-field-label gform-field-label--type-inline'>10+ years<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_16_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' >Practice Location<\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_16_11'>\n\t\t\t<li class='gchoice gchoice_16_11_0'>\n\t\t\t\t<input name='input_11' type='radio' value='Private practice'  id='choice_16_11_0'    \/>\n\t\t\t\t<label for='choice_16_11_0' id='label_16_11_0' class='gform-field-label gform-field-label--type-inline'>Private practice<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_16_11_1'>\n\t\t\t\t<input name='input_11' type='radio' value='Group practice'  id='choice_16_11_1'    \/>\n\t\t\t\t<label for='choice_16_11_1' id='label_16_11_1' class='gform-field-label gform-field-label--type-inline'>Group practice<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_16_11_2'>\n\t\t\t\t<input name='input_11' type='radio' value='Community Organization'  id='choice_16_11_2'    \/>\n\t\t\t\t<label for='choice_16_11_2' id='label_16_11_2' class='gform-field-label gform-field-label--type-inline'>Community Organization<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_16_11_3'>\n\t\t\t\t<input name='input_11' type='radio' value='Church'  id='choice_16_11_3'    \/>\n\t\t\t\t<label for='choice_16_11_3' id='label_16_11_3' class='gform-field-label gform-field-label--type-inline'>Church<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_16_11_4'>\n\t\t\t\t<input name='input_11' type='radio' value='School'  id='choice_16_11_4'    \/>\n\t\t\t\t<label for='choice_16_11_4' id='label_16_11_4' class='gform-field-label gform-field-label--type-inline'>School<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_16_11_5'>\n\t\t\t\t<input name='input_11' type='radio' value='Hospital'  id='choice_16_11_5'    \/>\n\t\t\t\t<label for='choice_16_11_5' id='label_16_11_5' class='gform-field-label gform-field-label--type-inline'>Hospital<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_16_11_6'>\n\t\t\t\t<input name='input_11' type='radio' value='gf_other_choice'  id='choice_16_11_6'   onfocus=\"jQuery(this).next('input').focus();\" \/>\n\t\t\t\t<input class='small' id='input_16_11_other' name='input_11_other' type='text' value='Other' aria-label='Other' onfocus='jQuery(this).prev(&quot;input&quot;)[0].click(); if(jQuery(this).val() == &quot;Other&quot;) { jQuery(this).val(&quot;&quot;); }' onblur='if(jQuery(this).val().replace(&quot; &quot;, &quot;&quot;) == &quot;&quot;) { jQuery(this).val(&quot;Other&quot;); }' data-no-translation-value=\"\" data-no-translation-aria-label=\"\" data-no-translation-onfocus=\"\" data-no-translation-onblur=\"\"   \/>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_16_14\" 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_16_14'>Name of practice\/organization<\/label><div class='ginput_container ginput_container_text'><input name='input_14' id='input_16_14' type='text' value='' class='medium'      aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_16_15\" class=\"gfield gfield--type-address 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' >Practice Address<\/label>    \n                    <div class='ginput_complex ginput_container has_street has_street2 has_city has_state has_zip has_country ginput_container_address gform-grid-row' id='input_16_15' >\n                         <span class='ginput_full address_line_1 ginput_address_line_1 gform-grid-col' id='input_16_15_1_container' >\n                                        <input type='text' name='input_15.1' id='input_16_15_1' value=''    aria-required='false'    \/>\n                                        <label for='input_16_15_1' id='input_16_15_1_label' class='gform-field-label gform-field-label--type-sub' data-no-translation=\"\" data-trp-gettext=\"\">Street Address<\/label>\n                                    <\/span><span class='ginput_full address_line_2 ginput_address_line_2 gform-grid-col' id='input_16_15_2_container' >\n                                        <input type='text' name='input_15.2' id='input_16_15_2' value=''     aria-required='false'   \/>\n                                        <label for='input_16_15_2' id='input_16_15_2_label' class='gform-field-label gform-field-label--type-sub' data-no-translation=\"\" data-trp-gettext=\"\">Address Line 2<\/label>\n                                    <\/span><span class='ginput_left address_city ginput_address_city gform-grid-col' id='input_16_15_3_container' >\n                                    <input type='text' name='input_15.3' id='input_16_15_3' value=''    aria-required='false'    \/>\n                                    <label for='input_16_15_3' id='input_16_15_3_label' class='gform-field-label gform-field-label--type-sub' data-no-translation=\"\" data-trp-gettext=\"\">City<\/label>\n                                 <\/span><span class='ginput_right address_state ginput_address_state gform-grid-col' id='input_16_15_4_container' >\n                                        <input type='text' name='input_15.4' id='input_16_15_4' value=''      aria-required='false'    \/>\n                                        <label for='input_16_15_4' id='input_16_15_4_label' class='gform-field-label gform-field-label--type-sub' data-no-translation=\"\" data-trp-gettext=\"\">State \/ Province \/ Region<\/label>\n                                      <\/span><span class='ginput_left address_zip ginput_address_zip gform-grid-col' id='input_16_15_5_container' >\n                                    <input type='text' name='input_15.5' id='input_16_15_5' value=''    aria-required='false'    \/>\n                                    <label for='input_16_15_5' id='input_16_15_5_label' class='gform-field-label gform-field-label--type-sub' data-no-translation=\"\" data-trp-gettext=\"\">ZIP \/ Postal Code<\/label>\n                                <\/span><span class='ginput_right address_country ginput_address_country gform-grid-col' id='input_16_15_6_container' >\n                                        <select name='input_15.6' id='input_16_15_6'   aria-required='false'    ><option value='' selected='selected'><\/option><option value='United States' data-no-translation=\"\" data-trp-gettext=\"\" data-no-translation-value=\"\" >United States<\/option><option value='American Samoa' data-no-translation=\"\" data-trp-gettext=\"\" data-no-translation-value=\"\" >American Samoa<\/option><option value='Guam' data-no-translation=\"\" data-trp-gettext=\"\" data-no-translation-value=\"\" >Guam<\/option><option value='Northern Mariana Islands' data-no-translation=\"\" data-trp-gettext=\"\" data-no-translation-value=\"\" >Northern Mariana Islands<\/option><option value='Puerto Rico' data-no-translation=\"\" data-trp-gettext=\"\" data-no-translation-value=\"\" >Puerto Rico<\/option><option value='Afghanistan' data-no-translation=\"\" data-trp-gettext=\"\" data-no-translation-value=\"\" >Afghanistan<\/option><option value='\u00c5land Islands' data-no-translation=\"\" data-trp-gettext=\"\" data-no-translation-value=\"\" >\u00c5land Islands<\/option><option value='Albania' data-no-translation=\"\" data-trp-gettext=\"\" data-no-translation-value=\"\" >Albania<\/option><option value='Algeria' data-no-translation=\"\" data-trp-gettext=\"\" data-no-translation-value=\"\" >Algeria<\/option><option