{"id":226,"date":"2020-09-09T19:39:36","date_gmt":"2020-09-09T19:39:36","guid":{"rendered":"https:\/\/gbcmt.org\/counseling\/?page_id=226"},"modified":"2025-03-10T15:56:54","modified_gmt":"2025-03-10T15:56:54","slug":"online-form","status":"publish","type":"page","link":"https:\/\/gbcmt.org\/counseling\/getting-started\/online-form\/","title":{"rendered":"Counseling Request Form"},"content":{"rendered":"<p>[et_pb_section fb_built=&#8221;1&#8243; fullwidth=&#8221;on&#8221; admin_label=&#8221;Header&#8221; _builder_version=&#8221;4.16&#8243; global_colors_info=&#8221;{}&#8221;][et_pb_fullwidth_header title=&#8221;Counseling Request Form&#8221; text_orientation=&#8221;center&#8221; _builder_version=&#8221;4.16&#8243; title_font=&#8221;Didact Gothic||||||||&#8221; title_font_size=&#8221;60px&#8221; title_line_height=&#8221;1.3em&#8221; content_font=&#8221;||||||||&#8221; content_font_size=&#8221;16px&#8221; content_line_height=&#8221;2em&#8221; subhead_font=&#8221;Didact Gothic||||||||&#8221; subhead_font_size=&#8221;20px&#8221; subhead_line_height=&#8221;1.8em&#8221; background_color=&#8221;rgba(0,0,0,0)&#8221; use_background_color_gradient=&#8221;on&#8221; background_color_gradient_type=&#8221;circular&#8221; background_color_gradient_stops=&#8221;rgba(64,100,156,0.65) 0%|rgba(31,41,82,0.83) 53%&#8221; background_color_gradient_overlays_image=&#8221;on&#8221; background_color_gradient_start=&#8221;rgba(64,100,156,0.65)&#8221; background_color_gradient_end=&#8221;rgba(31,41,82,0.83)&#8221; background_color_gradient_end_position=&#8221;53%&#8221; background_image=&#8221;https:\/\/gbcmt.org\/counseling\/wp-content\/uploads\/2020\/09\/pencils_blackwhite.jpg&#8221; custom_button_one=&#8221;on&#8221; button_one_text_size=&#8221;16px&#8221; button_one_text_color=&#8221;#ffffff&#8221; button_one_bg_color=&#8221;#a0beef&#8221; button_one_border_width=&#8221;8px&#8221; button_one_border_color=&#8221;rgba(0,0,0,0)&#8221; button_one_border_radius=&#8221;0px&#8221; button_one_letter_spacing=&#8221;3px&#8221; button_one_font=&#8221;Didact Gothic|700||on|||||&#8221; button_one_use_icon=&#8221;off&#8221; custom_button_two=&#8221;on&#8221; button_two_text_size=&#8221;16px&#8221; button_two_text_color=&#8221;#34587c&#8221; button_two_bg_color=&#8221;#ffffff&#8221; button_two_border_width=&#8221;8px&#8221; button_two_border_color=&#8221;rgba(0,0,0,0)&#8221; button_two_border_radius=&#8221;0px&#8221; button_two_letter_spacing=&#8221;3px&#8221; button_two_font=&#8221;Didact Gothic|700||on|||||&#8221; button_two_use_icon=&#8221;off&#8221; custom_padding=&#8221;1vw||1vw||false|false&#8221; custom_padding_tablet=&#8221;&#8221; custom_padding_phone=&#8221;||80px&#8221; custom_padding_last_edited=&#8221;on|phone&#8221; animation_style=&#8221;fade&#8221; animation_starting_opacity=&#8221;45%&#8221; title_font_size_tablet=&#8221;40px&#8221; title_font_size_phone=&#8221;30px&#8221; title_font_size_last_edited=&#8221;on|phone&#8221; subhead_font_size_tablet=&#8221;&#8221; subhead_font_size_phone=&#8221;18px&#8221; subhead_font_size_last_edited=&#8221;on|phone&#8221; global_colors_info=&#8221;{}&#8221;][\/et_pb_fullwidth_header][\/et_pb_section][et_pb_section fb_built=&#8221;1&#8243; _builder_version=&#8221;4.16&#8243; _module_preset=&#8221;default&#8221; global_colors_info=&#8221;{}&#8221;][et_pb_row _builder_version=&#8221;4.16&#8243; _module_preset=&#8221;default&#8221; global_colors_info=&#8221;{}&#8221;][et_pb_column type=&#8221;4_4&#8243; _builder_version=&#8221;4.16&#8243; _module_preset=&#8221;default&#8221; global_colors_info=&#8221;{}&#8221;][et_pb_text _builder_version=&#8221;4.27.4&#8243; _module_preset=&#8221;default&#8221; hover_enabled=&#8221;0&#8243; global_colors_info=&#8221;{}&#8221; sticky_enabled=&#8221;0&#8243;]<\/p>\n<h3>You will not be able to save your progress so plan to spend roughly 30 mins preparing this form, etc.<\/h3>\n<p>&nbsp;<\/p>\n<h3>Due to the high volume of counseling requests, there may be an extended wait time of a couple of months.<\/h3>\n<p>[\/et_pb_text][et_pb_divider _builder_version=&#8221;4.16&#8243; _module_preset=&#8221;default&#8221; global_colors_info=&#8221;{}&#8221;][\/et_pb_divider][et_pb_text _builder_version=&#8221;4.16&#8243; _module_preset=&#8221;default&#8221; global_colors_info=&#8221;{}&#8221;]<\/p>\n<p><span><script type=\"text\/javascript\">\n\/* <![CDATA[ *\/\nvar gform;gform||(document.addEventListener(\"gform_main_scripts_loaded\",function(){gform.scriptsLoaded=!0}),document.addEventListener(\"gform\/theme\/scripts_loaded\",function(){gform.themeScriptsLoaded=!0}),window.addEventListener(\"DOMContentLoaded\",function(){gform.domLoaded=!0}),gform={domLoaded:!1,scriptsLoaded:!1,themeScriptsLoaded:!1,isFormEditor:()=>\"function\"==typeof InitializeEditor,callIfLoaded:function(o){return!(!gform.domLoaded||!gform.scriptsLoaded||!gform.themeScriptsLoaded&&!gform.isFormEditor()||(gform.isFormEditor()&&console.warn(\"The use of gform.initializeOnLoaded() is deprecated in the form editor context and will be removed in Gravity Forms 3.1.\"),o(),0))},initializeOnLoaded:function(o){gform.callIfLoaded(o)||(document.addEventListener(\"gform_main_scripts_loaded\",()=>{gform.scriptsLoaded=!0,gform.callIfLoaded(o)}),document.addEventListener(\"gform\/theme\/scripts_loaded\",()=>{gform.themeScriptsLoaded=!0,gform.callIfLoaded(o)}),window.addEventListener(\"DOMContentLoaded\",()=>{gform.domLoaded=!0,gform.callIfLoaded(o)}))},hooks:{action:{},filter:{}},addAction:function(o,r,e,t){gform.addHook(\"action\",o,r,e,t)},addFilter:function(o,r,e,t){gform.addHook(\"filter\",o,r,e,t)},doAction:function(o){gform.doHook(\"action\",o,arguments)},applyFilters:function(o){return gform.doHook(\"filter\",o,arguments)},removeAction:function(o,r){gform.removeHook(\"action\",o,r)},removeFilter:function(o,r,e){gform.removeHook(\"filter\",o,r,e)},addHook:function(o,r,e,t,n){null==gform.hooks[o][r]&&(gform.hooks[o][r]=[]);var d=gform.hooks[o][r];null==n&&(n=r+\"_\"+d.length),gform.hooks[o][r].push({tag:n,callable:e,priority:t=null==t?10:t})},doHook:function(r,o,e){var t;if(e=Array.prototype.slice.call(e,1),null!=gform.hooks[r][o]&&((o=gform.hooks[r][o]).sort(function(o,r){return o.priority-r.priority}),o.forEach(function(o){\"function\"!=typeof(t=o.callable)&&(t=window[t]),\"action\"==r?t.apply(null,e):e[0]=t.apply(null,e)})),\"filter\"==r)return e[0]},removeHook:function(o,r,t,n){var e;null!=gform.hooks[o][r]&&(e=(e=gform.hooks[o][r]).filter(function(o,r,e){return!!(null!=n&&n!=o.tag||null!=t&&t!=o.priority)}),gform.hooks[o][r]=e)}});\n\/* ]]> *\/\n<\/script>\n\n                <div class='gf_browser_gecko gform_wrapper gform_legacy_markup_wrapper gform-theme--no-framework' data-form-theme='legacy' data-form-index='0' id='gform_wrapper_1' style='display:none'><div id='gf_1' class='gform_anchor' tabindex='-1'><\/div><form method='post' enctype='multipart\/form-data'  id='gform_1'  action='\/counseling\/wp-json\/wp\/v2\/pages\/226#gf_1' data-formid='1' novalidate>\n        <div id='gf_progressbar_wrapper_1' class='gf_progressbar_wrapper' data-start-at-zero=''>\n        \t<h3 class=\"gf_progressbar_title\">Step <span class='gf_step_current_page'>1<\/span> of <span class='gf_step_page_count'>8<\/span><span class='gf_step_page_name'><\/span>\n        \t<\/h3>\n            <div class='gf_progressbar gf_progressbar_blue' aria-hidden='true'>\n                <div class='gf_progressbar_percentage percentbar_blue percentbar_12' style='width:12%;'><span>12%<\/span><\/div>\n            <\/div><\/div>\n                        <div class='gform-body gform_body'><div id='gform_page_1_1' class='gform_page ' data-js='page-field-id-0' >\n\t\t\t\t\t<div class='gform_page_fields'><ul id='gform_fields_1' class='gform_fields top_label form_sublabel_below description_below validation_below'><li id=\"field_1_15\" class=\"gfield gfield--type-html gfield--input-type-html gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><ol>\n  <li>Our Counseling:\nIn association with Grace Bible Church (GBC), the Community of Grace Biblical Counseling Center offers Biblical Counseling. Biblical Counseling refers to a philosophy of counseling that is faith-based, believing that the Bible is God\u2019s word to mankind to be applied to the struggles of life that we all suffer. We believe that the Bible is without error, is authoritative, and is sufficient to provide God\u2019s answers to the spiritual issues of life, conduct, and relationships. We do not base our counseling on psychology. \nIf you have questions relating to legal, financial, medical, or technical matters, it is best to seek advice from others in those specific fields. Our counselors will be happy to cooperate with those advisors and help you to gain biblical perspectives and seek biblical solutions. \nAs an expression of our love for the Lord Jesus Christ and our desire to serve the community that we live in, our counseling is free of charge.  <\/li>\n  <li>Our Counselors:\nAll of our counselors have completed a training process to equip them to competently use the Bible as their source of authority. While a number of our counselors are certified through the Association of Certified Biblical Counselors (ACBC) or a similar certification organization, none are licensed by the state of Montana. \nGBC is active in training others to be Biblical Counselors.  Part of their training is to observe counseling sessions.  Therefore, there may be another person sitting in during your counseling sessions. They are bound by the same confidentiality guidelines as outlined below. <\/li>\n  <li>Confidentiality:\nWe wish to respect your privacy and maintain confidentiality about counseling issues.  There are certain exceptions:<\/li>\n    <ul>\n\t  <li>To provide you with the best Biblical Counseling possible, our counselors may discuss your issues with other GBC counselors, elders, and\/or pastors.<\/li>\n\t  <li>By state law, we are required to report issues of child abuse or elder abuse or neglect.<\/li>\n\t  <li>We must report if a counselee has committed or intends to commit a crime.<\/li>\n\t  <li>We may inform others if a counselee seems at risk to commit significant harm to themself or others.<\/li>\n\t  <li>If the counselor deems it necessary or helpful, they may communicate information to the counselee\u2019s affiliated church leadership.<\/li>\n\t<\/ul>\n  <li>Resolution of Disagreement: \n   Any disputes will be settled through a form of Christian conciliation, such as the conciliation division of Ken Sande's Relational Wisdom 360 <a href=\"www.rw360.com\">(rw360.com)<\/a>.<\/li>\n<\/ol><\/li><li id=\"field_1_17\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio 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' >I agree to the above agreement<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_1_17'>\n\t\t\t<li class='gchoice gchoice_1_17_0'>\n\t\t\t\t<input name='input_17' type='radio' value='Yes'  id='choice_1_17_0'    \/>\n\t\t\t\t<label for='choice_1_17_0' id='label_1_17_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_1_17_1'>\n\t\t\t\t<input name='input_17' type='radio' value='No'  id='choice_1_17_1'    \/>\n\t\t\t\t<label for='choice_1_17_1' id='label_1_17_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_1_145\" class=\"gfield gfield--type-name gfield--input-type-name gfield_contains_required field_sublabel_below gfield--has-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label gfield_label_before_complex' >Signature<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_complex ginput_container ginput_container--name no_prefix has_first_name no_middle_name has_last_name no_suffix gf_name_has_2 ginput_container_name gform-grid-row' id='input_1_145'>\n                            \n                            <span id='input_1_145_3_container' class='name_first gform-grid-col gform-grid-col--size-auto' >\n                                                    <input type='text' name='input_145.3' id='input_1_145_3' value=''   aria-required='true'     \/>\n                                                    <label for='input_1_145_3' class='gform-field-label gform-field-label--type-sub '>First<\/label>\n                                                <\/span>\n                            \n                            <span id='input_1_145_6_container' class='name_last gform-grid-col gform-grid-col--size-auto' >\n                                                    <input type='text' name='input_145.6' id='input_1_145_6' value=''   aria-required='true'     \/>\n                                                    <label for='input_1_145_6' class='gform-field-label gform-field-label--type-sub '>Last<\/label>\n                                                <\/span>\n                            \n                        <\/div><div class='gfield_description' id='gfield_description_1_145'>Please fill your name here as your signature.<\/div><\/li><li id=\"field_1_143\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' >Preferred means of communication:<\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_1_143'>\n\t\t\t<li class='gchoice gchoice_1_143_0'>\n\t\t\t\t<input name='input_143' type='radio' value='Phone Call'  id='choice_1_143_0'    \/>\n\t\t\t\t<label for='choice_1_143_0' id='label_1_143_0' class='gform-field-label gform-field-label--type-inline'>Phone Call<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_1_143_1'>\n\t\t\t\t<input name='input_143' type='radio' value='Text Message'  id='choice_1_143_1'    \/>\n\t\t\t\t<label for='choice_1_143_1' id='label_1_143_1' class='gform-field-label gform-field-label--type-inline'>Text Message<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_1_147\" class=\"gfield gfield--type-html gfield--input-type-html gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  >Expect to receive a call\/text from the Counseling Center receptionist (406-946-9782) on the next business Monday.<\/li><li id=\"field_1_146\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' >Preferred Monday counseling time:<\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_1_146'>\n\t\t\t<li class='gchoice gchoice_1_146_0'>\n\t\t\t\t<input name='input_146' type='radio' value='330pm'  id='choice_1_146_0'    \/>\n\t\t\t\t<label for='choice_1_146_0' id='label_1_146_0' class='gform-field-label gform-field-label--type-inline'>3:30pm<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_1_146_1'>\n\t\t\t\t<input name='input_146' type='radio' value='6pm'  id='choice_1_146_1'    \/>\n\t\t\t\t<label for='choice_1_146_1' id='label_1_146_1' class='gform-field-label gform-field-label--type-inline'>6:00pm<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_1_146_2'>\n\t\t\t\t<input name='input_146' type='radio' value='730pm'  id='choice_1_146_2'    \/>\n\t\t\t\t<label for='choice_1_146_2' id='label_1_146_2' class='gform-field-label gform-field-label--type-inline'>7:30pm<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><\/ul>\n                    <\/div>\n                    <div class='gform-page-footer gform_page_footer top_label'>\n                         <input type='button' id='gform_next_button_1_18' class='gform_next_button gform-theme-button button' onclick='gform.submission.handleButtonClick(this);' data-submission-type='next' value='Next'  \/> \n                    <\/div>\n                <\/div>\n                <div id='gform_page_1_2' class='gform_page' data-js='page-field-id-18' style='display:none;'>\n                    <div class='gform_page_fields'>\n                        <ul id='gform_fields_1_2' class='gform_fields top_label form_sublabel_below description_below validation_below'><li id=\"field_1_2\" class=\"gfield gfield--type-date gfield--input-type-date gfield--input-type-datepicker gfield--datepicker-no-icon 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_1_2'>Date<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_2' id='input_1_2' type='text' value='04\/09\/2026' class='datepicker gform-datepicker mdy datepicker_no_icon gdatepicker-no-icon'   placeholder='04\/09\/2026' aria-describedby=\"input_1_2_date_format\" aria-invalid=\"false\" aria-required=\"true\"\/>\n                            <span id='input_1_2_date_format' class='screen-reader-text'>MM slash DD slash YYYY<\/span>\n                        <\/div>\n                        <input type='hidden' id='gforms_calendar_icon_input_1_2' class='gform_hidden' value='https:\/\/gbcmt.org\/counseling\/wp-content\/plugins\/gravityforms\/images\/datepicker\/datepicker.svg'\/><\/li><li id=\"field_1_14\" class=\"gfield gfield--type-section gfield--input-type-section gsection field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><h2 class=\"gsection_title\">Personal Identification<\/h2><\/li><li id=\"field_1_1\" class=\"gfield gfield--type-name gfield--input-type-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 gfield_label_before_complex' >Name<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_complex ginput_container ginput_container--name no_prefix has_first_name no_middle_name has_last_name no_suffix gf_name_has_2 ginput_container_name gform-grid-row' id='input_1_1'>\n                            \n                            <span id='input_1_1_3_container' class='name_first gform-grid-col gform-grid-col--size-auto' >\n                                                    <input type='text' name='input_1.3' id='input_1_1_3' value=''   aria-required='true'     \/>\n                                                    <label for='input_1_1_3' class='gform-field-label gform-field-label--type-sub '>First<\/label>\n                                                <\/span>\n                            \n                            <span id='input_1_1_6_container' class='name_last gform-grid-col gform-grid-col--size-auto' >\n                                                    <input type='text' name='input_1.6' id='input_1_1_6' value=''   aria-required='true'     \/>\n                                                    <label for='input_1_1_6' class='gform-field-label gform-field-label--type-sub '>Last<\/label>\n                                                <\/span>\n                            \n                        <\/div><\/li><li id=\"field_1_3\" class=\"gfield gfield--type-phone gfield--input-type-phone 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_1_3'>Best phone number to contact you<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_phone'><input name='input_3' id='input_1_3' type='tel' value='' class='medium'   aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_1_4\" class=\"gfield gfield--type-address gfield--input-type-address field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label gfield_label_before_complex' >Address<\/label>    \n                    <div class='ginput_complex ginput_container has_street has_city has_state has_zip ginput_container_address gform-grid-row' id='input_1_4' >\n                         <span class='ginput_full address_line_1 ginput_address_line_1 gform-grid-col' id='input_1_4_1_container' >\n                                        <input type='text' name='input_4.1' id='input_1_4_1' value=''    aria-required='false'    \/>\n                                        <label for='input_1_4_1' id='input_1_4_1_label' class='gform-field-label gform-field-label--type-sub '>Street Address<\/label>\n                                    <\/span><span class='ginput_left address_city ginput_address_city gform-grid-col' id='input_1_4_3_container' >\n                                    <input type='text' name='input_4.3' id='input_1_4_3' value=''    aria-required='false'    \/>\n                                    <label for='input_1_4_3' id='input_1_4_3_label' class='gform-field-label gform-field-label--type-sub '>City<\/label>\n                                 <\/span><span class='ginput_right address_state ginput_address_state gform-grid-col' id='input_1_4_4_container' >\n                                        <select name='input_4.4' id='input_1_4_4'     aria-required='false'    ><option value='' ><\/option><option value='Alabama' >Alabama<\/option><option value='Alaska' >Alaska<\/option><option value='American Samoa' >American Samoa<\/option><option value='Arizona' >Arizona<\/option><option value='Arkansas' >Arkansas<\/option><option value='California' >California<\/option><option value='Colorado' >Colorado<\/option><option value='Connecticut' >Connecticut<\/option><option value='Delaware' >Delaware<\/option><option value='District of Columbia' >District of Columbia<\/option><option value='Florida' >Florida<\/option><option value='Georgia' >Georgia<\/option><option value='Guam' >Guam<\/option><option value='Hawaii' >Hawaii<\/option><option value='Idaho' >Idaho<\/option><option value='Illinois' >Illinois<\/option><option value='Indiana' >Indiana<\/option><option value='Iowa' >Iowa<\/option><option value='Kansas' >Kansas<\/option><option value='Kentucky' >Kentucky<\/option><option value='Louisiana' >Louisiana<\/option><option value='Maine' >Maine<\/option><option value='Maryland' >Maryland<\/option><option value='Massachusetts' >Massachusetts<\/option><option value='Michigan' >Michigan<\/option><option value='Minnesota' >Minnesota<\/option><option value='Mississippi' >Mississippi<\/option><option value='Missouri' >Missouri<\/option><option value='Montana' selected='selected'>Montana<\/option><option value='Nebraska' >Nebraska<\/option><option value='Nevada' >Nevada<\/option><option value='New Hampshire' >New Hampshire<\/option><option value='New Jersey' >New Jersey<\/option><option value='New Mexico' >New Mexico<\/option><option value='New York' >New York<\/option><option value='North Carolina' >North Carolina<\/option><option value='North Dakota' >North Dakota<\/option><option value='Northern Mariana Islands' >Northern Mariana Islands<\/option><option value='Ohio' >Ohio<\/option><option value='Oklahoma' >Oklahoma<\/option><option value='Oregon' >Oregon<\/option><option value='Pennsylvania' >Pennsylvania<\/option><option value='Puerto Rico' >Puerto Rico<\/option><option value='Rhode Island' >Rhode Island<\/option><option value='South Carolina' >South Carolina<\/option><option value='South Dakota' >South Dakota<\/option><option value='Tennessee' >Tennessee<\/option><option value='Texas' >Texas<\/option><option value='Utah' >Utah<\/option><option value='U.S. Virgin Islands' >U.S. Virgin Islands<\/option><option value='Vermont' >Vermont<\/option><option value='Virginia' >Virginia<\/option><option value='Washington' >Washington<\/option><option value='West Virginia' >West Virginia<\/option><option value='Wisconsin' >Wisconsin<\/option><option value='Wyoming' >Wyoming<\/option><option value='Armed Forces Americas' >Armed Forces Americas<\/option><option value='Armed Forces Europe' >Armed Forces Europe<\/option><option value='Armed Forces Pacific' >Armed Forces Pacific<\/option><\/select>\n                                        <label for='input_1_4_4' id='input_1_4_4_label' class='gform-field-label gform-field-label--type-sub '>State<\/label>\n                                      <\/span><span class='ginput_left address_zip ginput_address_zip gform-grid-col' id='input_1_4_5_container' >\n                                    <input type='text' name='input_4.5' id='input_1_4_5' value=''    aria-required='false'    \/>\n                                    <label for='input_1_4_5' id='input_1_4_5_label' class='gform-field-label gform-field-label--type-sub '>ZIP Code<\/label>\n                                <\/span><input type='hidden' class='gform_hidden' name='input_4.6' id='input_1_4_6' value='United States' \/>\n                    <div class='gf_clear gf_clear_complex'><\/div>\n                <\/div><\/li><li id=\"field_1_5\" class=\"gfield gfield--type-email gfield--input-type-email field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_1_5'>Email<\/label><div class='ginput_container ginput_container_email'>\n                            <input name='input_5' id='input_1_5' type='email' value='' class='medium'     aria-invalid=\"false\"  \/>\n                        <\/div><\/li><li id=\"field_1_6\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio 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' >Sex<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_1_6'>\n\t\t\t<li class='gchoice gchoice_1_6_0'>\n\t\t\t\t<input name='input_6' type='radio' value='Male'  id='choice_1_6_0'    \/>\n\t\t\t\t<label for='choice_1_6_0' id='label_1_6_0' class='gform-field-label gform-field-label--type-inline'>Male<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_1_6_1'>\n\t\t\t\t<input name='input_6' type='radio' value='Female'  id='choice_1_6_1'    \/>\n\t\t\t\t<label for='choice_1_6_1' id='label_1_6_1' class='gform-field-label gform-field-label--type-inline'>Female<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_1_7\" class=\"gfield gfield--type-text gfield--input-type-text 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_1_7'>Age<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_7' id='input_1_7' type='text' value='' class='medium' maxlength='15'    aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_1_8\" class=\"gfield gfield--type-date gfield--input-type-date gfield--input-type-datepicker gfield--datepicker-default-icon 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_1_8'>Birthdate<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_1_8' type='text' value='' class='datepicker gform-datepicker mdy datepicker_with_icon gdatepicker_with_icon'   placeholder='mm\/dd\/yyyy' aria-describedby=\"input_1_8_date_format\" aria-invalid=\"false\" aria-required=\"true\"\/>\n                            <span id='input_1_8_date_format' class='screen-reader-text'>MM slash DD slash YYYY<\/span>\n                        <\/div>\n                        <input type='hidden' id='gforms_calendar_icon_input_1_8' class='gform_hidden' value='https:\/\/gbcmt.org\/counseling\/wp-content\/plugins\/gravityforms\/images\/datepicker\/datepicker.svg'\/><\/li><li id=\"field_1_9\" class=\"gfield gfield--type-text gfield--input-type-text field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_1_9'>Education (last year completed)<\/label><div class='ginput_container ginput_container_text'><input name='input_9' id='input_1_9' type='text' value='' class='medium'      aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_1_10\" class=\"gfield gfield--type-phone gfield--input-type-phone field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_1_10'>Business\/Work Phone<\/label><div class='ginput_container ginput_container_phone'><input name='input_10' id='input_1_10' type='tel' value='' class='medium'    aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_1_11\" class=\"gfield gfield--type-text gfield--input-type-text field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_1_11'>Employer<\/label><div class='ginput_container ginput_container_text'><input name='input_11' id='input_1_11' type='text' value='' class='medium'      aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_1_12\" class=\"gfield gfield--type-text gfield--input-type-text field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_1_12'>Position<\/label><div class='ginput_container ginput_container_text'><input name='input_12' id='input_1_12' type='text' value='' class='medium'      aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_1_13\" class=\"gfield gfield--type-text gfield--input-type-text field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_1_13'>Years in position<\/label><div class='ginput_container ginput_container_text'><input name='input_13' id='input_1_13' type='text' value='' class='medium'      aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_1_19\" class=\"gfield gfield--type-section gfield--input-type-section gsection field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><h2 class=\"gsection_title\">Health Information<\/h2><\/li><li id=\"field_1_20\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio 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' >Rate Your Health<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_1_20'>\n\t\t\t<li class='gchoice gchoice_1_20_0'>\n\t\t\t\t<input name='input_20' type='radio' value='Very Good'  id='choice_1_20_0'    \/>\n\t\t\t\t<label for='choice_1_20_0' id='label_1_20_0' class='gform-field-label gform-field-label--type-inline'>Very Good<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_1_20_1'>\n\t\t\t\t<input name='input_20' type='radio' value='Good'  id='choice_1_20_1'    \/>\n\t\t\t\t<label for='choice_1_20_1' id='label_1_20_1' class='gform-field-label gform-field-label--type-inline'>Good<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_1_20_2'>\n\t\t\t\t<input name='input_20' type='radio' value='Average'  id='choice_1_20_2'    \/>\n\t\t\t\t<label for='choice_1_20_2' id='label_1_20_2' class='gform-field-label gform-field-label--type-inline'>Average<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_1_20_3'>\n\t\t\t\t<input name='input_20' type='radio' value='Declining'  id='choice_1_20_3'    \/>\n\t\t\t\t<label for='choice_1_20_3' id='label_1_20_3' class='gform-field-label gform-field-label--type-inline'>Declining<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_1_20_4'>\n\t\t\t\t<input name='input_20' type='radio' value='gf_other_choice'  id='choice_1_20_4'   onfocus=\"jQuery(this).next('input').focus();\" \/>\n\t\t\t\t<input class='small' id='input_1_20_other' name='input_20_other' type='text' value='Other' aria-label='Other' onfocus='jQuery(this).prev(\"input\")[0].click(); if(jQuery(this).val() == \"Other\") { jQuery(this).val(\"\"); }' onblur='if(jQuery(this).val().replace(\" \", \"\") == \"\") { jQuery(this).val(\"Other\"); }'   \/>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_1_21\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' >Do you have any chronic conditions?