{"id":23391,"date":"2017-03-06T18:43:06","date_gmt":"2017-03-06T18:43:06","guid":{"rendered":"http:\/\/pre-production.taftcollege.edu\/admissions\/?page_id=23391"},"modified":"2019-02-21T16:56:37","modified_gmt":"2019-02-21T16:56:37","slug":"confidential-counseling-self-referral-form","status":"publish","type":"page","link":"https:\/\/archive.taftcollege.edu\/admissions\/confidential-counseling-self-referral-form\/","title":{"rendered":"Confidential Counseling Self-Referral Form"},"content":{"rendered":"<section class=\"wpb-content-wrapper\"><p>[vc_row css_animation=&#8221;&#8221; row_type=&#8221;row&#8221; use_row_as_full_screen_section=&#8221;no&#8221; type=&#8221;full_width&#8221; text_align=&#8221;left&#8221;][vc_column][vc_column_text]<\/p>\n<p style=\"text-align: center;\"><strong>Confidential Counseling Self-Referral Form<\/strong><\/p>\n<p>[\/vc_column_text]<script type=\"text\/javascript\">\n\/* <![CDATA[ *\/\nvar 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action='\/admissions\/wp-json\/wp\/v2\/pages\/23391#gf_2' data-formid='2' novalidate>\n                        <div class='gform-body gform_body'><ul id='gform_fields_2' class='gform_fields top_label form_sublabel_below description_below validation_below'><li id=\"field_2_26\" class=\"gfield gfield--type-section gsection field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><h2 class=\"gsection_title\">Student Information<\/h2><\/li><li id=\"field_2_1\" class=\"gfield gfield--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 class='sr-only'> Required<\/span><\/span><\/span><\/label><div class='ginput_complex ginput_container ginput_container--name no_prefix has_first_name no_middle_name has_last_name has_suffix gf_name_has_3 ginput_container_name gform-grid-row' id='input_2_1'>\n                            \n                            <span id='input_2_1_3_container' class='name_first gform-grid-col gform-grid-col--size-auto' >\n                                                    <input type='text' name='input_1.3' id='input_2_1_3' value=''   aria-required='true'     \/>\n                                                    <label for='input_2_1_3' class='gform-field-label gform-field-label--type-sub '>First<\/label>\n                                                <\/span>\n                            \n                            <span id='input_2_1_6_container' class='name_last gform-grid-col gform-grid-col--size-auto' >\n                                                    <input type='text' name='input_1.6' id='input_2_1_6' value=''   aria-required='true'     \/>\n                                                    <label for='input_2_1_6' class='gform-field-label gform-field-label--type-sub '>Last<\/label>\n                                                <\/span>\n                            <span id='input_2_1_8_container' class='name_suffix  gform-grid-col gform-grid-col--size-auto' >\n                                                    <input type='text' name='input_1.8' id='input_2_1_8' value=''   aria-required='false'     \/>\n                                                    <label for='input_2_1_8' class='gform-field-label gform-field-label--type-sub '>Student ID<\/label>\n                                                <\/span>\n                        <\/div><\/fieldset><\/li><li id=\"field_2_6\" class=\"gfield gfield--type-email gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_2_6'>Email<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\"> * <span class='sr-only'> Required<\/span><\/span><\/span><\/label><div class='ginput_container ginput_container_email'>\n                            <input name='input_6' id='input_2_6' type='email' value='' class='medium'    aria-required=\"true\" aria-invalid=\"false\"  \/>\n                        <\/div><\/li><li id=\"field_2_29\" class=\"gfield gfield--type-phone gfield--width-full 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' for='input_2_29'>Phone<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\"> * <span class='sr-only'> Required<\/span><\/span><\/span><\/label><div class='ginput_container ginput_container_phone'><input name='input_29' id='input_2_29' type='tel' value='' class='large'   aria-required=\"true\" aria-invalid=\"false\" aria-describedby=\"gfield_description_2_29\"  \/><\/div><div class='gfield_description' id='gfield_description_2_29'>Please tell us how to contact you.<\/div><\/li><li id=\"field_2_7\" class=\"gfield gfield--type-checkbox gfield--type-choice gf_list_3col 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 box(es) where messages may be left:<\/label><div class='ginput_container ginput_container_checkbox'><ul class='gfield_checkbox' id='input_2_7'><li class='gchoice gchoice_2_7_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_7.1' type='checkbox'  value='Home'  id='choice_2_7_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_2_7_1' id='label_2_7_1' class='gform-field-label gform-field-label--type-inline'>Home<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_2_7_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_7.2' type='checkbox'  value='Cell'  id='choice_2_7_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_2_7_2' id='label_2_7_2' class='gform-field-label gform-field-label--type-inline'>Cell<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_2_7_3'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_7.3' type='checkbox'  value='Email'  id='choice_2_7_3'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_2_7_3' id='label_2_7_3' class='gform-field-label gform-field-label--type-inline'>Email<\/label>\n\t\t\t\t\t\t\t<\/li><\/ul><\/div><\/fieldset><\/li><li id=\"field_2_25\" class=\"gfield gfield--type-section gsection field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><h2 class=\"gsection_title\">Emergency Contact<\/h2><\/li><li id=\"field_2_8\" class=\"gfield gfield--type-text gf_left_half field_sublabel_below gfield--has-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_2_8'>Emergency Contact<\/label><div class='ginput_container ginput_container_text'><input name='input_8' id='input_2_8' type='text' value='' class='medium'  aria-describedby=\"gfield_description_2_8\"    aria-invalid=\"false\"   \/><\/div><div class='gfield_description' id='gfield_description_2_8'>Name of Emergency Contact<\/div><\/li><li id=\"field_2_9\" class=\"gfield gfield--type-text gf_right_half field_sublabel_below gfield--has-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_2_9'>Relationship<\/label><div class='ginput_container ginput_container_text'><input name='input_9' id='input_2_9' type='text' value='' class='medium'  aria-describedby=\"gfield_description_2_9\"    aria-invalid=\"false\"   \/><\/div><div class='gfield_description' id='gfield_description_2_9'>Relationship to Emergency Contact.