{"id":723,"date":"2024-10-16T13:30:23","date_gmt":"2024-10-16T17:30:23","guid":{"rendered":"https:\/\/forms.mhamichiana.org\/?page_id=723"},"modified":"2025-08-20T10:44:22","modified_gmt":"2025-08-20T14:44:22","slug":"aplicacion-para-el-proyecto-de-consejeria-pro-bono","status":"publish","type":"page","link":"https:\/\/forms.mhamichiana.org\/es\/aplicacion-para-el-proyecto-de-consejeria-pro-bono\/","title":{"rendered":"Aplicaci\u00f3n para el Proyecto de Consejeria Pro Bono"},"content":{"rendered":"<div data-elementor-type=\"wp-page\" data-elementor-id=\"723\" class=\"elementor elementor-723\" 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\">Aplicaci\u00f3n para el Proyecto de Consejeria Pro Bono\n<\/h1>\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t<div class=\"elementor-element elementor-element-f34d1bc elementor-widget elementor-widget-heading\" data-id=\"f34d1bc\" 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<p class=\"elementor-heading-title elementor-size-default\">Para calificar para los servicios del Proyecto de Consejer\u00eda Pro Bono, por favor de completar esta solicitud. \n\n<\/p>\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t<div class=\"elementor-element elementor-element-600f0d2 elementor-widget elementor-widget-heading\" data-id=\"600f0d2\" 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<p class=\"elementor-heading-title elementor-size-default\"><a href=\"https:\/\/mhamichiana.org\/es\/pro-bono-counseling-project\/\">Obtenga m\u00e1s informaci\u00f3n sobre el programa PBCP\n<\/a><\/p>\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_chrome gform_wrapper gravity-theme gform-theme--no-framework' data-form-theme='gravity-theme' data-form-index='0' id='gform_wrapper_18' style='display:none'>\n                        <div class='gform_heading'>\n\t\t\t\t\t\t\t<p class='gform_required_legend' data-no-translation=\"\" data-trp-gettext=\"\">\"<span class=\"gfield_required gfield_required_asterisk\">*<\/span>\" indica \u00e1reas requeridas<\/p>\n                        <\/div><form method='post' enctype='multipart\/form-data'  id='gform_18'  action='\/es\/aplicacion-para-el-proyecto-de-consejeria-pro-bono\/' data-formid='18' novalidate data-trp-original-action=\"\/es\/aplicacion-para-el-proyecto-de-consejeria-pro-bono\/\">\n                        <div class='gform-body gform_body'><div id='gform_fields_18' class='gform_fields top_label form_sublabel_below description_below validation_below'><div id=\"field_18_41\" class=\"gfield gfield--type-text gfield--width-half hipaa_forms_first_name gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_18_41'>Nombre<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_41' id='input_18_41' type='text' value='' class='large'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_18_42\" class=\"gfield gfield--type-text gfield--width-half hipaa_forms_last_name gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_18_42'>Apellido<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_42' id='input_18_42' type='text' value='' class='large'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_18_3\" class=\"gfield gfield--type-date gfield--input-type-datepicker gfield--datepicker-no-icon gfield--width-third gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_18_3'>Fecha de hoy<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_date'>\n                            <input name='input_3' id='input_18_3' type='text' value='' class='datepicker gform-datepicker mdy datepicker_no_icon gdatepicker-no-icon'   placeholder='mm\/dd\/yyyy' aria-describedby=\"input_18_3_date_format\" aria-invalid=\"false\" aria-required=\"true\" data-no-translation-placeholder=\"\"\/>\n                            <span id='input_18_3_date_format' class='screen-reader-text' data-no-translation=\"\" data-trp-gettext=\"\">MM slash DD slash YYYY<\/span>\n                        <\/div>\n                        <input type='hidden' id='gforms_calendar_icon_input_18_3' class='gform_hidden' value='https:\/\/forms.mhamichiana.org\/wp-content\/plugins\/gravityforms\/images\/datepicker\/datepicker.svg'\/><\/div><div id=\"field_18_4\" class=\"gfield gfield--type-select gfield--width-two-thirds field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_18_4'>Pronombre preferido (opcional)<\/label><div class='ginput_container ginput_container_select'><select name='input_4' id='input_18_4' class='large gfield_select'     aria-invalid=\"false\" ><option value='' selected='selected'><\/option><option value='Ella' >Ella<\/option><option value='El' >El<\/option><option value='Ellos' >Ellos<\/option><\/select><\/div><\/div><fieldset id=\"field_18_5\" class=\"gfield gfield--type-radio gfield--type-choice gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >\u00bfQui\u00e9n est\u00e1 completando esta solicitud?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_18_5'>\n\t\t\t<div class='gchoice gchoice_18_5_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_5' type='radio' value='La estoy completando para mi.'  id='choice_18_5_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_18_5_0' id='label_18_5_0' class='gform-field-label gform-field-label--type-inline'>La estoy completando para mi.<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_18_5_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_5' type='radio' value='La estoy completando para otra persona.'  id='choice_18_5_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_18_5_1' id='label_18_5_1' class='gform-field-label gform-field-label--type-inline'>La estoy completando para otra persona.<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_18_6\" class=\"gfield gfield--type-radio gfield--type-choice gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >Estoy interesado en recibir apoyo entre pares (peer support).<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_18_6'>\n\t\t\t<div class='gchoice gchoice_18_6_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_6' type='radio' value='S\u00ed'  id='choice_18_6_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_18_6_0' id='label_18_6_0' class='gform-field-label gform-field-label--type-inline'>S\u00ed<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_18_6_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_6' type='radio' value='No'  id='choice_18_6_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_18_6_1' id='label_18_6_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_18_6_2'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_6' type='radio' value='Tal vez'  id='choice_18_6_2' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_18_6_2' id='label_18_6_2' class='gform-field-label gform-field-label--type-inline'>Tal vez<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_18_7\" class=\"gfield gfield--type-email gfield--width-seven-twelfths hipaa_forms_email gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_18_7'>Correo electr\u00f3nico<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_email'>\n                            <input name='input_7' id='input_18_7' type='email' value='' class='large'    aria-required=\"true\" aria-invalid=\"false\"  \/>\n                        <\/div><\/div><div id=\"field_18_8\" class=\"gfield gfield--type-date gfield--input-type-datepicker gfield--datepicker-no-icon gfield--width-five-twelfths gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_18_8'>Fecha de nacimiento<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_date'>\n                            <input name='input_8' id='input_18_8' type='text' value='' class='datepicker gform-datepicker mdy datepicker_no_icon gdatepicker-no-icon'   placeholder='mm\/dd\/yyyy' aria-describedby=\"input_18_8_date_format\" aria-invalid=\"false\" aria-required=\"true\" data-no-translation-placeholder=\"\"\/>\n                            <span id='input_18_8_date_format' class='screen-reader-text' data-no-translation=\"\" data-trp-gettext=\"\">MM slash DD slash YYYY<\/span>\n                        <\/div>\n                        <input type='hidden' id='gforms_calendar_icon_input_18_8' class='gform_hidden' value='https:\/\/forms.mhamichiana.org\/wp-content\/plugins\/gravityforms\/images\/datepicker\/datepicker.svg'\/><\/div><div id=\"field_18_9\" class=\"gfield gfield--type-phone gfield--width-full field_sublabel_below gfield--has-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_18_9'>Tel\u00e9fono<\/label><div class='ginput_container ginput_container_phone'><input name='input_9' id='input_18_9' type='tel' value='' class='large'    aria-invalid=\"false\" aria-describedby=\"gfield_description_18_9\"  \/><\/div><div class='gfield_description' id='gfield_description_18_9'>Por favor indique su n\u00famero de tel\u00e9fono de 10 d\u00edgitos incluyendo el c\u00f3digo de \u00e1rea<\/div><\/div><fieldset id=\"field_18_10\" class=\"gfield gfield--type-address gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Direcci\u00f3n<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend>    \n                    <div class='ginput_complex ginput_container has_street has_street2 has_city has_state has_zip ginput_container_address gform-grid-row' id='input_18_10' >\n                         <span class='ginput_full address_line_1 ginput_address_line_1 gform-grid-col' id='input_18_10_1_container' >\n                                        <input type='text' name='input_10.1' id='input_18_10_1' value=''    