value='Andorra' data-no-translation=\"\" data-trp-gettext=\"\" data-no-translation-value=\"\" >Andorra<\/option><option value='Angola' data-no-translation=\"\" data-trp-gettext=\"\" data-no-translation-value=\"\" >Angola<\/option><option value='Anguilla' data-no-translation=\"\" data-trp-gettext=\"\" data-no-translation-value=\"\" >Anguilla<\/option><option value='Antarctica' data-no-translation=\"\" data-trp-gettext=\"\" data-no-translation-value=\"\" >Antarctica<\/option><option value='Antigua and Barbuda' data-no-translation=\"\" data-trp-gettext=\"\" data-no-translation-value=\"\" >Antigua and Barbuda<\/option><option value='Argentina' data-no-translation=\"\" data-trp-gettext=\"\" data-no-translation-value=\"\" >Argentina<\/option><option value='Armenia' data-no-translation=\"\" data-trp-gettext=\"\" data-no-translation-value=\"\" >Armenia<\/option><option value='Aruba' data-no-translation=\"\" data-trp-gettext=\"\" data-no-translation-value=\"\" >Aruba<\/option><option value='Australia' data-no-translation=\"\" data-trp-gettext=\"\" data-no-translation-value=\"\" >Australia<\/option><option value='Austria' data-no-translation=\"\" data-trp-gettext=\"\" data-no-translation-value=\"\" >Austria<\/option><option value='Azerbaijan' data-no-translation=\"\" data-trp-gettext=\"\" data-no-translation-value=\"\" >Azerbaijan<\/option><option value='Bahamas' data-no-translation=\"\" data-trp-gettext=\"\" data-no-translation-value=\"\" >Bahamas<\/option><option value='Bahrain' data-no-translation=\"\" data-trp-gettext=\"\" data-no-translation-value=\"\" >Bahrain<\/option><option value='Bangladesh' data-no-translation=\"\" data-trp-gettext=\"\" data-no-translation-value=\"\" >Bangladesh<\/option><option value='Barbados' data-no-translation=\"\" data-trp-gettext=\"\" data-no-translation-value=\"\" >Barbados<\/option><option value='Belarus' data-no-translation=\"\" data-trp-gettext=\"\" data-no-translation-value=\"\" >Belarus<\/option><option value='Belgium' data-no-translation=\"\" data-trp-gettext=\"\" data-no-translation-value=\"\" >Belgium<\/option><option value='Belize' data-no-translation=\"\" data-trp-gettext=\"\" data-no-translation-value=\"\" >Belize<\/option><option value='Benin' data-no-translation=\"\" data-trp-gettext=\"\" data-no-translation-value=\"\" >Benin<\/option><option value='Bermuda' data-no-translation=\"\" data-trp-gettext=\"\" data-no-translation-value=\"\" >Bermuda<\/option><option value='Bhutan' data-no-translation=\"\" data-trp-gettext=\"\" data-no-translation-value=\"\" >Bhutan<\/option><option value='Bolivia' data-no-translation=\"\" data-trp-gettext=\"\" data-no-translation-value=\"\" >Bolivia<\/option><option value='Bonaire, Sint Eustatius and Saba' data-no-translation=\"\" data-trp-gettext=\"\" data-no-translation-value=\"\" >Bonaire, Sint Eustatius and Saba<\/option><option value='Bosnia and Herzegovina' data-no-translation=\"\" data-trp-gettext=\"\" data-no-translation-value=\"\" >Bosnia and Herzegovina<\/option><option value='Botswana' data-no-translation=\"\" data-trp-gettext=\"\" data-no-translation-value=\"\" >Botswana<\/option><option value='Bouvet Island' data-no-translation=\"\" data-trp-gettext=\"\" data-no-translation-value=\"\" >Bouvet Island<\/option><option value='Brazil' data-no-translation=\"\" data-trp-gettext=\"\" data-no-translation-value=\"\" >Brazil<\/option><option value='British Indian Ocean Territory' data-no-translation=\"\" data-trp-gettext=\"\" data-no-translation-value=\"\" >British Indian Ocean Territory<\/option><option value='Brunei Darussalam' data-no-translation=\"\" data-trp-gettext=\"\" data-no-translation-value=\"\" >Brunei Darussalam<\/option><option value='Bulgaria' data-no-translation=\"\" data-trp-gettext=\"\" data-no-translation-value=\"\" >Bulgaria<\/option><option value='Burkina Faso' data-no-translation=\"\" data-trp-gettext=\"\" data-no-translation-value=\"\" >Burkina Faso<\/option><option value='Burundi' data-no-translation=\"\" data-trp-gettext=\"\" data-no-translation-value=\"\" >Burundi<\/option><option value='Cabo Verde' data-no-translation=\"\" data-trp-gettext=\"\" data-no-translation-value=\"\" >Cabo Verde<\/option><option value='Cambodia' data-no-translation=\"\" data-trp-gettext=\"\" data-no-translation-value=\"\" >Cambodia<\/option><option value='Cameroon' data-no-translation=\"\" data-trp-gettext=\"\" data-no-translation-value=\"\" >Cameroon<\/option><option value='Canada' data-no-translation=\"\" data-trp-gettext=\"\" data-no-translation-value=\"\" >Canada<\/option><option value='Cayman Islands' data-no-translation=\"\" data-trp-gettext=\"\" data-no-translation-value=\"\" >Cayman Islands<\/option><option value='Central African Republic' data-no-translation=\"\" data-trp-gettext=\"\" data-no-translation-value=\"\" >Central African Republic<\/option><option value='Chad' data-no-translation=\"\" data-trp-gettext=\"\" data-no-translation-value=\"\" >Chad<\/option><option value='Chile' data-no-translation=\"\" data-trp-gettext=\"\" data-no-translation-value=\"\" >Chile<\/option><option value='China' data-no-translation=\"\" data-trp-gettext=\"\" data-no-translation-value=\"\" >China<\/option><option value='Christmas Island' data-no-translation=\"\" data-trp-gettext=\"\" data-no-translation-value=\"\" >Christmas Island<\/option><option value='Cocos Islands' data-no-translation=\"\" data-trp-gettext=\"\" data-no-translation-value=\"\" >Cocos Islands<\/option><option value='Colombia' data-no-translation=\"\" data-trp-gettext=\"\" data-no-translation-value=\"\" >Colombia<\/option><option value='Comoros' data-no-translation=\"\" data-trp-gettext=\"\" data-no-translation-value=\"\" >Comoros<\/option><option value='Congo, Democratic Republic of the' data-no-translation=\"\" data-trp-gettext=\"\" data-no-translation-value=\"\" >Congo, Democratic Republic of the<\/option><option value='Congo' data-no-translation=\"\" data-trp-gettext=\"\" data-no-translation-value=\"\" >Congo<\/option><option value='Cook Islands' data-no-translation=\"\" data-trp-gettext=\"\" data-no-translation-value=\"\" >Cook Islands<\/option><option value='Costa Rica' data-no-translation=\"\" data-trp-gettext=\"\" data-no-translation-value=\"\" >Costa Rica<\/option><option value='C\u00f4te d&#039;Ivoire' data-no-translation=\"\" data-trp-gettext=\"\" data-no-translation-value=\"\" >C\u00f4te d&#039;Ivoire<\/option><option value='Croatia' data-no-translation=\"\" data-trp-gettext=\"\" data-no-translation-value=\"\" >Croatia<\/option><option value='Cuba' data-no-translation=\"\" data-trp-gettext=\"\" data-no-translation-value=\"\" >Cuba<\/option><option value='Cura\u00e7ao' data-no-translation=\"\" data-trp-gettext=\"\" data-no-translation-value=\"\" >Cura\u00e7ao<\/option><option value='Cyprus' data-no-translation=\"\" data-trp-gettext=\"\" data-no-translation-value=\"\" >Cyprus<\/option><option value='Czechia' data-no-translation=\"\" data-trp-gettext=\"\" data-no-translation-value=\"\" >Czechia<\/option><option value='Denmark' data-no-translation=\"\" data-trp-gettext=\"\" data-no-translation-value=\"\" >Denmark<\/option><option value='Djibouti' data-no-translation=\"\" data-trp-gettext=\"\" data-no-translation-value=\"\" >Djibouti<\/option><option value='Dominica' data-no-translation=\"\" data-trp-gettext=\"\" data-no-translation-value=\"\" >Dominica<\/option><option