<\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_1_21'>\n\t\t\t<li class='gchoice gchoice_1_21_0'>\n\t\t\t\t<input name='input_21' type='radio' value='Yes'  id='choice_1_21_0'    \/>\n\t\t\t\t<label for='choice_1_21_0' id='label_1_21_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_1_21_1'>\n\t\t\t\t<input name='input_21' type='radio' value='No'  id='choice_1_21_1'    \/>\n\t\t\t\t<label for='choice_1_21_1' id='label_1_21_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_1_22\" class=\"gfield gfield--type-textarea gfield--input-type-textarea field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_1_22'>If yes, please describe<\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_22' id='input_1_22' class='textarea medium'   maxlength='50'   aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/li><li id=\"field_1_23\" class=\"gfield gfield--type-textarea gfield--input-type-textarea field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_1_23'>List important illnesses and injuries or handicaps<\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_23' id='input_1_23' class='textarea medium'   maxlength='60'   aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/li><li id=\"field_1_24\" class=\"gfield gfield--type-date gfield--input-type-date gfield--input-type-datepicker gfield--datepicker-default-icon field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_1_24'>Date of last physical exam<\/label><div class='ginput_container ginput_container_date'>\n                            <input name='input_24' id='input_1_24' type='text' value='' class='datepicker gform-datepicker mdy datepicker_with_icon gdatepicker_with_icon'   placeholder='mm\/dd\/yyyy' aria-describedby=\"input_1_24_date_format\" aria-invalid=\"false\" \/>\n                            <span id='input_1_24_date_format' class='screen-reader-text'>MM slash DD slash YYYY<\/span>\n                        <\/div>\n                        <input type='hidden' id='gforms_calendar_icon_input_1_24' class='gform_hidden' value='https:\/\/gbcmt.org\/counseling\/wp-content\/plugins\/gravityforms\/images\/datepicker\/datepicker.svg'\/><\/li><li id=\"field_1_25\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' >Weight Changes Recently<\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_1_25'>\n\t\t\t<li class='gchoice gchoice_1_25_0'>\n\t\t\t\t<input name='input_25' type='radio' value='Lost'  id='choice_1_25_0'    \/>\n\t\t\t\t<label for='choice_1_25_0' id='label_1_25_0' class='gform-field-label gform-field-label--type-inline'>Lost<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_1_25_1'>\n\t\t\t\t<input name='input_25' type='radio' value='Gained'  id='choice_1_25_1'    \/>\n\t\t\t\t<label for='choice_1_25_1' id='label_1_25_1' class='gform-field-label gform-field-label--type-inline'>Gained<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_1_25_2'>\n\t\t\t\t<input name='input_25' type='radio' value='n\/a'  id='choice_1_25_2'    \/>\n\t\t\t\t<label for='choice_1_25_2' id='label_1_25_2' class='gform-field-label gform-field-label--type-inline'>n\/a<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_1_26\" class=\"gfield gfield--type-text gfield--input-type-text field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_1_26'>Amount of weight lost<\/label><div class='ginput_container ginput_container_text'><input name='input_26' id='input_1_26' type='text' value='' class='medium'      aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_1_142\" class=\"gfield gfield--type-text gfield--input-type-text field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_1_142'>Amount of weight gained<\/label><div class='ginput_container ginput_container_text'><input name='input_142' id='input_1_142' type='text' value='' class='medium'      aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_1_27\" class=\"gfield gfield--type-text gfield--input-type-text field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_1_27'>Your Physician&#039;s Name<\/label><div class='ginput_container ginput_container_text'><input name='input_27' id='input_1_27' type='text' value='' class='medium' maxlength='50'     aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_1_28\" class=\"gfield gfield--type-textarea gfield--input-type-textarea field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_1_28'>Please list current medications<\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_28' id='input_1_28' class='textarea medium'   maxlength='50'   aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/li><li id=\"field_1_29\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio 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' >Have you ever used drugs for other than medical purposes?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_1_29'>\n\t\t\t<li class='gchoice gchoice_1_29_0'>\n\t\t\t\t<input name='input_29' type='radio' value='Yes'  id='choice_1_29_0'    \/>\n\t\t\t\t<label for='choice_1_29_0' id='label_1_29_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_1_29_1'>\n\t\t\t\t<input name='input_29' type='radio' value='No'  id='choice_1_29_1'    \/>\n\t\t\t\t<label for='choice_1_29_1' id='label_1_29_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_1_30\" class=\"gfield gfield--type-textarea gfield--input-type-textarea field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_1_30'>What?<\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_30' id='input_1_30' class='textarea medium'   maxlength='40'   aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/li><li id=\"field_1_31\" class=\"gfield gfield--type-textarea gfield--input-type-textarea field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_1_31'>If yes, please explain<\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_31' id='input_1_31' class='textarea medium'   maxlength='80'   aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/li><li id=\"field_1_32\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' >Have you ever had a severe emotional upset?<\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_1_32'>\n\t\t\t<li class='gchoice gchoice_1_32_0'>\n\t\t\t\t<input name='input_32' type='radio' value='Yes'  id='choice_1_32_0'    \/>\n\t\t\t\t<label for='choice_1_32_0' id='label_1_32_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_1_32_1'>\n\t\t\t\t<input name='input_32' type='radio' value='No'  id='choice_1_32_1'    \/>\n\t\t\t\t<label for='choice_1_32_1' id='label_1_32_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_1_33\" class=\"gfield gfield--type-textarea gfield--input-type-textarea field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_1_33'>If so, explain.<\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_33' id='input_1_33' class='textarea medium'   maxlength='100'   aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/li><li id=\"field_1_34\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio 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' >Have you ever been convicted of a crime?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_1_34'>\n\t\t\t<li class='gchoice gchoice_1_34_0'>\n\t\t\t\t<input name='input_34' type='radio' value='Yes'  id='choice_1_34_0'    \/>\n\t\t\t\t<label for='choice_1_34_0' id='label_1_34_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_1_34_1'>\n\t\t\t\t<input name='input_34' type='radio' value='No'  id='choice_1_34_1'    \/>\n\t\t\t\t<label for='choice_1_34_1' id='label_1_34_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_1_35\" class=\"gfield gfield--type-textarea gfield--input-type-textarea field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_1_35'>If so, explain.<\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_35' id='input_1_35' class='textarea medium'   maxlength='100'   aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/li><li id=\"field_1_36\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' >Do you have problems sleeping?<\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_1_36'>\n\t\t\t<li class='gchoice gchoice_1_36_0'>\n\t\t\t\t<input name='input_36' type='radio' value='Yes'  id='choice_1_36_0'    \/>\n\t\t\t\t<label for='choice_1_36_0' id='label_1_36_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_1_36_1'>\n\t\t\t\t<input name='input_36' type='radio' value='No'  id='choice_1_36_1'    \/>\n\t\t\t\t<label for='choice_1_36_1' id='label_1_36_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_1_36_2'>\n\t\t\t\t<input name='input_36' type='radio' value='Sometimes'  id='choice_1_36_2'    \/>\n\t\t\t\t<label for='choice_1_36_2' id='label_1_36_2' class='gform-field-label gform-field-label--type-inline'>Sometimes<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><\/ul>\n                    <\/div>\n                    <div class='gform-page-footer gform_page_footer top_label'>\n                        <input type='button' id='gform_previous_button_1_130' class='gform_previous_button gform-theme-button gform-theme-button--secondary button' onclick='gform.submission.handleButtonClick(this);' data-submission-type='previous' value='Previous'  \/> <input type='button' id='gform_next_button_1_130' class='gform_next_button gform-theme-button button' onclick='gform.submission.handleButtonClick(this);' data-submission-type='next' value='Next'  \/> \n                    <\/div>\n                <\/div>\n                <div id='gform_page_1_3' class='gform_page' data-js='page-field-id-130' style='display:none;'>\n                    <div class='gform_page_fields'>\n                        <ul id='gform_fields_1_3' class='gform_fields top_label form_sublabel_below description_below validation_below'><li id=\"field_1_37\" class=\"gfield gfield--type-section gfield--input-type-section gsection field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><h2 class=\"gsection_title\">Religious Background<\/h2><\/li><li id=\"field_1_38\" class=\"gfield gfield--type-text gfield--input-type-text field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_1_38'>Denominational Preference<\/label><div class='ginput_container ginput_container_text'><input name='input_38' id='input_1_38' type='text' value='' class='medium' maxlength='30'     aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_1_39\" class=\"gfield gfield--type-text gfield--input-type-text 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_1_39'>Church currently attending<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_39' id='input_1_39' type='text' value='' class='medium' maxlength='22'    aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_1_40\" class=\"gfield gfield--type-text gfield--input-type-text 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_1_40'>How many sundays do you attend per month?<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_1_40' type='text' value='' class='medium' maxlength='10'    aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_1_41\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio 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' >Are you an official member of that church?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_1_41'>\n\t\t\t<li class='gchoice gchoice_1_41_0'>\n\t\t\t\t<input name='input_41' type='radio' value='Yes'  id='choice_1_41_0'    \/>\n\t\t\t\t<label for='choice_1_41_0' id='label_1_41_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_1_41_1'>\n\t\t\t\t<input name='input_41' type='radio' value='No'  id='choice_1_41_1'    \/>\n\t\t\t\t<label for='choice_1_41_1' id='label_1_41_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_1_148\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio 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' >Are you actively involved in an official ministry in your church?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_1_148'>\n\t\t\t<li class='gchoice gchoice_1_148_0'>\n\t\t\t\t<input name='input_148' type='radio' value='Yes'  id='choice_1_148_0'    \/>\n\t\t\t\t<label for='choice_1_148_0' id='label_1_148_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_1_148_1'>\n\t\t\t\t<input name='input_148' type='radio' value='No'  id='choice_1_148_1'    \/>\n\t\t\t\t<label for='choice_1_148_1' id='label_1_148_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_1_42\" class=\"gfield gfield--type-text gfield--input-type-text field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_1_42'>Church attended as a child<\/label><div class='ginput_container ginput_container_text'><input name='input_42' id='input_1_42' type='text' value='' class='medium' maxlength='30'     aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_1_43\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio 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' >Have you been baptized?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_1_43'>\n\t\t\t<li class='gchoice gchoice_1_43_0'>\n\t\t\t\t<input name='input_43' type='radio' value='No'  id='choice_1_43_0'    \/>\n\t\t\t\t<label for='choice_1_43_0' id='label_1_43_0' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_1_43_1'>\n\t\t\t\t<input name='input_43' type='radio' value='Yes As Adult'  id='choice_1_43_1'    \/>\n\t\t\t\t<label for='choice_1_43_1' id='label_1_43_1' class='gform-field-label gform-field-label--type-inline'>Yes, as an adult<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_1_43_2'>\n\t\t\t\t<input name='input_43' type='radio' value='Yes As Infant'  id='choice_1_43_2'    \/>\n\t\t\t\t<label for='choice_1_43_2' id='label_1_43_2' class='gform-field-label gform-field-label--type-inline'>Yes, as an infant<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_1_44\" class=\"gfield gfield--type-text gfield--input-type-text field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_1_44'>Religious background of spouse (if married)<\/label><div class='ginput_container ginput_container_text'><input name='input_44' id='input_1_44' type='text' value='' class='medium' maxlength='35'     aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_1_45\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio 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' >Do you consider yourself to be a religious person?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_1_45'>\n\t\t\t<li class='gchoice gchoice_1_45_0'>\n\t\t\t\t<input name='input_45' type='radio' value='Yes'  id='choice_1_45_0'    \/>\n\t\t\t\t<label for='choice_1_45_0' id='label_1_45_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_1_45_1'>\n\t\t\t\t<input name='input_45' type='radio' value='No'  id='choice_1_45_1'    \/>\n\t\t\t\t<label for='choice_1_45_1' id='label_1_45_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_1_45_2'>\n\t\t\t\t<input name='input_45' type='radio' value='Uncertain'  id='choice_1_45_2'    \/>\n\t\t\t\t<label for='choice_1_45_2' id='label_1_45_2' class='gform-field-label gform-field-label--type-inline'>Uncertain<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_1_46\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio 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' >Do you believe in God?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_1_46'>\n\t\t\t<li class='gchoice gchoice_1_46_0'>\n\t\t\t\t<input name='input_46' type='radio' value='Yes'  id='choice_1_46_0'    \/>\n\t\t\t\t<label for='choice_1_46_0' id='label_1_46_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_1_46_1'>\n\t\t\t\t<input name='input_46' type='radio' value='No'  id='choice_1_46_1'    \/>\n\t\t\t\t<label for='choice_1_46_1' id='label_1_46_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_1_46_2'>\n\t\t\t\t<input name='input_46' type='radio' value='Uncertain'  id='choice_1_46_2'    \/>\n\t\t\t\t<label for='choice_1_46_2' id='label_1_46_2' class='gform-field-label gform-field-label--type-inline'>Uncertain<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_1_47\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio 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' >Do you pray to God?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_1_47'>\n\t\t\t<li class='gchoice gchoice_1_47_0'>\n\t\t\t\t<input name='input_47' type='radio' value='Never'  id='choice_1_47_0'    \/>\n\t\t\t\t<label for='choice_1_47_0' id='label_1_47_0' class='gform-field-label gform-field-label--type-inline'>Never<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_1_47_1'>\n\t\t\t\t<input name='input_47' type='radio' value='Occasionally'  id='choice_1_47_1'    \/>\n\t\t\t\t<label for='choice_1_47_1' id='label_1_47_1' class='gform-field-label gform-field-label--type-inline'>Occasionally<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_1_47_2'>\n\t\t\t\t<input name='input_47' type='radio' value='Often'  id='choice_1_47_2'    \/>\n\t\t\t\t<label for='choice_1_47_2' id='label_1_47_2' class='gform-field-label gform-field-label--type-inline'>Often<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_1_48\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio 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' >How often do you read the Bible?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_1_48'>\n\t\t\t<li class='gchoice gchoice_1_48_0'>\n\t\t\t\t<input name='input_48' type='radio' value='Never'  id='choice_1_48_0'    \/>\n\t\t\t\t<label for='choice_1_48_0' id='label_1_48_0' class='gform-field-label gform-field-label--type-inline'>Never<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_1_48_1'>\n\t\t\t\t<input name='input_48' type='radio' value='Occasionally'  id='choice_1_48_1'    \/>\n\t\t\t\t<label for='choice_1_48_1' id='label_1_48_1' class='gform-field-label gform-field-label--type-inline'>Occasionally<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_1_48_2'>\n\t\t\t\t<input name='input_48' type='radio' value='Often'  id='choice_1_48_2'    \/>\n\t\t\t\t<label for='choice_1_48_2' id='label_1_48_2' class='gform-field-label gform-field-label--type-inline'>Often<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_1_49\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio 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' >Are you saved?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_1_49'>\n\t\t\t<li class='gchoice gchoice_1_49_0'>\n\t\t\t\t<input name='input_49' type='radio' value='Yes'  id='choice_1_49_0'    \/>\n\t\t\t\t<label for='choice_1_49_0' id='label_1_49_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_1_49_1'>\n\t\t\t\t<input name='input_49' type='radio' value='No'  id='choice_1_49_1'    \/>\n\t\t\t\t<label for='choice_1_49_1' id='label_1_49_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_1_49_2'>\n\t\t\t\t<input name='input_49' type='radio' value='Not sure what you mean'  id='choice_1_49_2'    \/>\n\t\t\t\t<label for='choice_1_49_2' id='label_1_49_2' class='gform-field-label gform-field-label--type-inline'>Not sure what you mean<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_1_50\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio 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' >If you were to die tonight, do you know with absolute certainty that you would go to heaven?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_1_50'>\n\t\t\t<li class='gchoice gchoice_1_50_0'>\n\t\t\t\t<input name='input_50' type='radio' value='Yes'  id='choice_1_50_0'    \/>\n\t\t\t\t<label for='choice_1_50_0' id='label_1_50_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_1_50_1'>\n\t\t\t\t<input name='input_50' type='radio' value='No'  id='choice_1_50_1'    \/>\n\t\t\t\t<label for='choice_1_50_1' id='label_1_50_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_1_50_2'>\n\t\t\t\t<input name='input_50' type='radio' value='Uncertain'  id='choice_1_50_2'    \/>\n\t\t\t\t<label for='choice_1_50_2' id='label_1_50_2' class='gform-field-label gform-field-label--type-inline'>Uncertain<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_1_51\" class=\"gfield gfield--type-textarea gfield--input-type-textarea 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_1_51'>If you were to die today and stand before God and He were to ask you, \u201cWhy should I let you into my heaven\u201d, what would you say?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_51' id='input_1_51' class='textarea medium'   maxlength='320'  aria-required=\"true\" aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/li><li id=\"field_1_52\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' >Do you have regular devotions?<\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_1_52'>\n\t\t\t<li class='gchoice gchoice_1_52_0'>\n\t\t\t\t<input name='input_52' type='radio' value='Yes'  id='choice_1_52_0'    \/>\n\t\t\t\t<label for='choice_1_52_0' id='label_1_52_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_1_52_1'>\n\t\t\t\t<input name='input_52' type='radio' value='No'  id='choice_1_52_1'    \/>\n\t\t\t\t<label for='choice_1_52_1' id='label_1_52_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_1_52_2'>\n\t\t\t\t<input name='input_52' type='radio' value='Not sure what you mean'  id='choice_1_52_2'    \/>\n\t\t\t\t<label for='choice_1_52_2' id='label_1_52_2' class='gform-field-label gform-field-label--type-inline'>Not sure what you mean<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_1_53\" class=\"gfield gfield--type-textarea gfield--input-type-textarea field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_1_53'>Explain recent changes in your religious life, if any:<\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_53' id='input_1_53' class='textarea medium'   maxlength='140'   aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/li><\/ul>\n                    <\/div>\n                    <div class='gform-page-footer gform_page_footer top_label'>\n                        <input type='button' id='gform_previous_button_1_129' class='gform_previous_button gform-theme-button gform-theme-button--secondary button' onclick='gform.submission.handleButtonClick(this);' data-submission-type='previous' value='Previous'  \/> <input type='button' id='gform_next_button_1_129' class='gform_next_button gform-theme-button button' onclick='gform.submission.handleButtonClick(this);' data-submission-type='next' value='Next'  \/> \n                    <\/div>\n                <\/div>\n                <div id='gform_page_1_4' class='gform_page' data-js='page-field-id-129' style='display:none;'>\n                    <div class='gform_page_fields'>\n                        <ul id='gform_fields_1_4' class='gform_fields top_label form_sublabel_below description_below validation_below'><li id=\"field_1_54\" class=\"gfield gfield--type-section gfield--input-type-section gsection field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><h2 class=\"gsection_title\">Marriage and Family<\/h2><\/li><li id=\"field_1_55\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio 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' >Marital Status<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_1_55'>\n\t\t\t<li class='gchoice gchoice_1_55_0'>\n\t\t\t\t<input name='input_55' type='radio' value='Single'  id='choice_1_55_0'    \/>\n\t\t\t\t<label for='choice_1_55_0' id='label_1_55_0' class='gform-field-label gform-field-label--type-inline'>Single<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_1_55_1'>\n\t\t\t\t<input name='input_55' type='radio' value='Dating'  id='choice_1_55_1'    \/>\n\t\t\t\t<label for='choice_1_55_1' id='label_1_55_1' class='gform-field-label gform-field-label--type-inline'>Dating<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_1_55_2'>\n\t\t\t\t<input name='input_55' type='radio' value='Engaged'  id='choice_1_55_2'    \/>\n\t\t\t\t<label for='choice_1_55_2' id='label_1_55_2' class='gform-field-label gform-field-label--type-inline'>Engaged<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_1_55_3'>\n\t\t\t\t<input name='input_55' type='radio' value='Married'  id='choice_1_55_3'    \/>\n\t\t\t\t<label for='choice_1_55_3' id='label_1_55_3' class='gform-field-label gform-field-label--type-inline'>Married<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_1_55_4'>\n\t\t\t\t<input name='input_55' type='radio' value='Separated'  id='choice_1_55_4'    \/>\n\t\t\t\t<label for='choice_1_55_4' id='label_1_55_4' class='gform-field-label gform-field-label--type-inline'>Separated<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_1_55_5'>\n\t\t\t\t<input name='input_55' type='radio' value='Divorced'  id='choice_1_55_5'    \/>\n\t\t\t\t<label for='choice_1_55_5' id='label_1_55_5' class='gform-field-label gform-field-label--type-inline'>Divorced<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_1_55_6'>\n\t\t\t\t<input name='input_55' type='radio' value='Widowed'  id='choice_1_55_6'    \/>\n\t\t\t\t<label for='choice_1_55_6' id='label_1_55_6' class='gform-field-label gform-field-label--type-inline'>Widowed<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_1_58\" class=\"gfield gfield--type-section gfield--input-type-section gsection field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><h2 class=\"gsection_title\"><\/h2><\/li><li id=\"field_1_56\" class=\"gfield gfield--type-text gfield--input-type-text field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_1_56'>Name of Spouse<\/label><div class='ginput_container ginput_container_text'><input name='input_56' id='input_1_56' type='text' value='' class='medium'      aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_1_57\" class=\"gfield gfield--type-text gfield--input-type-text field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_1_57'>Age of Spouse<\/label><div class='ginput_container ginput_container_text'><input name='input_57' id='input_1_57' type='text' value='' class='medium'      aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_1_59\" class=\"gfield gfield--type-text gfield--input-type-text field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_1_59'>Education of Spouse (in years)<\/label><div class='ginput_container ginput_container_text'><input name='input_59' id='input_1_59' type='text' value='' class='medium' maxlength='30'     aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_1_60\" class=\"gfield gfield--type-text gfield--input-type-text field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_1_60'>Spouse&#039;s Occupation<\/label><div class='ginput_container ginput_container_text'><input name='input_60' id='input_1_60' type='text' value='' class='medium' maxlength='30'     aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_1_61\" class=\"gfield gfield--type-text gfield--input-type-text field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_1_61'>Number of years Spouse Employed<\/label><div class='ginput_container ginput_container_text'><input name='input_61' id='input_1_61' type='text' value='' class='medium'      aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_1_144\" class=\"gfield gfield--type-phone gfield--input-type-phone field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_1_144'>Phone number of spouse<\/label><div class='ginput_container ginput_container_phone'><input name='input_144' id='input_1_144' type='tel' value='' class='medium'    aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_1_63\" class=\"gfield gfield--type-date gfield--input-type-date gfield--input-type-datepicker gfield--datepicker-default-icon field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_1_63'>Date of Marriage<\/label><div class='ginput_container ginput_container_date'>\n                            <input name='input_63' id='input_1_63' type='text' value='' class='datepicker gform-datepicker mdy datepicker_with_icon gdatepicker_with_icon'   placeholder='mm\/dd\/yyyy' aria-describedby=\"input_1_63_date_format\" aria-invalid=\"false\" \/>\n                            <span id='input_1_63_date_format' class='screen-reader-text'>MM slash DD slash YYYY<\/span>\n                        <\/div>\n                        <input type='hidden' id='gforms_calendar_icon_input_1_63' class='gform_hidden' value='https:\/\/gbcmt.org\/counseling\/wp-content\/plugins\/gravityforms\/images\/datepicker\/datepicker.svg'\/><\/li><li id=\"field_1_65\" class=\"gfield gfield--type-text gfield--input-type-text field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_1_65'>Length of Dating<\/label><div class='ginput_container ginput_container_text'><input name='input_65' id='input_1_65' type='text' value='' class='medium' maxlength='15'     aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_1_66\" class=\"gfield gfield--type-textarea gfield--input-type-textarea field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_1_66'>Give a brief summary of circumstances of meeting and dating<\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_66' id='input_1_66' class='textarea medium'   maxlength='320'   aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/li><li id=\"field_1_67\" class=\"gfield gfield--type-text gfield--input-type-text field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_1_67'>Husband&#039;s Age When Married<\/label><div class='ginput_container ginput_container_text'><input name='input_67' id='input_1_67' type='text' value='' class='medium' maxlength='10'     aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_1_68\" class=\"gfield gfield--type-text gfield--input-type-text field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_1_68'>Wife&#039;s Age When Married<\/label><div class='ginput_container ginput_container_text'><input name='input_68' id='input_1_68' type='text' value='' class='medium' maxlength='10'     aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_1_69\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' >Have you ever been separated?<\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_1_69'>\n\t\t\t<li class='gchoice gchoice_1_69_0'>\n\t\t\t\t<input name='input_69' type='radio' value='Yes'  id='choice_1_69_0'    \/>\n\t\t\t\t<label for='choice_1_69_0' id='label_1_69_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_1_69_1'>\n\t\t\t\t<input name='input_69' type='radio' value='No'  id='choice_1_69_1'    \/>\n\t\t\t\t<label for='choice_1_69_1' id='label_1_69_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_1_70\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' >Have you ever filed for divorce?<\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_1_70'>\n\t\t\t<li class='gchoice gchoice_1_70_0'>\n\t\t\t\t<input name='input_70' type='radio' value='Yes'  id='choice_1_70_0'    \/>\n\t\t\t\t<label for='choice_1_70_0' id='label_1_70_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_1_70_1'>\n\t\t\t\t<input name='input_70' type='radio' value='No'  id='choice_1_70_1'    \/>\n\t\t\t\t<label for='choice_1_70_1' id='label_1_70_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_1_71\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' >Have either of you been previously married?<\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_1_71'>\n\t\t\t<li class='gchoice gchoice_1_71_0'>\n\t\t\t\t<input name='input_71' type='radio' value='Yes'  id='choice_1_71_0'    \/>\n\t\t\t\t<label for='choice_1_71_0' id='label_1_71_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_1_71_1'>\n\t\t\t\t<input name='input_71' type='radio' value='No'  id='choice_1_71_1'    \/>\n\t\t\t\t<label for='choice_1_71_1' id='label_1_71_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_1_72\" class=\"gfield gfield--type-text gfield--input-type-text field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_1_72'>If yes, who?