<\/div><\/li><li id=\"field_2_10\" class=\"gfield gfield--type-phone gf_left_half field_sublabel_below gfield--has-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_2_10'>Emergency Contact Phone<\/label><div class='ginput_container ginput_container_phone'><input name='input_10' id='input_2_10' type='tel' value='' class='medium'    aria-invalid=\"false\" aria-describedby=\"gfield_description_2_10\"  \/><\/div><div class='gfield_description' id='gfield_description_2_10'>Phone Number of Emergency Contact.<\/div><\/li><li id=\"field_2_11\" class=\"gfield gfield--type-checkbox gfield--type-choice gf_right_half 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' >Check Here to give permission to contact<\/label><div class='ginput_container ginput_container_checkbox'><ul class='gfield_checkbox' id='input_2_11'><li class='gchoice gchoice_2_11_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_11.1' type='checkbox'  value='I permit contact.'  id='choice_2_11_1'   aria-describedby=\"gfield_description_2_11\"\/>\n\t\t\t\t\t\t\t\t<label for='choice_2_11_1' id='label_2_11_1' class='gform-field-label gform-field-label--type-inline'>I permit contact.<\/label>\n\t\t\t\t\t\t\t<\/li><\/ul><\/div><div class='gfield_description' id='gfield_description_2_11'>Check this box if you give permission to contact this individual<\/div><\/fieldset><\/li><li id=\"field_2_12\" class=\"gfield gfield--type-textarea cucomment field_sublabel_below gfield--has-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_2_12'>Current Concerns<\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_12' id='input_2_12' class='textarea medium'  aria-describedby=\"gfield_description_2_12\"    aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><div class='gfield_description' id='gfield_description_2_12'>Please explain your reason for requesting services.<\/div><\/li><li id=\"field_2_13\" class=\"gfield gfield--type-radio gfield--type-choice gf_left_third field_sublabel_below gfield--has-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' >Are you thinking of killing yourself?<\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_2_13'>\n\t\t\t<li class='gchoice gchoice_2_13_0'>\n\t\t\t\t<input name='input_13' type='radio' value='Yes'  id='choice_2_13_0'    \/>\n\t\t\t\t<label for='choice_2_13_0' id='label_2_13_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_2_13_1'>\n\t\t\t\t<input name='input_13' type='radio' value='No'  id='choice_2_13_1'    \/>\n\t\t\t\t<label for='choice_2_13_1' id='label_2_13_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/li><\/ul><\/div><div class='gfield_description' id='gfield_description_2_13'>Please choose Yes or No.<\/div><\/fieldset><\/li><li id=\"field_2_14\" class=\"gfield gfield--type-radio gfield--type-choice gf_middle_third field_sublabel_below gfield--has-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' >Are you thinking of harming or killing another person?<\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_2_14'>\n\t\t\t<li class='gchoice gchoice_2_14_0'>\n\t\t\t\t<input name='input_14' type='radio' value='Yes'  id='choice_2_14_0'    \/>\n\t\t\t\t<label for='choice_2_14_0' id='label_2_14_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_2_14_1'>\n\t\t\t\t<input name='input_14' type='radio' value='No'  id='choice_2_14_1'    \/>\n\t\t\t\t<label for='choice_2_14_1' id='label_2_14_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/li><\/ul><\/div><div class='gfield_description' id='gfield_description_2_14'>Please choose Yes or No.<\/div><\/fieldset><\/li><li id=\"field_2_15\" class=\"gfield gfield--type-radio gfield--type-choice gf_right_third field_sublabel_below gfield--has-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' >Are you having suicidal thoughts?<\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_2_15'>\n\t\t\t<li class='gchoice gchoice_2_15_0'>\n\t\t\t\t<input name='input_15' type='radio' value='Yes'  id='choice_2_15_0'    \/>\n\t\t\t\t<label for='choice_2_15_0' id='label_2_15_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_2_15_1'>\n\t\t\t\t<input name='input_15' type='radio' value='No'  id='choice_2_15_1'    \/>\n\t\t\t\t<label for='choice_2_15_1' id='label_2_15_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/li><\/ul><\/div><div class='gfield_description' id='gfield_description_2_15'>Please choose Yes or No.<\/div><\/fieldset><\/li><li id=\"field_2_16\" class=\"gfield gfield--type-checkbox gfield--type-choice gf_list_5col 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' >Please check any Stressful Events That May Apply to You.