value='Dominican Republic' data-no-translation=\"\" data-trp-gettext=\"\" data-no-translation-value=\"\" >Dominican Republic<\/option><option value='Ecuador' data-no-translation=\"\" data-trp-gettext=\"\" data-no-translation-value=\"\" >Ecuador<\/option><option value='Egypt' data-no-translation=\"\" data-trp-gettext=\"\" data-no-translation-value=\"\" >Egypt<\/option><option value='El Salvador' data-no-translation=\"\" data-trp-gettext=\"\" data-no-translation-value=\"\" >El Salvador<\/option><option value='Equatorial Guinea' data-no-translation=\"\" data-trp-gettext=\"\" data-no-translation-value=\"\" >Equatorial Guinea<\/option><option value='Eritrea' data-no-translation=\"\" data-trp-gettext=\"\" data-no-translation-value=\"\" >Eritrea<\/option><option value='Estonia' data-no-translation=\"\" data-trp-gettext=\"\" data-no-translation-value=\"\" >Estonia<\/option><option value='Eswatini' data-no-translation=\"\" data-trp-gettext=\"\" data-no-translation-value=\"\" >Eswatini<\/option><option value='Ethiopia' data-no-translation=\"\" data-trp-gettext=\"\" data-no-translation-value=\"\" >Ethiopia<\/option><option value='Falkland Islands' data-no-translation=\"\" data-trp-gettext=\"\" data-no-translation-value=\"\" >Falkland Islands<\/option><option value='Faroe Islands' data-no-translation=\"\" data-trp-gettext=\"\" data-no-translation-value=\"\" >Faroe Islands<\/option><option value='Fiji' data-no-translation=\"\" data-trp-gettext=\"\" data-no-translation-value=\"\" >Fiji<\/option><option value='Finland' data-no-translation=\"\" data-trp-gettext=\"\" data-no-translation-value=\"\" >Finland<\/option><option value='France' data-no-translation=\"\" data-trp-gettext=\"\" data-no-translation-value=\"\" >France<\/option><option value='French Guiana' data-no-translation=\"\" data-trp-gettext=\"\" data-no-translation-value=\"\" >French Guiana<\/option><option value='French Polynesia' data-no-translation=\"\" data-trp-gettext=\"\" data-no-translation-value=\"\" >French Polynesia<\/option><option value='French Southern Territories' data-no-translation=\"\" data-trp-gettext=\"\" data-no-translation-value=\"\" >French Southern Territories<\/option><option value='Gabon' data-no-translation=\"\" data-trp-gettext=\"\" data-no-translation-value=\"\" >Gabon<\/option><option value='Gambia' data-no-translation=\"\" data-trp-gettext=\"\" data-no-translation-value=\"\" >Gambia<\/option><option value='Georgia' data-no-translation=\"\" data-trp-gettext=\"\" data-no-translation-value=\"\" >Georgia<\/option><option value='Germany' data-no-translation=\"\" data-trp-gettext=\"\" data-no-translation-value=\"\" >Germany<\/option><option value='Ghana' data-no-translation=\"\" data-trp-gettext=\"\" data-no-translation-value=\"\" >Ghana<\/option><option value='Gibraltar' data-no-translation=\"\" data-trp-gettext=\"\" data-no-translation-value=\"\" >Gibraltar<\/option><option value='Greece' data-no-translation=\"\" data-trp-gettext=\"\" data-no-translation-value=\"\" >Greece<\/option><option value='Greenland' data-no-translation=\"\" data-trp-gettext=\"\" data-no-translation-value=\"\" >Greenland<\/option><option value='Grenada' data-no-translation=\"\" data-trp-gettext=\"\" data-no-translation-value=\"\" >Grenada<\/option><option value='Guadeloupe' data-no-translation=\"\" data-trp-gettext=\"\" data-no-translation-value=\"\" >Guadeloupe<\/option><option value='Guatemala' data-no-translation=\"\" data-trp-gettext=\"\" data-no-translation-value=\"\" >Guatemala<\/option><option value='Guernsey' data-no-translation=\"\" data-trp-gettext=\"\" data-no-translation-value=\"\" >Guernsey<\/option><option value='Guinea' data-no-translation=\"\" data-trp-gettext=\"\" data-no-translation-value=\"\" >Guinea<\/option><option value='Guinea-Bissau' data-no-translation=\"\" data-trp-gettext=\"\" data-no-translation-value=\"\" >Guinea-Bissau<\/option><option value='Guyana' data-no-translation=\"\" data-trp-gettext=\"\" data-no-translation-value=\"\" >Guyana<\/option><option value='Haiti' data-no-translation=\"\" data-trp-gettext=\"\" data-no-translation-value=\"\" >Haiti<\/option><option value='Heard Island and McDonald Islands' data-no-translation=\"\" data-trp-gettext=\"\" data-no-translation-value=\"\" >Heard Island and McDonald Islands<\/option><option value='Holy See' data-no-translation=\"\" data-trp-gettext=\"\" data-no-translation-value=\"\" >Holy See<\/option><option value='Honduras' data-no-translation=\"\" data-trp-gettext=\"\" data-no-translation-value=\"\" >Honduras<\/option><option value='Hong Kong' data-no-translation=\"\" data-trp-gettext=\"\" data-no-translation-value=\"\" >Hong Kong<\/option><option value='Hungary' data-no-translation=\"\" data-trp-gettext=\"\" data-no-translation-value=\"\" >Hungary<\/option><option value='Iceland' data-no-translation=\"\" data-trp-gettext=\"\" data-no-translation-value=\"\" >Iceland<\/option><option value='India' data-no-translation=\"\" data-trp-gettext=\"\" data-no-translation-value=\"\" >India<\/option><option value='Indonesia' data-no-translation=\"\" data-trp-gettext=\"\" data-no-translation-value=\"\" >Indonesia<\/option><option value='Iran' data-no-translation=\"\" data-trp-gettext=\"\" data-no-translation-value=\"\" >Iran<\/option><option value='Iraq' data-no-translation=\"\" data-trp-gettext=\"\" data-no-translation-value=\"\" >Iraq<\/option><option value='Ireland' data-no-translation=\"\" data-trp-gettext=\"\" data-no-translation-value=\"\" >Ireland<\/option><option value='Isle of Man' data-no-translation=\"\" data-trp-gettext=\"\" data-no-translation-value=\"\" >Isle of Man<\/option><option value='Israel' data-no-translation=\"\" data-trp-gettext=\"\" data-no-translation-value=\"\" >Israel<\/option><option value='Italy' data-no-translation=\"\" data-trp-gettext=\"\" data-no-translation-value=\"\" >Italy<\/option><option value='Jamaica' data-no-translation=\"\" data-trp-gettext=\"\" data-no-translation-value=\"\" >Jamaica<\/option><option value='Japan' data-no-translation=\"\" data-trp-gettext=\"\" data-no-translation-value=\"\" >Japan<\/option><option value='Jersey' data-no-translation=\"\" data-trp-gettext=\"\" data-no-translation-value=\"\" >Jersey<\/option><option value='Jordan' data-no-translation=\"\" data-trp-gettext=\"\" data-no-translation-value=\"\" >Jordan<\/option><option value='Kazakhstan' data-no-translation=\"\" data-trp-gettext=\"\" data-no-translation-value=\"\" >Kazakhstan<\/option><option value='Kenya' data-no-translation=\"\" data-trp-gettext=\"\" data-no-translation-value=\"\" >Kenya<\/option><option value='Kiribati' data-no-translation=\"\" data-trp-gettext=\"\" data-no-translation-value=\"\" >Kiribati<\/option><option value='Korea, Democratic People&#039;s Republic of' data-no-translation=\"\" data-trp-gettext=\"\" data-no-translation-value=\"\" >Korea, Democratic People&#039;s Republic of<\/option><option value='Korea, Republic of' data-no-translation=\"\" data-trp-gettext=\"\" data-no-translation-value=\"\" >Korea, Republic of<\/option><option value='Kuwait' data-no-translation=\"\" data-trp-gettext=\"\" data-no-translation-value=\"\" >Kuwait<\/option><option value='Kyrgyzstan' data-no-translation=\"\" data-trp-gettext=\"\" data-no-translation-value=\"\" >Kyrgyzstan<\/option><option value='Lao