<\/label><div class='ginput_container ginput_container_text'><input name='input_72' id='input_1_72' type='text' value='' class='medium'      aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_1_73\" class=\"gfield gfield--type-textarea gfield--input-type-textarea field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_1_73'>Give a brief information about any previous marriages:<\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_73' id='input_1_73' class='textarea medium'   maxlength='175'   aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/li><\/ul>\n                    <\/div>\n                    <div class='gform-page-footer gform_page_footer top_label'>\n                        <input type='button' id='gform_previous_button_1_128' class='gform_previous_button gform-theme-button gform-theme-button--secondary button' onclick='gform.submission.handleButtonClick(this);' data-submission-type='previous' value='Previous'  \/> <input type='button' id='gform_next_button_1_128' class='gform_next_button gform-theme-button button' onclick='gform.submission.handleButtonClick(this);' data-submission-type='next' value='Next'  \/> \n                    <\/div>\n                <\/div>\n                <div id='gform_page_1_5' class='gform_page' data-js='page-field-id-128' style='display:none;'>\n                    <div class='gform_page_fields'>\n                        <ul id='gform_fields_1_5' class='gform_fields top_label form_sublabel_below description_below validation_below'><li id=\"field_1_64\" class=\"gfield gfield--type-section gfield--input-type-section gsection field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><h2 class=\"gsection_title\">Children<\/h2><\/li><li id=\"field_1_74\" class=\"gfield gfield--type-select gfield--input-type-select field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_1_74'>How many children?<\/label><div class='ginput_container ginput_container_select'><select name='input_74' id='input_1_74' class='medium gfield_select'     aria-invalid=\"false\" ><option value='0' >0<\/option><option value='1' >1<\/option><option value='2' >2<\/option><option value='3' >3<\/option><option value='4' >4<\/option><option value='5' >5<\/option><\/select><\/div><\/li><li id=\"field_1_75\" class=\"gfield gfield--type-section gfield--input-type-section gsection field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><h2 class=\"gsection_title\">Child 1<\/h2><\/li><li id=\"field_1_76\" class=\"gfield gfield--type-name gfield--input-type-name field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label gfield_label_before_complex' >Child&#039;s Name<\/label><div class='ginput_complex ginput_container ginput_container--name no_prefix has_first_name no_middle_name has_last_name no_suffix gf_name_has_2 ginput_container_name gform-grid-row' id='input_1_76'>\n                            \n                            <span id='input_1_76_3_container' class='name_first gform-grid-col gform-grid-col--size-auto' >\n                                                    <input type='text' name='input_76.3' id='input_1_76_3' value=''   aria-required='false'     \/>\n                                                    <label for='input_1_76_3' class='gform-field-label gform-field-label--type-sub '>First<\/label>\n                                                <\/span>\n                            \n                            <span id='input_1_76_6_container' class='name_last gform-grid-col gform-grid-col--size-auto' >\n                                                    <input type='text' name='input_76.6' id='input_1_76_6' value=''   aria-required='false'     \/>\n                                                    <label for='input_1_76_6' class='gform-field-label gform-field-label--type-sub '>Last<\/label>\n                                                <\/span>\n                            \n                        <\/div><\/li><li id=\"field_1_78\" class=\"gfield gfield--type-text gfield--input-type-text field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_1_78'>Child&#039;s Age<\/label><div class='ginput_container ginput_container_text'><input name='input_78' id='input_1_78' type='text' value='' class='medium'      aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_1_79\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' >Child&#039;s Sex<\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_1_79'>\n\t\t\t<li class='gchoice gchoice_1_79_0'>\n\t\t\t\t<input name='input_79' type='radio' value='M'  id='choice_1_79_0'    \/>\n\t\t\t\t<label for='choice_1_79_0' id='label_1_79_0' class='gform-field-label gform-field-label--type-inline'>M<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_1_79_1'>\n\t\t\t\t<input name='input_79' type='radio' value='F'  id='choice_1_79_1'    \/>\n\t\t\t\t<label for='choice_1_79_1' id='label_1_79_1' class='gform-field-label gform-field-label--type-inline'>F<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_1_80\" class=\"gfield gfield--type-text gfield--input-type-text field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_1_80'>Currently Living With:<\/label><div class='ginput_container ginput_container_text'><input name='input_80' id='input_1_80' type='text' value='' class='medium'      aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_1_81\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' >Stepchild?<\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_1_81'>\n\t\t\t<li class='gchoice gchoice_1_81_0'>\n\t\t\t\t<input name='input_81' type='radio' value='Yes'  id='choice_1_81_0'    \/>\n\t\t\t\t<label for='choice_1_81_0' id='label_1_81_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_1_81_1'>\n\t\t\t\t<input name='input_81' type='radio' value='No'  id='choice_1_81_1'    \/>\n\t\t\t\t<label for='choice_1_81_1' id='label_1_81_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_1_82\" class=\"gfield gfield--type-section gfield--input-type-section gsection field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><h2 class=\"gsection_title\">Child 2<\/h2><\/li><li id=\"field_1_83\" class=\"gfield gfield--type-name gfield--input-type-name field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label gfield_label_before_complex' >Child&#039;s Name<\/label><div class='ginput_complex ginput_container ginput_container--name no_prefix has_first_name no_middle_name has_last_name no_suffix gf_name_has_2 ginput_container_name gform-grid-row' id='input_1_83'>\n                            \n                            <span id='input_1_83_3_container' class='name_first gform-grid-col gform-grid-col--size-auto' >\n                                                    <input type='text' name='input_83.3' id='input_1_83_3' value=''   aria-required='false'     \/>\n                                                    <label for='input_1_83_3' class='gform-field-label gform-field-label--type-sub '>First<\/label>\n                                                <\/span>\n                            \n                            <span id='input_1_83_6_container' class='name_last gform-grid-col gform-grid-col--size-auto' >\n                                                    <input type='text' name='input_83.6' id='input_1_83_6' value=''   aria-required='false'     \/>\n                                                    <label for='input_1_83_6' class='gform-field-label gform-field-label--type-sub '>Last<\/label>\n                                                <\/span>\n                            \n                        <\/div><\/li><li id=\"field_1_84\" class=\"gfield gfield--type-text gfield--input-type-text field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_1_84'>Child&#039;s Age<\/label><div class='ginput_container ginput_container_text'><input name='input_84' id='input_1_84' type='text' value='' class='medium'      aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_1_85\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' >Child&#039;s Sex<\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_1_85'>\n\t\t\t<li class='gchoice gchoice_1_85_0'>\n\t\t\t\t<input name='input_85' type='radio' value='M'  id='choice_1_85_0'    \/>\n\t\t\t\t<label for='choice_1_85_0' id='label_1_85_0' class='gform-field-label gform-field-label--type-inline'>M<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_1_85_1'>\n\t\t\t\t<input name='input_85' type='radio' value='F'  id='choice_1_85_1'    \/>\n\t\t\t\t<label for='choice_1_85_1' id='label_1_85_1' class='gform-field-label gform-field-label--type-inline'>F<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_1_86\" class=\"gfield gfield--type-text gfield--input-type-text field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_1_86'>Currently Living With:<\/label><div class='ginput_container ginput_container_text'><input name='input_86' id='input_1_86' type='text' value='' class='medium'      aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_1_87\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' >Stepchild?<\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_1_87'>\n\t\t\t<li class='gchoice gchoice_1_87_0'>\n\t\t\t\t<input name='input_87' type='radio' value='Yes'  id='choice_1_87_0'    \/>\n\t\t\t\t<label for='choice_1_87_0' id='label_1_87_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_1_87_1'>\n\t\t\t\t<input name='input_87' type='radio' value='No'  id='choice_1_87_1'    \/>\n\t\t\t\t<label for='choice_1_87_1' id='label_1_87_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_1_88\" class=\"gfield gfield--type-section gfield--input-type-section gsection field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><h2 class=\"gsection_title\">Child 3<\/h2><\/li><li id=\"field_1_89\" class=\"gfield gfield--type-name gfield--input-type-name field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label gfield_label_before_complex' >Child&#039;s Name<\/label><div class='ginput_complex ginput_container ginput_container--name no_prefix has_first_name no_middle_name has_last_name no_suffix gf_name_has_2 ginput_container_name gform-grid-row' id='input_1_89'>\n                            \n                            <span id='input_1_89_3_container' class='name_first gform-grid-col gform-grid-col--size-auto' >\n                                                    <input type='text' name='input_89.3' id='input_1_89_3' value=''   aria-required='false'     \/>\n                                                    <label for='input_1_89_3' class='gform-field-label gform-field-label--type-sub '>First<\/label>\n                                                <\/span>\n                            \n                            <span id='input_1_89_6_container' class='name_last gform-grid-col gform-grid-col--size-auto' >\n                                                    <input type='text' name='input_89.6' id='input_1_89_6' value=''   aria-required='false'     \/>\n                                                    <label for='input_1_89_6' class='gform-field-label gform-field-label--type-sub '>Last<\/label>\n                                                <\/span>\n                            \n                        <\/div><\/li><li id=\"field_1_90\" class=\"gfield gfield--type-text gfield--input-type-text field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_1_90'>Child&#039;s Age<\/label><div class='ginput_container ginput_container_text'><input name='input_90' id='input_1_90' type='text' value='' class='medium'      aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_1_91\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' >Child&#039;s Sex<\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_1_91'>\n\t\t\t<li class='gchoice gchoice_1_91_0'>\n\t\t\t\t<input name='input_91' type='radio' value='M'  id='choice_1_91_0'    \/>\n\t\t\t\t<label for='choice_1_91_0' id='label_1_91_0' class='gform-field-label gform-field-label--type-inline'>M<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_1_91_1'>\n\t\t\t\t<input name='input_91' type='radio' value='F'  id='choice_1_91_1'    \/>\n\t\t\t\t<label for='choice_1_91_1' id='label_1_91_1' class='gform-field-label gform-field-label--type-inline'>F<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_1_92\" class=\"gfield gfield--type-text gfield--input-type-text field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_1_92'>Currently Living With:<\/label><div class='ginput_container ginput_container_text'><input name='input_92' id='input_1_92' type='text' value='' class='medium'      aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_1_93\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' >Stepchild?<\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_1_93'>\n\t\t\t<li class='gchoice gchoice_1_93_0'>\n\t\t\t\t<input name='input_93' type='radio' value='Yes'  id='choice_1_93_0'    \/>\n\t\t\t\t<label for='choice_1_93_0' id='label_1_93_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_1_93_1'>\n\t\t\t\t<input name='input_93' type='radio' value='No'  id='choice_1_93_1'    \/>\n\t\t\t\t<label for='choice_1_93_1' id='label_1_93_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_1_94\" class=\"gfield gfield--type-section gfield--input-type-section gsection field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><h2 class=\"gsection_title\">Child 4<\/h2><\/li><li id=\"field_1_95\" class=\"gfield gfield--type-name gfield--input-type-name field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label gfield_label_before_complex' >Child&#039;s Name<\/label><div class='ginput_complex ginput_container ginput_container--name no_prefix has_first_name no_middle_name has_last_name no_suffix gf_name_has_2 ginput_container_name gform-grid-row' id='input_1_95'>\n                            \n                            <span id='input_1_95_3_container' class='name_first gform-grid-col gform-grid-col--size-auto' >\n                                                    <input type='text' name='input_95.3' id='input_1_95_3' value=''   aria-required='false'     \/>\n                                                    <label for='input_1_95_3' class='gform-field-label gform-field-label--type-sub '>First<\/label>\n                                                <\/span>\n                            \n                            <span id='input_1_95_6_container' class='name_last gform-grid-col gform-grid-col--size-auto' >\n                                                    <input type='text' name='input_95.6' id='input_1_95_6' value=''   aria-required='false'     \/>\n                                                    <label for='input_1_95_6' class='gform-field-label gform-field-label--type-sub '>Last<\/label>\n                                                <\/span>\n                            \n                        <\/div><\/li><li id=\"field_1_96\" class=\"gfield gfield--type-text gfield--input-type-text field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_1_96'>Child&#039;s Age<\/label><div class='ginput_container ginput_container_text'><input name='input_96' id='input_1_96' type='text' value='' class='medium'      aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_1_97\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' >Child&#039;s Sex<\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_1_97'>\n\t\t\t<li class='gchoice gchoice_1_97_0'>\n\t\t\t\t<input name='input_97' type='radio' value='M'  id='choice_1_97_0'    \/>\n\t\t\t\t<label for='choice_1_97_0' id='label_1_97_0' class='gform-field-label gform-field-label--type-inline'>M<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_1_97_1'>\n\t\t\t\t<input name='input_97' type='radio' value='F'  id='choice_1_97_1'    \/>\n\t\t\t\t<label for='choice_1_97_1' id='label_1_97_1' class='gform-field-label gform-field-label--type-inline'>F<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_1_98\" class=\"gfield gfield--type-text gfield--input-type-text field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_1_98'>Currently Living With:<\/label><div class='ginput_container ginput_container_text'><input name='input_98' id='input_1_98' type='text' value='' class='medium'      aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_1_99\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' >Stepchild?<\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_1_99'>\n\t\t\t<li class='gchoice gchoice_1_99_0'>\n\t\t\t\t<input name='input_99' type='radio' value='Yes'  id='choice_1_99_0'    \/>\n\t\t\t\t<label for='choice_1_99_0' id='label_1_99_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_1_99_1'>\n\t\t\t\t<input name='input_99' type='radio' value='No'  id='choice_1_99_1'    \/>\n\t\t\t\t<label for='choice_1_99_1' id='label_1_99_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_1_100\" class=\"gfield gfield--type-section gfield--input-type-section gsection field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><h2 class=\"gsection_title\">Child 5<\/h2><\/li><li id=\"field_1_101\" class=\"gfield gfield--type-name gfield--input-type-name field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label gfield_label_before_complex' >Child&#039;s Name<\/label><div class='ginput_complex ginput_container ginput_container--name no_prefix has_first_name no_middle_name has_last_name no_suffix gf_name_has_2 ginput_container_name gform-grid-row' id='input_1_101'>\n                            \n                            <span id='input_1_101_3_container' class='name_first gform-grid-col gform-grid-col--size-auto' >\n                                                    <input type='text' name='input_101.3' id='input_1_101_3' value=''   aria-required='false'     \/>\n                                                    <label for='input_1_101_3' class='gform-field-label gform-field-label--type-sub '>First<\/label>\n                                                <\/span>\n                            \n                            <span id='input_1_101_6_container' class='name_last gform-grid-col gform-grid-col--size-auto' >\n                                                    <input type='text' name='input_101.6' id='input_1_101_6' value=''   aria-required='false'     \/>\n                                                    <label for='input_1_101_6' class='gform-field-label gform-field-label--type-sub '>Last<\/label>\n                                                <\/span>\n                            \n                        <\/div><\/li><li id=\"field_1_102\" class=\"gfield gfield--type-text gfield--input-type-text field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_1_102'>Child&#039;s Age<\/label><div class='ginput_container ginput_container_text'><input name='input_102' id='input_1_102' type='text' value='' class='medium'      aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_1_103\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' >Child&#039;s Sex<\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_1_103'>\n\t\t\t<li class='gchoice gchoice_1_103_0'>\n\t\t\t\t<input name='input_103' type='radio' value='M'  id='choice_1_103_0'    \/>\n\t\t\t\t<label for='choice_1_103_0' id='label_1_103_0' class='gform-field-label gform-field-label--type-inline'>M<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_1_103_1'>\n\t\t\t\t<input name='input_103' type='radio' value='F'  id='choice_1_103_1'    \/>\n\t\t\t\t<label for='choice_1_103_1' id='label_1_103_1' class='gform-field-label gform-field-label--type-inline'>F<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_1_104\" class=\"gfield gfield--type-text gfield--input-type-text field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_1_104'>Currently Living With:<\/label><div class='ginput_container ginput_container_text'><input name='input_104' id='input_1_104' type='text' value='' class='medium'      aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_1_105\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' >Stepchild?<\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_1_105'>\n\t\t\t<li class='gchoice gchoice_1_105_0'>\n\t\t\t\t<input name='input_105' type='radio' value='Yes'  id='choice_1_105_0'    \/>\n\t\t\t\t<label for='choice_1_105_0' id='label_1_105_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_1_105_1'>\n\t\t\t\t<input name='input_105' type='radio' value='No'  id='choice_1_105_1'    \/>\n\t\t\t\t<label for='choice_1_105_1' id='label_1_105_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><\/ul>\n                    <\/div>\n                    <div class='gform-page-footer gform_page_footer top_label'>\n                        <input type='button' id='gform_previous_button_1_106' class='gform_previous_button gform-theme-button gform-theme-button--secondary button' onclick='gform.submission.handleButtonClick(this);' data-submission-type='previous' value='Previous'  \/> <input type='button' id='gform_next_button_1_106' class='gform_next_button gform-theme-button button' onclick='gform.submission.handleButtonClick(this);' data-submission-type='next' value='Next'  \/> \n                    <\/div>\n                <\/div>\n                <div id='gform_page_1_6' class='gform_page' data-js='page-field-id-106' style='display:none;'>\n                    <div class='gform_page_fields'>\n                        <ul id='gform_fields_1_6' class='gform_fields top_label form_sublabel_below description_below validation_below'><li id=\"field_1_107\" class=\"gfield gfield--type-section gfield--input-type-section gsection field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><h2 class=\"gsection_title\">Personality Information<\/h2><\/li><li id=\"field_1_108\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio 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' >Have you ever had any psychotherapy or counseling before?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_1_108'>\n\t\t\t<li class='gchoice gchoice_1_108_0'>\n\t\t\t\t<input name='input_108' type='radio' value='Yes'  id='choice_1_108_0'    \/>\n\t\t\t\t<label for='choice_1_108_0' id='label_1_108_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_1_108_1'>\n\t\t\t\t<input name='input_108' type='radio' value='No'  id='choice_1_108_1'    \/>\n\t\t\t\t<label for='choice_1_108_1' id='label_1_108_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_1_109\" class=\"gfield gfield--type-textarea gfield--input-type-textarea field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_1_109'>If yes, list counselor or therapist and dates<\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_109' id='input_1_109' class='textarea medium'   maxlength='100'   aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/li><li id=\"field_1_110\" class=\"gfield gfield--type-textarea gfield--input-type-textarea field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_1_110'>What was the outcome?<\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_110' id='input_1_110' class='textarea medium'   maxlength='100'   aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/li><li id=\"field_1_111\" class=\"gfield gfield--type-textarea gfield--input-type-textarea field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_1_111'>What, if anything, do you fear?<\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_111' id='input_1_111' class='textarea medium'   maxlength='80'   aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/li><li id=\"field_1_112\" class=\"gfield gfield--type-textarea gfield--input-type-textarea field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_1_112'>Is there any other information that would help us to help you?<\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_112' id='input_1_112' class='textarea medium'   maxlength='60'   aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/li><li id=\"field_1_113\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' >Have you recently suffered a loss from serious social, business, or other reversals, etc?<\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_1_113'>\n\t\t\t<li class='gchoice gchoice_1_113_0'>\n\t\t\t\t<input name='input_113' type='radio' value='Yes'  id='choice_1_113_0'    \/>\n\t\t\t\t<label for='choice_1_113_0' id='label_1_113_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_1_113_1'>\n\t\t\t\t<input name='input_113' type='radio' value='No'  id='choice_1_113_1'    \/>\n\t\t\t\t<label for='choice_1_113_1' id='label_1_113_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_1_114\" class=\"gfield gfield--type-textarea gfield--input-type-textarea field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_1_114'>Explain if yes<\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_114' id='input_1_114' class='textarea medium'   maxlength='100'   aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/li><li id=\"field_1_115\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield--input-type-checkbox 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 gfield_label_before_complex' >Check any of the following words which best describe you now:<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_checkbox'><ul class='gfield_checkbox' id='input_1_115'><li class='gchoice gchoice_1_115_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_115.1' type='checkbox'  value='Active'  id='choice_1_115_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_1_115_1' id='label_1_115_1' class='gform-field-label gform-field-label--type-inline'>Active<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_1_115_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_115.2' type='checkbox'  value='Ambitious'  id='choice_1_115_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_1_115_2' id='label_1_115_2' class='gform-field-label gform-field-label--type-inline'>Ambitious<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_1_115_3'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_115.3' type='checkbox'  value='Self-Confident'  id='choice_1_115_3'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_1_115_3' id='label_1_115_3' class='gform-field-label gform-field-label--type-inline'>Self-Confident<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_1_115_4'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_115.4' type='checkbox'  value='Persistent'  id='choice_1_115_4'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_1_115_4' id='label_1_115_4' class='gform-field-label gform-field-label--type-inline'>Persistent<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_1_115_5'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_115.5' type='checkbox'  value='Nervous'  id='choice_1_115_5'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_1_115_5' id='label_1_115_5' class='gform-field-label gform-field-label--type-inline'>Nervous<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_1_115_6'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_115.6' type='checkbox'  value='Hardworking'  id='choice_1_115_6'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_1_115_6' id='label_1_115_6' class='gform-field-label gform-field-label--type-inline'>Hardworking<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_1_115_7'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_115.7' type='checkbox'  value='Impatient'  id='choice_1_115_7'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_1_115_7' id='label_1_115_7' class='gform-field-label gform-field-label--type-inline'>Impatient<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_1_115_8'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_115.8' type='checkbox'  value='Impulsive'  id='choice_1_115_8'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_1_115_8' id='label_1_115_8' class='gform-field-label gform-field-label--type-inline'>Impulsive<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_1_115_9'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_115.9' type='checkbox'  value='Moody'  id='choice_1_115_9'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_1_115_9' id='label_1_115_9' class='gform-field-label gform-field-label--type-inline'>Moody<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_1_115_11'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_115.11' type='checkbox'  value='Often-blue'  id='choice_1_115_11'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_1_115_11' id='label_1_115_11' class='gform-field-label gform-field-label--type-inline'>Often-blue<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_1_115_12'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_115.12' type='checkbox'  value='Excitable'  id='choice_1_115_12'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_1_115_12' id='label_1_115_12' class='gform-field-label gform-field-label--type-inline'>Excitable<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_1_115_13'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_115.13' type='checkbox'  value='Imaginative'  id='choice_1_115_13'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_1_115_13' id='label_1_115_13' class='gform-field-label gform-field-label--type-inline'>Imaginative<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_1_115_14'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_115.14' type='checkbox'  value='Calm'  id='choice_1_115_14'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_1_115_14' id='label_1_115_14' class='gform-field-label gform-field-label--type-inline'>Calm<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_1_115_15'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_115.15' type='checkbox'  value='Serious'  id='choice_1_115_15'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_1_115_15' id='label_1_115_15' class='gform-field-label gform-field-label--type-inline'>Serious<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_1_115_16'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_115.16' type='checkbox'  value='Easy-going'  id='choice_1_115_16'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_1_115_16' id='label_1_115_16' class='gform-field-label gform-field-label--type-inline'>Easy-going<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_1_115_17'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_115.17' type='checkbox'  value='Shy'  id='choice_1_115_17'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_1_115_17' id='label_1_115_17' class='gform-field-label gform-field-label--type-inline'>Shy<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_1_115_18'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_115.18' type='checkbox'  value='Good-natured'  id='choice_1_115_18'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_1_115_18' id='label_1_115_18' class='gform-field-label gform-field-label--type-inline'>Good-natured<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_1_115_19'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_115.19' type='checkbox'  value='Introvert'  id='choice_1_115_19'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_1_115_19' id='label_1_115_19' class='gform-field-label gform-field-label--type-inline'>Introvert<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_1_115_21'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_115.21' type='checkbox'  value='Extrovert'  id='choice_1_115_21'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_1_115_21' id='label_1_115_21' class='gform-field-label gform-field-label--type-inline'>Extrovert<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_1_115_22'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_115.22' type='checkbox'  value='Likable'  id='choice_1_115_22'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_1_115_22' id='label_1_115_22' class='gform-field-label gform-field-label--type-inline'>Likable<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_1_115_23'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_115.23' type='checkbox'  value='Leader'  id='choice_1_115_23'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_1_115_23' id='label_1_115_23' class='gform-field-label gform-field-label--type-inline'>Leader<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_1_115_24'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_115.24' type='checkbox'  value='Quiet'  id='choice_1_115_24'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_1_115_24' id='label_1_115_24' class='gform-field-label gform-field-label--type-inline'>Quiet<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_1_115_25'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_115.25' type='checkbox'  value='Submissive'  id='choice_1_115_25'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_1_115_25' id='label_1_115_25' class='gform-field-label gform-field-label--type-inline'>Submissive<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_1_115_26'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_115.26' type='checkbox'  value='Self-conscious'  id='choice_1_115_26'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_1_115_26' id='label_1_115_26' class='gform-field-label gform-field-label--type-inline'>Self-conscious<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_1_115_27'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_115.27' type='checkbox'  value='Lonely'  id='choice_1_115_27'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_1_115_27' id='label_1_115_27' class='gform-field-label gform-field-label--type-inline'>Lonely<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_1_115_28'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_115.28' type='checkbox'  value='Sensitive'  id='choice_1_115_28'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_1_115_28' id='label_1_115_28' class='gform-field-label gform-field-label--type-inline'>Sensitive<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_1_115_29'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_115.29' type='checkbox'  value='Other'  id='choice_1_115_29'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_1_115_29' id='label_1_115_29' class='gform-field-label gform-field-label--type-inline'>Other<\/label>\n\t\t\t\t\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_1_116\" class=\"gfield gfield--type-textarea gfield--input-type-textarea field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_1_116'>You selected other, please explain<\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_116' id='input_1_116' class='textarea medium'   maxlength='50'   aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/li><li id=\"field_1_117\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio 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' >Do you drink coffee or other caffeinated drinks?