aria-required='true'    \/>\n                                        <label for='input_18_10_1' id='input_18_10_1_label' class='gform-field-label gform-field-label--type-sub'>Direcci\u00f3n<\/label>\n                                    <\/span><span class='ginput_full address_line_2 ginput_address_line_2 gform-grid-col' id='input_18_10_2_container' >\n                                        <input type='text' name='input_10.2' id='input_18_10_2' value=''     aria-required='false'   \/>\n                                        <label for='input_18_10_2' id='input_18_10_2_label' class='gform-field-label gform-field-label--type-sub'>Direcci\u00f3n l\u00ednea 2<\/label>\n                                    <\/span><span class='ginput_left address_city ginput_address_city gform-grid-col' id='input_18_10_3_container' >\n                                    <input type='text' name='input_10.3' id='input_18_10_3' value=''    aria-required='true'    \/>\n                                    <label for='input_18_10_3' id='input_18_10_3_label' class='gform-field-label gform-field-label--type-sub'>Ciudad<\/label>\n                                 <\/span><span class='ginput_right address_state ginput_address_state gform-grid-col' id='input_18_10_4_container' >\n                                        <input type='text' name='input_10.4' id='input_18_10_4' value=''      aria-required='true'    \/>\n                                        <label for='input_18_10_4' id='input_18_10_4_label' class='gform-field-label gform-field-label--type-sub'>Estado<\/label>\n                                      <\/span><span class='ginput_left address_zip ginput_address_zip gform-grid-col' id='input_18_10_5_container' >\n                                    <input type='text' name='input_10.5' id='input_18_10_5' value=''    aria-required='true'    \/>\n                                    <label for='input_18_10_5' id='input_18_10_5_label' class='gform-field-label gform-field-label--type-sub'>C\u00f3digo postal<\/label>\n                                <\/span><input type='hidden' class='gform_hidden' name='input_10.6' id='input_18_10_6' value='' \/>\n                    <div class='gf_clear gf_clear_complex'><\/div>\n                <\/div><\/fieldset><div id=\"field_18_11\" class=\"gfield gfield--type-text gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_18_11'>\u00bfCu\u00e1l es su idioma preferido?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_11' id='input_18_11' type='text' value='' class='large'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_18_12\" class=\"gfield gfield--type-text gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_18_12'>\u00bfC\u00f3mo se enter\u00f3 del Proyecto de Consejer\u00eda Pro Bono?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_12' id='input_18_12' type='text' value='' class='large'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><fieldset id=\"field_18_30\" class=\"gfield gfield--type-radio gfield--type-choice gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >\u00bfCu\u00e1l es su situaci\u00f3n laboral?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_18_30'>\n\t\t\t<div class='gchoice gchoice_18_30_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_30' type='radio' value='Tiempo Completo'  id='choice_18_30_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_18_30_0' id='label_18_30_0' class='gform-field-label gform-field-label--type-inline'>Tiempo Completo<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_18_30_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_30' type='radio' value='Medio Tiempo'  id='choice_18_30_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_18_30_1' id='label_18_30_1' class='gform-field-label gform-field-label--type-inline'>Medio Tiempo<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_18_30_2'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_30' type='radio' value='Desempleado'  id='choice_18_30_2' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_18_30_2' id='label_18_30_2' class='gform-field-label gform-field-label--type-inline'>Desempleado<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_18_30_3'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_30' type='radio' value='Cuidador'  id='choice_18_30_3' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_18_30_3' id='label_18_30_3' class='gform-field-label gform-field-label--type-inline'>Cuidador<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_18_30_4'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_30' type='radio' value='Otro'  id='choice_18_30_4' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_18_30_4' id='label_18_30_4' class='gform-field-label gform-field-label--type-inline'>Otro<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_18_14\" class=\"gfield gfield--type-text gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_18_14'>\u00bfDe cu\u00e1ntas personas eres responsable financieramente?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_14' id='input_18_14' type='text' value='' class='large'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><fieldset id=\"field_18_15\" class=\"gfield gfield--type-radio gfield--type-choice gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >\u00bfAlguien m\u00e1s en el hogar ayuda econ\u00f3micamente con los gastos del hogar?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_18_15'>\n\t\t\t<div class='gchoice gchoice_18_15_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_15' type='radio' value='S\u00ed'  id='choice_18_15_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_18_15_0' id='label_18_15_0' class='gform-field-label gform-field-label--type-inline'>S\u00ed<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_18_15_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_15' type='radio' value='No'  id='choice_18_15_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_18_15_1' id='label_18_15_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_18_31\" class=\"gfield gfield--type-radio gfield--type-choice gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >Elige el que mejor se adapte a tu situaci\u00f3n:<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_18_31'>\n\t\t\t<div class='gchoice gchoice_18_31_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_31' type='radio' value='Tengo seguro m\u00e9dico a trav\u00e9s de mi trabajo.'  id='choice_18_31_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_18_31_0' id='label_18_31_0' class='gform-field-label gform-field-label--type-inline'>Tengo seguro m\u00e9dico a trav\u00e9s de mi trabajo.<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_18_31_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_31' type='radio' value='Tengo medicaid'  id='choice_18_31_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_18_31_1' id='label_18_31_1' class='gform-field-label gform-field-label--type-inline'>Tengo medicaid<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_18_31_2'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_31' type='radio' value='No tengo seguro medico'  id='choice_18_31_2' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_18_31_2' id='label_18_31_2' class='gform-field-label gform-field-label--type-inline'>No tengo seguro medico<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_18_31_3'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_31' type='radio' value='Tengo seguro a trav\u00e9s de la Ley del Cuidado de Salud a Bajo Precio'  id='choice_18_31_3' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_18_31_3' id='label_18_31_3' class='gform-field-label gform-field-label--type-inline'>Tengo seguro a trav\u00e9s de la Ley del Cuidado de Salud a Bajo Precio<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_18_31_4'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_31' type='radio' value='Tengo medicare'  id='choice_18_31_4' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_18_31_4' id='label_18_31_4' class='gform-field-label gform-field-label--type-inline'>Tengo medicare<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_18_32\" class=\"gfield gfield--type-radio gfield--type-choice gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >Tengo suficiente dinero para pagar las cuentas de mi hogar<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_18_32'>\n\t\t\t<div class='gchoice gchoice_18_32_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_32' type='radio' value='Totalmente de acuerdo'  id='choice_18_32_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_18_32_0' id='label_18_32_0' class='gform-field-label gform-field-label--type-inline'>Totalmente de acuerdo<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_18_32_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_32' type='radio' value='De acuerdo'  id='choice_18_32_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_18_32_1' id='label_18_32_1' class='gform-field-label gform-field-label--type-inline'>De acuerdo<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_18_32_2'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_32' type='radio' value='Neutral'  id='choice_18_32_2' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_18_32_2' id='label_18_32_2' class='gform-field-label gform-field-label--type-inline'>Neutral<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_18_32_3'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_32' type='radio' value='En