People&#039;s Democratic Republic' data-no-translation=\"\" data-trp-gettext=\"\" data-no-translation-value=\"\" >Lao People&#039;s Democratic Republic<\/option><option value='Latvia' data-no-translation=\"\" data-trp-gettext=\"\" data-no-translation-value=\"\" >Latvia<\/option><option value='Lebanon' data-no-translation=\"\" data-trp-gettext=\"\" data-no-translation-value=\"\" >Lebanon<\/option><option value='Lesotho' data-no-translation=\"\" data-trp-gettext=\"\" data-no-translation-value=\"\" >Lesotho<\/option><option value='Liberia' data-no-translation=\"\" data-trp-gettext=\"\" data-no-translation-value=\"\" >Liberia<\/option><option value='Libya' data-no-translation=\"\" data-trp-gettext=\"\" data-no-translation-value=\"\" >Libya<\/option><option value='Liechtenstein' data-no-translation=\"\" data-trp-gettext=\"\" data-no-translation-value=\"\" >Liechtenstein<\/option><option value='Lithuania' data-no-translation=\"\" data-trp-gettext=\"\" data-no-translation-value=\"\" >Lithuania<\/option><option value='Luxembourg' data-no-translation=\"\" data-trp-gettext=\"\" data-no-translation-value=\"\" >Luxembourg<\/option><option value='Macao' data-no-translation=\"\" data-trp-gettext=\"\" data-no-translation-value=\"\" >Macao<\/option><option value='Madagascar' data-no-translation=\"\" data-trp-gettext=\"\" data-no-translation-value=\"\" >Madagascar<\/option><option value='Malawi' data-no-translation=\"\" data-trp-gettext=\"\" data-no-translation-value=\"\" >Malawi<\/option><option value='Malaysia' data-no-translation=\"\" data-trp-gettext=\"\" data-no-translation-value=\"\" >Malaysia<\/option><option value='Maldives' data-no-translation=\"\" data-trp-gettext=\"\" data-no-translation-value=\"\" >Maldives<\/option><option value='Mali' data-no-translation=\"\" data-trp-gettext=\"\" data-no-translation-value=\"\" >Mali<\/option><option value='Malta' data-no-translation=\"\" data-trp-gettext=\"\" data-no-translation-value=\"\" >Malta<\/option><option value='Marshall Islands' data-no-translation=\"\" data-trp-gettext=\"\" data-no-translation-value=\"\" >Marshall Islands<\/option><option value='Martinique' data-no-translation=\"\" data-trp-gettext=\"\" data-no-translation-value=\"\" >Martinique<\/option><option value='Mauritania' data-no-translation=\"\" data-trp-gettext=\"\" data-no-translation-value=\"\" >Mauritania<\/option><option value='Mauritius' data-no-translation=\"\" data-trp-gettext=\"\" data-no-translation-value=\"\" >Mauritius<\/option><option value='Mayotte' data-no-translation=\"\" data-trp-gettext=\"\" data-no-translation-value=\"\" >Mayotte<\/option><option value='Mexico' data-no-translation=\"\" data-trp-gettext=\"\" data-no-translation-value=\"\" >Mexico<\/option><option value='Micronesia' data-no-translation=\"\" data-trp-gettext=\"\" data-no-translation-value=\"\" >Micronesia<\/option><option value='Moldova' data-no-translation=\"\" data-trp-gettext=\"\" data-no-translation-value=\"\" >Moldova<\/option><option value='Monaco' data-no-translation=\"\" data-trp-gettext=\"\" data-no-translation-value=\"\" >Monaco<\/option><option value='Mongolia' data-no-translation=\"\" data-trp-gettext=\"\" data-no-translation-value=\"\" >Mongolia<\/option><option value='Montenegro' data-no-translation=\"\" data-trp-gettext=\"\" data-no-translation-value=\"\" >Montenegro<\/option><option value='Montserrat' data-no-translation=\"\" data-trp-gettext=\"\" data-no-translation-value=\"\" >Montserrat<\/option><option value='Morocco' data-no-translation=\"\" data-trp-gettext=\"\" data-no-translation-value=\"\" >Morocco<\/option><option value='Mozambique' data-no-translation=\"\" data-trp-gettext=\"\" data-no-translation-value=\"\" >Mozambique<\/option><option value='Myanmar' data-no-translation=\"\" data-trp-gettext=\"\" data-no-translation-value=\"\" >Myanmar<\/option><option value='Namibia' data-no-translation=\"\" data-trp-gettext=\"\" data-no-translation-value=\"\" >Namibia<\/option><option value='Nauru' data-no-translation=\"\" data-trp-gettext=\"\" data-no-translation-value=\"\" >Nauru<\/option><option value='Nepal' data-no-translation=\"\" data-trp-gettext=\"\" data-no-translation-value=\"\" >Nepal<\/option><option value='Netherlands' data-no-translation=\"\" data-trp-gettext=\"\" data-no-translation-value=\"\" >Netherlands<\/option><option value='New Caledonia' data-no-translation=\"\" data-trp-gettext=\"\" data-no-translation-value=\"\" >New Caledonia<\/option><option value='New Zealand' data-no-translation=\"\" data-trp-gettext=\"\" data-no-translation-value=\"\" >New Zealand<\/option><option value='Nicaragua' data-no-translation=\"\" data-trp-gettext=\"\" data-no-translation-value=\"\" >Nicaragua<\/option><option value='Niger' data-no-translation=\"\" data-trp-gettext=\"\" data-no-translation-value=\"\" >Niger<\/option><option value='Nigeria' data-no-translation=\"\" data-trp-gettext=\"\" data-no-translation-value=\"\" >Nigeria<\/option><option value='Niue' data-no-translation=\"\" data-trp-gettext=\"\" data-no-translation-value=\"\" >Niue<\/option><option value='Norfolk Island' data-no-translation=\"\" data-trp-gettext=\"\" data-no-translation-value=\"\" >Norfolk Island<\/option><option value='North Macedonia' data-no-translation=\"\" data-trp-gettext=\"\" data-no-translation-value=\"\" >North Macedonia<\/option><option value='Norway' data-no-translation=\"\" data-trp-gettext=\"\" data-no-translation-value=\"\" >Norway<\/option><option value='Oman' data-no-translation=\"\" data-trp-gettext=\"\" data-no-translation-value=\"\" >Oman<\/option><option value='Pakistan' data-no-translation=\"\" data-trp-gettext=\"\" data-no-translation-value=\"\" >Pakistan<\/option><option value='Palau' data-no-translation=\"\" data-trp-gettext=\"\" data-no-translation-value=\"\" >Palau<\/option><option value='Palestine, State of' data-no-translation=\"\" data-trp-gettext=\"\" data-no-translation-value=\"\" >Palestine, State of<\/option><option value='Panama' data-no-translation=\"\" data-trp-gettext=\"\" data-no-translation-value=\"\" >Panama<\/option><option value='Papua New Guinea' data-no-translation=\"\" data-trp-gettext=\"\" data-no-translation-value=\"\" >Papua New Guinea<\/option><option value='Paraguay' data-no-translation=\"\" data-trp-gettext=\"\" data-no-translation-value=\"\" >Paraguay<\/option><option value='Peru' data-no-translation=\"\" data-trp-gettext=\"\" data-no-translation-value=\"\" >Peru<\/option><option value='Philippines' data-no-translation=\"\" data-trp-gettext=\"\" data-no-translation-value=\"\" >Philippines<\/option><option value='Pitcairn' data-no-translation=\"\" data-trp-gettext=\"\" data-no-translation-value=\"\" >Pitcairn<\/option><option value='Poland' data-no-translation=\"\" data-trp-gettext=\"\" data-no-translation-value=\"\" >Poland<\/option><option value='Portugal' data-no-translation=\"\" data-trp-gettext=\"\" data-no-translation-value=\"\" >Portugal<\/option><option value='Qatar' data-no-translation=\"\" data-trp-gettext=\"\" data-no-translation-value=\"\" >Qatar<\/option><option value='R\u00e9union' data-no-translation=\"\" data-trp-gettext=\"\" data-no-translation-value=\"\" >R\u00e9union<\/option><option value='Romania' data-no-translation=\"\" data-trp-gettext=\"\" data-no-translation-value=\"\" >Romania<\/option><option value='Russian