<\/label><div class='ginput_container ginput_container_checkbox'><ul class='gfield_checkbox' id='input_2_16'><li class='gchoice gchoice_2_16_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_16.1' type='checkbox'  value='Depression'  id='choice_2_16_1'   aria-describedby=\"gfield_description_2_16\"\/>\n\t\t\t\t\t\t\t\t<label for='choice_2_16_1' id='label_2_16_1' class='gform-field-label gform-field-label--type-inline'>Depression<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_2_16_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_16.2' type='checkbox'  value='Grief and loss'  id='choice_2_16_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_2_16_2' id='label_2_16_2' class='gform-field-label gform-field-label--type-inline'>Grief and loss<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_2_16_3'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_16.3' type='checkbox'  value='Addiction or recovery issues'  id='choice_2_16_3'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_2_16_3' id='label_2_16_3' class='gform-field-label gform-field-label--type-inline'>Addiction or recovery issues<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_2_16_4'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_16.4' type='checkbox'  value='Difficulty adjusting to life changes'  id='choice_2_16_4'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_2_16_4' id='label_2_16_4' class='gform-field-label gform-field-label--type-inline'>Difficulty adjusting to life changes<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_2_16_5'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_16.5' type='checkbox'  value='Parenting issues'  id='choice_2_16_5'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_2_16_5' id='label_2_16_5' class='gform-field-label gform-field-label--type-inline'>Parenting issues<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_2_16_6'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_16.6' type='checkbox'  value='Anxiety'  id='choice_2_16_6'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_2_16_6' id='label_2_16_6' class='gform-field-label gform-field-label--type-inline'>Anxiety<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_2_16_7'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_16.7' type='checkbox'  value='Victim of abuse'  id='choice_2_16_7'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_2_16_7' id='label_2_16_7' class='gform-field-label gform-field-label--type-inline'>Victim of abuse<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_2_16_8'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_16.8' type='checkbox'  value='Relationship issues'  id='choice_2_16_8'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_2_16_8' id='label_2_16_8' class='gform-field-label gform-field-label--type-inline'>Relationship issues<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_2_16_9'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_16.9' type='checkbox'  value='LGBT issues'  id='choice_2_16_9'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_2_16_9' id='label_2_16_9' class='gform-field-label gform-field-label--type-inline'>LGBT issues<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_2_16_11'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_16.11' type='checkbox'  value='Other'  id='choice_2_16_11'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_2_16_11' id='label_2_16_11' class='gform-field-label gform-field-label--type-inline'>Other<\/label>\n\t\t\t\t\t\t\t<\/li><\/ul><\/div><div class='gfield_description' id='gfield_description_2_16'>Please check all that apply.<\/div><\/fieldset><\/li><li id=\"field_2_17\" class=\"gfield gfield--type-textarea cucomment field_sublabel_below gfield--has-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_2_17'>Other<\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_17' id='input_2_17' class='textarea medium'  aria-describedby=\"gfield_description_2_17\"    aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><div class='gfield_description' id='gfield_description_2_17'>Please tell us about the Stressful Event.<\/div><\/li><li id=\"field_2_18\" class=\"gfield gfield--type-radio gfield--type-choice gf_list_3col field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' >Rate your current level of distress<\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_2_18'>\n\t\t\t<li class='gchoice gchoice_2_18_0'>\n\t\t\t\t<input name='input_18' type='radio' value='MINAMAL'  id='choice_2_18_0'    \/>\n\t\t\t\t<label for='choice_2_18_0' id='label_2_18_0' class='gform-field-label gform-field-label--type-inline'>MINAMAL<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_2_18_1'>\n\t\t\t\t<input name='input_18' type='radio' value='MILD'  id='choice_2_18_1'    \/>\n\t\t\t\t<label for='choice_2_18_1' id='label_2_18_1' class='gform-field-label gform-field-label--type-inline'>MILD<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_2_18_2'>\n\t\t\t\t<input name='input_18' type='radio' value='MODERATE SEVERE'  id='choice_2_18_2'    \/>\n\t\t\t\t<label for='choice_2_18_2' id='label_2_18_2' class='gform-field-label gform-field-label--type-inline'>MODERATE SEVERE<\/label>\n\t\t\t<\/li><\/ul><\/div><\/fieldset><\/li><li id=\"field_2_19\" class=\"gfield gfield--type-radio gfield--type-choice gf_list_inline 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 received mental health counseling before?<\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_2_19'>\n\t\t\t<li class='gchoice gchoice_2_19_0'>\n\t\t\t\t<input name='input_19' type='radio' value='Yes'  id='choice_2_19_0'    \/>\n\t\t\t\t<label for='choice_2_19_0' id='label_2_19_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_2_19_1'>\n\t\t\t\t<input name='input_19' type='radio' value='No'  id='choice_2_19_1'    \/>\n\t\t\t\t<label for='choice_2_19_1' id='label_2_19_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/li><\/ul><\/div><\/fieldset><\/li><li id=\"field_2_20\" class=\"gfield gfield--type-text field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_2_20'>If \u201cYes,\u201d please give the name of previous counselor, or agency<\/label><div class='ginput_container ginput_container_text'><input name='input_20' id='input_2_20' type='text' value='' class='medium'      aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_2_21\" class=\"gfield gfield--type-radio gfield--type-choice gf_list_inline 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 a primary care physician (PCP)?<\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_2_21'>\n\t\t\t<li class='gchoice gchoice_2_21_0'>\n\t\t\t\t<input name='input_21' type='radio' value='Yes'  id='choice_2_21_0'    \/>\n\t\t\t\t<label for='choice_2_21_0' id='label_2_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_2_21_1'>\n\t\t\t\t<input name='input_21' type='radio' value='No'  id='choice_2_21_1'    \/>\n\t\t\t\t<label for='choice_2_21_1' id='label_2_21_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/li><\/ul><\/div><\/fieldset><\/li><li id=\"field_2_22\" class=\"gfield gfield--type-text field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_2_22'>If \u201cYes,\u201d please give the name of your PCP and their clinic<\/label><div class='ginput_container ginput_container_text'><input name='input_22' id='input_2_22' type='text' value='' class='medium'      aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_2_23\" class=\"gfield gfield--type-radio gfield--type-choice gf_list_inline 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 insurance?