desacuerdo'  id='choice_18_32_3' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_18_32_3' id='label_18_32_3' class='gform-field-label gform-field-label--type-inline'>En desacuerdo<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_18_32_4'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_32' type='radio' value='Totalmente  en desacuerdo'  id='choice_18_32_4' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_18_32_4' id='label_18_32_4' class='gform-field-label gform-field-label--type-inline'>Totalmente  en desacuerdo<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_18_33\" class=\"gfield gfield--type-radio gfield--type-choice gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >Tengo suficiente dinero para comprar el tipo de ropa que necesito<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_18_33'>\n\t\t\t<div class='gchoice gchoice_18_33_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_33' type='radio' value='Totalmente de acuerdo'  id='choice_18_33_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_18_33_0' id='label_18_33_0' class='gform-field-label gform-field-label--type-inline'>Totalmente de acuerdo<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_18_33_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_33' type='radio' value='De acuerdo'  id='choice_18_33_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_18_33_1' id='label_18_33_1' class='gform-field-label gform-field-label--type-inline'>De acuerdo<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_18_33_2'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_33' type='radio' value='Neutral'  id='choice_18_33_2' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_18_33_2' id='label_18_33_2' class='gform-field-label gform-field-label--type-inline'>Neutral<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_18_33_3'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_33' type='radio' value='En desacuerdo'  id='choice_18_33_3' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_18_33_3' id='label_18_33_3' class='gform-field-label gform-field-label--type-inline'>En desacuerdo<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_18_33_4'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_33' type='radio' value='Totalmente  en desacuerdo'  id='choice_18_33_4' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_18_33_4' id='label_18_33_4' class='gform-field-label gform-field-label--type-inline'>Totalmente  en desacuerdo<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_18_35\" class=\"gfield gfield--type-radio gfield--type-choice gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >Tengo suficiente dinero para pagar mis cuentas m\u00e9dicas<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_18_35'>\n\t\t\t<div class='gchoice gchoice_18_35_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_35' type='radio' value='Totalmente de acuerdo'  id='choice_18_35_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_18_35_0' id='label_18_35_0' class='gform-field-label gform-field-label--type-inline'>Totalmente de acuerdo<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_18_35_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_35' type='radio' value='De acuerdo'  id='choice_18_35_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_18_35_1' id='label_18_35_1' class='gform-field-label gform-field-label--type-inline'>De acuerdo<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_18_35_2'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_35' type='radio' value='Neutral'  id='choice_18_35_2' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_18_35_2' id='label_18_35_2' class='gform-field-label gform-field-label--type-inline'>Neutral<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_18_35_3'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_35' type='radio' value='En desacuerdo'  id='choice_18_35_3' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_18_35_3' id='label_18_35_3' class='gform-field-label gform-field-label--type-inline'>En desacuerdo<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_18_35_4'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_35' type='radio' value='Totalmente  en desacuerdo'  id='choice_18_35_4' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_18_35_4' id='label_18_35_4' class='gform-field-label gform-field-label--type-inline'>Totalmente  en desacuerdo<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_18_34\" class=\"gfield gfield--type-radio gfield--type-choice gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >Tengo suficiente dinero para gastar en actividades de diversi\u00f3n<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_18_34'>\n\t\t\t<div class='gchoice gchoice_18_34_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_34' type='radio' value='Totalmente de acuerdo'  id='choice_18_34_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_18_34_0' id='label_18_34_0' class='gform-field-label gform-field-label--type-inline'>Totalmente de acuerdo<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_18_34_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_34' type='radio' value='De acuerdo'  id='choice_18_34_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_18_34_1' id='label_18_34_1' class='gform-field-label gform-field-label--type-inline'>De acuerdo<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_18_34_2'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_34' type='radio' value='Neutral'  id='choice_18_34_2' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_18_34_2' id='label_18_34_2' class='gform-field-label gform-field-label--type-inline'>Neutral<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_18_34_3'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_34' type='radio' value='En desacuerdo'  id='choice_18_34_3' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_18_34_3' id='label_18_34_3' class='gform-field-label gform-field-label--type-inline'>En desacuerdo<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_18_34_4'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_34' type='radio' value='Totalmente  en desacuerdo'  id='choice_18_34_4' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_18_34_4' id='label_18_34_4' class='gform-field-label gform-field-label--type-inline'>Totalmente  en desacuerdo<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_18_36\" 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\"  ><legend class='gfield_label gform-field-label' >Tengo suficiente dinero para comprar el tipo de comida que necesito<\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_18_36'>\n\t\t\t<div class='gchoice gchoice_18_36_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_36' type='radio' value='Totalmente de acuerdo'  id='choice_18_36_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_18_36_0' id='label_18_36_0' class='gform-field-label gform-field-label--type-inline'>Totalmente de acuerdo<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_18_36_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_36' type='radio' value='De acuerdo'  id='choice_18_36_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_18_36_1' id='label_18_36_1' class='gform-field-label gform-field-label--type-inline'>De acuerdo<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_18_36_2'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_36' type='radio' value='Neutral'  id='choice_18_36_2' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_18_36_2' id='label_18_36_2' class='gform-field-label gform-field-label--type-inline'>Neutral<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_18_36_3'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_36' type='radio' value='En desacuerdo'  id='choice_18_36_3' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_18_36_3' id='label_18_36_3' class='gform-field-label gform-field-label--type-inline'>En desacuerdo<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_18_36_4'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_36' type='radio' value='Totalmente  en desacuerdo'  id='choice_18_36_4' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_18_36_4' id='label_18_36_4' class='gform-field-label gform-field-label--type-inline'>Totalmente  en desacuerdo<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_18_37\" class=\"gfield gfield--type-radio gfield--type-choice gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >Al final del mes tengo suficiente dinero para pagar mis cuentas<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_18_37'>\n\t\t\t<div class='gchoice gchoice_18_37_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_37' type='radio' value='Totalmente de acuerdo'  id='choice_18_37_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_18_37_0' id='label_18_37_0' class='gform-field-label gform-field-label--type-inline'>Totalmente de acuerdo<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_18_37_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_37' type='radio' value='De acuerdo'  id='choice_18_37_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_18_37_1' id='label_18_37_1' class='gform-field-label gform-field-label--type-inline'>De acuerdo<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_18_37_2'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_37' type='radio' value='Neutral'  id='choice_18_37_2' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_18_37_2' id='label_18_37_2' class='gform-field-label gform-field-label--type-inline'>Neutral<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_18_37_3'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_37' type='radio' value='En desacuerdo'  id='choice_18_37_3' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_18_37_3' id='label_18_37_3' class='gform-field-label gform-field-label--type-inline'>En desacuerdo<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_18_37_4'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_37' type='radio' value='Totalmente  en desacuerdo'  id='choice_18_37_4' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_18_37_4' id='label_18_37_4' class='gform-field-label gform-field-label--type-inline'>Totalmente  en desacuerdo<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_18_23\" class=\"gfield gfield--type-radio gfield--type-choice gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >\u00bfEst\u00e1 embarazada o ha estado embarazada en los \u00faltimos 12 meses?