Federation' data-no-translation=\"\" data-trp-gettext=\"\" data-no-translation-value=\"\" >Russian Federation<\/option><option value='Rwanda' data-no-translation=\"\" data-trp-gettext=\"\" data-no-translation-value=\"\" >Rwanda<\/option><option value='Saint Barth\u00e9lemy' data-no-translation=\"\" data-trp-gettext=\"\" data-no-translation-value=\"\" >Saint Barth\u00e9lemy<\/option><option value='Saint Helena, Ascension and Tristan da Cunha' data-no-translation=\"\" data-trp-gettext=\"\" data-no-translation-value=\"\" >Saint Helena, Ascension and Tristan da Cunha<\/option><option value='Saint Kitts and Nevis' data-no-translation=\"\" data-trp-gettext=\"\" data-no-translation-value=\"\" >Saint Kitts and Nevis<\/option><option value='Saint Lucia' data-no-translation=\"\" data-trp-gettext=\"\" data-no-translation-value=\"\" >Saint Lucia<\/option><option value='Saint Martin' data-no-translation=\"\" data-trp-gettext=\"\" data-no-translation-value=\"\" >Saint Martin<\/option><option value='Saint Pierre and Miquelon' data-no-translation=\"\" data-trp-gettext=\"\" data-no-translation-value=\"\" >Saint Pierre and Miquelon<\/option><option value='Saint Vincent and the Grenadines' data-no-translation=\"\" data-trp-gettext=\"\" data-no-translation-value=\"\" >Saint Vincent and the Grenadines<\/option><option value='Samoa' data-no-translation=\"\" data-trp-gettext=\"\" data-no-translation-value=\"\" >Samoa<\/option><option value='San Marino' data-no-translation=\"\" data-trp-gettext=\"\" data-no-translation-value=\"\" >San Marino<\/option><option value='Sao Tome and Principe' data-no-translation=\"\" data-trp-gettext=\"\" data-no-translation-value=\"\" >Sao Tome and Principe<\/option><option value='Saudi Arabia' data-no-translation=\"\" data-trp-gettext=\"\" data-no-translation-value=\"\" >Saudi Arabia<\/option><option value='Senegal' data-no-translation=\"\" data-trp-gettext=\"\" data-no-translation-value=\"\" >Senegal<\/option><option value='Serbia' data-no-translation=\"\" data-trp-gettext=\"\" data-no-translation-value=\"\" >Serbia<\/option><option value='Seychelles' data-no-translation=\"\" data-trp-gettext=\"\" data-no-translation-value=\"\" >Seychelles<\/option><option value='Sierra Leone' data-no-translation=\"\" data-trp-gettext=\"\" data-no-translation-value=\"\" >Sierra Leone<\/option><option value='Singapore' data-no-translation=\"\" data-trp-gettext=\"\" data-no-translation-value=\"\" >Singapore<\/option><option value='Sint Maarten' data-no-translation=\"\" data-trp-gettext=\"\" data-no-translation-value=\"\" >Sint Maarten<\/option><option value='Slovakia' data-no-translation=\"\" data-trp-gettext=\"\" data-no-translation-value=\"\" >Slovakia<\/option><option value='Slovenia' data-no-translation=\"\" data-trp-gettext=\"\" data-no-translation-value=\"\" >Slovenia<\/option><option value='Solomon Islands' data-no-translation=\"\" data-trp-gettext=\"\" data-no-translation-value=\"\" >Solomon Islands<\/option><option value='Somalia' data-no-translation=\"\" data-trp-gettext=\"\" data-no-translation-value=\"\" >Somalia<\/option><option value='South Africa' data-no-translation=\"\" data-trp-gettext=\"\" data-no-translation-value=\"\" >South Africa<\/option><option value='South Georgia and the South Sandwich Islands' data-no-translation=\"\" data-trp-gettext=\"\" data-no-translation-value=\"\" >South Georgia and the South Sandwich Islands<\/option><option value='South Sudan' data-no-translation=\"\" data-trp-gettext=\"\" data-no-translation-value=\"\" >South Sudan<\/option><option value='Spain' data-no-translation=\"\" data-trp-gettext=\"\" data-no-translation-value=\"\" >Spain<\/option><option value='Sri Lanka' data-no-translation=\"\" data-trp-gettext=\"\" data-no-translation-value=\"\" >Sri Lanka<\/option><option value='Sudan' data-no-translation=\"\" data-trp-gettext=\"\" data-no-translation-value=\"\" >Sudan<\/option><option value='Suriname' data-no-translation=\"\" data-trp-gettext=\"\" data-no-translation-value=\"\" >Suriname<\/option><option value='Svalbard and Jan Mayen' data-no-translation=\"\" data-trp-gettext=\"\" data-no-translation-value=\"\" >Svalbard and Jan Mayen<\/option><option value='Sweden' data-no-translation=\"\" data-trp-gettext=\"\" data-no-translation-value=\"\" >Sweden<\/option><option value='Switzerland' data-no-translation=\"\" data-trp-gettext=\"\" data-no-translation-value=\"\" >Switzerland<\/option><option value='Syria Arab Republic' data-no-translation=\"\" data-trp-gettext=\"\" data-no-translation-value=\"\" >Syria Arab Republic<\/option><option value='Taiwan' data-no-translation=\"\" data-trp-gettext=\"\" data-no-translation-value=\"\" >Taiwan<\/option><option value='Tajikistan' data-no-translation=\"\" data-trp-gettext=\"\" data-no-translation-value=\"\" >Tajikistan<\/option><option value='Tanzania, the United Republic of' data-no-translation=\"\" data-trp-gettext=\"\" data-no-translation-value=\"\" >Tanzania, the United Republic of<\/option><option value='Thailand' data-no-translation=\"\" data-trp-gettext=\"\" data-no-translation-value=\"\" >Thailand<\/option><option value='Timor-Leste' data-no-translation=\"\" data-trp-gettext=\"\" data-no-translation-value=\"\" >Timor-Leste<\/option><option value='Togo' data-no-translation=\"\" data-trp-gettext=\"\" data-no-translation-value=\"\" >Togo<\/option><option value='Tokelau' data-no-translation=\"\" data-trp-gettext=\"\" data-no-translation-value=\"\" >Tokelau<\/option><option value='Tonga' data-no-translation=\"\" data-trp-gettext=\"\" data-no-translation-value=\"\" >Tonga<\/option><option value='Trinidad and Tobago' data-no-translation=\"\" data-trp-gettext=\"\" data-no-translation-value=\"\" >Trinidad and Tobago<\/option><option value='Tunisia' data-no-translation=\"\" data-trp-gettext=\"\" data-no-translation-value=\"\" >Tunisia<\/option><option value='T\u00fcrkiye' data-no-translation=\"\" data-trp-gettext=\"\" data-no-translation-value=\"\" >T\u00fcrkiye<\/option><option value='Turkmenistan' data-no-translation=\"\" data-trp-gettext=\"\" data-no-translation-value=\"\" >Turkmenistan<\/option><option value='Turks and Caicos Islands' data-no-translation=\"\" data-trp-gettext=\"\" data-no-translation-value=\"\" >Turks and Caicos Islands<\/option><option value='Tuvalu' data-no-translation=\"\" data-trp-gettext=\"\" data-no-translation-value=\"\" >Tuvalu<\/option><option value='Uganda' data-no-translation=\"\" data-trp-gettext=\"\" data-no-translation-value=\"\" >Uganda<\/option><option value='Ukraine' data-no-translation=\"\" data-trp-gettext=\"\" data-no-translation-value=\"\" >Ukraine<\/option><option value='United Arab Emirates' data-no-translation=\"\" data-trp-gettext=\"\" data-no-translation-value=\"\" >United Arab Emirates<\/option><option value='United Kingdom' data-no-translation=\"\" data-trp-gettext=\"\" data-no-translation-value=\"\" >United Kingdom<\/option><option value='Uruguay' data-no-translation=\"\" data-trp-gettext=\"\" data-no-translation-value=\"\" >Uruguay<\/option><option value='US Minor Outlying Islands' data-no-translation=\"\" data-trp-gettext=\"\" data-no-translation-value=\"\" >US Minor Outlying Islands<\/option><option value='Uzbekistan' data-no-translation=\"\" data-trp-gettext=\"\" data-no-translation-value=\"\" >Uzbekistan<\/option><option value='Vanuatu' data-no-translation=\"\" data-trp-gettext=\"\" data-no-translation-value=\"\" >Vanuatu<\/option><option value='Venezuela' data-no-translation=\"\" data-trp-gettext=\"\" data-no-translation-value=\"\" >Venezuela<\/option><option value='Viet Nam' data-no-translation=\"\" data-trp-gettext=\"\" data-no-translation-value=\"\" >Viet Nam<\/option><option value='Virgin Islands, British' data-no-translation=\"\" data-trp-gettext=\"\" data-no-translation-value=\"\" >Virgin Islands, British<\/option><option value='Virgin Islands, U.S.' data-no-translation=\"\" data-trp-gettext=\"\" data-no-translation-value=\"\" >Virgin Islands, U.S.