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_1_117'>\n\t\t\t<li class='gchoice gchoice_1_117_0'>\n\t\t\t\t<input name='input_117' type='radio' value='Yes'  id='choice_1_117_0'    \/>\n\t\t\t\t<label for='choice_1_117_0' id='label_1_117_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_1_117_1'>\n\t\t\t\t<input name='input_117' type='radio' value='No'  id='choice_1_117_1'    \/>\n\t\t\t\t<label for='choice_1_117_1' id='label_1_117_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_1_118\" class=\"gfield gfield--type-text gfield--input-type-text field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_1_118'>How much caffeine per day?<\/label><div class='ginput_container ginput_container_text'><input name='input_118' id='input_1_118' type='text' value='' class='medium' maxlength='30'     aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_1_119\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio 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' >Do you smoke?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_1_119'>\n\t\t\t<li class='gchoice gchoice_1_119_0'>\n\t\t\t\t<input name='input_119' type='radio' value='Yes'  id='choice_1_119_0'    \/>\n\t\t\t\t<label for='choice_1_119_0' id='label_1_119_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_1_119_1'>\n\t\t\t\t<input name='input_119' type='radio' value='No'  id='choice_1_119_1'    \/>\n\t\t\t\t<label for='choice_1_119_1' id='label_1_119_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_1_120\" class=\"gfield gfield--type-text gfield--input-type-text field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_1_120'>How much do you smoke?<\/label><div class='ginput_container ginput_container_text'><input name='input_120' id='input_1_120' type='text' value='' class='medium' maxlength='30'     aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_1_121\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio 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' >Do you explode when you get angry?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_1_121'>\n\t\t\t<li class='gchoice gchoice_1_121_0'>\n\t\t\t\t<input name='input_121' type='radio' value='Yes'  id='choice_1_121_0'    \/>\n\t\t\t\t<label for='choice_1_121_0' id='label_1_121_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_1_121_1'>\n\t\t\t\t<input name='input_121' type='radio' value='No'  id='choice_1_121_1'    \/>\n\t\t\t\t<label for='choice_1_121_1' id='label_1_121_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_1_122\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio 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' >Do you withdraw when you get angry or hurt?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_1_122'>\n\t\t\t<li class='gchoice gchoice_1_122_0'>\n\t\t\t\t<input name='input_122' type='radio' value='Yes'  id='choice_1_122_0'    \/>\n\t\t\t\t<label for='choice_1_122_0' id='label_1_122_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_1_122_1'>\n\t\t\t\t<input name='input_122' type='radio' value='No'  id='choice_1_122_1'    \/>\n\t\t\t\t<label for='choice_1_122_1' id='label_1_122_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_1_123\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio 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' >Do you frequently argue with significant other people?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_1_123'>\n\t\t\t<li class='gchoice gchoice_1_123_0'>\n\t\t\t\t<input name='input_123' type='radio' value='Yes'  id='choice_1_123_0'    \/>\n\t\t\t\t<label for='choice_1_123_0' id='label_1_123_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_1_123_1'>\n\t\t\t\t<input name='input_123' type='radio' value='No'  id='choice_1_123_1'    \/>\n\t\t\t\t<label for='choice_1_123_1' id='label_1_123_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_1_124\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio 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' >Have you ever been enslaved to anything (Coffee, drugs, alcohol, pornography, gambling, etc.)?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_1_124'>\n\t\t\t<li class='gchoice gchoice_1_124_0'>\n\t\t\t\t<input name='input_124' type='radio' value='Yes'  id='choice_1_124_0'    \/>\n\t\t\t\t<label for='choice_1_124_0' id='label_1_124_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_1_124_1'>\n\t\t\t\t<input name='input_124' type='radio' value='No'  id='choice_1_124_1'    \/>\n\t\t\t\t<label for='choice_1_124_1' id='label_1_124_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_1_125\" class=\"gfield gfield--type-textarea gfield--input-type-textarea 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_1_125'>If yes, please explain.<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_125' id='input_1_125' class='textarea medium'   maxlength='360'  aria-required=\"true\" aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/li><\/ul>\n                    <\/div>\n                    <div class='gform-page-footer gform_page_footer top_label'>\n                        <input type='button' id='gform_previous_button_1_126' class='gform_previous_button gform-theme-button gform-theme-button--secondary button' onclick='gform.submission.handleButtonClick(this);' data-submission-type='previous' value='Previous'  \/> <input type='button' id='gform_next_button_1_126' class='gform_next_button gform-theme-button button' onclick='gform.submission.handleButtonClick(this);' data-submission-type='next' value='Next'  \/> \n                    <\/div>\n                <\/div>\n                <div id='gform_page_1_7' class='gform_page' data-js='page-field-id-126' style='display:none;'>\n                    <div class='gform_page_fields'>\n                        <ul id='gform_fields_1_7' class='gform_fields top_label form_sublabel_below description_below validation_below'><li id=\"field_1_127\" class=\"gfield gfield--type-section gfield--input-type-section gsection field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><h2 class=\"gsection_title\">Fear of Man Questionnaire<\/h2><\/li><li id=\"field_1_131\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield--input-type-checkbox 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 gfield_label_before_complex' >Fear of Man Questionnaire<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_checkbox'><ul class='gfield_checkbox' id='input_1_131'><li class='gchoice gchoice_1_131_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_131.1' type='checkbox'  value='Peer'  id='choice_1_131_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_1_131_1' id='label_1_131_1' class='gform-field-label gform-field-label--type-inline'>I struggle with peer pressure. In adulthood, it looks different than when a teen. Now it might be by trying to impress others.<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_1_131_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_131.2' type='checkbox'  value='Over-committed'  id='choice_1_131_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_1_131_2' id='label_1_131_2' class='gform-field-label gform-field-label--type-inline'>I am over-committed. I find it hard to say, \u201cNo.\u201d I am a people pleaser.<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_1_131_3'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_131.3' type='checkbox'  value='Need'  id='choice_1_131_3'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_1_131_3' id='label_1_131_3' class='gform-field-label gform-field-label--type-inline'>I \u2018need\u2019 something from my spouse or others in my life (such as the person I am dating, a roommate, other friends).<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_1_131_4'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_131.4' type='checkbox'  value='Low Self'  id='choice_1_131_4'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_1_131_4' id='label_1_131_4' class='gform-field-label gform-field-label--type-inline'>I feel like I have low self-esteem. I am concerned with what others think of me.<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_1_131_5'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_131.5' type='checkbox'  value='Imposter'  id='choice_1_131_5'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_1_131_5' id='label_1_131_5' class='gform-field-label gform-field-label--type-inline'>I often feel like I will be exposed as an imposter. I am afraid others will think I am a failure.<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_1_131_6'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_131.6' type='checkbox'  value='Decisions'  id='choice_1_131_6'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_1_131_6' id='label_1_131_6' class='gform-field-label gform-field-label--type-inline'>I find myself second-guessing decisions because of what others might think. I am afraid of making mistakes.<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_1_131_7'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_131.7' type='checkbox'  value='Empty'  id='choice_1_131_7'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_1_131_7' id='label_1_131_7' class='gform-field-label gform-field-label--type-inline'>I feel empty or meaningless. I often feel hungry for love.<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_1_131_8'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_131.8' type='checkbox'  value='Embarrassed'  id='choice_1_131_8'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_1_131_8' id='label_1_131_8' class='gform-field-label gform-field-label--type-inline'>I easily get embarrassed.<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_1_131_9'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_131.9' type='checkbox'  value='Lie'  id='choice_1_131_9'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_1_131_9' id='label_1_131_9' class='gform-field-label gform-field-label--type-inline'>I lie, even little white lies, in order to make myself look better before other people.<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_1_131_11'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_131.11' type='checkbox'  value='Jealous'  id='choice_1_131_11'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_1_131_11' id='label_1_131_11' class='gform-field-label gform-field-label--type-inline'>I am sometimes jealous of other people.<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_1_131_12'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_131.12' type='checkbox'  value='Angry'  id='choice_1_131_12'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_1_131_12' id='label_1_131_12' class='gform-field-label gform-field-label--type-inline'>People often make me angry or depressed. They make me \u201ccrazy.\u201d<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_1_131_13'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_131.13' type='checkbox'  value='Avoid People'  id='choice_1_131_13'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_1_131_13' id='label_1_131_13' class='gform-field-label gform-field-label--type-inline'>I often avoid people.<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_1_131_14'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_131.14' type='checkbox'  value='Hungry'  id='choice_1_131_14'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_1_131_14' id='label_1_131_14' class='gform-field-label gform-field-label--type-inline'>I am hungry for people to notice my efforts and to praise me, but when they do, it\u2019s not enough or I don\u2019t believe them.<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_1_131_15'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_131.15' type='checkbox'  value='Compare'  id='choice_1_131_15'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_1_131_15' id='label_1_131_15' class='gform-field-label gform-field-label--type-inline'>I often compare myself to others and either feel wanting or feel like I\u2019m not so bad.<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_1_131_16'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_131.16' type='checkbox'  value='Keep Others'  id='choice_1_131_16'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_1_131_16' id='label_1_131_16' class='gform-field-label gform-field-label--type-inline'>I feel I have to keep others from knowing my secret thoughts or actions for fear they won\u2019t like or love me.<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_1_131_17'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_131.17' type='checkbox'  value='Cover Up'  id='choice_1_131_17'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_1_131_17' id='label_1_131_17' class='gform-field-label gform-field-label--type-inline'>I cover up, justify, blame, avoid, or change the subject often.<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_1_131_18'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_131.18' type='checkbox'  value='Favoritism'  id='choice_1_131_18'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_1_131_18' id='label_1_131_18' class='gform-field-label gform-field-label--type-inline'>I show favoritism, respecting one person over another.<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_1_131_19'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_131.19' type='checkbox'  value='Responsible'  id='choice_1_131_19'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_1_131_19' id='label_1_131_19' class='gform-field-label gform-field-label--type-inline'>I often think and feel responsible for other people and their actions or behaviors.<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_1_131_21'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_131.21' type='checkbox'  value='Fix People'  id='choice_1_131_21'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_1_131_21' id='label_1_131_21' class='gform-field-label gform-field-label--type-inline'>I am compelled to \u201cfix people\u201d.<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_1_131_22'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_131.22' type='checkbox'  value='Always Giving'  id='choice_1_131_22'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_1_131_22' id='label_1_131_22' class='gform-field-label gform-field-label--type-inline'>I get tired of feeling like I am always giving to others and no one gives to me.<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_1_131_23'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_131.23' type='checkbox'  value='Blame'  id='choice_1_131_23'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_1_131_23' id='label_1_131_23' class='gform-field-label gform-field-label--type-inline'>I blame others or blame circumstances.<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_1_131_24'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_131.24' type='checkbox'  value='Unappreciated'  id='choice_1_131_24'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_1_131_24' id='label_1_131_24' class='gform-field-label gform-field-label--type-inline'>I often feel unappreciated.<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_1_131_25'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_131.25' type='checkbox'  value='Rejected'  id='choice_1_131_25'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_1_131_25' id='label_1_131_25' class='gform-field-label gform-field-label--type-inline'>I often am afraid of being rejected.<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_1_131_26'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_131.26' type='checkbox'  value='Ashamed'  id='choice_1_131_26'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_1_131_26' id='label_1_131_26' class='gform-field-label gform-field-label--type-inline'>I often feel ashamed of who I am.<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_1_131_27'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_131.27' type='checkbox'  value='Focus'  id='choice_1_131_27'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_1_131_27' id='label_1_131_27' class='gform-field-label gform-field-label--type-inline'>I often focus my energy on other people and\/or on problems.<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_1_131_28'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_131.28' type='checkbox'  value='Threaten'  id='choice_1_131_28'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_1_131_28' id='label_1_131_28' class='gform-field-label gform-field-label--type-inline'>I frequently threaten, bribe, or beg.<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_1_131_29'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_131.29' type='checkbox'  value='Please Others'  id='choice_1_131_29'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_1_131_29' id='label_1_131_29' class='gform-field-label gform-field-label--type-inline'>I try to say or do what I think will please others or get what I want.<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_1_131_31'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_131.31' type='checkbox'  value='Manipulate'  id='choice_1_131_31'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_1_131_31' id='label_1_131_31' class='gform-field-label gform-field-label--type-inline'>I manipulate people and situations.<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_1_131_32'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_131.32' type='checkbox'  value='Hurting Me'  id='choice_1_131_32'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_1_131_32' id='label_1_131_32' class='gform-field-label gform-field-label--type-inline'>I let other people keep hurting me and never say anything.<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_1_131_33'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_131.33' type='checkbox'  value='Feel Angry'  id='choice_1_131_33'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_1_131_33' id='label_1_131_33' class='gform-field-label gform-field-label--type-inline'>I feel angry.<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_1_131_34'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_131.34' type='checkbox'  value='Martyr'  id='choice_1_131_34'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_1_131_34' id='label_1_131_34' class='gform-field-label gform-field-label--type-inline'>I feel like a martyr.<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_1_131_35'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_131.35' type='checkbox'  value='Responsible Irresponsible'  id='choice_1_131_35'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_1_131_35' id='label_1_131_35' class='gform-field-label gform-field-label--type-inline'>I feel extremely responsible or irresponsible.<\/label>\n\t\t\t\t\t\t\t<\/li><\/ul><\/div><\/li><\/ul>\n                    <\/div>\n                    <div class='gform-page-footer gform_page_footer top_label'>\n                        <input type='button' id='gform_previous_button_1_132' class='gform_previous_button gform-theme-button gform-theme-button--secondary button' onclick='gform.submission.handleButtonClick(this);' data-submission-type='previous' value='Previous'  \/> <input type='button' id='gform_next_button_1_132' class='gform_next_button gform-theme-button button' onclick='gform.submission.handleButtonClick(this);' data-submission-type='next' value='Next'  \/> \n                    <\/div>\n                <\/div>\n                <div id='gform_page_1_8' class='gform_page' data-js='page-field-id-132' style='display:none;'>\n                    <div class='gform_page_fields'>\n                        <ul id='gform_fields_1_8' class='gform_fields top_label form_sublabel_below description_below validation_below'><li id=\"field_1_133\" class=\"gfield gfield--type-section gfield--input-type-section gsection field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><h2 class=\"gsection_title\">Briefly answer the following questions<\/h2><\/li><li id=\"field_1_134\" class=\"gfield gfield--type-textarea gfield--input-type-textarea 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_1_134'>What is the main problem as you see it? What brings you here?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_134' id='input_1_134' class='textarea medium'   maxlength='900'  aria-required=\"true\" aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/li><li id=\"field_1_135\" class=\"gfield gfield--type-textarea gfield--input-type-textarea 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_1_135'>What have you done about your problem?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_135' id='input_1_135' class='textarea medium'   maxlength='700'  aria-required=\"true\" aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/li><li id=\"field_1_136\" class=\"gfield gfield--type-textarea gfield--input-type-textarea 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_1_136'>What can we do? (What are your expectations in coming here?)<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_136' id='input_1_136' class='textarea medium'   maxlength='700'  aria-required=\"true\" aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/li><li id=\"field_1_137\" class=\"gfield gfield--type-textarea gfield--input-type-textarea 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_1_137'>As you see yourself, what kind of person are you? Describe yourself:<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_137' id='input_1_137' class='textarea medium'   maxlength='700'  aria-required=\"true\" aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/li><li id=\"field_1_141\" class=\"gfield gfield--type-textarea gfield--input-type-textarea field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_1_141'>Give details of any family background that might be pertinent to the struggles in your own life. (I.e., do others in your family have similar problems? What did your home life look like? Did mom lead or dad? Was dad at home a lot or gone a lot? Was \u201cself-control\u201d taught from early on? Etc.<\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_141' id='input_1_141' class='textarea medium'   maxlength='700'   aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/li><li id=\"field_1_139\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield--input-type-checkbox 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 gfield_label_before_complex' >Problem Checklist (Check those which are current problems)<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_checkbox'><ul class='gfield_checkbox' id='input_1_139'><li class='gchoice gchoice_1_139_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_139.1' type='checkbox'  value='Anger'  id='choice_1_139_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_1_139_1' id='label_1_139_1' class='gform-field-label gform-field-label--type-inline'>Anger<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_1_139_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_139.2' type='checkbox'  value='Fear'  id='choice_1_139_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_1_139_2' id='label_1_139_2' class='gform-field-label gform-field-label--type-inline'>Fear<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_1_139_3'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_139.3' type='checkbox'  value='Moodiness'  id='choice_1_139_3'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_1_139_3' id='label_1_139_3' class='gform-field-label gform-field-label--type-inline'>Moodiness<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_1_139_4'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_139.4' type='checkbox'  value='Health'  id='choice_1_139_4'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_1_139_4' id='label_1_139_4' class='gform-field-label gform-field-label--type-inline'>Health<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_1_139_5'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_139.5' type='checkbox'  value='Sleep'  id='choice_1_139_5'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_1_139_5' id='label_1_139_5' class='gform-field-label gform-field-label--type-inline'>Sleep<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_1_139_6'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_139.6' type='checkbox'  value='Deception'  id='choice_1_139_6'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_1_139_6' id='label_1_139_6' class='gform-field-label gform-field-label--type-inline'>Deception<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_1_139_7'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_139.7' type='checkbox'  value='Adultery'  id='choice_1_139_7'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_1_139_7' id='label_1_139_7' class='gform-field-label gform-field-label--type-inline'>Adultery<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_1_139_8'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_139.8' type='checkbox'  value='Envy'  id='choice_1_139_8'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_1_139_8' id='label_1_139_8' class='gform-field-label gform-field-label--type-inline'>Envy<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_1_139_9'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_139.9' type='checkbox'  value='Memory'  id='choice_1_139_9'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_1_139_9' id='label_1_139_9' class='gform-field-label gform-field-label--type-inline'>Memory<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_1_139_11'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_139.11' type='checkbox'  value='Bitterness'  id='choice_1_139_11'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_1_139_11' id='label_1_139_11' class='gform-field-label gform-field-label--type-inline'>Bitterness<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_1_139_12'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_139.12' type='checkbox'  value='Sex'  id='choice_1_139_12'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_1_139_12' id='label_1_139_12' class='gform-field-label gform-field-label--type-inline'>Sex<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_1_139_13'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_139.13' type='checkbox'  value='Depression'  id='choice_1_139_13'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_1_139_13' id='label_1_139_13' class='gform-field-label gform-field-label--type-inline'>Depression<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_1_139_14'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_139.14' type='checkbox'  value='In-Laws'  id='choice_1_139_14'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_1_139_14' id='label_1_139_14' class='gform-field-label gform-field-label--type-inline'>In-Laws<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_1_139_15'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_139.15' type='checkbox'  value='Lust'  id='choice_1_139_15'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_1_139_15' id='label_1_139_15' class='gform-field-label gform-field-label--type-inline'>Lust<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_1_139_16'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_139.16' type='checkbox'  value='Appetite'  id='choice_1_139_16'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_1_139_16' id='label_1_139_16' class='gform-field-label gform-field-label--type-inline'>Appetite<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_1_139_17'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_139.17' type='checkbox'  value='Apathy'  id='choice_1_139_17'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_1_139_17' id='label_1_139_17' class='gform-field-label gform-field-label--type-inline'>Apathy<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_1_139_18'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_139.18' type='checkbox'  value='Guilt'  id='choice_1_139_18'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_1_139_18' id='label_1_139_18' class='gform-field-label gform-field-label--type-inline'>Guilt<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_1_139_19'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_139.19' type='checkbox'  value='Children'  id='choice_1_139_19'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_1_139_19' id='label_1_139_19' class='gform-field-label gform-field-label--type-inline'>Children<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_1_139_21'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_139.21' type='checkbox'  value='Impotence'  id='choice_1_139_21'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_1_139_21' id='label_1_139_21' class='gform-field-label gform-field-label--type-inline'>Impotence<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_1_139_22'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_139.22' type='checkbox'  value='Self-harm'  id='choice_1_139_22'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_1_139_22' id='label_1_139_22' class='gform-field-label gform-field-label--type-inline'>Self-harm<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_1_139_23'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_139.23' type='checkbox'  value='Addiction'  id='choice_1_139_23'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_1_139_23' id='label_1_139_23' class='gform-field-label gform-field-label--type-inline'>Addiction<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_1_139_24'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_139.24' type='checkbox'  value='Anxiety'  id='choice_1_139_24'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_1_139_24' id='label_1_139_24' class='gform-field-label gform-field-label--type-inline'>Anxiety<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_1_139_25'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_139.25' type='checkbox'  value='Gluttony'  id='choice_1_139_25'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_1_139_25' id='label_1_139_25' class='gform-field-label gform-field-label--type-inline'>Gluttony<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_1_139_26'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_139.26' type='checkbox'  value='Rebellion'  id='choice_1_139_26'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_1_139_26' id='label_1_139_26' class='gform-field-label gform-field-label--type-inline'>Rebellion<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_1_139_27'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_139.27' type='checkbox'  value='Sexual identity'  id='choice_1_139_27'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_1_139_27' id='label_1_139_27' class='gform-field-label gform-field-label--type-inline'>Sexual identity<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_1_139_28'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_139.28' type='checkbox'  value='Spouse Abuse'  id='choice_1_139_28'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_1_139_28' id='label_1_139_28' class='gform-field-label gform-field-label--type-inline'>Spouse Abuse<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_1_139_29'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_139.29' type='checkbox'  value='Change in Lifestyle'  id='choice_1_139_29'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_1_139_29' id='label_1_139_29' class='gform-field-label gform-field-label--type-inline'>Change in Lifestyle<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_1_139_31'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' 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custom_padding__hover=&#8221;|||&#8221;][et_pb_text _builder_version=&#8221;4.16&#8243; text_font=&#8221;||||||||&#8221; text_font_size=&#8221;16px&#8221; text_line_height=&#8221;1.5em&#8221; link_font=&#8221;||||||||&#8221; link_text_color=&#8221;#a0beef&#8221; link_font_size=&#8221;16px&#8221; link_line_height=&#8221;2em&#8221; header_font=&#8221;||||||||&#8221; header_4_font=&#8221;|700|||||||&#8221; header_4_line_height=&#8221;1.5em&#8221; background_layout=&#8221;dark&#8221; global_colors_info=&#8221;{}&#8221; link_text_color__hover=&#8221;#ffffff&#8221;]<\/p>\n<p><a href=\"https:\/\/gbcmt.org\/counseling\/\">Home<\/a><br \/><a href=\"https:\/\/gbcmt.org\/counseling\/what-is-biblical-counseling\/\">What is Biblical Counseling?