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_18_23'>\n\t\t\t<div class='gchoice gchoice_18_23_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_23' type='radio' value='S\u00ed'  id='choice_18_23_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_18_23_0' id='label_18_23_0' class='gform-field-label gform-field-label--type-inline'>S\u00ed<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_18_23_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_23' type='radio' value='No'  id='choice_18_23_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_18_23_1' id='label_18_23_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_18_23_2'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_23' type='radio' value='No aplica'  id='choice_18_23_2' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_18_23_2' id='label_18_23_2' class='gform-field-label gform-field-label--type-inline'>No aplica<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_18_24\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Cu\u00e9ntenos un poco sobre los problemas que est\u00e1n sucediendo en su vida que lo est\u00e1n trayendo a terapia.<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox' id='input_18_24'><div class='gchoice gchoice_18_24_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_24.1' type='checkbox'  value='Dificultad para afrontar problemas, situaciones'  id='choice_18_24_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_18_24_1' id='label_18_24_1' class='gform-field-label gform-field-label--type-inline'>Dificultad para afrontar problemas, situaciones<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_18_24_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_24.2' type='checkbox'  value='Dificultades en las relaciones'  id='choice_18_24_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_18_24_2' id='label_18_24_2' class='gform-field-label gform-field-label--type-inline'>Dificultades en las relaciones<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_18_24_3'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_24.3' type='checkbox'  value='Dolor\/p\u00e9rdida'  id='choice_18_24_3'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_18_24_3' id='label_18_24_3' class='gform-field-label gform-field-label--type-inline'>Dolor\/p\u00e9rdida<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_18_24_4'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_24.4' type='checkbox'  value='Transici\u00f3n de vida'  id='choice_18_24_4'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_18_24_4' id='label_18_24_4' class='gform-field-label gform-field-label--type-inline'>Transici\u00f3n de vida<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_18_24_5'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_24.5' type='checkbox'  value='Problemas en el trabajo'  id='choice_18_24_5'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_18_24_5' id='label_18_24_5' class='gform-field-label gform-field-label--type-inline'>Problemas en el trabajo<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_18_24_6'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_24.6' type='checkbox'  value='Problemas en la escuela'  id='choice_18_24_6'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_18_24_6' id='label_18_24_6' class='gform-field-label gform-field-label--type-inline'>Problemas en la escuela<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_18_24_7'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_24.7' type='checkbox'  value='Enfermedad\/salud'  id='choice_18_24_7'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_18_24_7' id='label_18_24_7' class='gform-field-label gform-field-label--type-inline'>Enfermedad\/salud<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_18_24_8'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_24.8' type='checkbox'  value='Estr\u00e9s financiero'  id='choice_18_24_8'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_18_24_8' id='label_18_24_8' class='gform-field-label gform-field-label--type-inline'>Estr\u00e9s financiero<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_18_24_9'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_24.9' type='checkbox'  value='Problemas familiares'  id='choice_18_24_9'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_18_24_9' id='label_18_24_9' class='gform-field-label gform-field-label--type-inline'>Problemas familiares<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_18_24_11'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_24.11' type='checkbox'  value='Enfermedad mental'  id='choice_18_24_11'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_18_24_11' id='label_18_24_11' class='gform-field-label gform-field-label--type-inline'>Enfermedad mental<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_18_24_12'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_24.12' type='checkbox'  value='Adicciones'  id='choice_18_24_12'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_18_24_12' id='label_18_24_12' class='gform-field-label gform-field-label--type-inline'>Adicciones<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_18_24_13'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_24.13' type='checkbox'  value='Otro:'  id='choice_18_24_13'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_18_24_13' id='label_18_24_13' class='gform-field-label gform-field-label--type-inline'>Otro:<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_18_25\" 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_18_25'>Otro<\/label><div class='ginput_container ginput_container_text'><input name='input_25' id='input_18_25' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_18_40\" class=\"gfield gfield--type-text gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_18_40'>\u00bfHa recibido terapia en el pasado? Si es as\u00ed, \u00bfhace cu\u00e1nto tiempo?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_40' id='input_18_40' type='text' value='' class='large'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_18_39\" class=\"gfield gfield--type-number gfield--width-full field_sublabel_below gfield--has-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_18_39'>\u00bfCu\u00e1ntos d\u00edas en los \u00faltimos 30 d\u00edas dir\u00eda que su salud mental no fue buena (dificultad para afrontar situaciones)?<\/label><div class='ginput_container ginput_container_number'><input name='input_39' id='input_18_39' type='number' step='any' min='0' max='30' value='' class='large'      aria-invalid=\"false\" aria-describedby=\"gfield_instruction_18_39 gfield_description_18_39\" \/><div class='gfield_description instruction' id='gfield_instruction_18_39' data-no-translation=\"\" data-trp-gettext=\"\">Please enter a number from <strong>0<\/strong> to <strong>30<\/strong>.<\/div><\/div><div class='gfield_description' id='gfield_description_18_39'>Por favor indique un n\u00famero del 0 al 30.<\/div><\/div><fieldset id=\"field_18_27\" class=\"gfield gfield--type-radio gfield--type-choice gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >\u00bfCu\u00e1ntos adultos de confianza tienes en tu vida con quienes puedes hablar sobre tu salud mental?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_18_27'>\n\t\t\t<div class='gchoice gchoice_18_27_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_27' type='radio' value='0'  id='choice_18_27_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_18_27_0' id='label_18_27_0' class='gform-field-label gform-field-label--type-inline'>0<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_18_27_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_27' type='radio' value='1'  id='choice_18_27_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_18_27_1' id='label_18_27_1' class='gform-field-label gform-field-label--type-inline'>1<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_18_27_2'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_27' type='radio' value='2 o m\u00e1s'  id='choice_18_27_2' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_18_27_2' id='label_18_27_2' class='gform-field-label gform-field-label--type-inline'>2 o m\u00e1s<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_18_28\" 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_18_28'>Por favor d\u00edganos qu\u00e9 cambios le gustar\u00eda hacer en su vida con la ayuda del Proyecto de Consejer\u00eda Pro Bono.