<\/option><option value='Wallis and Futuna' data-no-translation=\"\" data-trp-gettext=\"\" data-no-translation-value=\"\" >Wallis and Futuna<\/option><option value='Western Sahara' data-no-translation=\"\" data-trp-gettext=\"\" data-no-translation-value=\"\" >Western Sahara<\/option><option value='Yemen' data-no-translation=\"\" data-trp-gettext=\"\" data-no-translation-value=\"\" >Yemen<\/option><option value='Zambia' data-no-translation=\"\" data-trp-gettext=\"\" data-no-translation-value=\"\" >Zambia<\/option><option value='Zimbabwe' data-no-translation=\"\" data-trp-gettext=\"\" data-no-translation-value=\"\" >Zimbabwe<\/option><\/select>\n                                        <label for='input_16_15_6' id='input_16_15_6_label' class='gform-field-label gform-field-label--type-sub' data-no-translation=\"\" data-trp-gettext=\"\">Country<\/label>\n                                    <\/span>\n                    <div class='gf_clear gf_clear_complex'><\/div>\n                <\/div><\/li><li id=\"field_16_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' >Are you able to see clients in person or virtually?<\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_16_16'>\n\t\t\t<li class='gchoice gchoice_16_16_0'>\n\t\t\t\t<input name='input_16' type='radio' value='In person'  id='choice_16_16_0'    \/>\n\t\t\t\t<label for='choice_16_16_0' id='label_16_16_0' class='gform-field-label gform-field-label--type-inline'>In person<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_16_16_1'>\n\t\t\t\t<input name='input_16' type='radio' value='Virtually'  id='choice_16_16_1'    \/>\n\t\t\t\t<label for='choice_16_16_1' id='label_16_16_1' class='gform-field-label gform-field-label--type-inline'>Virtually<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_16_16_2'>\n\t\t\t\t<input name='input_16' type='radio' value='Either'  id='choice_16_16_2'    \/>\n\t\t\t\t<label for='choice_16_16_2' id='label_16_16_2' class='gform-field-label gform-field-label--type-inline'>Either<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_16_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' >Do you carry your own malpractice insurance?<\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_16_17'>\n\t\t\t<li class='gchoice gchoice_16_17_0'>\n\t\t\t\t<input name='input_17' type='radio' value='Yes'  id='choice_16_17_0'    \/>\n\t\t\t\t<label for='choice_16_17_0' id='label_16_17_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_16_17_1'>\n\t\t\t\t<input name='input_17' type='radio' value='No'  id='choice_16_17_1'    \/>\n\t\t\t\t<label for='choice_16_17_1' id='label_16_17_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_16_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' >Do you speak another language, other than English?<\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_16_18'>\n\t\t\t<li class='gchoice gchoice_16_18_0'>\n\t\t\t\t<input name='input_18' type='radio' value='Yes'  id='choice_16_18_0'    \/>\n\t\t\t\t<label for='choice_16_18_0' id='label_16_18_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_16_18_1'>\n\t\t\t\t<input name='input_18' type='radio' value='No'  id='choice_16_18_1'    \/>\n\t\t\t\t<label for='choice_16_18_1' id='label_16_18_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_16_18_2'>\n\t\t\t\t<input name='input_18' type='radio' value='gf_other_choice'  id='choice_16_18_2'   onfocus=\"jQuery(this).next('input').focus();\" \/>\n\t\t\t\t<input class='small' id='input_16_18_other' name='input_18_other' type='text' value='Other' aria-label='Other' onfocus='jQuery(this).prev(&quot;input&quot;)[0].click(); if(jQuery(this).val() == &quot;Other&quot;) { jQuery(this).val(&quot;&quot;); }' onblur='if(jQuery(this).val().replace(&quot; &quot;, &quot;&quot;) == &quot;&quot;) { jQuery(this).val(&quot;Other&quot;); }' data-no-translation-value=\"\" data-no-translation-aria-label=\"\" data-no-translation-onfocus=\"\" data-no-translation-onblur=\"\"   \/>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_16_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' >Have you had cultural competence training in the past 3 years?<\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_16_19'>\n\t\t\t<li class='gchoice gchoice_16_19_0'>\n\t\t\t\t<input name='input_19' type='radio' value='Yes'  id='choice_16_19_0'    \/>\n\t\t\t\t<label for='choice_16_19_0' id='label_16_19_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_16_19_1'>\n\t\t\t\t<input name='input_19' type='radio' value='No'  id='choice_16_19_1'    \/>\n\t\t\t\t<label for='choice_16_19_1' id='label_16_19_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_16_25\" 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' >Have you had training on HIPAA compliance with Telehealth?<\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_16_25'>\n\t\t\t<li class='gchoice gchoice_16_25_0'>\n\t\t\t\t<input name='input_25' type='radio' value='Yes'  id='choice_16_25_0'    \/>\n\t\t\t\t<label for='choice_16_25_0' id='label_16_25_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_16_25_1'>\n\t\t\t\t<input name='input_25' type='radio' value='No'  id='choice_16_25_1'    \/>\n\t\t\t\t<label for='choice_16_25_1' id='label_16_25_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_16_20\" 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' >Please check all modalities that apply to your practice<\/label><div class='ginput_container ginput_container_checkbox'><ul class='gfield_checkbox' id='input_16_20'><li class='gchoice gchoice_16_20_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_20.1' type='checkbox'  value='Individual'  id='choice_16_20_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_16_20_1' id='label_16_20_1' class='gform-field-label gform-field-label--type-inline'>Individual<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_16_20_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_20.2' type='checkbox'  value='Family'  id='choice_16_20_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_16_20_2' id='label_16_20_2' class='gform-field-label gform-field-label--type-inline'>Family<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_16_20_3'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_20.3' type='checkbox'  value='Couples'  id='choice_16_20_3'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_16_20_3' id='label_16_20_3' class='gform-field-label gform-field-label--type-inline'>Couples<\/label>\n\t\t\t\t\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_16_21\" 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_16_21'>Please note practice specialties<\/label><div class='ginput_container ginput_container_text'><input name='input_21' id='input_16_21' type='text' value='' class='medium'      aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_16_22\" 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' >Do you currently offer sliding scale or pro bono services?