<\/a><br \/><a href=\"https:\/\/gbcmt.org\/counseling\/getting-started\/\">Getting Started<\/a><br \/><a href=\"https:\/\/gbcmt.org\/counseling\/our-leadership-team\/\">Our Leadership Team<\/a><\/p>\n<p>[\/et_pb_text][\/et_pb_column][et_pb_column type=&#8221;1_2&#8243; _builder_version=&#8221;4.16&#8243; custom_padding=&#8221;|||&#8221; global_colors_info=&#8221;{}&#8221; custom_padding__hover=&#8221;|||&#8221;][et_pb_text _builder_version=&#8221;4.16&#8243; text_font=&#8221;|700|||||||&#8221; text_text_color=&#8221;#8ca3d1&#8243; text_font_size=&#8221;16px&#8221; text_line_height=&#8221;1.2em&#8221; link_font=&#8221;||||||||&#8221; link_text_color=&#8221;#a0beef&#8221; link_font_size=&#8221;16px&#8221; link_line_height=&#8221;2em&#8221; header_font=&#8221;||||||||&#8221; header_4_font=&#8221;|700|||||||&#8221; header_4_line_height=&#8221;1.5em&#8221; background_layout=&#8221;dark&#8221; locked=&#8221;off&#8221; global_colors_info=&#8221;{}&#8221; link_text_color__hover=&#8221;#ffffff&#8221;]<\/p>\n<h3><strong>Grace Bible Church<\/strong><\/h3>\n<p> 3625 South 19th Ave<br \/> Bozeman, MT 59718<br \/> T. (406) 586-9782<\/p>\n<p>[\/et_pb_text][\/et_pb_column][\/et_pb_row][et_pb_row _builder_version=&#8221;4.16&#8243; global_colors_info=&#8221;{}&#8221;][et_pb_column type=&#8221;4_4&#8243; _builder_version=&#8221;4.16&#8243; custom_padding=&#8221;|||&#8221; global_colors_info=&#8221;{}&#8221; custom_padding__hover=&#8221;|||&#8221;][et_pb_signup mailchimp_list=&#8221;elegantthemestest|26e9af0331&#8243; layout=&#8221;top_bottom&#8221; name_field=&#8221;on&#8221; title=&#8221;Stay In Touch&#8221; disabled_on=&#8221;on|on|on&#8221; _builder_version=&#8221;4.16&#8243; form_field_background_color=&#8221;rgba(0,0,0,0)&#8221; form_field_text_color=&#8221;#ffffff&#8221; header_font=&#8221;Didact Gothic||||||||&#8221; header_font_size=&#8221;60px&#8221; header_line_height=&#8221;1.3em&#8221; body_font=&#8221;||||||||&#8221; form_field_font=&#8221;||||||||&#8221; use_background_color=&#8221;off&#8221; custom_button=&#8221;on&#8221; button_text_size=&#8221;16px&#8221; button_text_color=&#8221;#34587c&#8221; 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header_text_shadow_style__hover=&#8221;none&#8221; header_text_shadow_style__hover_enabled=&#8221;none&#8221; header_text_shadow_color__hover=&#8221;rgba(0,0,0,0.4)&#8221; header_text_shadow_color__hover_enabled=&#8221;rgba(0,0,0,0.4)&#8221;][\/et_pb_signup][et_pb_social_media_follow disabled_on=&#8221;on|on|on&#8221; _builder_version=&#8221;4.16&#8243; text_orientation=&#8221;center&#8221; border_radii=&#8221;on|0px|0px|0px|0px&#8221; disabled=&#8221;on&#8221; global_colors_info=&#8221;{}&#8221;][et_pb_social_media_follow_network social_network=&#8221;facebook&#8221; url=&#8221;https:\/\/www.facebook.com\/groups\/194233220639006\/&#8221; _builder_version=&#8221;4.16&#8243; background_color=&#8221;#a0beef&#8221; custom_margin=&#8221;|6px||6px||true&#8221; custom_padding=&#8221;10px|10px|10px|10px|true|true&#8221; global_colors_info=&#8221;{}&#8221; follow_button=&#8221;off&#8221; url_new_window=&#8221;on&#8221;]facebook[\/et_pb_social_media_follow_network][\/et_pb_social_media_follow][\/et_pb_column][\/et_pb_row][\/et_pb_section]<\/p>\n","protected":false},"excerpt":{"rendered":"<p>You will not be able to save your progress so plan to spend roughly 30 mins preparing this form, etc. &nbsp; Due to the high volume of counseling requests, there may be an extended wait time of a couple of months.\n                <div class='gf_browser_gecko gform_wrapper gform_legacy_markup_wrapper gform-theme--no-framework' data-form-theme='legacy' data-form-index='0' id='gform_wrapper_1' style='display:none'><div id='gf_1' class='gform_anchor' tabindex='-1'><\/div><form method='post' enctype='multipart\/form-data'  id='gform_1'  action='\/counseling\/wp-json\/wp\/v2\/pages\/226#gf_1' data-formid='1' novalidate>\n        <div id='gf_progressbar_wrapper_1' class='gf_progressbar_wrapper' data-start-at-zero=''>\n        \t<h3 class=\"gf_progressbar_title\">Step <span class='gf_step_current_page'>1<\/span> of <span class='gf_step_page_count'>8<\/span><span class='gf_step_page_name'><\/span>\n        \t<\/h3>\n            <div class='gf_progressbar gf_progressbar_blue' aria-hidden='true'>\n                <div class='gf_progressbar_percentage percentbar_blue percentbar_12' style='width:12%;'><span>12%<\/span><\/div>\n            <\/div><\/div>\n                        <div class='gform-body gform_body'><div id='gform_page_1_1' class='gform_page ' data-js='page-field-id-0' >\n\t\t\t\t\t<div class='gform_page_fields'><ul id='gform_fields_1' class='gform_fields top_label form_sublabel_below description_below validation_below'><li id=\"field_1_15\" class=\"gfield gfield--type-html gfield--input-type-html gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><ol>\n  <li>Our Counseling:\nIn association with Grace Bible Church (GBC), the Community of Grace Biblical Counseling Center offers Biblical Counseling. Biblical Counseling refers to a philosophy of counseling that is faith-based, believing that the Bible is God\u2019s word to mankind to be applied to the struggles of life that we all suffer. We believe that the Bible is without error, is authoritative, and is sufficient to provide God\u2019s answers to the spiritual issues of life, conduct, and relationships. We do not base our counseling on psychology. \nIf you have questions relating to legal, financial, medical, or technical matters, it is best to seek advice from others in those specific fields. Our counselors will be happy to cooperate with those advisors and help you to gain biblical perspectives and seek biblical solutions. \nAs an expression of our love for the Lord Jesus Christ and our desire to serve the community that we live in, our counseling is free of charge.  <\/li>\n  <li>Our Counselors:\nAll of our counselors have completed a training process to equip them to competently use the Bible as their source of authority. While a number of our counselors are certified through the Association of Certified Biblical Counselors (ACBC) or a similar certification organization, none are licensed by the state of Montana. \nGBC is active in training others to be Biblical Counselors.  Part of their training is to observe counseling sessions.  Therefore, there may be another person sitting in during your counseling sessions. They are bound by the same confidentiality guidelines as outlined below. <\/li>\n  <li>Confidentiality:\nWe wish to respect your privacy and maintain confidentiality about counseling issues.  There are certain exceptions:<\/li>\n    <ul>\n\t  <li>To provide you with the best Biblical Counseling possible, our counselors may discuss your issues with other GBC counselors, elders, and\/or pastors.<\/li>\n\t  <li>By state law, we are required to report issues of child abuse or elder abuse or neglect.<\/li>\n\t  <li>We must report if a counselee has committed or intends to commit a crime.<\/li>\n\t  <li>We may inform others if a counselee seems at risk to commit significant harm to themself or others.<\/li>\n\t  <li>If the counselor deems it necessary or helpful, they may communicate information to the counselee\u2019s affiliated church leadership.<\/li>\n\t<\/ul>\n  <li>Resolution of Disagreement: \n   Any disputes will be settled through a form of Christian conciliation, such as the conciliation division of Ken Sande's Relational Wisdom 360 <a href=\"www.rw360.com\">(rw360.com)<\/a>.<\/li>\n<\/ol><\/li><li id=\"field_1_17\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio 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' >I agree to the above agreement<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_1_17'>\n\t\t\t<li class='gchoice gchoice_1_17_0'>\n\t\t\t\t<input name='input_17' type='radio' value='Yes'  id='choice_1_17_0'    \/>\n\t\t\t\t<label for='choice_1_17_0' id='label_1_17_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_1_17_1'>\n\t\t\t\t<input name='input_17' type='radio' value='No'  id='choice_1_17_1'    \/>\n\t\t\t\t<label for='choice_1_17_1' id='label_1_17_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_1_145\" class=\"gfield gfield--type-name gfield--input-type-name gfield_contains_required field_sublabel_below gfield--has-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label gfield_label_before_complex' >Signature<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_complex ginput_container ginput_container--name no_prefix has_first_name no_middle_name has_last_name no_suffix gf_name_has_2 ginput_container_name gform-grid-row' id='input_1_145'>\n                            \n                            <span id='input_1_145_3_container' class='name_first gform-grid-col gform-grid-col--size-auto' >\n                                                    <input type='text' name='input_145.3' id='input_1_145_3' value=''   aria-required='true'     \/>\n                                                    <label for='input_1_145_3' class='gform-field-label gform-field-label--type-sub '>First<\/label>\n                                                <\/span>\n                            \n                            <span id='input_1_145_6_container' class='name_last gform-grid-col gform-grid-col--size-auto' >\n                                                    <input type='text' name='input_145.6' id='input_1_145_6' value=''   aria-required='true'     \/>\n                                                    <label for='input_1_145_6' class='gform-field-label gform-field-label--type-sub '>Last<\/label>\n                                                <\/span>\n                            \n                        <\/div><div class='gfield_description' id='gfield_description_1_145'>Please fill your name here as your signature.<\/div><\/li><li id=\"field_1_143\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' >Preferred means of communication:<\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_1_143'>\n\t\t\t<li class='gchoice gchoice_1_143_0'>\n\t\t\t\t<input name='input_143' type='radio' value='Phone Call'  id='choice_1_143_0'    \/>\n\t\t\t\t<label for='choice_1_143_0' id='label_1_143_0' class='gform-field-label gform-field-label--type-inline'>Phone Call<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_1_143_1'>\n\t\t\t\t<input name='input_143' type='radio' value='Text Message'  id='choice_1_143_1'    \/>\n\t\t\t\t<label for='choice_1_143_1' id='label_1_143_1' class='gform-field-label gform-field-label--type-inline'>Text Message<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_1_147\" class=\"gfield gfield--type-html gfield--input-type-html gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  >Expect to receive a call\/text from the Counseling Center receptionist (406-946-9782) on the next business Monday.<\/li><li id=\"field_1_146\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' >Preferred Monday counseling time:<\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_1_146'>\n\t\t\t<li class='gchoice gchoice_1_146_0'>\n\t\t\t\t<input name='input_146' type='radio' value='330pm'  id='choice_1_146_0'    \/>\n\t\t\t\t<label for='choice_1_146_0' id='label_1_146_0' class='gform-field-label gform-field-label--type-inline'>3:30pm<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_1_146_1'>\n\t\t\t\t<input name='input_146' type='radio' value='6pm'  id='choice_1_146_1'    \/>\n\t\t\t\t<label for='choice_1_146_1' id='label_1_146_1' class='gform-field-label gform-field-label--type-inline'>6:00pm<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_1_146_2'>\n\t\t\t\t<input name='input_146' type='radio' value='730pm'  id='choice_1_146_2'    \/>\n\t\t\t\t<label for='choice_1_146_2' id='label_1_146_2' class='gform-field-label gform-field-label--type-inline'>7:30pm<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><\/ul>\n                    <\/div>\n                    <div class='gform-page-footer gform_page_footer top_label'>\n                         <input type='button' id='gform_next_button_1_18' class='gform_next_button gform-theme-button button' onclick='gform.submission.handleButtonClick(this);' data-submission-type='next' value='Next'  \/> \n                    <\/div>\n                <\/div>\n                <div id='gform_page_1_2' class='gform_page' data-js='page-field-id-18' style='display:none;'>\n                    <div class='gform_page_fields'>\n                        <ul id='gform_fields_1_2' class='gform_fields top_label form_sublabel_below description_below validation_below'><li id=\"field_1_2\" class=\"gfield gfield--type-date gfield--input-type-date gfield--input-type-datepicker gfield--datepicker-no-icon 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_1_2'>Date<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_2' id='input_1_2' type='text' value='04\/09\/2026' class='datepicker gform-datepicker mdy datepicker_no_icon gdatepicker-no-icon'   placeholder='04\/09\/2026' aria-describedby=\"input_1_2_date_format\" aria-invalid=\"false\" aria-required=\"true\"\/>\n                            <span id='input_1_2_date_format' class='screen-reader-text'>MM slash DD slash YYYY<\/span>\n                        <\/div>\n                        <input type='hidden' id='gforms_calendar_icon_input_1_2' class='gform_hidden' value='https:\/\/gbcmt.org\/counseling\/wp-content\/plugins\/gravityforms\/images\/datepicker\/datepicker.svg'\/><\/li><li id=\"field_1_14\" class=\"gfield gfield--type-section gfield--input-type-section gsection field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><h2 class=\"gsection_title\">Personal Identification<\/h2><\/li><li id=\"field_1_1\" class=\"gfield gfield--type-name gfield--input-type-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 gfield_label_before_complex' >Name<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_complex ginput_container ginput_container--name no_prefix has_first_name no_middle_name has_last_name no_suffix gf_name_has_2 ginput_container_name gform-grid-row' id='input_1_1'>\n                            \n                            <span id='input_1_1_3_container' class='name_first gform-grid-col gform-grid-col--size-auto' >\n                                                    <input type='text' name='input_1.3' id='input_1_1_3' value=''   aria-required='true'     \/>\n                                                    <label for='input_1_1_3' class='gform-field-label gform-field-label--type-sub '>First<\/label>\n                                                <\/span>\n                            \n                            <span id='input_1_1_6_container' class='name_last gform-grid-col gform-grid-col--size-auto' >\n                                                    <input type='text' name='input_1.6' id='input_1_1_6' value=''   aria-required='true'     \/>\n                                                    <label for='input_1_1_6' class='gform-field-label gform-field-label--type-sub '>Last<\/label>\n                                                <\/span>\n                            \n                        <\/div><\/li><li id=\"field_1_3\" class=\"gfield gfield--type-phone gfield--input-type-phone 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_1_3'>Best phone number to contact you<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_phone'><input name='input_3' id='input_1_3' type='tel' value='' class='medium'   aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_1_4\" class=\"gfield gfield--type-address gfield--input-type-address field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label gfield_label_before_complex' >Address<\/label>    \n                    <div class='ginput_complex ginput_container has_street has_city has_state has_zip ginput_container_address gform-grid-row' id='input_1_4' >\n                         <span class='ginput_full address_line_1 ginput_address_line_1 gform-grid-col' id='input_1_4_1_container' >\n                                        <input type='text' name='input_4.1' id='input_1_4_1' value=''    aria-required='false'    \/>\n                                        <label for='input_1_4_1' id='input_1_4_1_label' class='gform-field-label gform-field-label--type-sub '>Street Address<\/label>\n                                    <\/span><span class='ginput_left address_city ginput_address_city gform-grid-col' id='input_1_4_3_container' >\n                                    <input type='text' name='input_4.3' id='input_1_4_3' value=''    aria-required='false'    \/>\n                                    <label for='input_1_4_3' id='input_1_4_3_label' class='gform-field-label gform-field-label--type-sub '>City<\/label>\n                                 <\/span><span class='ginput_right address_state ginput_address_state gform-grid-col' id='input_1_4_4_container' >\n                                        <select name='input_4.4' id='input_1_4_4'     aria-required='false'    ><option value='' ><\/option><option value='Alabama' >Alabama<\/option><option value='Alaska' >Alaska<\/option><option value='American Samoa' >American Samoa<\/option><option value='Arizona' >Arizona<\/option><option value='Arkansas' >Arkansas<\/option><option value='California' >California<\/option><option value='Colorado' >Colorado<\/option><option value='Connecticut' >Connecticut<\/option><option value='Delaware' >Delaware<\/option><option value='District of Columbia' >District of Columbia<\/option><option value='Florida' >Florida<\/option><option value='Georgia' >Georgia<\/option><option value='Guam' >Guam<\/option><option value='Hawaii' >Hawaii<\/option><option value='Idaho' >Idaho<\/option><option value='Illinois' >Illinois<\/option><option value='Indiana' >Indiana<\/option><option value='Iowa' >Iowa<\/option><option value='Kansas' >Kansas<\/option><option value='Kentucky' >Kentucky<\/option><option value='Louisiana' >Louisiana<\/option><option value='Maine' >Maine<\/option><option value='Maryland' >Maryland<\/option><option value='Massachusetts' >Massachusetts<\/option><option value='Michigan' >Michigan<\/option><option value='Minnesota' >Minnesota<\/option><option value='Mississippi' >Mississippi<\/option><option value='Missouri' >Missouri<\/option><option value='Montana' selected='selected'>Montana<\/option><option value='Nebraska' >Nebraska<\/option><option value='Nevada' >Nevada<\/option><option value='New Hampshire' >New Hampshire<\/option><option value='New Jersey' >New Jersey<\/option><option value='New Mexico' >New Mexico<\/option><option value='New York' >New York<\/option><option value='North Carolina' >North Carolina<\/option><option value='North Dakota' >North Dakota<\/option><option value='Northern Mariana Islands' >Northern Mariana Islands<\/option><option value='Ohio' >Ohio<\/option><option value='Oklahoma' >Oklahoma<\/option><option value='Oregon' >Oregon<\/option><option value='Pennsylvania' >Pennsylvania<\/option><option value='Puerto Rico' >Puerto Rico<\/option><option value='Rhode Island' >Rhode Island<\/option><option value='South Carolina' >South Carolina<\/option><option value='South Dakota' >South Dakota<\/option><option value='Tennessee' >Tennessee<\/option><option value='Texas' >Texas<\/option><option value='Utah' >Utah<\/option><option value='U.S. Virgin Islands' >U.S. Virgin Islands<\/option><option value='Vermont' >Vermont<\/option><option value='Virginia' >Virginia<\/option><option value='Washington' >Washington<\/option><option value='West Virginia' >West Virginia<\/option><option value='Wisconsin' >Wisconsin<\/option><option value='Wyoming' >Wyoming<\/option><option value='Armed Forces Americas' >Armed Forces Americas<\/option><option value='Armed Forces Europe' >Armed Forces Europe<\/option><option value='Armed Forces Pacific' >Armed Forces Pacific<\/option><\/select>\n                                        <label for='input_1_4_4' id='input_1_4_4_label' class='gform-field-label gform-field-label--type-sub '>State<\/label>\n                                      <\/span><span class='ginput_left address_zip ginput_address_zip gform-grid-col' id='input_1_4_5_container' >\n                                    <input type='text' name='input_4.5' id='input_1_4_5' value=''    aria-required='false'    \/>\n                                    <label for='input_1_4_5' id='input_1_4_5_label' class='gform-field-label gform-field-label--type-sub '>ZIP Code<\/label>\n                                <\/span><input type='hidden' class='gform_hidden' name='input_4.6' id='input_1_4_6' value='United States' \/>\n                    <div class='gf_clear gf_clear_complex'><\/div>\n                <\/div><\/li><li id=\"field_1_5\" class=\"gfield gfield--type-email gfield--input-type-email field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_1_5'>Email<\/label><div class='ginput_container ginput_container_email'>\n                            <input name='input_5' id='input_1_5' type='email' value='' class='medium'     aria-invalid=\"false\"  \/>\n                        <\/div><\/li><li id=\"field_1_6\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio 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' >Sex<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_1_6'>\n\t\t\t<li class='gchoice gchoice_1_6_0'>\n\t\t\t\t<input name='input_6' type='radio' value='Male'  id='choice_1_6_0'    \/>\n\t\t\t\t<label for='choice_1_6_0' id='label_1_6_0' class='gform-field-label gform-field-label--type-inline'>Male<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_1_6_1'>\n\t\t\t\t<input name='input_6' type='radio' value='Female'  id='choice_1_6_1'    \/>\n\t\t\t\t<label for='choice_1_6_1' id='label_1_6_1' class='gform-field-label gform-field-label--type-inline'>Female<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_1_7\" class=\"gfield gfield--type-text gfield--input-type-text 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_1_7'>Age<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_7' id='input_1_7' type='text' value='' class='medium' maxlength='15'    aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_1_8\" class=\"gfield gfield--type-date gfield--input-type-date gfield--input-type-datepicker gfield--datepicker-default-icon 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_1_8'>Birthdate<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_1_8' type='text' value='' class='datepicker gform-datepicker mdy datepicker_with_icon gdatepicker_with_icon'   placeholder='mm\/dd\/yyyy' aria-describedby=\"input_1_8_date_format\" aria-invalid=\"false\" aria-required=\"true\"\/>\n                            <span id='input_1_8_date_format' class='screen-reader-text'>MM slash DD slash YYYY<\/span>\n                        <\/div>\n                        <input type='hidden' id='gforms_calendar_icon_input_1_8' class='gform_hidden' value='https:\/\/gbcmt.org\/counseling\/wp-content\/plugins\/gravityforms\/images\/datepicker\/datepicker.svg'\/><\/li><li id=\"field_1_9\" class=\"gfield gfield--type-text gfield--input-type-text field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_1_9'>Education (last year completed)<\/label><div class='ginput_container ginput_container_text'><input name='input_9' id='input_1_9' type='text' value='' class='medium'      aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_1_10\" class=\"gfield gfield--type-phone gfield--input-type-phone field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_1_10'>Business\/Work Phone<\/label><div class='ginput_container ginput_container_phone'><input name='input_10' id='input_1_10' type='tel' value='' class='medium'    aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_1_11\" class=\"gfield gfield--type-text gfield--input-type-text field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_1_11'>Employer<\/label><div class='ginput_container ginput_container_text'><input name='input_11' id='input_1_11' type='text' value='' class='medium'      aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_1_12\" class=\"gfield gfield--type-text gfield--input-type-text field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_1_12'>Position<\/label><div class='ginput_container ginput_container_text'><input name='input_12' id='input_1_12' type='text' value='' class='medium'      aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_1_13\" class=\"gfield gfield--type-text gfield--input-type-text field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_1_13'>Years in position<\/label><div class='ginput_container ginput_container_text'><input name='input_13' id='input_1_13' type='text' value='' class='medium'      aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_1_19\" class=\"gfield gfield--type-section gfield--input-type-section gsection field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><h2 class=\"gsection_title\">Health Information<\/h2><\/li><li id=\"field_1_20\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio 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' >Rate Your Health<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_1_20'>\n\t\t\t<li class='gchoice gchoice_1_20_0'>\n\t\t\t\t<input name='input_20' type='radio' value='Very Good'  id='choice_1_20_0'    \/>\n\t\t\t\t<label for='choice_1_20_0' id='label_1_20_0' class='gform-field-label gform-field-label--type-inline'>Very Good<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_1_20_1'>\n\t\t\t\t<input name='input_20' type='radio' value='Good'  id='choice_1_20_1'    \/>\n\t\t\t\t<label for='choice_1_20_1' id='label_1_20_1' class='gform-field-label gform-field-label--type-inline'>Good<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_1_20_2'>\n\t\t\t\t<input name='input_20' type='radio' value='Average'  id='choice_1_20_2'    \/>\n\t\t\t\t<label for='choice_1_20_2' id='label_1_20_2' class='gform-field-label gform-field-label--type-inline'>Average<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_1_20_3'>\n\t\t\t\t<input name='input_20' type='radio' value='Declining'  id='choice_1_20_3'    \/>\n\t\t\t\t<label for='choice_1_20_3' id='label_1_20_3' class='gform-field-label gform-field-label--type-inline'>Declining<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_1_20_4'>\n\t\t\t\t<input name='input_20' type='radio' value='gf_other_choice'  id='choice_1_20_4'   onfocus=\"jQuery(this).next('input').focus();\" \/>\n\t\t\t\t<input class='small' id='input_1_20_other' name='input_20_other' type='text' value='Other' aria-label='Other' onfocus='jQuery(this).prev(\"input\")[0].click(); if(jQuery(this).val() == \"Other\") { jQuery(this).val(\"\"); }' onblur='if(jQuery(this).val().replace(\" \", \"\") == \"\") { jQuery(this).val(\"Other\"); }'   \/>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_1_21\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' >Do you have any chronic conditions?