<\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_28' id='input_18_28' class='textarea medium'      aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/div><\/div><\/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_18' value='postback' \/>\n            <input type='hidden' class='gform_hidden' name='gform_theme' data-js='gform_theme_18' id='gform_theme_18' value='gravity-theme' \/>\n            <input type='hidden' class='gform_hidden' name='gform_style_settings' data-js='gform_style_settings_18' id='gform_style_settings_18' value='[]' \/>\n            <input type='hidden' class='gform_hidden' name='is_submit_18' value='1' \/>\n            <input type='hidden' class='gform_hidden' name='gform_submit' value='18' \/>\n            \n            <input type='hidden' class='gform_hidden' name='gform_currency' data-currency='USD' value='+j6uLAIfP2UDVyYT8CeYATWr6F49oH0fTcQQFSFIlx2B3TbCQX6R8P4lYj9s0JHov0TctM9GiYxIA91qfjnex\/ETr0EjlXxArKi3jloA8LB5X8g=' \/>\n            <input type='hidden' class='gform_hidden' name='gform_unique_id' value='' \/>\n            <input type='hidden' class='gform_hidden' name='state_18' 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data-form-theme='gravity-theme' data-form-index='0' id='gform_wrapper_18' style='display:none'>\n                        <div class='gform_heading'>\n                            <h2 class=\"gform_title\">Aplicaci\u00f3n para el Proyecto de Consejeria Pro Bono<\/h2>\n                            <p class='gform_description'><\/p>\n\t\t\t\t\t\t\t<p class='gform_required_legend'>\"<span class=\"gfield_required gfield_required_asterisk\">*<\/span>\" indica \u00e1reas requeridas<\/p>\n                        <\/div><form method='post' enctype='multipart\/form-data'  id='gform_18'  action='\/es\/wp-json\/wp\/v2\/pages\/723' data-formid='18' novalidate data-trp-original-action=\"\/es\/wp-json\/wp\/v2\/pages\/723\">\n                        <div class='gform-body gform_body'><div id='gform_fields_18' class='gform_fields top_label form_sublabel_below description_below validation_below'><div id=\"field_18_41\" class=\"gfield gfield--type-text gfield--width-half hipaa_forms_first_name gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_18_41'>Nombre<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_41' id='input_18_41' type='text' value='' class='large'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_18_42\" class=\"gfield gfield--type-text gfield--width-half hipaa_forms_last_name gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_18_42'>Apellido<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_42' id='input_18_42' type='text' value='' class='large'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_18_3\" class=\"gfield gfield--type-date gfield--input-type-datepicker gfield--datepicker-no-icon gfield--width-third gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_18_3'>Fecha de hoy<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_date'>\n                            <input name='input_3' id='input_18_3' type='text' value='' class='datepicker gform-datepicker mdy datepicker_no_icon gdatepicker-no-icon'   placeholder='mm\/dd\/yyyy' aria-describedby=\"input_18_3_date_format\" aria-invalid=\"false\" aria-required=\"true\"\/>\n                            <span id='input_18_3_date_format' class='screen-reader-text'>MM slash DD slash YYYY<\/span>\n                        <\/div>\n                        <input type='hidden' id='gforms_calendar_icon_input_18_3' class='gform_hidden' value='https:\/\/forms.mhamichiana.org\/wp-content\/plugins\/gravityforms\/images\/datepicker\/datepicker.svg'\/><\/div><div id=\"field_18_4\" class=\"gfield gfield--type-select gfield--width-two-thirds field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_18_4'>Pronombre preferido (opcional)<\/label><div class='ginput_container ginput_container_select'><select name='input_4' id='input_18_4' class='large gfield_select'     aria-invalid=\"false\" ><option value='' selected='selected'><\/option><option value='Ella' >Ella<\/option><option value='El' >El<\/option><option value='Ellos' >Ellos<\/option><\/select><\/div><\/div><fieldset id=\"field_18_5\" class=\"gfield gfield--type-radio gfield--type-choice gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >\u00bfQui\u00e9n est\u00e1 completando esta solicitud?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_18_5'>\n\t\t\t<div class='gchoice gchoice_18_5_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_5' type='radio' value='La estoy completando para mi.'  id='choice_18_5_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_18_5_0' id='label_18_5_0' class='gform-field-label gform-field-label--type-inline'>La estoy completando para mi.<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_18_5_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_5' type='radio' value='La estoy completando para otra persona.'  id='choice_18_5_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_18_5_1' id='label_18_5_1' class='gform-field-label gform-field-label--type-inline'>La estoy completando para otra persona.<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_18_6\" class=\"gfield gfield--type-radio gfield--type-choice gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >Estoy interesado en recibir apoyo entre pares (peer support).<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_18_6'>\n\t\t\t<div class='gchoice gchoice_18_6_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_6' type='radio' value='S\u00ed'  id='choice_18_6_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_18_6_0' id='label_18_6_0' class='gform-field-label gform-field-label--type-inline'>S\u00ed<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_18_6_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_6' type='radio' value='No'  id='choice_18_6_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_18_6_1' id='label_18_6_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_18_6_2'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_6' type='radio' value='Tal vez'  id='choice_18_6_2' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_18_6_2' id='label_18_6_2' class='gform-field-label gform-field-label--type-inline'>Tal vez<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_18_7\" class=\"gfield gfield--type-email gfield--width-seven-twelfths hipaa_forms_email gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_18_7'>Correo electr\u00f3nico<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_email'>\n                            <input name='input_7' id='input_18_7' type='email' value='' class='large'    aria-required=\"true\" aria-invalid=\"false\"  \/>\n                        <\/div><\/div><div id=\"field_18_8\" class=\"gfield gfield--type-date gfield--input-type-datepicker gfield--datepicker-no-icon gfield--width-five-twelfths gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_18_8'>Fecha de nacimiento<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_date'>\n                            <input name='input_8' id='input_18_8' type='text' value='' class='datepicker gform-datepicker mdy datepicker_no_icon gdatepicker-no-icon'   placeholder='mm\/dd\/yyyy' aria-describedby=\"input_18_8_date_format\" aria-invalid=\"false\" aria-required=\"true\"\/>\n                            <span id='input_18_8_date_format' class='screen-reader-text'>MM slash DD slash YYYY<\/span>\n                        <\/div>\n                        <input type='hidden' id='gforms_calendar_icon_input_18_8' class='gform_hidden' value='https:\/\/forms.mhamichiana.org\/wp-content\/plugins\/gravityforms\/images\/datepicker\/datepicker.svg'\/><\/div><div id=\"field_18_9\" class=\"gfield gfield--type-phone gfield--width-full field_sublabel_below gfield--has-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_18_9'>Tel\u00e9fono<\/label><div class='ginput_container ginput_container_phone'><input name='input_9' id='input_18_9' type='tel' value='' class='large'    aria-invalid=\"false\" aria-describedby=\"gfield_description_18_9\"  \/><\/div><div class='gfield_description' id='gfield_description_18_9'>Por favor indique su n\u00famero de tel\u00e9fono de 10 d\u00edgitos incluyendo el c\u00f3digo de \u00e1rea<\/div><\/div><fieldset id=\"field_18_10\" class=\"gfield gfield--type-address gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Direcci\u00f3n<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend>    \n                    <div class='ginput_complex ginput_container has_street has_street2 has_city has_state has_zip ginput_container_address gform-grid-row' id='input_18_10' >\n                         <span class='ginput_full address_line_1 ginput_address_line_1 gform-grid-col' id='input_18_10_1_container' >\n                                        <input type='text' name='input_10.1' id='input_18_10_1' value=''    aria-required='true'    \/>\n                                        <label for='input_18_10_1' id='input_18_10_1_label' class='gform-field-label gform-field-label--type-sub'>Direcci\u00f3n<\/label>\n                                    <\/span><span class='ginput_full address_line_2 ginput_address_line_2 gform-grid-col' id='input_18_10_2_container' >\n                                        <input type='text' name='input_10.2' id='input_18_10_2' value=''     