<\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_16_22'>\n\t\t\t<li class='gchoice gchoice_16_22_0'>\n\t\t\t\t<input name='input_22' type='radio' value='Sliding scale'  id='choice_16_22_0'    \/>\n\t\t\t\t<label for='choice_16_22_0' id='label_16_22_0' class='gform-field-label gform-field-label--type-inline'>Sliding scale<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_16_22_1'>\n\t\t\t\t<input name='input_22' type='radio' value='Pro bono'  id='choice_16_22_1'    \/>\n\t\t\t\t<label for='choice_16_22_1' id='label_16_22_1' class='gform-field-label gform-field-label--type-inline'>Pro bono<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_16_22_2'>\n\t\t\t\t<input name='input_22' type='radio' value='Neither at this time'  id='choice_16_22_2'    \/>\n\t\t\t\t<label for='choice_16_22_2' id='label_16_22_2' class='gform-field-label gform-field-label--type-inline'>Neither at this time<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_16_22_3'>\n\t\t\t\t<input name='input_22' type='radio' value='Both'  id='choice_16_22_3'    \/>\n\t\t\t\t<label for='choice_16_22_3' id='label_16_22_3' class='gform-field-label gform-field-label--type-inline'>Both<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_16_26\" 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' >Were you referred by a current therapist volunteer?<\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_16_26'>\n\t\t\t<li class='gchoice gchoice_16_26_0'>\n\t\t\t\t<input name='input_26' type='radio' value='Yes'  id='choice_16_26_0'    \/>\n\t\t\t\t<label for='choice_16_26_0' id='label_16_26_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_16_26_1'>\n\t\t\t\t<input name='input_26' type='radio' value='No'  id='choice_16_26_1'    \/>\n\t\t\t\t<label for='choice_16_26_1' id='label_16_26_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_16_27\" 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_16_27'>If yes, who?<\/label><div class='ginput_container ginput_container_text'><input name='input_27' id='input_16_27' type='text' value='' class='medium'      aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_16_29\" class=\"gfield gfield--type-section gsection field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><h2 class=\"gsection_title\">Supervision<\/h2><\/li><li id=\"field_16_30\" 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' >Are you interested in providing clinical supervision to other PBCP volunteer therapists?<\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_16_30'>\n\t\t\t<li class='gchoice gchoice_16_30_0'>\n\t\t\t\t<input name='input_30' type='radio' value='Yes'  id='choice_16_30_0'    \/>\n\t\t\t\t<label for='choice_16_30_0' id='label_16_30_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_16_30_1'>\n\t\t\t\t<input name='input_30' type='radio' value='No'  id='choice_16_30_1'    \/>\n\t\t\t\t<label for='choice_16_30_1' id='label_16_30_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_16_30_2'>\n\t\t\t\t<input name='input_30' type='radio' value='Maybe, but need more information'  id='choice_16_30_2'    \/>\n\t\t\t\t<label for='choice_16_30_2' id='label_16_30_2' class='gform-field-label gform-field-label--type-inline'>Maybe, but need more information<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_16_31\" 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' >Have you received training or do you have experience providing clinical supervision?<\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_16_31'>\n\t\t\t<li class='gchoice gchoice_16_31_0'>\n\t\t\t\t<input name='input_31' type='radio' value='Yes'  id='choice_16_31_0'    \/>\n\t\t\t\t<label for='choice_16_31_0' id='label_16_31_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_16_31_1'>\n\t\t\t\t<input name='input_31' type='radio' value='No'  id='choice_16_31_1'    \/>\n\t\t\t\t<label for='choice_16_31_1' id='label_16_31_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_16_32\" class=\"gfield gfield--type-textarea 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_16_32'>Please explain:<\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_32' id='input_16_32' class='textarea large'      aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/li><li id=\"field_16_33\" 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' >Are you interested in being trained to provide clinical supervision?<\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_16_33'>\n\t\t\t<li class='gchoice gchoice_16_33_0'>\n\t\t\t\t<input name='input_33' type='radio' value='Yes'  id='choice_16_33_0'    \/>\n\t\t\t\t<label for='choice_16_33_0' id='label_16_33_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_16_33_1'>\n\t\t\t\t<input name='input_33' type='radio' value='No'  id='choice_16_33_1'    \/>\n\t\t\t\t<label for='choice_16_33_1' id='label_16_33_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_16_33_2'>\n\t\t\t\t<input name='input_33' type='radio' value='Not sure'  id='choice_16_33_2'    \/>\n\t\t\t\t<label for='choice_16_33_2' id='label_16_33_2' class='gform-field-label gform-field-label--type-inline'>Not sure<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_16_34\" 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' >Are you interested in receiving clinical supervision, either one on one or as part of a group?<\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_16_34'>\n\t\t\t<li class='gchoice gchoice_16_34_0'>\n\t\t\t\t<input name='input_34' type='radio' value='Yes'  id='choice_16_34_0'    \/>\n\t\t\t\t<label for='choice_16_34_0' id='label_16_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_16_34_1'>\n\t\t\t\t<input name='input_34' type='radio' value='No'  id='choice_16_34_1'    \/>\n\t\t\t\t<label for='choice_16_34_1' id='label_16_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_16_34_2'>\n\t\t\t\t<input name='input_34' type='radio' value='Maybe'  id='choice_16_34_2'    \/>\n\t\t\t\t<label for='choice_16_34_2' id='label_16_34_2' class='gform-field-label gform-field-label--type-inline'>Maybe<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_16_23\" 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_16_23'>Please tell us why you would like to participate in this project. Thank you!