<\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_2_23'>\n\t\t\t<li class='gchoice gchoice_2_23_0'>\n\t\t\t\t<input name='input_23' type='radio' value='Yes'  id='choice_2_23_0'    \/>\n\t\t\t\t<label for='choice_2_23_0' id='label_2_23_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_2_23_1'>\n\t\t\t\t<input name='input_23' type='radio' value='No'  id='choice_2_23_1'    \/>\n\t\t\t\t<label for='choice_2_23_1' id='label_2_23_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/li><\/ul><\/div><\/fieldset><\/li><li id=\"field_2_24\" class=\"gfield gfield--type-text field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_2_24'>If so, what type<\/label><div class='ginput_container ginput_container_text'><input name='input_24' id='input_2_24' type='text' value='' class='medium'      aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_2_28\" class=\"gfield gfield--type-captcha field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_2_28'>CAPTCHA<\/label><div id='input_2_28' class='ginput_container ginput_recaptcha' data-sitekey='6LdnShATAAAAAFLb7O2paFy9ZtLWttHkcZtCLSzc'  data-theme='light' data-tabindex='0'  data-badge=''><\/div><\/li><\/ul><\/div>\n        <div class='gform-footer gform_footer top_label'> <input type='submit' id='gform_submit_button_2' class='gform_button button' onclick='gform.submission.handleButtonClick(this);' data-submission-type='submit' value='Submit'  \/> <input type='hidden' name='gform_ajax' value='form_id=2&amp;title=&amp;description=&amp;tabindex=0&amp;theme=legacy&amp;styles=[]&amp;hash=31bbf390b990d5409a7f5b90b306724d' \/>\n            <input type='hidden' class='gform_hidden' name='gform_submission_method' data-js='gform_submission_method_2' value='iframe' \/>\n            <input type='hidden' class='gform_hidden' name='gform_theme' data-js='gform_theme_2' id='gform_theme_2' value='legacy' \/>\n            <input type='hidden' class='gform_hidden' name='gform_style_settings' data-js='gform_style_settings_2' id='gform_style_settings_2' value='[]' \/>\n            <input type='hidden' class='gform_hidden' name='is_submit_2' value='1' \/>\n            <input type='hidden' class='gform_hidden' name='gform_submit' value='2' \/>\n            \n            <input type='hidden' class='gform_hidden' name='gform_currency' data-currency='USD' value='ufkAKnY9VeHn1QImhMVSJCXBcbO0UrQ7KHpcr4Ibh0vjYpeVkR\/Qv1ljWoMJCK1lgZwxsWwZSb+RGjMuOYOmvAGa3S2EShECuaLlKDuc64Bfv9c=' \/>\n            <input type='hidden' class='gform_hidden' name='gform_unique_id' value='' \/>\n            <input type='hidden' class='gform_hidden' name='state_2' value='WyJbXSIsIjg5Y2NmOWYyZWNkNTQ4ZGZjZGM4ZjdlYTZjYzU2ZTgzIl0=' \/>\n            <input type='hidden' autocomplete='off' class='gform_hidden' name='gform_target_page_number_2' id='gform_target_page_number_2' value='0' \/>\n            <input type='hidden' autocomplete='off' class='gform_hidden' name='gform_source_page_number_2' id='gform_source_page_number_2' value='1' \/>\n            <input type='hidden' name='gform_field_values' value='' \/>\n            \n        <\/div>\n                        <\/form>\n                        <\/div>\n\t\t                <iframe style='display:none;width:0px;height:0px;' src='about:blank' name='gform_ajax_frame_2' id='gform_ajax_frame_2' title='This iframe contains the logic required to handle Ajax powered Gravity Forms.'><\/iframe>\n\t\t                <script type=\"text\/javascript\">\n\/* <![CDATA[ *\/\n gform.initializeOnLoaded( function() {gformInitSpinner( 2, 'https:\/\/archive.taftcollege.edu\/admissions\/wp-content\/plugins\/gravityforms\/images\/spinner.svg', true );jQuery('#gform_ajax_frame_2').on('load',function(){var contents = jQuery(this).contents().find('*').html();var is_postback = contents.indexOf('GF_AJAX_POSTBACK') >= 0;if(!is_postback){return;}var form_content = jQuery(this).contents().find('#gform_wrapper_2');var is_confirmation = jQuery(this).contents().find('#gform_confirmation_wrapper_2').length > 0;var is_redirect = contents.indexOf('gformRedirect(){') >= 0;var is_form = form_content.length > 0 && ! is_redirect && ! is_confirmation;var mt = parseInt(jQuery('html').css('margin-top'), 10) + parseInt(jQuery('body').css('margin-top'), 10) + 100;if(is_form){form_content.find('form').css('opacity', 0);jQuery('#gform_wrapper_2').html(form_content.html());if(form_content.hasClass('gform_validation_error')){jQuery('#gform_wrapper_2').addClass('gform_validation_error');} else {jQuery('#gform_wrapper_2').removeClass('gform_validation_error');}setTimeout( function() { \/* delay the scroll by 50 milliseconds to fix a bug in chrome *\/ jQuery(document).scrollTop(jQuery('#gform_wrapper_2').offset().top - mt); }, 50 );if(window['gformInitDatepicker']) {gformInitDatepicker();}if(window['gformInitPriceFields']) {gformInitPriceFields();}var current_page = jQuery('#gform_source_page_number_2').val();gformInitSpinner( 2, 'https:\/\/archive.taftcollege.edu\/admissions\/wp-content\/plugins\/gravityforms\/images\/spinner.svg', true );jQuery(document).trigger('gform_page_loaded', [2, current_page]);window['gf_submitting_2'] = false;}else if(!is_redirect){var confirmation_content = jQuery(this).contents().find('.GF_AJAX_POSTBACK').html();if(!confirmation_content){confirmation_content = contents;}jQuery('#gform_wrapper_2').replaceWith(confirmation_content);jQuery(document).scrollTop(jQuery('#gf_2').offset().top - mt);jQuery(document).trigger('gform_confirmation_loaded', [2]);window['gf_submitting_2'] = false;wp.a11y.speak(jQuery('#gform_confirmation_message_2').text());}else{jQuery('#gform_2').append(contents);if(window['gformRedirect']) {gformRedirect();}}jQuery(document).trigger(\"gform_pre_post_render\", [{ formId: \"2\", currentPage: \"current_page\", abort: function() { this.preventDefault(); } }]);        if (event && event.defaultPrevented) {                return;        }        const gformWrapperDiv = document.getElementById( \"gform_wrapper_2\" );        if ( gformWrapperDiv ) {            const visibilitySpan = document.createElement( \"span\" );            visibilitySpan.id = \"gform_visibility_test_2\";            gformWrapperDiv.insertAdjacentElement( \"afterend\", visibilitySpan );        }        const visibilityTestDiv = document.getElementById( \"gform_visibility_test_2\" );        let postRenderFired = false;        function triggerPostRender() {            if ( postRenderFired ) {                return;            }            postRenderFired = true;            gform.core.triggerPostRenderEvents( 2, current_page );            if ( visibilityTestDiv ) {                visibilityTestDiv.parentNode.removeChild( visibilityTestDiv );            }        }        function debounce( func, wait, immediate ) {            var timeout;            return function() {                var context = this, args = arguments;                var later = function() {                    timeout = null;                    if ( !immediate ) func.apply( context, args );                };                var callNow = immediate && !timeout;                clearTimeout( timeout );                timeout = setTimeout( later, wait );                if ( callNow ) func.apply( context, args );            };        }        const debouncedTriggerPostRender = debounce( function() {            triggerPostRender();        }, 200 );        if ( visibilityTestDiv && visibilityTestDiv.offsetParent === null ) {            const observer = new MutationObserver( ( mutations ) => {                mutations.forEach( ( mutation ) => {                    if ( mutation.type === 'attributes' && visibilityTestDiv.offsetParent !== null ) {                        debouncedTriggerPostRender();                        observer.disconnect();                    }                });            });            observer.observe( document.body, {                attributes: true,                childList: false,                subtree: true,                attributeFilter: [ 'style', 'class' ],            });        } else {            triggerPostRender();        }    } );} ); \n\/* ]]> *\/\n<\/script>\n[vc_column_text]<\/p>\n<p class=\"Default\" style=\"text-align: center;\" align=\"center\"><b><span style=\"font-size: 10.0pt;\">LIMITED CONFIDENTIALITY<\/span><\/b><\/p>\n<p class=\"Default\"><span style=\"font-size: 10.0pt;\">Information shared with Wellness Center staff will be kept confidential except within a few specific circumstances. Wellness staff are <b>mandated reporters<\/b>. Information related to <b>harm to self or others<\/b>, <b>child abuse<\/b>, <b>elder abuse<\/b>, or <b>dependent adult abuse <\/b>will be shared with the appropriate authorities.<\/span><\/p>\n<p>[\/vc_column_text][\/vc_column][\/vc_row]<\/p>\n<\/section>","protected":false},"excerpt":{"rendered":"<p>[vc_row css_animation=&#8221;&#8221; row_type=&#8221;row&#8221; use_row_as_full_screen_section=&#8221;no&#8221; type=&#8221;full_width&#8221; text_align=&#8221;left&#8221;][vc_column][vc_column_text]  Confidential Counseling Self-Referral Form  [\/vc_column_text]\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_2' style='display:none'><div id='gf_2' class='gform_anchor' tabindex='-1'><\/div><form method='post' enctype='multipart\/form-data' target='gform_ajax_frame_2' id='gform_2'  action='\/admissions\/wp-json\/wp\/v2\/pages\/23391#gf_2' data-formid='2' novalidate>\n                        <div class='gform-body gform_body'><ul id='gform_fields_2' class='gform_fields top_label form_sublabel_below description_below validation_below'><li id=\"field_2_26\" class=\"gfield gfield--type-section gsection field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><h2 class=\"gsection_title\">Student Information<\/h2><\/li><li id=\"field_2_1\" class=\"gfield gfield--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 class='sr-only'> Required<\/span><\/span><\/span><\/label><div class='ginput_complex ginput_container ginput_container--name no_prefix has_first_name no_middle_name has_last_name has_suffix gf_name_has_3 ginput_container_name gform-grid-row' id='input_2_1'>\n                            \n                            <span id='input_2_1_3_container' class='name_first gform-grid-col gform-grid-col--size-auto' >\n                                                    <input type='text' name='input_1.3' id='input_2_1_3' value=''   aria-required='true'     \/>\n                                                    <label for='input_2_1_3' class='gform-field-label gform-field-label--type-sub '>First<\/label>\n                                                <\/span>\n                            \n                            <span id='input_2_1_6_container' class='name_last gform-grid-col gform-grid-col--size-auto' >\n                                                    <input type='text' name='input_1.6' id='input_2_1_6' value=''   aria-required='true'     \/>\n                                                    <label for='input_2_1_6' class='gform-field-label gform-field-label--type-sub '>Last<\/label>\n                                                <\/span>\n                            <span id='input_2_1_8_container' class='name_suffix  gform-grid-col gform-grid-col--size-auto' >\n                                                    <input type='text' name='input_1.8' id='input_2_1_8' value=''   aria-required='false'     \/>\n                                                    <label for='input_2_1_8' class='gform-field-label gform-field-label--type-sub '>Student ID<\/label>\n                                                <\/span>\n                        <\/div><\/fieldset><\/li><li id=\"field_2_6\" class=\"gfield gfield--type-email gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_2_6'>Email<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\"> * <span