<\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_1_21'>\n\t\t\t<li class='gchoice gchoice_1_21_0'>\n\t\t\t\t<input name='input_21' type='radio' value='Yes'  id='choice_1_21_0'    \/>\n\t\t\t\t<label for='choice_1_21_0' id='label_1_21_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_1_21_1'>\n\t\t\t\t<input name='input_21' type='radio' value='No'  id='choice_1_21_1'    \/>\n\t\t\t\t<label for='choice_1_21_1' id='label_1_21_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_1_22\" class=\"gfield gfield--type-textarea gfield--input-type-textarea field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_1_22'>If yes, please describe<\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_22' id='input_1_22' class='textarea medium'   maxlength='50'   aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/li><li id=\"field_1_23\" class=\"gfield gfield--type-textarea gfield--input-type-textarea field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_1_23'>List important illnesses and injuries or handicaps<\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_23' id='input_1_23' class='textarea medium'   maxlength='60'   aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/li><li id=\"field_1_24\" class=\"gfield gfield--type-date gfield--input-type-date gfield--input-type-datepicker gfield--datepicker-default-icon field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_1_24'>Date of last physical exam<\/label><div class='ginput_container ginput_container_date'>\n                            <input name='input_24' id='input_1_24' type='text' value='' class='datepicker gform-datepicker mdy datepicker_with_icon gdatepicker_with_icon'   placeholder='mm\/dd\/yyyy' aria-describedby=\"input_1_24_date_format\" aria-invalid=\"false\" \/>\n                            <span id='input_1_24_date_format' class='screen-reader-text'>MM slash DD slash YYYY<\/span>\n                        <\/div>\n                        <input type='hidden' id='gforms_calendar_icon_input_1_24' class='gform_hidden' value='https:\/\/gbcmt.org\/counseling\/wp-content\/plugins\/gravityforms\/images\/datepicker\/datepicker.svg'\/><\/li><li id=\"field_1_25\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' >Weight Changes Recently<\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_1_25'>\n\t\t\t<li class='gchoice gchoice_1_25_0'>\n\t\t\t\t<input name='input_25' type='radio' value='Lost'  id='choice_1_25_0'    \/>\n\t\t\t\t<label for='choice_1_25_0' id='label_1_25_0' class='gform-field-label gform-field-label--type-inline'>Lost<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_1_25_1'>\n\t\t\t\t<input name='input_25' type='radio' value='Gained'  id='choice_1_25_1'    \/>\n\t\t\t\t<label for='choice_1_25_1' id='label_1_25_1' class='gform-field-label gform-field-label--type-inline'>Gained<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_1_25_2'>\n\t\t\t\t<input name='input_25' type='radio' value='n\/a'  id='choice_1_25_2'    \/>\n\t\t\t\t<label for='choice_1_25_2' id='label_1_25_2' class='gform-field-label gform-field-label--type-inline'>n\/a<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_1_26\" class=\"gfield gfield--type-text gfield--input-type-text field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_1_26'>Amount of weight lost<\/label><div class='ginput_container ginput_container_text'><input name='input_26' id='input_1_26' type='text' value='' class='medium'      aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_1_142\" class=\"gfield gfield--type-text gfield--input-type-text field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_1_142'>Amount of weight gained<\/label><div class='ginput_container ginput_container_text'><input name='input_142' id='input_1_142' type='text' value='' class='medium'      aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_1_27\" class=\"gfield gfield--type-text gfield--input-type-text field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_1_27'>Your Physician&#039;s Name<\/label><div class='ginput_container ginput_container_text'><input name='input_27' id='input_1_27' type='text' value='' class='medium' maxlength='50'     aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_1_28\" class=\"gfield gfield--type-textarea gfield--input-type-textarea field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_1_28'>Please list current medications<\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_28' id='input_1_28' class='textarea medium'   maxlength='50'   aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/li><li id=\"field_1_29\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio 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' >Have you ever used drugs for other than medical purposes?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_1_29'>\n\t\t\t<li class='gchoice gchoice_1_29_0'>\n\t\t\t\t<input name='input_29' type='radio' value='Yes'  id='choice_1_29_0'    \/>\n\t\t\t\t<label for='choice_1_29_0' id='label_1_29_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_1_29_1'>\n\t\t\t\t<input name='input_29' type='radio' value='No'  id='choice_1_29_1'    \/>\n\t\t\t\t<label for='choice_1_29_1' id='label_1_29_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_1_30\" class=\"gfield gfield--type-textarea gfield--input-type-textarea field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_1_30'>What?<\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_30' id='input_1_30' class='textarea medium'   maxlength='40'   aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/li><li id=\"field_1_31\" class=\"gfield gfield--type-textarea gfield--input-type-textarea field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_1_31'>If yes, please explain<\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_31' id='input_1_31' class='textarea medium'   maxlength='80'   aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/li><li id=\"field_1_32\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' >Have you ever had a severe emotional upset?<\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_1_32'>\n\t\t\t<li class='gchoice gchoice_1_32_0'>\n\t\t\t\t<input name='input_32' type='radio' value='Yes'  id='choice_1_32_0'    \/>\n\t\t\t\t<label for='choice_1_32_0' id='label_1_32_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_1_32_1'>\n\t\t\t\t<input name='input_32' type='radio' value='No'  id='choice_1_32_1'    \/>\n\t\t\t\t<label for='choice_1_32_1' id='label_1_32_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_1_33\" class=\"gfield gfield--type-textarea gfield--input-type-textarea field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_1_33'>If so, explain.<\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_33' id='input_1_33' class='textarea medium'   maxlength='100'   aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/li><li id=\"field_1_34\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio 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' >Have you ever been convicted of a crime?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_1_34'>\n\t\t\t<li class='gchoice gchoice_1_34_0'>\n\t\t\t\t<input name='input_34' type='radio' value='Yes'  id='choice_1_34_0'    \/>\n\t\t\t\t<label for='choice_1_34_0' id='label_1_34_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_1_34_1'>\n\t\t\t\t<input name='input_34' type='radio' value='No'  id='choice_1_34_1'    \/>\n\t\t\t\t<label for='choice_1_34_1' id='label_1_34_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_1_35\" class=\"gfield gfield--type-textarea gfield--input-type-textarea field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_1_35'>If so, explain.<\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_35' id='input_1_35' class='textarea medium'   maxlength='100'   aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/li><li id=\"field_1_36\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' >Do you have problems sleeping?<\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_1_36'>\n\t\t\t<li class='gchoice gchoice_1_36_0'>\n\t\t\t\t<input name='input_36' type='radio' value='Yes'  id='choice_1_36_0'    \/>\n\t\t\t\t<label for='choice_1_36_0' id='label_1_36_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_1_36_1'>\n\t\t\t\t<input name='input_36' type='radio' value='No'  id='choice_1_36_1'    \/>\n\t\t\t\t<label for='choice_1_36_1' id='label_1_36_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_1_36_2'>\n\t\t\t\t<input name='input_36' type='radio' value='Sometimes'  id='choice_1_36_2'    \/>\n\t\t\t\t<label for='choice_1_36_2' id='label_1_36_2' class='gform-field-label gform-field-label--type-inline'>Sometimes<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><\/ul>\n                    <\/div>\n                    <div class='gform-page-footer gform_page_footer top_label'>\n                        <input type='button' id='gform_previous_button_1_130' class='gform_previous_button gform-theme-button gform-theme-button--secondary button' onclick='gform.submission.handleButtonClick(this);' data-submission-type='previous' value='Previous'  \/> <input type='button' id='gform_next_button_1_130' class='gform_next_button gform-theme-button button' onclick='gform.submission.handleButtonClick(this);' data-submission-type='next' value='Next'  \/> \n                    <\/div>\n                <\/div>\n                <div id='gform_page_1_3' class='gform_page' data-js='page-field-id-130' style='display:none;'>\n                    <div class='gform_page_fields'>\n                        <ul id='gform_fields_1_3' class='gform_fields top_label form_sublabel_below description_below validation_below'><li id=\"field_1_37\" class=\"gfield gfield--type-section gfield--input-type-section gsection field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><h2 class=\"gsection_title\">Religious Background<\/h2><\/li><li id=\"field_1_38\" class=\"gfield gfield--type-text gfield--input-type-text field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_1_38'>Denominational Preference<\/label><div class='ginput_container ginput_container_text'><input name='input_38' id='input_1_38' type='text' value='' class='medium' maxlength='30'     aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_1_39\" class=\"gfield gfield--type-text gfield--input-type-text 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_1_39'>Church currently attending<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_39' id='input_1_39' type='text' value='' class='medium' maxlength='22'    aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_1_40\" class=\"gfield gfield--type-text gfield--input-type-text 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_1_40'>How many sundays do you attend per month?<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_1_40' type='text' value='' class='medium' maxlength='10'    aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_1_41\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio 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' >Are you an official member of that church?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_1_41'>\n\t\t\t<li class='gchoice gchoice_1_41_0'>\n\t\t\t\t<input name='input_41' type='radio' value='Yes'  id='choice_1_41_0'    \/>\n\t\t\t\t<label for='choice_1_41_0' id='label_1_41_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_1_41_1'>\n\t\t\t\t<input name='input_41' type='radio' value='No'  id='choice_1_41_1'    \/>\n\t\t\t\t<label for='choice_1_41_1' id='label_1_41_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_1_148\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio 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' >Are you actively involved in an official ministry in your church?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_1_148'>\n\t\t\t<li class='gchoice gchoice_1_148_0'>\n\t\t\t\t<input name='input_148' type='radio' value='Yes'  id='choice_1_148_0'    \/>\n\t\t\t\t<label for='choice_1_148_0' id='label_1_148_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_1_148_1'>\n\t\t\t\t<input name='input_148' type='radio' value='No'  id='choice_1_148_1'    \/>\n\t\t\t\t<label for='choice_1_148_1' id='label_1_148_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_1_42\" class=\"gfield gfield--type-text gfield--input-type-text field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_1_42'>Church attended as a child<\/label><div class='ginput_container ginput_container_text'><input name='input_42' id='input_1_42' type='text' value='' class='medium' maxlength='30'     aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_1_43\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio 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' >Have you been baptized?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_1_43'>\n\t\t\t<li class='gchoice gchoice_1_43_0'>\n\t\t\t\t<input name='input_43' type='radio' value='No'  id='choice_1_43_0'    \/>\n\t\t\t\t<label for='choice_1_43_0' id='label_1_43_0' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_1_43_1'>\n\t\t\t\t<input name='input_43' type='radio' value='Yes As Adult'  id='choice_1_43_1'    \/>\n\t\t\t\t<label for='choice_1_43_1' id='label_1_43_1' class='gform-field-label gform-field-label--type-inline'>Yes, as an adult<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_1_43_2'>\n\t\t\t\t<input name='input_43' type='radio' value='Yes As Infant'  id='choice_1_43_2'    \/>\n\t\t\t\t<label for='choice_1_43_2' id='label_1_43_2' class='gform-field-label gform-field-label--type-inline'>Yes, as an infant<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_1_44\" class=\"gfield gfield--type-text gfield--input-type-text field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_1_44'>Religious background of spouse (if married)<\/label><div class='ginput_container ginput_container_text'><input name='input_44' id='input_1_44' type='text' value='' class='medium' maxlength='35'     aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_1_45\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio 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' >Do you consider yourself to be a religious person?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_1_45'>\n\t\t\t<li class='gchoice gchoice_1_45_0'>\n\t\t\t\t<input name='input_45' type='radio' value='Yes'  id='choice_1_45_0'    \/>\n\t\t\t\t<label for='choice_1_45_0' id='label_1_45_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_1_45_1'>\n\t\t\t\t<input name='input_45' type='radio' value='No'  id='choice_1_45_1'    \/>\n\t\t\t\t<label for='choice_1_45_1' id='label_1_45_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_1_45_2'>\n\t\t\t\t<input name='input_45' type='radio' value='Uncertain'  id='choice_1_45_2'    \/>\n\t\t\t\t<label for='choice_1_45_2' id='label_1_45_2' class='gform-field-label gform-field-label--type-inline'>Uncertain<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_1_46\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio 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' >Do you believe in God?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_1_46'>\n\t\t\t<li class='gchoice gchoice_1_46_0'>\n\t\t\t\t<input name='input_46' type='radio' value='Yes'  id='choice_1_46_0'    \/>\n\t\t\t\t<label for='choice_1_46_0' id='label_1_46_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_1_46_1'>\n\t\t\t\t<input name='input_46' type='radio' value='No'  id='choice_1_46_1'    \/>\n\t\t\t\t<label for='choice_1_46_1' id='label_1_46_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_1_46_2'>\n\t\t\t\t<input name='input_46' type='radio' value='Uncertain'  id='choice_1_46_2'    \/>\n\t\t\t\t<label for='choice_1_46_2' id='label_1_46_2' class='gform-field-label gform-field-label--type-inline'>Uncertain<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_1_47\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio 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' >Do you pray to God?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_1_47'>\n\t\t\t<li class='gchoice gchoice_1_47_0'>\n\t\t\t\t<input name='input_47' type='radio' value='Never'  id='choice_1_47_0'    \/>\n\t\t\t\t<label for='choice_1_47_0' id='label_1_47_0' class='gform-field-label gform-field-label--type-inline'>Never<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_1_47_1'>\n\t\t\t\t<input name='input_47' type='radio' value='Occasionally'  id='choice_1_47_1'    \/>\n\t\t\t\t<label for='choice_1_47_1' id='label_1_47_1' class='gform-field-label gform-field-label--type-inline'>Occasionally<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_1_47_2'>\n\t\t\t\t<input name='input_47' type='radio' value='Often'  id='choice_1_47_2'    \/>\n\t\t\t\t<label for='choice_1_47_2' id='label_1_47_2' class='gform-field-label gform-field-label--type-inline'>Often<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_1_48\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio 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' >How often do you read the Bible?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_1_48'>\n\t\t\t<li class='gchoice gchoice_1_48_0'>\n\t\t\t\t<input name='input_48' type='radio' value='Never'  id='choice_1_48_0'    \/>\n\t\t\t\t<label for='choice_1_48_0' id='label_1_48_0' class='gform-field-label gform-field-label--type-inline'>Never<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_1_48_1'>\n\t\t\t\t<input name='input_48' type='radio' value='Occasionally'  id='choice_1_48_1'    \/>\n\t\t\t\t<label for='choice_1_48_1' id='label_1_48_1' class='gform-field-label gform-field-label--type-inline'>Occasionally<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_1_48_2'>\n\t\t\t\t<input name='input_48' type='radio' value='Often'  id='choice_1_48_2'    \/>\n\t\t\t\t<label for='choice_1_48_2' id='label_1_48_2' class='gform-field-label gform-field-label--type-inline'>Often<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_1_49\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio 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' >Are you saved?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_1_49'>\n\t\t\t<li class='gchoice gchoice_1_49_0'>\n\t\t\t\t<input name='input_49' type='radio' value='Yes'  id='choice_1_49_0'    \/>\n\t\t\t\t<label for='choice_1_49_0' id='label_1_49_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_1_49_1'>\n\t\t\t\t<input name='input_49' type='radio' value='No'  id='choice_1_49_1'    \/>\n\t\t\t\t<label for='choice_1_49_1' id='label_1_49_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_1_49_2'>\n\t\t\t\t<input name='input_49' type='radio' value='Not sure what you mean'  id='choice_1_49_2'    \/>\n\t\t\t\t<label for='choice_1_49_2' id='label_1_49_2' class='gform-field-label gform-field-label--type-inline'>Not sure what you mean<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_1_50\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio 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' >If you were to die tonight, do you know with absolute certainty that you would go to heaven?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_1_50'>\n\t\t\t<li class='gchoice gchoice_1_50_0'>\n\t\t\t\t<input name='input_50' type='radio' value='Yes'  id='choice_1_50_0'    \/>\n\t\t\t\t<label for='choice_1_50_0' id='label_1_50_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_1_50_1'>\n\t\t\t\t<input name='input_50' type='radio' value='No'  id='choice_1_50_1'    \/>\n\t\t\t\t<label for='choice_1_50_1' id='label_1_50_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_1_50_2'>\n\t\t\t\t<input name='input_50' type='radio' value='Uncertain'  id='choice_1_50_2'    \/>\n\t\t\t\t<label for='choice_1_50_2' id='label_1_50_2' class='gform-field-label gform-field-label--type-inline'>Uncertain<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_1_51\" class=\"gfield gfield--type-textarea gfield--input-type-textarea 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_1_51'>If you were to die today and stand before God and He were to ask you, \u201cWhy should I let you into my heaven\u201d, what would you say?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_51' id='input_1_51' class='textarea medium'   maxlength='320'  aria-required=\"true\" aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/li><li id=\"field_1_52\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' >Do you have regular devotions?<\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_1_52'>\n\t\t\t<li class='gchoice gchoice_1_52_0'>\n\t\t\t\t<input name='input_52' type='radio' value='Yes'  id='choice_1_52_0'    \/>\n\t\t\t\t<label for='choice_1_52_0' id='label_1_52_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_1_52_1'>\n\t\t\t\t<input name='input_52' type='radio' value='No'  id='choice_1_52_1'    \/>\n\t\t\t\t<label for='choice_1_52_1' id='label_1_52_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_1_52_2'>\n\t\t\t\t<input name='input_52' type='radio' value='Not sure what you mean'  id='choice_1_52_2'    \/>\n\t\t\t\t<label for='choice_1_52_2' id='label_1_52_2' class='gform-field-label gform-field-label--type-inline'>Not sure what you mean<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_1_53\" class=\"gfield gfield--type-textarea gfield--input-type-textarea field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_1_53'>Explain recent changes in your religious life, if any:<\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_53' id='input_1_53' class='textarea medium'   maxlength='140'   aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/li><\/ul>\n                    <\/div>\n                    <div class='gform-page-footer gform_page_footer top_label'>\n                        <input type='button' id='gform_previous_button_1_129' class='gform_previous_button gform-theme-button gform-theme-button--secondary button' onclick='gform.submission.handleButtonClick(this);' data-submission-type='previous' value='Previous'  \/> <input type='button' id='gform_next_button_1_129' class='gform_next_button gform-theme-button button' onclick='gform.submission.handleButtonClick(this);' data-submission-type='next' value='Next'  \/> \n                    <\/div>\n                <\/div>\n                <div id='gform_page_1_4' class='gform_page' data-js='page-field-id-129' style='display:none;'>\n                    <div class='gform_page_fields'>\n                        <ul id='gform_fields_1_4' class='gform_fields top_label form_sublabel_below description_below validation_below'><li id=\"field_1_54\" class=\"gfield gfield--type-section gfield--input-type-section gsection field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><h2 class=\"gsection_title\">Marriage and Family<\/h2><\/li><li id=\"field_1_55\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio 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' >Marital Status<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_1_55'>\n\t\t\t<li class='gchoice gchoice_1_55_0'>\n\t\t\t\t<input name='input_55' type='radio' value='Single'  id='choice_1_55_0'    \/>\n\t\t\t\t<label for='choice_1_55_0' id='label_1_55_0' class='gform-field-label gform-field-label--type-inline'>Single<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_1_55_1'>\n\t\t\t\t<input name='input_55' type='radio' value='Dating'  id='choice_1_55_1'    \/>\n\t\t\t\t<label for='choice_1_55_1' id='label_1_55_1' class='gform-field-label gform-field-label--type-inline'>Dating<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_1_55_2'>\n\t\t\t\t<input name='input_55' type='radio' value='Engaged'  id='choice_1_55_2'    \/>\n\t\t\t\t<label for='choice_1_55_2' id='label_1_55_2' class='gform-field-label gform-field-label--type-inline'>Engaged<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_1_55_3'>\n\t\t\t\t<input name='input_55' type='radio' value='Married'  id='choice_1_55_3'    \/>\n\t\t\t\t<label for='choice_1_55_3' id='label_1_55_3' class='gform-field-label gform-field-label--type-inline'>Married<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_1_55_4'>\n\t\t\t\t<input name='input_55' type='radio' value='Separated'  id='choice_1_55_4'    \/>\n\t\t\t\t<label for='choice_1_55_4' id='label_1_55_4' class='gform-field-label gform-field-label--type-inline'>Separated<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_1_55_5'>\n\t\t\t\t<input name='input_55' type='radio' value='Divorced'  id='choice_1_55_5'    \/>\n\t\t\t\t<label for='choice_1_55_5' id='label_1_55_5' class='gform-field-label gform-field-label--type-inline'>Divorced<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_1_55_6'>\n\t\t\t\t<input name='input_55' type='radio' value='Widowed'  id='choice_1_55_6'    \/>\n\t\t\t\t<label for='choice_1_55_6' id='label_1_55_6' class='gform-field-label gform-field-label--type-inline'>Widowed<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_1_58\" class=\"gfield gfield--type-section gfield--input-type-section gsection field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><h2 class=\"gsection_title\"><\/h2><\/li><li id=\"field_1_56\" class=\"gfield gfield--type-text gfield--input-type-text field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_1_56'>Name of Spouse<\/label><div class='ginput_container ginput_container_text'><input name='input_56' id='input_1_56' type='text' value='' class='medium'      aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_1_57\" class=\"gfield gfield--type-text gfield--input-type-text field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_1_57'>Age of Spouse<\/label><div class='ginput_container ginput_container_text'><input name='input_57' id='input_1_57' type='text' value='' class='medium'      aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_1_59\" class=\"gfield gfield--type-text gfield--input-type-text field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_1_59'>Education of Spouse (in years)<\/label><div class='ginput_container ginput_container_text'><input name='input_59' id='input_1_59' type='text' value='' class='medium' maxlength='30'     aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_1_60\" class=\"gfield gfield--type-text gfield--input-type-text field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_1_60'>Spouse&#039;s Occupation<\/label><div class='ginput_container ginput_container_text'><input name='input_60' id='input_1_60' type='text' value='' class='medium' maxlength='30'     aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_1_61\" class=\"gfield gfield--type-text gfield--input-type-text field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_1_61'>Number of years Spouse Employed<\/label><div class='ginput_container ginput_container_text'><input name='input_61' id='input_1_61' type='text' value='' class='medium'      aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_1_144\" class=\"gfield gfield--type-phone gfield--input-type-phone field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_1_144'>Phone number of spouse<\/label><div class='ginput_container ginput_container_phone'><input name='input_144' id='input_1_144' type='tel' value='' class='medium'    aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_1_63\" class=\"gfield gfield--type-date gfield--input-type-date gfield--input-type-datepicker gfield--datepicker-default-icon field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_1_63'>Date of Marriage<\/label><div class='ginput_container ginput_container_date'>\n                            <input name='input_63' id='input_1_63' type='text' value='' class='datepicker gform-datepicker mdy datepicker_with_icon gdatepicker_with_icon'   placeholder='mm\/dd\/yyyy' aria-describedby=\"input_1_63_date_format\" aria-invalid=\"false\" \/>\n                            <span id='input_1_63_date_format' class='screen-reader-text'>MM slash DD slash YYYY<\/span>\n                        <\/div>\n                        <input type='hidden' id='gforms_calendar_icon_input_1_63' class='gform_hidden' value='https:\/\/gbcmt.org\/counseling\/wp-content\/plugins\/gravityforms\/images\/datepicker\/datepicker.svg'\/><\/li><li id=\"field_1_65\" class=\"gfield gfield--type-text gfield--input-type-text field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_1_65'>Length of Dating<\/label><div class='ginput_container ginput_container_text'><input name='input_65' id='input_1_65' type='text' value='' class='medium' maxlength='15'     aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_1_66\" class=\"gfield gfield--type-textarea gfield--input-type-textarea field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_1_66'>Give a brief summary of circumstances of meeting and dating<\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_66' id='input_1_66' class='textarea medium'   maxlength='320'   aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/li><li id=\"field_1_67\" class=\"gfield gfield--type-text gfield--input-type-text field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_1_67'>Husband&#039;s Age When Married<\/label><div class='ginput_container ginput_container_text'><input name='input_67' id='input_1_67' type='text' value='' class='medium' maxlength='10'     aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_1_68\" class=\"gfield gfield--type-text gfield--input-type-text field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_1_68'>Wife&#039;s Age When Married<\/label><div class='ginput_container ginput_container_text'><input name='input_68' id='input_1_68' type='text' value='' class='medium' maxlength='10'     aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_1_69\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' >Have you ever been separated?<\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_1_69'>\n\t\t\t<li class='gchoice gchoice_1_69_0'>\n\t\t\t\t<input name='input_69' type='radio' value='Yes'  id='choice_1_69_0'    \/>\n\t\t\t\t<label for='choice_1_69_0' id='label_1_69_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_1_69_1'>\n\t\t\t\t<input name='input_69' type='radio' value='No'  id='choice_1_69_1'    \/>\n\t\t\t\t<label for='choice_1_69_1' id='label_1_69_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_1_70\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' >Have you ever filed for divorce?<\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_1_70'>\n\t\t\t<li class='gchoice gchoice_1_70_0'>\n\t\t\t\t<input name='input_70' type='radio' value='Yes'  id='choice_1_70_0'    \/>\n\t\t\t\t<label for='choice_1_70_0' id='label_1_70_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_1_70_1'>\n\t\t\t\t<input name='input_70' type='radio' value='No'  id='choice_1_70_1'    \/>\n\t\t\t\t<label for='choice_1_70_1' id='label_1_70_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_1_71\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' >Have either of you been previously married?