aria-required='false'   \/>\n                                        <label for='input_18_10_2' id='input_18_10_2_label' class='gform-field-label gform-field-label--type-sub'>Direcci\u00f3n l\u00ednea 2<\/label>\n                                    <\/span><span class='ginput_left address_city ginput_address_city gform-grid-col' id='input_18_10_3_container' >\n                                    <input type='text' name='input_10.3' id='input_18_10_3' value=''    aria-required='true'    \/>\n                                    <label for='input_18_10_3' id='input_18_10_3_label' class='gform-field-label gform-field-label--type-sub'>Ciudad<\/label>\n                                 <\/span><span class='ginput_right address_state ginput_address_state gform-grid-col' id='input_18_10_4_container' >\n                                        <input type='text' name='input_10.4' id='input_18_10_4' value=''      aria-required='true'    \/>\n                                        <label for='input_18_10_4' id='input_18_10_4_label' class='gform-field-label gform-field-label--type-sub'>Estado<\/label>\n                                      <\/span><span class='ginput_left address_zip ginput_address_zip gform-grid-col' id='input_18_10_5_container' >\n                                    <input type='text' name='input_10.5' id='input_18_10_5' value=''    aria-required='true'    \/>\n                                    <label for='input_18_10_5' id='input_18_10_5_label' class='gform-field-label gform-field-label--type-sub'>C\u00f3digo postal<\/label>\n                                <\/span><input type='hidden' class='gform_hidden' name='input_10.6' id='input_18_10_6' value='' \/>\n                    <div class='gf_clear gf_clear_complex'><\/div>\n                <\/div><\/fieldset><div id=\"field_18_11\" class=\"gfield gfield--type-text gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_18_11'>\u00bfCu\u00e1l es su idioma preferido?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_11' id='input_18_11' type='text' value='' class='large'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_18_12\" class=\"gfield gfield--type-text gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_18_12'>\u00bfC\u00f3mo se enter\u00f3 del Proyecto de Consejer\u00eda Pro Bono?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_12' id='input_18_12' type='text' value='' class='large'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><fieldset id=\"field_18_30\" class=\"gfield gfield--type-radio gfield--type-choice gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >\u00bfCu\u00e1l es su situaci\u00f3n laboral?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_18_30'>\n\t\t\t<div class='gchoice gchoice_18_30_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_30' type='radio' value='Tiempo Completo'  id='choice_18_30_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_18_30_0' id='label_18_30_0' class='gform-field-label gform-field-label--type-inline'>Tiempo Completo<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_18_30_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_30' type='radio' value='Medio Tiempo'  id='choice_18_30_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_18_30_1' id='label_18_30_1' class='gform-field-label gform-field-label--type-inline'>Medio Tiempo<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_18_30_2'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_30' type='radio' value='Desempleado'  id='choice_18_30_2' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_18_30_2' id='label_18_30_2' class='gform-field-label gform-field-label--type-inline'>Desempleado<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_18_30_3'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_30' type='radio' value='Cuidador'  id='choice_18_30_3' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_18_30_3' id='label_18_30_3' class='gform-field-label gform-field-label--type-inline'>Cuidador<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_18_30_4'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_30' type='radio' value='Otro'  id='choice_18_30_4' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_18_30_4' id='label_18_30_4' class='gform-field-label gform-field-label--type-inline'>Otro<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_18_14\" class=\"gfield gfield--type-text gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_18_14'>\u00bfDe cu\u00e1ntas personas eres responsable financieramente?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_14' id='input_18_14' type='text' value='' class='large'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><fieldset id=\"field_18_15\" class=\"gfield gfield--type-radio gfield--type-choice gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >\u00bfAlguien m\u00e1s en el hogar ayuda econ\u00f3micamente con los gastos del hogar?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_18_15'>\n\t\t\t<div class='gchoice gchoice_18_15_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_15' type='radio' value='S\u00ed'  id='choice_18_15_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_18_15_0' id='label_18_15_0' class='gform-field-label gform-field-label--type-inline'>S\u00ed<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_18_15_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_15' type='radio' value='No'  id='choice_18_15_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_18_15_1' id='label_18_15_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_18_31\" class=\"gfield gfield--type-radio gfield--type-choice gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >Elige el que mejor se adapte a tu situaci\u00f3n:<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_18_31'>\n\t\t\t<div class='gchoice gchoice_18_31_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_31' type='radio' value='Tengo seguro m\u00e9dico a trav\u00e9s de mi trabajo.'  id='choice_18_31_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_18_31_0' id='label_18_31_0' class='gform-field-label gform-field-label--type-inline'>Tengo seguro m\u00e9dico a trav\u00e9s de mi trabajo.<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_18_31_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_31' type='radio' value='Tengo medicaid'  id='choice_18_31_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_18_31_1' id='label_18_31_1' class='gform-field-label gform-field-label--type-inline'>Tengo medicaid<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_18_31_2'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_31' type='radio' value='No tengo seguro medico'  id='choice_18_31_2' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_18_31_2' id='label_18_31_2' class='gform-field-label gform-field-label--type-inline'>No tengo seguro medico<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_18_31_3'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_31' type='radio' value='Tengo seguro a trav\u00e9s de la Ley del Cuidado de Salud a Bajo Precio'  id='choice_18_31_3' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_18_31_3' id='label_18_31_3' class='gform-field-label gform-field-label--type-inline'>Tengo seguro a trav\u00e9s de la Ley del Cuidado de Salud a Bajo Precio<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_18_31_4'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_31' type='radio' value='Tengo medicare'  id='choice_18_31_4' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_18_31_4' id='label_18_31_4' class='gform-field-label gform-field-label--type-inline'>Tengo medicare<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_18_32\" class=\"gfield gfield--type-radio gfield--type-choice gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >Tengo suficiente dinero para pagar las cuentas de mi hogar<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_18_32'>\n\t\t\t<div class='gchoice gchoice_18_32_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_32' type='radio' value='Totalmente de acuerdo'  id='choice_18_32_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_18_32_0' id='label_18_32_0' class='gform-field-label gform-field-label--type-inline'>Totalmente de acuerdo<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_18_32_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_32' type='radio' value='De acuerdo'  id='choice_18_32_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_18_32_1' id='label_18_32_1' class='gform-field-label gform-field-label--type-inline'>De acuerdo<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_18_32_2'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_32' type='radio' value='Neutral'  id='choice_18_32_2' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_18_32_2' id='label_18_32_2' class='gform-field-label gform-field-label--type-inline'>Neutral<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_18_32_3'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_32' type='radio' value='En desacuerdo'  id='choice_18_32_3' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_18_32_3' id='label_18_32_3' class='gform-field-label gform-field-label--type-inline'>En desacuerdo<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_18_32_4'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_32' type='radio' value='Totalmente  en desacuerdo'  