class='sr-only'> Required<\/span><\/span><\/span><\/label><div class='ginput_container ginput_container_email'>\n                            <input name='input_6' id='input_2_6' type='email' value='' class='medium'    aria-required=\"true\" aria-invalid=\"false\"  \/>\n                        <\/div><\/li><li id=\"field_2_29\" class=\"gfield gfield--type-phone gfield--width-full 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' for='input_2_29'>Phone<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\"> * <span class='sr-only'> Required<\/span><\/span><\/span><\/label><div class='ginput_container ginput_container_phone'><input name='input_29' id='input_2_29' type='tel' value='' class='large'   aria-required=\"true\" aria-invalid=\"false\" aria-describedby=\"gfield_description_2_29\"  \/><\/div><div class='gfield_description' id='gfield_description_2_29'>Please tell us how to contact you.<\/div><\/li><li id=\"field_2_7\" class=\"gfield gfield--type-checkbox gfield--type-choice gf_list_3col 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 box(es) where messages may be left:<\/label><div class='ginput_container ginput_container_checkbox'><ul class='gfield_checkbox' id='input_2_7'><li class='gchoice gchoice_2_7_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_7.1' type='checkbox'  value='Home'  id='choice_2_7_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_2_7_1' id='label_2_7_1' class='gform-field-label gform-field-label--type-inline'>Home<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_2_7_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_7.2' type='checkbox'  value='Cell'  id='choice_2_7_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_2_7_2' id='label_2_7_2' class='gform-field-label gform-field-label--type-inline'>Cell<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_2_7_3'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_7.3' type='checkbox'  value='Email'  id='choice_2_7_3'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_2_7_3' id='label_2_7_3' class='gform-field-label gform-field-label--type-inline'>Email<\/label>\n\t\t\t\t\t\t\t<\/li><\/ul><\/div><\/fieldset><\/li><li id=\"field_2_25\" class=\"gfield gfield--type-section gsection field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><h2 class=\"gsection_title\">Emergency Contact<\/h2><\/li><li id=\"field_2_8\" class=\"gfield gfield--type-text gf_left_half field_sublabel_below gfield--has-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_2_8'>Emergency Contact<\/label><div class='ginput_container ginput_container_text'><input name='input_8' id='input_2_8' type='text' value='' class='medium'  aria-describedby=\"gfield_description_2_8\"    aria-invalid=\"false\"   \/><\/div><div class='gfield_description' id='gfield_description_2_8'>Name of Emergency Contact<\/div><\/li><li id=\"field_2_9\" class=\"gfield gfield--type-text gf_right_half field_sublabel_below gfield--has-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_2_9'>Relationship<\/label><div class='ginput_container ginput_container_text'><input name='input_9' id='input_2_9' type='text' value='' class='medium'  aria-describedby=\"gfield_description_2_9\"    aria-invalid=\"false\"   \/><\/div><div class='gfield_description' id='gfield_description_2_9'>Relationship to Emergency Contact.<\/div><\/li><li id=\"field_2_10\" class=\"gfield gfield--type-phone gf_left_half field_sublabel_below gfield--has-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_2_10'>Emergency Contact Phone<\/label><div class='ginput_container ginput_container_phone'><input name='input_10' id='input_2_10' type='tel' value='' class='medium'    aria-invalid=\"false\" aria-describedby=\"gfield_description_2_10\"  \/><\/div><div class='gfield_description' id='gfield_description_2_10'>Phone Number of Emergency Contact.<\/div><\/li><li id=\"field_2_11\" class=\"gfield gfield--type-checkbox gfield--type-choice gf_right_half 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' >Check Here to give permission to contact<\/label><div class='ginput_container ginput_container_checkbox'><ul class='gfield_checkbox' id='input_2_11'><li class='gchoice gchoice_2_11_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_11.1' type='checkbox'  value='I permit contact.'  id='choice_2_11_1'   aria-describedby=\"gfield_description_2_11\"\/>\n\t\t\t\t\t\t\t\t<label for='choice_2_11_1' id='label_2_11_1' class='gform-field-label gform-field-label--type-inline'>I permit contact.<\/label>\n\t\t\t\t\t\t\t<\/li><\/ul><\/div><div class='gfield_description' id='gfield_description_2_11'>Check this box if you give permission to contact this individual<\/div><\/fieldset><\/li><li id=\"field_2_12\" class=\"gfield gfield--type-textarea cucomment field_sublabel_below gfield--has-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_2_12'>Current Concerns<\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_12' id='input_2_12' class='textarea medium'  aria-describedby=\"gfield_description_2_12\"    aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><div class='gfield_description' id='gfield_description_2_12'>Please explain your reason for requesting services.<\/div><\/li><li id=\"field_2_13\" class=\"gfield gfield--type-radio gfield--type-choice gf_left_third field_sublabel_below gfield--has-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' >Are you thinking of killing yourself?<\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_2_13'>\n\t\t\t<li class='gchoice gchoice_2_13_0'>\n\t\t\t\t<input name='input_13' type='radio' value='Yes'  id='choice_2_13_0'    \/>\n\t\t\t\t<label for='choice_2_13_0' id='label_2_13_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_2_13_1'>\n\t\t\t\t<input name='input_13' type='radio' value='No'  id='choice_2_13_1'    \/>\n\t\t\t\t<label for='choice_2_13_1' id='label_2_13_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/li><\/ul><\/div><div class='gfield_description' id='gfield_description_2_13'>Please choose Yes or No.