<\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_1_71'>\n\t\t\t<li class='gchoice gchoice_1_71_0'>\n\t\t\t\t<input name='input_71' type='radio' value='Yes'  id='choice_1_71_0'    \/>\n\t\t\t\t<label for='choice_1_71_0' id='label_1_71_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_1_71_1'>\n\t\t\t\t<input name='input_71' type='radio' value='No'  id='choice_1_71_1'    \/>\n\t\t\t\t<label for='choice_1_71_1' id='label_1_71_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_1_72\" class=\"gfield gfield--type-text gfield--input-type-text field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_1_72'>If yes, who?<\/label><div class='ginput_container ginput_container_text'><input name='input_72' id='input_1_72' type='text' value='' class='medium'      aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_1_73\" class=\"gfield gfield--type-textarea gfield--input-type-textarea field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_1_73'>Give a brief information about any previous marriages:<\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_73' id='input_1_73' class='textarea medium'   maxlength='175'   aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/li><\/ul>\n                    <\/div>\n                    <div class='gform-page-footer gform_page_footer top_label'>\n                        <input type='button' id='gform_previous_button_1_128' class='gform_previous_button gform-theme-button gform-theme-button--secondary button' onclick='gform.submission.handleButtonClick(this);' data-submission-type='previous' value='Previous'  \/> <input type='button' id='gform_next_button_1_128' class='gform_next_button gform-theme-button button' onclick='gform.submission.handleButtonClick(this);' data-submission-type='next' value='Next'  \/> \n                    <\/div>\n                <\/div>\n                <div id='gform_page_1_5' class='gform_page' data-js='page-field-id-128' style='display:none;'>\n                    <div class='gform_page_fields'>\n                        <ul id='gform_fields_1_5' class='gform_fields top_label form_sublabel_below description_below validation_below'><li id=\"field_1_64\" class=\"gfield gfield--type-section gfield--input-type-section gsection field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><h2 class=\"gsection_title\">Children<\/h2><\/li><li id=\"field_1_74\" class=\"gfield gfield--type-select gfield--input-type-select field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_1_74'>How many children?<\/label><div class='ginput_container ginput_container_select'><select name='input_74' id='input_1_74' class='medium gfield_select'     aria-invalid=\"false\" ><option value='0' >0<\/option><option value='1' >1<\/option><option value='2' >2<\/option><option value='3' >3<\/option><option value='4' >4<\/option><option value='5' >5<\/option><\/select><\/div><\/li><li id=\"field_1_75\" class=\"gfield gfield--type-section gfield--input-type-section gsection field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><h2 class=\"gsection_title\">Child 1<\/h2><\/li><li id=\"field_1_76\" class=\"gfield gfield--type-name gfield--input-type-name field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label gfield_label_before_complex' >Child&#039;s Name<\/label><div class='ginput_complex ginput_container ginput_container--name no_prefix has_first_name no_middle_name has_last_name no_suffix gf_name_has_2 ginput_container_name gform-grid-row' id='input_1_76'>\n                            \n                            <span id='input_1_76_3_container' class='name_first gform-grid-col gform-grid-col--size-auto' >\n                                                    <input type='text' name='input_76.3' id='input_1_76_3' value=''   aria-required='false'     \/>\n                                                    <label for='input_1_76_3' class='gform-field-label gform-field-label--type-sub '>First<\/label>\n                                                <\/span>\n                            \n                            <span id='input_1_76_6_container' class='name_last gform-grid-col gform-grid-col--size-auto' >\n                                                    <input type='text' name='input_76.6' id='input_1_76_6' value=''   aria-required='false'     \/>\n                                                    <label for='input_1_76_6' class='gform-field-label gform-field-label--type-sub '>Last<\/label>\n                                                <\/span>\n                            \n                        <\/div><\/li><li id=\"field_1_78\" class=\"gfield gfield--type-text gfield--input-type-text field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_1_78'>Child&#039;s Age<\/label><div class='ginput_container ginput_container_text'><input name='input_78' id='input_1_78' type='text' value='' class='medium'      aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_1_79\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' >Child&#039;s Sex<\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_1_79'>\n\t\t\t<li class='gchoice gchoice_1_79_0'>\n\t\t\t\t<input name='input_79' type='radio' value='M'  id='choice_1_79_0'    \/>\n\t\t\t\t<label for='choice_1_79_0' id='label_1_79_0' class='gform-field-label gform-field-label--type-inline'>M<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_1_79_1'>\n\t\t\t\t<input name='input_79' type='radio' value='F'  id='choice_1_79_1'    \/>\n\t\t\t\t<label for='choice_1_79_1' id='label_1_79_1' class='gform-field-label gform-field-label--type-inline'>F<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_1_80\" class=\"gfield gfield--type-text gfield--input-type-text field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_1_80'>Currently Living With:<\/label><div class='ginput_container ginput_container_text'><input name='input_80' id='input_1_80' type='text' value='' class='medium'      aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_1_81\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' >Stepchild?<\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_1_81'>\n\t\t\t<li class='gchoice gchoice_1_81_0'>\n\t\t\t\t<input name='input_81' type='radio' value='Yes'  id='choice_1_81_0'    \/>\n\t\t\t\t<label for='choice_1_81_0' id='label_1_81_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_1_81_1'>\n\t\t\t\t<input name='input_81' type='radio' value='No'  id='choice_1_81_1'    \/>\n\t\t\t\t<label for='choice_1_81_1' id='label_1_81_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_1_82\" class=\"gfield gfield--type-section gfield--input-type-section gsection field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><h2 class=\"gsection_title\">Child 2<\/h2><\/li><li id=\"field_1_83\" class=\"gfield gfield--type-name gfield--input-type-name field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label gfield_label_before_complex' >Child&#039;s Name<\/label><div class='ginput_complex ginput_container ginput_container--name no_prefix has_first_name no_middle_name has_last_name no_suffix gf_name_has_2 ginput_container_name gform-grid-row' id='input_1_83'>\n                            \n                            <span id='input_1_83_3_container' class='name_first gform-grid-col gform-grid-col--size-auto' >\n                                                    <input type='text' name='input_83.3' id='input_1_83_3' value=''   aria-required='false'     \/>\n                                                    <label for='input_1_83_3' class='gform-field-label gform-field-label--type-sub '>First<\/label>\n                                                <\/span>\n                            \n                            <span id='input_1_83_6_container' class='name_last gform-grid-col gform-grid-col--size-auto' >\n                                                    <input type='text' name='input_83.6' id='input_1_83_6' value=''   aria-required='false'     \/>\n                                                    <label for='input_1_83_6' class='gform-field-label gform-field-label--type-sub '>Last<\/label>\n                                                <\/span>\n                            \n                        <\/div><\/li><li id=\"field_1_84\" class=\"gfield gfield--type-text gfield--input-type-text field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_1_84'>Child&#039;s Age<\/label><div class='ginput_container ginput_container_text'><input name='input_84' id='input_1_84' type='text' value='' class='medium'      aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_1_85\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' >Child&#039;s Sex<\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_1_85'>\n\t\t\t<li class='gchoice gchoice_1_85_0'>\n\t\t\t\t<input name='input_85' type='radio' value='M'  id='choice_1_85_0'    \/>\n\t\t\t\t<label for='choice_1_85_0' id='label_1_85_0' class='gform-field-label gform-field-label--type-inline'>M<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_1_85_1'>\n\t\t\t\t<input name='input_85' type='radio' value='F'  id='choice_1_85_1'    \/>\n\t\t\t\t<label for='choice_1_85_1' id='label_1_85_1' class='gform-field-label gform-field-label--type-inline'>F<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_1_86\" class=\"gfield gfield--type-text gfield--input-type-text field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_1_86'>Currently Living With:<\/label><div class='ginput_container ginput_container_text'><input name='input_86' id='input_1_86' type='text' value='' class='medium'      aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_1_87\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' >Stepchild?<\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_1_87'>\n\t\t\t<li class='gchoice gchoice_1_87_0'>\n\t\t\t\t<input name='input_87' type='radio' value='Yes'  id='choice_1_87_0'    \/>\n\t\t\t\t<label for='choice_1_87_0' id='label_1_87_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_1_87_1'>\n\t\t\t\t<input name='input_87' type='radio' value='No'  id='choice_1_87_1'    \/>\n\t\t\t\t<label for='choice_1_87_1' id='label_1_87_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_1_88\" class=\"gfield gfield--type-section gfield--input-type-section gsection field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><h2 class=\"gsection_title\">Child 3<\/h2><\/li><li id=\"field_1_89\" class=\"gfield gfield--type-name gfield--input-type-name field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label gfield_label_before_complex' >Child&#039;s Name<\/label><div class='ginput_complex ginput_container ginput_container--name no_prefix has_first_name no_middle_name has_last_name no_suffix gf_name_has_2 ginput_container_name gform-grid-row' id='input_1_89'>\n                            \n                            <span id='input_1_89_3_container' class='name_first gform-grid-col gform-grid-col--size-auto' >\n                                                    <input type='text' name='input_89.3' id='input_1_89_3' value=''   aria-required='false'     \/>\n                                                    <label for='input_1_89_3' class='gform-field-label gform-field-label--type-sub '>First<\/label>\n                                                <\/span>\n                            \n                            <span id='input_1_89_6_container' class='name_last gform-grid-col gform-grid-col--size-auto' >\n                                                    <input type='text' name='input_89.6' id='input_1_89_6' value=''   aria-required='false'     \/>\n                                                    <label for='input_1_89_6' class='gform-field-label gform-field-label--type-sub '>Last<\/label>\n                                                <\/span>\n                            \n                        <\/div><\/li><li id=\"field_1_90\" class=\"gfield gfield--type-text gfield--input-type-text field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_1_90'>Child&#039;s Age<\/label><div class='ginput_container ginput_container_text'><input name='input_90' id='input_1_90' type='text' value='' class='medium'      aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_1_91\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' >Child&#039;s Sex<\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_1_91'>\n\t\t\t<li class='gchoice gchoice_1_91_0'>\n\t\t\t\t<input name='input_91' type='radio' value='M'  id='choice_1_91_0'    \/>\n\t\t\t\t<label for='choice_1_91_0' id='label_1_91_0' class='gform-field-label gform-field-label--type-inline'>M<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_1_91_1'>\n\t\t\t\t<input name='input_91' type='radio' value='F'  id='choice_1_91_1'    \/>\n\t\t\t\t<label for='choice_1_91_1' id='label_1_91_1' class='gform-field-label gform-field-label--type-inline'>F<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_1_92\" class=\"gfield gfield--type-text gfield--input-type-text field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_1_92'>Currently Living With:<\/label><div class='ginput_container ginput_container_text'><input name='input_92' id='input_1_92' type='text' value='' class='medium'      aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_1_93\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' >Stepchild?<\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_1_93'>\n\t\t\t<li class='gchoice gchoice_1_93_0'>\n\t\t\t\t<input name='input_93' type='radio' value='Yes'  id='choice_1_93_0'    \/>\n\t\t\t\t<label for='choice_1_93_0' id='label_1_93_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_1_93_1'>\n\t\t\t\t<input name='input_93' type='radio' value='No'  id='choice_1_93_1'    \/>\n\t\t\t\t<label for='choice_1_93_1' id='label_1_93_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_1_94\" class=\"gfield gfield--type-section gfield--input-type-section gsection field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><h2 class=\"gsection_title\">Child 4<\/h2><\/li><li id=\"field_1_95\" class=\"gfield gfield--type-name gfield--input-type-name field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label gfield_label_before_complex' >Child&#039;s Name<\/label><div class='ginput_complex ginput_container ginput_container--name no_prefix has_first_name no_middle_name has_last_name no_suffix gf_name_has_2 ginput_container_name gform-grid-row' id='input_1_95'>\n                            \n                            <span id='input_1_95_3_container' class='name_first gform-grid-col gform-grid-col--size-auto' >\n                                                    <input type='text' name='input_95.3' id='input_1_95_3' value=''   aria-required='false'     \/>\n                                                    <label for='input_1_95_3' class='gform-field-label gform-field-label--type-sub '>First<\/label>\n                                                <\/span>\n                            \n                            <span id='input_1_95_6_container' class='name_last gform-grid-col gform-grid-col--size-auto' >\n                                                    <input type='text' name='input_95.6' id='input_1_95_6' value=''   aria-required='false'     \/>\n                                                    <label for='input_1_95_6' class='gform-field-label gform-field-label--type-sub '>Last<\/label>\n                                                <\/span>\n                            \n                        <\/div><\/li><li id=\"field_1_96\" class=\"gfield gfield--type-text gfield--input-type-text field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_1_96'>Child&#039;s Age<\/label><div class='ginput_container ginput_container_text'><input name='input_96' id='input_1_96' type='text' value='' class='medium'      aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_1_97\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' >Child&#039;s Sex<\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_1_97'>\n\t\t\t<li class='gchoice gchoice_1_97_0'>\n\t\t\t\t<input name='input_97' type='radio' value='M'  id='choice_1_97_0'    \/>\n\t\t\t\t<label for='choice_1_97_0' id='label_1_97_0' class='gform-field-label gform-field-label--type-inline'>M<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_1_97_1'>\n\t\t\t\t<input name='input_97' type='radio' value='F'  id='choice_1_97_1'    \/>\n\t\t\t\t<label for='choice_1_97_1' id='label_1_97_1' class='gform-field-label gform-field-label--type-inline'>F<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_1_98\" class=\"gfield gfield--type-text gfield--input-type-text field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_1_98'>Currently Living With:<\/label><div class='ginput_container ginput_container_text'><input name='input_98' id='input_1_98' type='text' value='' class='medium'      aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_1_99\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' >Stepchild?<\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_1_99'>\n\t\t\t<li class='gchoice gchoice_1_99_0'>\n\t\t\t\t<input name='input_99' type='radio' value='Yes'  id='choice_1_99_0'    \/>\n\t\t\t\t<label for='choice_1_99_0' id='label_1_99_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_1_99_1'>\n\t\t\t\t<input name='input_99' type='radio' value='No'  id='choice_1_99_1'    \/>\n\t\t\t\t<label for='choice_1_99_1' id='label_1_99_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_1_100\" class=\"gfield gfield--type-section gfield--input-type-section gsection field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><h2 class=\"gsection_title\">Child 5<\/h2><\/li><li id=\"field_1_101\" class=\"gfield gfield--type-name gfield--input-type-name field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label gfield_label_before_complex' >Child&#039;s Name<\/label><div class='ginput_complex ginput_container ginput_container--name no_prefix has_first_name no_middle_name has_last_name no_suffix gf_name_has_2 ginput_container_name gform-grid-row' id='input_1_101'>\n                            \n                            <span id='input_1_101_3_container' class='name_first gform-grid-col gform-grid-col--size-auto' >\n                                                    <input type='text' name='input_101.3' id='input_1_101_3' value=''   aria-required='false'     \/>\n                                                    <label for='input_1_101_3' class='gform-field-label gform-field-label--type-sub '>First<\/label>\n                                                <\/span>\n                            \n                            <span id='input_1_101_6_container' class='name_last gform-grid-col gform-grid-col--size-auto' >\n                                                    <input type='text' name='input_101.6' id='input_1_101_6' value=''   aria-required='false'     \/>\n                                                    <label for='input_1_101_6' class='gform-field-label gform-field-label--type-sub '>Last<\/label>\n                                                <\/span>\n                            \n                        <\/div><\/li><li id=\"field_1_102\" class=\"gfield gfield--type-text gfield--input-type-text field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_1_102'>Child&#039;s Age<\/label><div class='ginput_container ginput_container_text'><input name='input_102' id='input_1_102' type='text' value='' class='medium'      aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_1_103\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' >Child&#039;s Sex<\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_1_103'>\n\t\t\t<li class='gchoice gchoice_1_103_0'>\n\t\t\t\t<input name='input_103' type='radio' value='M'  id='choice_1_103_0'    \/>\n\t\t\t\t<label for='choice_1_103_0' id='label_1_103_0' class='gform-field-label gform-field-label--type-inline'>M<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_1_103_1'>\n\t\t\t\t<input name='input_103' type='radio' value='F'  id='choice_1_103_1'    \/>\n\t\t\t\t<label for='choice_1_103_1' id='label_1_103_1' class='gform-field-label gform-field-label--type-inline'>F<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_1_104\" class=\"gfield gfield--type-text gfield--input-type-text field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_1_104'>Currently Living With:<\/label><div class='ginput_container ginput_container_text'><input name='input_104' id='input_1_104' type='text' value='' class='medium'      aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_1_105\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' >Stepchild?<\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_1_105'>\n\t\t\t<li class='gchoice gchoice_1_105_0'>\n\t\t\t\t<input name='input_105' type='radio' value='Yes'  id='choice_1_105_0'    \/>\n\t\t\t\t<label for='choice_1_105_0' id='label_1_105_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_1_105_1'>\n\t\t\t\t<input name='input_105' type='radio' value='No'  id='choice_1_105_1'    \/>\n\t\t\t\t<label for='choice_1_105_1' id='label_1_105_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><\/ul>\n                    <\/div>\n                    <div class='gform-page-footer gform_page_footer top_label'>\n                        <input type='button' id='gform_previous_button_1_106' class='gform_previous_button gform-theme-button gform-theme-button--secondary button' onclick='gform.submission.handleButtonClick(this);' data-submission-type='previous' value='Previous'  \/> <input type='button' id='gform_next_button_1_106' class='gform_next_button gform-theme-button button' onclick='gform.submission.handleButtonClick(this);' data-submission-type='next' value='Next'  \/> \n                    <\/div>\n                <\/div>\n                <div id='gform_page_1_6' class='gform_page' data-js='page-field-id-106' style='display:none;'>\n                    <div class='gform_page_fields'>\n                        <ul id='gform_fields_1_6' class='gform_fields top_label form_sublabel_below description_below validation_below'><li id=\"field_1_107\" class=\"gfield gfield--type-section gfield--input-type-section gsection field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><h2 class=\"gsection_title\">Personality Information<\/h2><\/li><li id=\"field_1_108\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio 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' >Have you ever had any psychotherapy or counseling before?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_1_108'>\n\t\t\t<li class='gchoice gchoice_1_108_0'>\n\t\t\t\t<input name='input_108' type='radio' value='Yes'  id='choice_1_108_0'    \/>\n\t\t\t\t<label for='choice_1_108_0' id='label_1_108_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_1_108_1'>\n\t\t\t\t<input name='input_108' type='radio' value='No'  id='choice_1_108_1'    \/>\n\t\t\t\t<label for='choice_1_108_1' id='label_1_108_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_1_109\" class=\"gfield gfield--type-textarea gfield--input-type-textarea field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_1_109'>If yes, list counselor or therapist and dates<\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_109' id='input_1_109' class='textarea medium'   maxlength='100'   aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/li><li id=\"field_1_110\" class=\"gfield gfield--type-textarea gfield--input-type-textarea field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_1_110'>What was the outcome?<\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_110' id='input_1_110' class='textarea medium'   maxlength='100'   aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/li><li id=\"field_1_111\" class=\"gfield gfield--type-textarea gfield--input-type-textarea field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_1_111'>What, if anything, do you fear?<\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_111' id='input_1_111' class='textarea medium'   maxlength='80'   aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/li><li id=\"field_1_112\" class=\"gfield gfield--type-textarea gfield--input-type-textarea field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_1_112'>Is there any other information that would help us to help you?<\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_112' id='input_1_112' class='textarea medium'   maxlength='60'   aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/li><li id=\"field_1_113\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' >Have you recently suffered a loss from serious social, business, or other reversals, etc?<\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_1_113'>\n\t\t\t<li class='gchoice gchoice_1_113_0'>\n\t\t\t\t<input name='input_113' type='radio' value='Yes'  id='choice_1_113_0'    \/>\n\t\t\t\t<label for='choice_1_113_0' id='label_1_113_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_1_113_1'>\n\t\t\t\t<input name='input_113' type='radio' value='No'  id='choice_1_113_1'    \/>\n\t\t\t\t<label for='choice_1_113_1' id='label_1_113_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_1_114\" class=\"gfield gfield--type-textarea gfield--input-type-textarea field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_1_114'>Explain if yes<\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_114' id='input_1_114' class='textarea medium'   maxlength='100'   aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/li><li id=\"field_1_115\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield--input-type-checkbox 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 gfield_label_before_complex' >Check any of the following words which best describe you now:<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_checkbox'><ul class='gfield_checkbox' id='input_1_115'><li class='gchoice gchoice_1_115_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_115.1' type='checkbox'  value='Active'  id='choice_1_115_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_1_115_1' id='label_1_115_1' class='gform-field-label gform-field-label--type-inline'>Active<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_1_115_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_115.2' type='checkbox'  value='Ambitious'  id='choice_1_115_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_1_115_2' id='label_1_115_2' class='gform-field-label gform-field-label--type-inline'>Ambitious<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_1_115_3'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_115.3' type='checkbox'  value='Self-Confident'  id='choice_1_115_3'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_1_115_3' id='label_1_115_3' class='gform-field-label gform-field-label--type-inline'>Self-Confident<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_1_115_4'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_115.4' type='checkbox'  value='Persistent'  id='choice_1_115_4'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_1_115_4' id='label_1_115_4' class='gform-field-label gform-field-label--type-inline'>Persistent<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_1_115_5'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_115.5' type='checkbox'  value='Nervous'  id='choice_1_115_5'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_1_115_5' id='label_1_115_5' class='gform-field-label gform-field-label--type-inline'>Nervous<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_1_115_6'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_115.6' type='checkbox'  value='Hardworking'  id='choice_1_115_6'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_1_115_6' id='label_1_115_6' class='gform-field-label gform-field-label--type-inline'>Hardworking<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_1_115_7'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_115.7' type='checkbox'  value='Impatient'  id='choice_1_115_7'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_1_115_7' id='label_1_115_7' class='gform-field-label gform-field-label--type-inline'>Impatient<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_1_115_8'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_115.8' type='checkbox'  value='Impulsive'  id='choice_1_115_8'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_1_115_8' id='label_1_115_8' class='gform-field-label gform-field-label--type-inline'>Impulsive<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_1_115_9'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_115.9' type='checkbox'  value='Moody'  id='choice_1_115_9'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_1_115_9' id='label_1_115_9' class='gform-field-label gform-field-label--type-inline'>Moody<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_1_115_11'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_115.11' type='checkbox'  value='Often-blue'  id='choice_1_115_11'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_1_115_11' id='label_1_115_11' class='gform-field-label gform-field-label--type-inline'>Often-blue<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_1_115_12'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_115.12' type='checkbox'  value='Excitable'  id='choice_1_115_12'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_1_115_12' id='label_1_115_12' class='gform-field-label gform-field-label--type-inline'>Excitable<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_1_115_13'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_115.13' type='checkbox'  value='Imaginative'  id='choice_1_115_13'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_1_115_13' id='label_1_115_13' class='gform-field-label gform-field-label--type-inline'>Imaginative<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_1_115_14'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_115.14' type='checkbox'  value='Calm'  id='choice_1_115_14'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_1_115_14' id='label_1_115_14' class='gform-field-label gform-field-label--type-inline'>Calm<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_1_115_15'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_115.15' type='checkbox'  value='Serious'  id='choice_1_115_15'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_1_115_15' id='label_1_115_15' class='gform-field-label gform-field-label--type-inline'>Serious<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_1_115_16'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_115.16' type='checkbox'  value='Easy-going'  id='choice_1_115_16'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_1_115_16' id='label_1_115_16' class='gform-field-label gform-field-label--type-inline'>Easy-going<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_1_115_17'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_115.17' type='checkbox'  value='Shy'  id='choice_1_115_17'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_1_115_17' id='label_1_115_17' class='gform-field-label gform-field-label--type-inline'>Shy<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_1_115_18'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_115.18' type='checkbox'  value='Good-natured'  id='choice_1_115_18'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_1_115_18' id='label_1_115_18' class='gform-field-label gform-field-label--type-inline'>Good-natured<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_1_115_19'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_115.19' type='checkbox'  value='Introvert'  id='choice_1_115_19'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_1_115_19' id='label_1_115_19' class='gform-field-label gform-field-label--type-inline'>Introvert<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_1_115_21'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_115.21' type='checkbox'  value='Extrovert'  id='choice_1_115_21'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_1_115_21' id='label_1_115_21' class='gform-field-label gform-field-label--type-inline'>Extrovert<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_1_115_22'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_115.22' type='checkbox'  value='Likable'  id='choice_1_115_22'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_1_115_22' id='label_1_115_22' class='gform-field-label gform-field-label--type-inline'>Likable<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_1_115_23'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_115.23' type='checkbox'  value='Leader'  id='choice_1_115_23'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_1_115_23' id='label_1_115_23' class='gform-field-label gform-field-label--type-inline'>Leader<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_1_115_24'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_115.24' type='checkbox'  value='Quiet'  id='choice_1_115_24'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_1_115_24' id='label_1_115_24' class='gform-field-label gform-field-label--type-inline'>Quiet<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_1_115_25'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_115.25' type='checkbox'  value='Submissive'  id='choice_1_115_25'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_1_115_25' id='label_1_115_25' class='gform-field-label gform-field-label--type-inline'>Submissive<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_1_115_26'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_115.26' type='checkbox'  value='Self-conscious'  id='choice_1_115_26'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_1_115_26' id='label_1_115_26' class='gform-field-label gform-field-label--type-inline'>Self-conscious<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_1_115_27'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_115.27' type='checkbox'  value='Lonely'  id='choice_1_115_27'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_1_115_27' id='label_1_115_27' class='gform-field-label gform-field-label--type-inline'>Lonely<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_1_115_28'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_115.28' type='checkbox'  value='Sensitive'  id='choice_1_115_28'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_1_115_28' id='label_1_115_28' class='gform-field-label gform-field-label--type-inline'>Sensitive<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_1_115_29'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_115.29' type='checkbox'  value='Other'  id='choice_1_115_29'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_1_115_29' id='label_1_115_29' class='gform-field-label gform-field-label--type-inline'>Other<\/label>\n\t\t\t\t\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_1_116\" class=\"gfield gfield--type-textarea gfield--input-type-textarea field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_1_116'>You selected other, please explain<\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_116' id='input_1_116' class='textarea medium'   maxlength='50'   aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/li><li id=\"field_1_117\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio 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' >Do you drink coffee or other caffeinated drinks?