<\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_23' id='input_16_23' class='textarea medium'      aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/li><\/ul><\/div>\n        <div class='gform-footer gform_footer top_label'>  \n            <input type='hidden' class='gform_hidden' name='gform_submission_method' data-js='gform_submission_method_16' value='postback' \/>\n            <input type='hidden' class='gform_hidden' name='gform_theme' data-js='gform_theme_16' id='gform_theme_16' value='legacy' \/>\n            <input type='hidden' class='gform_hidden' name='gform_style_settings' data-js='gform_style_settings_16' id='gform_style_settings_16' value='[]' \/>\n            <input type='hidden' class='gform_hidden' name='is_submit_16' value='1' \/>\n            <input type='hidden' class='gform_hidden' name='gform_submit' value='16' \/>\n            \n            <input type='hidden' class='gform_hidden' name='gform_currency' data-currency='USD' value='HLaji7yegkUXToLDloNXv9kDR2KHj9cm4pEokDUg2fi+8q7ahuFSuIEEFv9duizoiJtpF6mS4fHx4FTqieT5jysuz6tTu3nQXx72KRoPHKrdLUk=' \/>\n            <input type='hidden' class='gform_hidden' name='gform_unique_id' value='' \/>\n            <input type='hidden' class='gform_hidden' name='state_16' value='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' \/>\n            <input type='hidden' autocomplete='off' class='gform_hidden' name='gform_target_page_number_16' id='gform_target_page_number_16' value='0' \/>\n            <input type='hidden' autocomplete='off' class='gform_hidden' name='gform_source_page_number_16' id='gform_source_page_number_16' value='1' \/>\n            <input type='hidden' name='gform_field_values' value='' \/>\n            \n        <\/div>\n                        <input type=\"hidden\" name=\"trp-form-language\" value=\"es\"\/><\/form>\n                        <\/div><script type=\"text\/javascript\">\n\/* <![CDATA[ *\/\n gform.initializeOnLoaded( function() {gformInitSpinner( 16, 'https:\/\/forms.mhamichiana.org\/wp-content\/plugins\/gravityforms\/images\/spinner.svg', true );jQuery('#gform_ajax_frame_16').on('load',function(){var contents = jQuery(this).contents().find('*').html();var is_postback = contents.indexOf('GF_AJAX_POSTBACK') >= 0;if(!is_postback){return;}var form_content = jQuery(this).contents().find('#gform_wrapper_16');var is_confirmation = jQuery(this).contents().find('#gform_confirmation_wrapper_16').length > 0;var is_redirect = contents.indexOf('gformRedirect(){') >= 0;var is_form = form_content.length > 0 && ! is_redirect && ! is_confirmation;var mt = parseInt(jQuery('html').css('margin-top'), 10) + parseInt(jQuery('body').css('margin-top'), 10) + 100;if(is_form){form_content.find('form').css('opacity', 0);jQuery('#gform_wrapper_16').html(form_content.html());if(form_content.hasClass('gform_validation_error')){jQuery('#gform_wrapper_16').addClass('gform_validation_error');} else {jQuery('#gform_wrapper_16').removeClass('gform_validation_error');}setTimeout( function() { \/* delay the scroll by 50 milliseconds to fix a bug in chrome *\/  }, 50 );if(window['gformInitDatepicker']) {gformInitDatepicker();}if(window['gformInitPriceFields']) {gformInitPriceFields();}var current_page = jQuery('#gform_source_page_number_16').val();gformInitSpinner( 16, 'https:\/\/forms.mhamichiana.org\/wp-content\/plugins\/gravityforms\/images\/spinner.svg', true );jQuery(document).trigger('gform_page_loaded', [16, current_page]);window['gf_submitting_16'] = false;}else if(!is_redirect){var confirmation_content = jQuery(this).contents().find('.GF_AJAX_POSTBACK').html();if(!confirmation_content){confirmation_content = contents;}jQuery('#gform_wrapper_16').replaceWith(confirmation_content);jQuery(document).trigger('gform_confirmation_loaded', [16]);window['gf_submitting_16'] = false;wp.a11y.speak(jQuery('#gform_confirmation_message_16').text());}else{jQuery('#gform_16').append(contents);if(window['gformRedirect']) {gformRedirect();}}jQuery(document).trigger(\"gform_pre_post_render\", [{ formId: \"16\", currentPage: \"current_page\", abort: function() { this.preventDefault(); } }]);        if (event && event.defaultPrevented) {                return;        }        const gformWrapperDiv = document.getElementById( \"gform_wrapper_16\" );        if ( gformWrapperDiv ) {            const visibilitySpan = document.createElement( \"span\" );            visibilitySpan.id = \"gform_visibility_test_16\";            gformWrapperDiv.insertAdjacentElement( \"afterend\", visibilitySpan );        }        const visibilityTestDiv = document.getElementById( \"gform_visibility_test_16\" );        let postRenderFired = false;        function triggerPostRender() {            if ( postRenderFired ) {                return;            }            postRenderFired = true;            gform.core.triggerPostRenderEvents( 16, current_page );            if ( visibilityTestDiv ) {                visibilityTestDiv.parentNode.removeChild( visibilityTestDiv );            }        }        function debounce( func, wait, immediate ) {            var timeout;            return function() {                var context = this, args = arguments;                var later = function() {                    timeout = null;                    if ( !immediate ) func.apply( context, args );                };                var callNow = immediate && !timeout;                clearTimeout( timeout );                timeout = setTimeout( later, wait );                if ( callNow ) func.apply( context, args );            };        }        const debouncedTriggerPostRender = debounce( function() {            triggerPostRender();        }, 200 );        if ( visibilityTestDiv && visibilityTestDiv.offsetParent === null ) {            const observer = new MutationObserver( ( mutations ) => {                mutations.forEach( ( mutation ) => {                    if ( mutation.type === 'attributes' && visibilityTestDiv.offsetParent !== null ) {                        debouncedTriggerPostRender();                        observer.disconnect();                    }                });            });            observer.observe( document.body, {                attributes: true,                childList: false,                subtree: true,                attributeFilter: [ 'style', 'class' ],            });        } else {            triggerPostRender();        }    } );} ); \n\/* ]]> *\/\n<\/script>\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\t<\/div>\n\t\t<\/div>\n\t\t\t\t\t<\/div>\n\t\t<\/section>\n\t\t\t\t<\/div>","protected":false},"excerpt":{"rendered":"<p>Volunteer Counselor Form First Name Last Name Email Phone Mailing Address Street Address Address Line 2 City State \/ Province \/ Region ZIP \/ Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCabo VerdeCambodiaCameroonCanadaCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongoCongo, Democratic Republic of theCook IslandsCosta RicaCroatiaCubaCura\u00e7aoCyprusCzechiaC\u00f4te d&#039;IvoireDenmarkDjiboutiDominicaDominican [&hellip;]<\/p>","protected":false},"author":1,"featured_media":0,"parent":0,"menu_order":0,"comment_status":"closed","ping_status":"closed","template":"elementor_header_footer","meta":{"footnotes":""},"class_list":["post-621","page","type-page","status-publish","hentry"],"_links":{"self":[{"href":"https:\/\/forms.mhamichiana.org\/es\/wp-json\/wp\/v2\/pages\/621","targetHints":{"allow":["GET"]}}],"collection":[{"href":"https:\/\/forms.mhamichiana.org\/es\/wp-json\/wp\/v2\/pages"}],"about":[{"href":"https:\/\/forms.mhamichiana.org\/es\/wp-json\/wp\/v2\/types\/page"}],"author":[{"embeddable":true,"href":"https:\/\/forms.mhamichiana.org\/es\/wp-json\/wp\/v2\/users\/1"}],"replies":[{"embeddable":true,"href":"https:\/\/forms.mhamichiana.org\/es\/wp-json\/wp\/v2\/comments?post=621"}],"version-history":[{"count":7,"href":"https:\/\/forms.mhamichiana.org\/es\/wp-json\/wp\/v2\/pages\/621\/revisions"}],"predecessor-version":[{"id":831,"href":"https:\/\/forms.mhamichiana.org\/es\/wp-json\/wp\/v2\/pages\/621\/revisions\/831"}],"wp:attachment":[{"href":"https:\/\/forms.mhamichiana.org\/es\/wp-json\/wp\/v2\/media?parent=621"}],"curies":[{"name":"wp","href":"https:\/\/api.w.org\/{rel}","templated":true}]}}