<\/div><\/fieldset><\/li><li id=\"field_2_14\" class=\"gfield gfield--type-radio gfield--type-choice gf_middle_third field_sublabel_below gfield--has-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' >Are you thinking of harming or killing another person?<\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_2_14'>\n\t\t\t<li class='gchoice gchoice_2_14_0'>\n\t\t\t\t<input name='input_14' type='radio' value='Yes'  id='choice_2_14_0'    \/>\n\t\t\t\t<label for='choice_2_14_0' id='label_2_14_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_2_14_1'>\n\t\t\t\t<input name='input_14' type='radio' value='No'  id='choice_2_14_1'    \/>\n\t\t\t\t<label for='choice_2_14_1' id='label_2_14_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/li><\/ul><\/div><div class='gfield_description' id='gfield_description_2_14'>Please choose Yes or No.<\/div><\/fieldset><\/li><li id=\"field_2_15\" class=\"gfield gfield--type-radio gfield--type-choice gf_right_third field_sublabel_below gfield--has-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' >Are you having suicidal thoughts?<\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_2_15'>\n\t\t\t<li class='gchoice gchoice_2_15_0'>\n\t\t\t\t<input name='input_15' type='radio' value='Yes'  id='choice_2_15_0'    \/>\n\t\t\t\t<label for='choice_2_15_0' id='label_2_15_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_2_15_1'>\n\t\t\t\t<input name='input_15' type='radio' value='No'  id='choice_2_15_1'    \/>\n\t\t\t\t<label for='choice_2_15_1' id='label_2_15_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/li><\/ul><\/div><div class='gfield_description' id='gfield_description_2_15'>Please choose Yes or No.<\/div><\/fieldset><\/li><li id=\"field_2_16\" class=\"gfield gfield--type-checkbox gfield--type-choice gf_list_5col 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' >Please check any Stressful Events That May Apply to You.<\/label><div class='ginput_container ginput_container_checkbox'><ul class='gfield_checkbox' id='input_2_16'><li class='gchoice gchoice_2_16_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_16.1' type='checkbox'  value='Depression'  id='choice_2_16_1'   aria-describedby=\"gfield_description_2_16\"\/>\n\t\t\t\t\t\t\t\t<label for='choice_2_16_1' id='label_2_16_1' class='gform-field-label gform-field-label--type-inline'>Depression<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_2_16_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_16.2' type='checkbox'  value='Grief and loss'  id='choice_2_16_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_2_16_2' id='label_2_16_2' class='gform-field-label gform-field-label--type-inline'>Grief and loss<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_2_16_3'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_16.3' type='checkbox'  value='Addiction or recovery issues'  id='choice_2_16_3'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_2_16_3' id='label_2_16_3' class='gform-field-label gform-field-label--type-inline'>Addiction or recovery issues<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_2_16_4'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_16.4' type='checkbox'  value='Difficulty adjusting to life changes'  id='choice_2_16_4'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_2_16_4' id='label_2_16_4' class='gform-field-label gform-field-label--type-inline'>Difficulty adjusting to life changes<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_2_16_5'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_16.5' type='checkbox'  value='Parenting issues'  id='choice_2_16_5'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_2_16_5' id='label_2_16_5' class='gform-field-label gform-field-label--type-inline'>Parenting issues<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_2_16_6'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_16.6' type='checkbox'  value='Anxiety'  id='choice_2_16_6'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_2_16_6' id='label_2_16_6' class='gform-field-label gform-field-label--type-inline'>Anxiety<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_2_16_7'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_16.7' type='checkbox'  value='Victim of abuse'  id='choice_2_16_7'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_2_16_7' id='label_2_16_7' class='gform-field-label gform-field-label--type-inline'>Victim of abuse<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_2_16_8'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_16.8' type='checkbox'  value='Relationship issues'  id='choice_2_16_8'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_2_16_8' id='label_2_16_8' class='gform-field-label gform-field-label--type-inline'>Relationship issues<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_2_16_9'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_16.9' type='checkbox'  value='LGBT issues'  id='choice_2_16_9'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_2_16_9' id='label_2_16_9' class='gform-field-label gform-field-label--type-inline'>LGBT issues<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_2_16_11'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_16.11' type='checkbox'  value='Other'  id='choice_2_16_11'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_2_16_11' id='label_2_16_11' class='gform-field-label gform-field-label--type-inline'>Other<\/label>\n\t\t\t\t\t\t\t<\/li><\/ul><\/div><div class='gfield_description' id='gfield_description_2_16'>Please check all that apply.<\/div><\/fieldset><\/li><li id=\"field_2_17\" class=\"gfield gfield--type-textarea cucomment field_sublabel_below gfield--has-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_2_17'>Other<\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_17' id='input_2_17' class='textarea medium'  aria-describedby=\"gfield_description_2_17\"    aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><div class='gfield_description' id='gfield_description_2_17'>Please tell us about the Stressful Event.