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_1_117'>\n\t\t\t<li class='gchoice gchoice_1_117_0'>\n\t\t\t\t<input name='input_117' type='radio' value='Yes'  id='choice_1_117_0'    \/>\n\t\t\t\t<label for='choice_1_117_0' id='label_1_117_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_1_117_1'>\n\t\t\t\t<input name='input_117' type='radio' value='No'  id='choice_1_117_1'    \/>\n\t\t\t\t<label for='choice_1_117_1' id='label_1_117_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_1_118\" class=\"gfield gfield--type-text gfield--input-type-text field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_1_118'>How much caffeine per day?<\/label><div class='ginput_container ginput_container_text'><input name='input_118' id='input_1_118' type='text' value='' class='medium' maxlength='30'     aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_1_119\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio 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' >Do you smoke?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_1_119'>\n\t\t\t<li class='gchoice gchoice_1_119_0'>\n\t\t\t\t<input name='input_119' type='radio' value='Yes'  id='choice_1_119_0'    \/>\n\t\t\t\t<label for='choice_1_119_0' id='label_1_119_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_1_119_1'>\n\t\t\t\t<input name='input_119' type='radio' value='No'  id='choice_1_119_1'    \/>\n\t\t\t\t<label for='choice_1_119_1' id='label_1_119_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_1_120\" class=\"gfield gfield--type-text gfield--input-type-text field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_1_120'>How much do you smoke?<\/label><div class='ginput_container ginput_container_text'><input name='input_120' id='input_1_120' type='text' value='' class='medium' maxlength='30'     aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_1_121\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio 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' >Do you explode when you get angry?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_1_121'>\n\t\t\t<li class='gchoice gchoice_1_121_0'>\n\t\t\t\t<input name='input_121' type='radio' value='Yes'  id='choice_1_121_0'    \/>\n\t\t\t\t<label for='choice_1_121_0' id='label_1_121_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_1_121_1'>\n\t\t\t\t<input name='input_121' type='radio' value='No'  id='choice_1_121_1'    \/>\n\t\t\t\t<label for='choice_1_121_1' id='label_1_121_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_1_122\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio 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' >Do you withdraw when you get angry or hurt?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_1_122'>\n\t\t\t<li class='gchoice gchoice_1_122_0'>\n\t\t\t\t<input name='input_122' type='radio' value='Yes'  id='choice_1_122_0'    \/>\n\t\t\t\t<label for='choice_1_122_0' id='label_1_122_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_1_122_1'>\n\t\t\t\t<input name='input_122' type='radio' value='No'  id='choice_1_122_1'    \/>\n\t\t\t\t<label for='choice_1_122_1' id='label_1_122_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_1_123\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio 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' >Do you frequently argue with significant other people?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_1_123'>\n\t\t\t<li class='gchoice gchoice_1_123_0'>\n\t\t\t\t<input name='input_123' type='radio' value='Yes'  id='choice_1_123_0'    \/>\n\t\t\t\t<label for='choice_1_123_0' id='label_1_123_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_1_123_1'>\n\t\t\t\t<input name='input_123' type='radio' value='No'  id='choice_1_123_1'    \/>\n\t\t\t\t<label for='choice_1_123_1' id='label_1_123_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_1_124\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio 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' >Have you ever been enslaved to anything (Coffee, drugs, alcohol, pornography, gambling, etc.)?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_1_124'>\n\t\t\t<li class='gchoice gchoice_1_124_0'>\n\t\t\t\t<input name='input_124' type='radio' value='Yes'  id='choice_1_124_0'    \/>\n\t\t\t\t<label for='choice_1_124_0' id='label_1_124_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_1_124_1'>\n\t\t\t\t<input name='input_124' type='radio' value='No'  id='choice_1_124_1'    \/>\n\t\t\t\t<label for='choice_1_124_1' id='label_1_124_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_1_125\" class=\"gfield gfield--type-textarea gfield--input-type-textarea 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_1_125'>If yes, please explain.<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_125' id='input_1_125' class='textarea medium'   maxlength='360'  aria-required=\"true\" aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/li><\/ul>\n                    <\/div>\n                    <div class='gform-page-footer gform_page_footer top_label'>\n                        <input type='button' id='gform_previous_button_1_126' class='gform_previous_button gform-theme-button gform-theme-button--secondary button' onclick='gform.submission.handleButtonClick(this);' data-submission-type='previous' value='Previous'  \/> <input type='button' id='gform_next_button_1_126' class='gform_next_button gform-theme-button button' onclick='gform.submission.handleButtonClick(this);' data-submission-type='next' value='Next'  \/> \n                    <\/div>\n                <\/div>\n                <div id='gform_page_1_7' class='gform_page' data-js='page-field-id-126' style='display:none;'>\n                    <div class='gform_page_fields'>\n                        <ul id='gform_fields_1_7' class='gform_fields top_label form_sublabel_below description_below validation_below'><li id=\"field_1_127\" class=\"gfield gfield--type-section gfield--input-type-section gsection field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><h2 class=\"gsection_title\">Fear of Man Questionnaire<\/h2><\/li><li id=\"field_1_131\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield--input-type-checkbox 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 gfield_label_before_complex' >Fear of Man Questionnaire<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_checkbox'><ul class='gfield_checkbox' id='input_1_131'><li class='gchoice gchoice_1_131_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_131.1' type='checkbox'  value='Peer'  id='choice_1_131_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_1_131_1' id='label_1_131_1' class='gform-field-label gform-field-label--type-inline'>I struggle with peer pressure. In adulthood, it looks different than when a teen. Now it might be by trying to impress others.<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_1_131_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_131.2' type='checkbox'  value='Over-committed'  id='choice_1_131_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_1_131_2' id='label_1_131_2' class='gform-field-label gform-field-label--type-inline'>I am over-committed. I find it hard to say, \u201cNo.\u201d I am a people pleaser.<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_1_131_3'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_131.3' type='checkbox'  value='Need'  id='choice_1_131_3'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_1_131_3' id='label_1_131_3' class='gform-field-label gform-field-label--type-inline'>I \u2018need\u2019 something from my spouse or others in my life (such as the person I am dating, a roommate, other friends).<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_1_131_4'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_131.4' type='checkbox'  value='Low Self'  id='choice_1_131_4'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_1_131_4' id='label_1_131_4' class='gform-field-label gform-field-label--type-inline'>I feel like I have low self-esteem. I am concerned with what others think of me.<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_1_131_5'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_131.5' type='checkbox'  value='Imposter'  id='choice_1_131_5'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_1_131_5' id='label_1_131_5' class='gform-field-label gform-field-label--type-inline'>I often feel like I will be exposed as an imposter. I am afraid others will think I am a failure.<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_1_131_6'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_131.6' type='checkbox'  value='Decisions'  id='choice_1_131_6'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_1_131_6' id='label_1_131_6' class='gform-field-label gform-field-label--type-inline'>I find myself second-guessing decisions because of what others might think. I am afraid of making mistakes.<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_1_131_7'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_131.7' type='checkbox'  value='Empty'  id='choice_1_131_7'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_1_131_7' id='label_1_131_7' class='gform-field-label gform-field-label--type-inline'>I feel empty or meaningless. I often feel hungry for love.<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_1_131_8'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_131.8' type='checkbox'  value='Embarrassed'  id='choice_1_131_8'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_1_131_8' id='label_1_131_8' class='gform-field-label gform-field-label--type-inline'>I easily get embarrassed.<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_1_131_9'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_131.9' type='checkbox'  value='Lie'  id='choice_1_131_9'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_1_131_9' id='label_1_131_9' class='gform-field-label gform-field-label--type-inline'>I lie, even little white lies, in order to make myself look better before other people.<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_1_131_11'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_131.11' type='checkbox'  value='Jealous'  id='choice_1_131_11'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_1_131_11' id='label_1_131_11' class='gform-field-label gform-field-label--type-inline'>I am sometimes jealous of other people.<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_1_131_12'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_131.12' type='checkbox'  value='Angry'  id='choice_1_131_12'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_1_131_12' id='label_1_131_12' class='gform-field-label gform-field-label--type-inline'>People often make me angry or depressed. They make me \u201ccrazy.\u201d<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_1_131_13'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_131.13' type='checkbox'  value='Avoid People'  id='choice_1_131_13'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_1_131_13' id='label_1_131_13' class='gform-field-label gform-field-label--type-inline'>I often avoid people.<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_1_131_14'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_131.14' type='checkbox'  value='Hungry'  id='choice_1_131_14'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_1_131_14' id='label_1_131_14' class='gform-field-label gform-field-label--type-inline'>I am hungry for people to notice my efforts and to praise me, but when they do, it\u2019s not enough or I don\u2019t believe them.<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_1_131_15'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_131.15' type='checkbox'  value='Compare'  id='choice_1_131_15'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_1_131_15' id='label_1_131_15' class='gform-field-label gform-field-label--type-inline'>I often compare myself to others and either feel wanting or feel like I\u2019m not so bad.<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_1_131_16'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_131.16' type='checkbox'  value='Keep Others'  id='choice_1_131_16'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_1_131_16' id='label_1_131_16' class='gform-field-label gform-field-label--type-inline'>I feel I have to keep others from knowing my secret thoughts or actions for fear they won\u2019t like or love me.<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_1_131_17'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_131.17' type='checkbox'  value='Cover Up'  id='choice_1_131_17'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_1_131_17' id='label_1_131_17' class='gform-field-label gform-field-label--type-inline'>I cover up, justify, blame, avoid, or change the subject often.<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_1_131_18'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_131.18' type='checkbox'  value='Favoritism'  id='choice_1_131_18'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_1_131_18' id='label_1_131_18' class='gform-field-label gform-field-label--type-inline'>I show favoritism, respecting one person over another.<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_1_131_19'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_131.19' type='checkbox'  value='Responsible'  id='choice_1_131_19'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_1_131_19' id='label_1_131_19' class='gform-field-label gform-field-label--type-inline'>I often think and feel responsible for other people and their actions or behaviors.<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_1_131_21'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_131.21' type='checkbox'  value='Fix People'  id='choice_1_131_21'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_1_131_21' id='label_1_131_21' class='gform-field-label gform-field-label--type-inline'>I am compelled to \u201cfix people\u201d.<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_1_131_22'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_131.22' type='checkbox'  value='Always Giving'  id='choice_1_131_22'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_1_131_22' id='label_1_131_22' class='gform-field-label gform-field-label--type-inline'>I get tired of feeling like I am always giving to others and no one gives to me.<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_1_131_23'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_131.23' type='checkbox'  value='Blame'  id='choice_1_131_23'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_1_131_23' id='label_1_131_23' class='gform-field-label gform-field-label--type-inline'>I blame others or blame circumstances.<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_1_131_24'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_131.24' type='checkbox'  value='Unappreciated'  id='choice_1_131_24'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_1_131_24' id='label_1_131_24' class='gform-field-label gform-field-label--type-inline'>I often feel unappreciated.<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_1_131_25'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_131.25' type='checkbox'  value='Rejected'  id='choice_1_131_25'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_1_131_25' id='label_1_131_25' class='gform-field-label gform-field-label--type-inline'>I often am afraid of being rejected.<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_1_131_26'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_131.26' type='checkbox'  value='Ashamed'  id='choice_1_131_26'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_1_131_26' id='label_1_131_26' class='gform-field-label gform-field-label--type-inline'>I often feel ashamed of who I am.<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_1_131_27'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_131.27' type='checkbox'  value='Focus'  id='choice_1_131_27'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_1_131_27' id='label_1_131_27' class='gform-field-label gform-field-label--type-inline'>I often focus my energy on other people and\/or on problems.<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_1_131_28'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_131.28' type='checkbox'  value='Threaten'  id='choice_1_131_28'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_1_131_28' id='label_1_131_28' class='gform-field-label gform-field-label--type-inline'>I frequently threaten, bribe, or beg.<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_1_131_29'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_131.29' type='checkbox'  value='Please Others'  id='choice_1_131_29'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_1_131_29' id='label_1_131_29' class='gform-field-label gform-field-label--type-inline'>I try to say or do what I think will please others or get what I want.<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_1_131_31'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_131.31' type='checkbox'  value='Manipulate'  id='choice_1_131_31'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_1_131_31' id='label_1_131_31' class='gform-field-label gform-field-label--type-inline'>I manipulate people and situations.<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_1_131_32'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_131.32' type='checkbox'  value='Hurting Me'  id='choice_1_131_32'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_1_131_32' id='label_1_131_32' class='gform-field-label gform-field-label--type-inline'>I let other people keep hurting me and never say anything.<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_1_131_33'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_131.33' type='checkbox'  value='Feel Angry'  id='choice_1_131_33'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_1_131_33' id='label_1_131_33' class='gform-field-label gform-field-label--type-inline'>I feel angry.<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_1_131_34'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_131.34' type='checkbox'  value='Martyr'  id='choice_1_131_34'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_1_131_34' id='label_1_131_34' class='gform-field-label gform-field-label--type-inline'>I feel like a martyr.<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_1_131_35'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_131.35' type='checkbox'  value='Responsible Irresponsible'  id='choice_1_131_35'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_1_131_35' id='label_1_131_35' class='gform-field-label gform-field-label--type-inline'>I feel extremely responsible or irresponsible.<\/label>\n\t\t\t\t\t\t\t<\/li><\/ul><\/div><\/li><\/ul>\n                    <\/div>\n                    <div class='gform-page-footer gform_page_footer top_label'>\n                        <input type='button' id='gform_previous_button_1_132' class='gform_previous_button gform-theme-button gform-theme-button--secondary button' onclick='gform.submission.handleButtonClick(this);' data-submission-type='previous' value='Previous'  \/> <input type='button' id='gform_next_button_1_132' class='gform_next_button gform-theme-button button' onclick='gform.submission.handleButtonClick(this);' data-submission-type='next' value='Next'  \/> \n                    <\/div>\n                <\/div>\n                <div id='gform_page_1_8' class='gform_page' data-js='page-field-id-132' style='display:none;'>\n                    <div class='gform_page_fields'>\n                        <ul id='gform_fields_1_8' class='gform_fields top_label form_sublabel_below description_below validation_below'><li id=\"field_1_133\" class=\"gfield gfield--type-section gfield--input-type-section gsection field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><h2 class=\"gsection_title\">Briefly answer the following questions<\/h2><\/li><li id=\"field_1_134\" class=\"gfield gfield--type-textarea gfield--input-type-textarea 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_1_134'>What is the main problem as you see it? What brings you here?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_134' id='input_1_134' class='textarea medium'   maxlength='900'  aria-required=\"true\" aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/li><li id=\"field_1_135\" class=\"gfield gfield--type-textarea gfield--input-type-textarea 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_1_135'>What have you done about your problem?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_135' id='input_1_135' class='textarea medium'   maxlength='700'  aria-required=\"true\" aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/li><li id=\"field_1_136\" class=\"gfield gfield--type-textarea gfield--input-type-textarea 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_1_136'>What can we do? (What are your expectations in coming here?)<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_136' id='input_1_136' class='textarea medium'   maxlength='700'  aria-required=\"true\" aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/li><li id=\"field_1_137\" class=\"gfield gfield--type-textarea gfield--input-type-textarea 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_1_137'>As you see yourself, what kind of person are you? Describe yourself:<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_137' id='input_1_137' class='textarea medium'   maxlength='700'  aria-required=\"true\" aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/li><li id=\"field_1_141\" class=\"gfield gfield--type-textarea gfield--input-type-textarea field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_1_141'>Give details of any family background that might be pertinent to the struggles in your own life. (I.e., do others in your family have similar problems? What did your home life look like? Did mom lead or dad? Was dad at home a lot or gone a lot? Was \u201cself-control\u201d taught from early on? Etc.<\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_141' id='input_1_141' class='textarea medium'   maxlength='700'   aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/li><li id=\"field_1_139\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield--input-type-checkbox 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 gfield_label_before_complex' >Problem Checklist (Check those which are current problems)<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_checkbox'><ul class='gfield_checkbox' id='input_1_139'><li class='gchoice gchoice_1_139_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_139.1' type='checkbox'  value='Anger'  id='choice_1_139_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_1_139_1' id='label_1_139_1' class='gform-field-label gform-field-label--type-inline'>Anger<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_1_139_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_139.2' type='checkbox'  value='Fear'  id='choice_1_139_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_1_139_2' id='label_1_139_2' class='gform-field-label gform-field-label--type-inline'>Fear<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_1_139_3'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_139.3' type='checkbox'  value='Moodiness'  id='choice_1_139_3'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_1_139_3' id='label_1_139_3' class='gform-field-label gform-field-label--type-inline'>Moodiness<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_1_139_4'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_139.4' type='checkbox'  value='Health'  id='choice_1_139_4'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_1_139_4' id='label_1_139_4' class='gform-field-label gform-field-label--type-inline'>Health<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_1_139_5'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_139.5' type='checkbox'  value='Sleep'  id='choice_1_139_5'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_1_139_5' id='label_1_139_5' class='gform-field-label gform-field-label--type-inline'>Sleep<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_1_139_6'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_139.6' type='checkbox'  value='Deception'  id='choice_1_139_6'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_1_139_6' id='label_1_139_6' class='gform-field-label gform-field-label--type-inline'>Deception<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_1_139_7'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_139.7' type='checkbox'  value='Adultery'  id='choice_1_139_7'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_1_139_7' id='label_1_139_7' class='gform-field-label gform-field-label--type-inline'>Adultery<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_1_139_8'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_139.8' type='checkbox'  value='Envy'  id='choice_1_139_8'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_1_139_8' id='label_1_139_8' class='gform-field-label gform-field-label--type-inline'>Envy<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_1_139_9'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_139.9' type='checkbox'  value='Memory'  id='choice_1_139_9'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_1_139_9' id='label_1_139_9' class='gform-field-label gform-field-label--type-inline'>Memory<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_1_139_11'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_139.11' type='checkbox'  value='Bitterness'  id='choice_1_139_11'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_1_139_11' id='label_1_139_11' class='gform-field-label gform-field-label--type-inline'>Bitterness<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_1_139_12'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_139.12' type='checkbox'  value='Sex'  id='choice_1_139_12'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_1_139_12' id='label_1_139_12' class='gform-field-label gform-field-label--type-inline'>Sex<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_1_139_13'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_139.13' type='checkbox'  value='Depression'  id='choice_1_139_13'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_1_139_13' id='label_1_139_13' class='gform-field-label gform-field-label--type-inline'>Depression<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_1_139_14'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_139.14' type='checkbox'  value='In-Laws'  id='choice_1_139_14'   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