id='choice_18_32_4' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_18_32_4' id='label_18_32_4' class='gform-field-label gform-field-label--type-inline'>Totalmente  en desacuerdo<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_18_33\" class=\"gfield gfield--type-radio gfield--type-choice gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >Tengo suficiente dinero para comprar el tipo de ropa que necesito<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_18_33'>\n\t\t\t<div class='gchoice gchoice_18_33_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_33' type='radio' value='Totalmente de acuerdo'  id='choice_18_33_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_18_33_0' id='label_18_33_0' class='gform-field-label gform-field-label--type-inline'>Totalmente de acuerdo<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_18_33_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_33' type='radio' value='De acuerdo'  id='choice_18_33_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_18_33_1' id='label_18_33_1' class='gform-field-label gform-field-label--type-inline'>De acuerdo<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_18_33_2'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_33' type='radio' value='Neutral'  id='choice_18_33_2' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_18_33_2' id='label_18_33_2' class='gform-field-label gform-field-label--type-inline'>Neutral<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_18_33_3'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_33' type='radio' value='En desacuerdo'  id='choice_18_33_3' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_18_33_3' id='label_18_33_3' class='gform-field-label gform-field-label--type-inline'>En desacuerdo<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_18_33_4'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_33' type='radio' value='Totalmente  en desacuerdo'  id='choice_18_33_4' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_18_33_4' id='label_18_33_4' class='gform-field-label gform-field-label--type-inline'>Totalmente  en desacuerdo<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_18_35\" class=\"gfield gfield--type-radio gfield--type-choice gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >Tengo suficiente dinero para pagar mis cuentas m\u00e9dicas<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_18_35'>\n\t\t\t<div class='gchoice gchoice_18_35_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_35' type='radio' value='Totalmente de acuerdo'  id='choice_18_35_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_18_35_0' id='label_18_35_0' class='gform-field-label gform-field-label--type-inline'>Totalmente de acuerdo<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_18_35_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_35' type='radio' value='De acuerdo'  id='choice_18_35_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_18_35_1' id='label_18_35_1' class='gform-field-label gform-field-label--type-inline'>De acuerdo<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_18_35_2'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_35' type='radio' value='Neutral'  id='choice_18_35_2' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_18_35_2' id='label_18_35_2' class='gform-field-label gform-field-label--type-inline'>Neutral<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_18_35_3'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_35' type='radio' value='En desacuerdo'  id='choice_18_35_3' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_18_35_3' id='label_18_35_3' class='gform-field-label gform-field-label--type-inline'>En desacuerdo<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_18_35_4'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_35' type='radio' value='Totalmente  en desacuerdo'  id='choice_18_35_4' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_18_35_4' id='label_18_35_4' class='gform-field-label gform-field-label--type-inline'>Totalmente  en desacuerdo<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_18_34\" class=\"gfield gfield--type-radio gfield--type-choice gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >Tengo suficiente dinero para gastar en actividades de diversi\u00f3n<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_18_34'>\n\t\t\t<div class='gchoice gchoice_18_34_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_34' type='radio' value='Totalmente de acuerdo'  id='choice_18_34_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_18_34_0' id='label_18_34_0' class='gform-field-label gform-field-label--type-inline'>Totalmente de acuerdo<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_18_34_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_34' type='radio' value='De acuerdo'  id='choice_18_34_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_18_34_1' id='label_18_34_1' class='gform-field-label gform-field-label--type-inline'>De acuerdo<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_18_34_2'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_34' type='radio' value='Neutral'  id='choice_18_34_2' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_18_34_2' id='label_18_34_2' class='gform-field-label gform-field-label--type-inline'>Neutral<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_18_34_3'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_34' type='radio' value='En desacuerdo'  id='choice_18_34_3' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_18_34_3' id='label_18_34_3' class='gform-field-label gform-field-label--type-inline'>En desacuerdo<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_18_34_4'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_34' type='radio' value='Totalmente  en desacuerdo'  id='choice_18_34_4' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_18_34_4' id='label_18_34_4' class='gform-field-label gform-field-label--type-inline'>Totalmente  en desacuerdo<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_18_36\" 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\"  ><legend class='gfield_label gform-field-label' >Tengo suficiente dinero para comprar el tipo de comida que necesito<\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_18_36'>\n\t\t\t<div class='gchoice gchoice_18_36_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_36' type='radio' value='Totalmente de acuerdo'  id='choice_18_36_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_18_36_0' id='label_18_36_0' class='gform-field-label gform-field-label--type-inline'>Totalmente de acuerdo<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_18_36_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_36' type='radio' value='De acuerdo'  id='choice_18_36_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_18_36_1' id='label_18_36_1' class='gform-field-label gform-field-label--type-inline'>De acuerdo<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_18_36_2'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_36' type='radio' value='Neutral'  id='choice_18_36_2' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_18_36_2' id='label_18_36_2' class='gform-field-label gform-field-label--type-inline'>Neutral<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_18_36_3'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_36' type='radio' value='En desacuerdo'  id='choice_18_36_3' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_18_36_3' id='label_18_36_3' class='gform-field-label gform-field-label--type-inline'>En desacuerdo<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_18_36_4'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_36' type='radio' value='Totalmente  en desacuerdo'  id='choice_18_36_4' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_18_36_4' id='label_18_36_4' class='gform-field-label gform-field-label--type-inline'>Totalmente  en desacuerdo<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_18_37\" class=\"gfield gfield--type-radio gfield--type-choice gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >Al final del mes tengo suficiente dinero para pagar mis cuentas<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_18_37'>\n\t\t\t<div class='gchoice gchoice_18_37_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_37' type='radio' value='Totalmente de acuerdo'  id='choice_18_37_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_18_37_0' id='label_18_37_0' class='gform-field-label gform-field-label--type-inline'>Totalmente de acuerdo<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_18_37_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_37' type='radio' value='De acuerdo'  id='choice_18_37_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_18_37_1' id='label_18_37_1' class='gform-field-label gform-field-label--type-inline'>De acuerdo<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_18_37_2'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_37' type='radio' value='Neutral'  id='choice_18_37_2' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_18_37_2' id='label_18_37_2' class='gform-field-label gform-field-label--type-inline'>Neutral<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_18_37_3'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_37' type='radio' value='En desacuerdo'  id='choice_18_37_3' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_18_37_3' id='label_18_37_3' class='gform-field-label gform-field-label--type-inline'>En desacuerdo<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_18_37_4'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_37' type='radio' value='Totalmente  en desacuerdo'  id='choice_18_37_4' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_18_37_4' id='label_18_37_4' class='gform-field-label gform-field-label--type-inline'>Totalmente  en desacuerdo<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_18_23\" class=\"gfield gfield--type-radio gfield--type-choice gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >\u00bfEst\u00e1 embarazada o ha estado embarazada en los \u00faltimos 12 meses?