<\/div><\/li><li id=\"field_2_18\" class=\"gfield gfield--type-radio gfield--type-choice gf_list_3col field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' >Rate your current level of distress<\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_2_18'>\n\t\t\t<li class='gchoice gchoice_2_18_0'>\n\t\t\t\t<input name='input_18' type='radio' value='MINAMAL'  id='choice_2_18_0'    \/>\n\t\t\t\t<label for='choice_2_18_0' id='label_2_18_0' class='gform-field-label gform-field-label--type-inline'>MINAMAL<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_2_18_1'>\n\t\t\t\t<input name='input_18' type='radio' value='MILD'  id='choice_2_18_1'    \/>\n\t\t\t\t<label for='choice_2_18_1' id='label_2_18_1' class='gform-field-label gform-field-label--type-inline'>MILD<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_2_18_2'>\n\t\t\t\t<input name='input_18' type='radio' value='MODERATE SEVERE'  id='choice_2_18_2'    \/>\n\t\t\t\t<label for='choice_2_18_2' id='label_2_18_2' class='gform-field-label gform-field-label--type-inline'>MODERATE SEVERE<\/label>\n\t\t\t<\/li><\/ul><\/div><\/fieldset><\/li><li id=\"field_2_19\" class=\"gfield gfield--type-radio gfield--type-choice gf_list_inline 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 received mental health counseling before?<\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_2_19'>\n\t\t\t<li class='gchoice gchoice_2_19_0'>\n\t\t\t\t<input name='input_19' type='radio' value='Yes'  id='choice_2_19_0'    \/>\n\t\t\t\t<label for='choice_2_19_0' id='label_2_19_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_2_19_1'>\n\t\t\t\t<input name='input_19' type='radio' value='No'  id='choice_2_19_1'    \/>\n\t\t\t\t<label for='choice_2_19_1' id='label_2_19_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/li><\/ul><\/div><\/fieldset><\/li><li id=\"field_2_20\" class=\"gfield gfield--type-text field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_2_20'>If \u201cYes,\u201d please give the name of previous counselor, or agency<\/label><div class='ginput_container ginput_container_text'><input name='input_20' id='input_2_20' type='text' value='' class='medium'      aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_2_21\" class=\"gfield gfield--type-radio gfield--type-choice gf_list_inline 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 a primary care physician (PCP)?<\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_2_21'>\n\t\t\t<li class='gchoice gchoice_2_21_0'>\n\t\t\t\t<input name='input_21' type='radio' value='Yes'  id='choice_2_21_0'    \/>\n\t\t\t\t<label for='choice_2_21_0' id='label_2_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_2_21_1'>\n\t\t\t\t<input name='input_21' type='radio' value='No'  id='choice_2_21_1'    \/>\n\t\t\t\t<label for='choice_2_21_1' id='label_2_21_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/li><\/ul><\/div><\/fieldset><\/li><li id=\"field_2_22\" class=\"gfield gfield--type-text field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_2_22'>If \u201cYes,\u201d please give the name of your PCP and their clinic<\/label><div class='ginput_container ginput_container_text'><input name='input_22' id='input_2_22' type='text' value='' class='medium'      aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_2_23\" class=\"gfield gfield--type-radio gfield--type-choice gf_list_inline 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 insurance?<\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_2_23'>\n\t\t\t<li class='gchoice gchoice_2_23_0'>\n\t\t\t\t<input name='input_23' type='radio' value='Yes'  id='choice_2_23_0'    \/>\n\t\t\t\t<label for='choice_2_23_0' id='label_2_23_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_2_23_1'>\n\t\t\t\t<input name='input_23' type='radio' value='No'  id='choice_2_23_1'    \/>\n\t\t\t\t<label for='choice_2_23_1' id='label_2_23_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/li><\/ul><\/div><\/fieldset><\/li><li id=\"field_2_24\" class=\"gfield gfield--type-text field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_2_24'>If so, what type<\/label><div class='ginput_container ginput_container_text'><input name='input_24' id='input_2_24' type='text' value='' class='medium'      aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_2_28\" class=\"gfield gfield--type-captcha field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_2_28'>CAPTCHA<\/label><div id='input_2_28' class='ginput_container ginput_recaptcha' data-sitekey='6LdnShATAAAAAFLb7O2paFy9ZtLWttHkcZtCLSzc'  data-theme='light' data-tabindex='0'  data-badge=''><\/div><\/li><\/ul><\/div>\n        <div class='gform-footer gform_footer top_label'> <input type='submit' id='gform_submit_button_2' class='gform_button button' onclick='gform.submission.handleButtonClick(this);' data-submission-type='submit' value='Submit'  \/> <input type='hidden' name='gform_ajax' value='form_id=2&amp;title=&amp;description=&amp;tabindex=0&amp;theme=legacy&amp;styles=[]&amp;hash=31bbf390b990d5409a7f5b90b306724d' \/>\n            <input type='hidden' class='gform_hidden' name='gform_submission_method' data-js='gform_submission_method_2' value='iframe' \/>\n            <input type='hidden' class='gform_hidden' name='gform_theme' data-js='gform_theme_2' id='gform_theme_2' value='legacy' \/>\n            <input type='hidden' class='gform_hidden' name='gform_style_settings' data-js='gform_style_settings_2' id='gform_style_settings_2' value='[]' \/>\n            <input type='hidden' class='gform_hidden' name='is_submit_2' value='1' \/>\n            <input type='hidden' class='gform_hidden' name='gform_submit' value='2' \/>\n            \n            <input type='hidden' class='gform_hidden' name='gform_currency' data-currency='USD' value='CLHS+R3YbkrMojR6oV7m1Wc6D\/Z45g4oz9LkbWmRgMnfIKh5O3LfyP+zVM5JDpdDwi0ehQcdhvkp5GNtYHPfNXrGREn9gzlhT067jBPRl3Dm\/TI=' \/>\n            <input type='hidden' class='gform_hidden' name='gform_unique_id' value='' \/>\n            <input type='hidden' class='gform_hidden' name='state_2' value='WyJbXSIsIjg5Y2NmOWYyZWNkNTQ4ZGZjZGM4ZjdlYTZjYzU2ZTgzIl0=' \/>\n            <input type='hidden' autocomplete='off' class='gform_hidden' name='gform_target_page_number_2' id='gform_target_page_number_2' value='0' \/>\n            <input type='hidden' autocomplete='off' class='gform_hidden' 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