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_18_23'>\n\t\t\t<div class='gchoice gchoice_18_23_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_23' type='radio' value='S\u00ed'  id='choice_18_23_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_18_23_0' id='label_18_23_0' class='gform-field-label gform-field-label--type-inline'>S\u00ed<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_18_23_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_23' type='radio' value='No'  id='choice_18_23_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_18_23_1' id='label_18_23_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_18_23_2'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_23' type='radio' value='No aplica'  id='choice_18_23_2' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_18_23_2' id='label_18_23_2' class='gform-field-label gform-field-label--type-inline'>No aplica<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_18_24\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Cu\u00e9ntenos un poco sobre los problemas que est\u00e1n sucediendo en su vida que lo est\u00e1n trayendo a terapia.<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox' id='input_18_24'><div class='gchoice gchoice_18_24_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_24.1' type='checkbox'  value='Dificultad para afrontar problemas, situaciones'  id='choice_18_24_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_18_24_1' id='label_18_24_1' class='gform-field-label gform-field-label--type-inline'>Dificultad para afrontar problemas, situaciones<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_18_24_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_24.2' type='checkbox'  value='Dificultades en las relaciones'  id='choice_18_24_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_18_24_2' id='label_18_24_2' class='gform-field-label gform-field-label--type-inline'>Dificultades en las relaciones<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_18_24_3'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_24.3' type='checkbox'  value='Dolor\/p\u00e9rdida'  id='choice_18_24_3'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_18_24_3' id='label_18_24_3' class='gform-field-label gform-field-label--type-inline'>Dolor\/p\u00e9rdida<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_18_24_4'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_24.4' type='checkbox'  value='Transici\u00f3n de vida'  id='choice_18_24_4'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_18_24_4' id='label_18_24_4' class='gform-field-label gform-field-label--type-inline'>Transici\u00f3n de vida<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_18_24_5'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_24.5' type='checkbox'  value='Problemas en el trabajo'  id='choice_18_24_5'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_18_24_5' id='label_18_24_5' class='gform-field-label gform-field-label--type-inline'>Problemas en el trabajo<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_18_24_6'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_24.6' type='checkbox'  value='Problemas en la escuela'  id='choice_18_24_6'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_18_24_6' id='label_18_24_6' class='gform-field-label gform-field-label--type-inline'>Problemas en la escuela<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_18_24_7'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_24.7' type='checkbox'  value='Enfermedad\/salud'  id='choice_18_24_7'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_18_24_7' id='label_18_24_7' class='gform-field-label gform-field-label--type-inline'>Enfermedad\/salud<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_18_24_8'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_24.8' type='checkbox'  value='Estr\u00e9s financiero'  id='choice_18_24_8'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_18_24_8' id='label_18_24_8' class='gform-field-label gform-field-label--type-inline'>Estr\u00e9s financiero<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_18_24_9'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_24.9' type='checkbox'  value='Problemas familiares'  id='choice_18_24_9'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_18_24_9' id='label_18_24_9' class='gform-field-label gform-field-label--type-inline'>Problemas familiares<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_18_24_11'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_24.11' type='checkbox'  value='Enfermedad mental'  id='choice_18_24_11'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_18_24_11' id='label_18_24_11' class='gform-field-label gform-field-label--type-inline'>Enfermedad mental<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_18_24_12'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_24.12' type='checkbox'  value='Adicciones'  id='choice_18_24_12'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_18_24_12' id='label_18_24_12' class='gform-field-label gform-field-label--type-inline'>Adicciones<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_18_24_13'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_24.13' type='checkbox'  value='Otro:'  id='choice_18_24_13'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_18_24_13' id='label_18_24_13' class='gform-field-label gform-field-label--type-inline'>Otro:<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_18_25\" 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_18_25'>Otro<\/label><div class='ginput_container ginput_container_text'><input name='input_25' id='input_18_25' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_18_40\" class=\"gfield gfield--type-text gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_18_40'>\u00bfHa recibido terapia en el pasado? Si es as\u00ed, \u00bfhace cu\u00e1nto tiempo?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_40' id='input_18_40' type='text' value='' class='large'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_18_39\" class=\"gfield gfield--type-number gfield--width-full field_sublabel_below gfield--has-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_18_39'>\u00bfCu\u00e1ntos d\u00edas en los \u00faltimos 30 d\u00edas dir\u00eda que su salud mental no fue buena (dificultad para afrontar situaciones)?<\/label><div class='ginput_container ginput_container_number'><input name='input_39' id='input_18_39' type='number' step='any' min='0' max='30' value='' class='large'      aria-invalid=\"false\" aria-describedby=\"gfield_instruction_18_39 gfield_description_18_39\" \/><div class='gfield_description instruction' id='gfield_instruction_18_39'>Please enter a number from <strong>0<\/strong> to <strong>30<\/strong>.<\/div><\/div><div class='gfield_description' id='gfield_description_18_39'>Por favor indique un n\u00famero del 0 al 30.<\/div><\/div><fieldset id=\"field_18_27\" class=\"gfield gfield--type-radio gfield--type-choice gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >\u00bfCu\u00e1ntos adultos de confianza tienes en tu vida con quienes puedes hablar sobre tu salud mental?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_18_27'>\n\t\t\t<div class='gchoice gchoice_18_27_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_27' type='radio' value='0'  id='choice_18_27_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_18_27_0' id='label_18_27_0' class='gform-field-label gform-field-label--type-inline'>0<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_18_27_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_27' type='radio' value='1'  id='choice_18_27_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_18_27_1' id='label_18_27_1' class='gform-field-label gform-field-label--type-inline'>1<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_18_27_2'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_27' type='radio' value='2 o m\u00e1s'  id='choice_18_27_2' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_18_27_2' id='label_18_27_2' class='gform-field-label gform-field-label--type-inline'>2 o m\u00e1s<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_18_28\" 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_18_28'>Por favor d\u00edganos qu\u00e9 cambios le gustar\u00eda hacer en su vida con la ayuda del Proyecto de Consejer\u00eda Pro Bono.<\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_28' id='input_18_28' class='textarea medium'      aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/div><\/div><\/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_18' value='postback' \/>\n            <input type='hidden' class='gform_hidden' name='gform_theme' data-js='gform_theme_18' id='gform_theme_18' 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