{"id":15517,"date":"2023-05-31T19:37:03","date_gmt":"2023-05-31T16:07:03","guid":{"rendered":"https:\/\/avadaroon.com\/wood\/%da%98%d9%86-%d9%88-%d9%85%db%8e%d8%b1%d8%af\/"},"modified":"2023-09-03T18:10:10","modified_gmt":"2023-09-03T14:40:10","slug":"%da%98%d9%86-%d9%88-%d9%85%db%8e%d8%b1%d8%af","status":"publish","type":"page","link":"https:\/\/avadaroon.com\/ku\/%da%98%d9%86-%d9%88-%d9%85%db%8e%d8%b1%d8%af\/","title":{"rendered":"\u0698\u0646 \u0648 \u0645\u06ce\u0631\u062f"},"content":{"rendered":"\t\t<div data-elementor-type=\"wp-page\" data-elementor-id=\"15517\" class=\"elementor elementor-15517 elementor-8812\" data-elementor-post-type=\"page\">\n\t\t\t\t\t\t<section class=\"wd-negative-gap elementor-section elementor-top-section elementor-element elementor-element-4db0576 wd-section-stretch elementor-reverse-tablet elementor-reverse-mobile elementor-section-boxed elementor-section-height-default elementor-section-height-default\" data-id=\"4db0576\" 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gform;gform||(document.addEventListener(\"gform_main_scripts_loaded\",function(){gform.scriptsLoaded=!0}),window.addEventListener(\"DOMContentLoaded\",function(){gform.domLoaded=!0}),gform={domLoaded:!1,scriptsLoaded:!1,initializeOnLoaded:function(o){gform.domLoaded&&gform.scriptsLoaded?o():!gform.domLoaded&&gform.scriptsLoaded?window.addEventListener(\"DOMContentLoaded\",o):document.addEventListener(\"gform_main_scripts_loaded\",o)},hooks:{action:{},filter:{}},addAction:function(o,n,r,t){gform.addHook(\"action\",o,n,r,t)},addFilter:function(o,n,r,t){gform.addHook(\"filter\",o,n,r,t)},doAction:function(o){gform.doHook(\"action\",o,arguments)},applyFilters:function(o){return gform.doHook(\"filter\",o,arguments)},removeAction:function(o,n){gform.removeHook(\"action\",o,n)},removeFilter:function(o,n,r){gform.removeHook(\"filter\",o,n,r)},addHook:function(o,n,r,t,i){null==gform.hooks[o][n]&&(gform.hooks[o][n]=[]);var 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      <div id='gf_progressbar_wrapper_9' class='gf_progressbar_wrapper'>\n        \t<p class=\"gf_progressbar_title\">Step <span class='gf_step_current_page'>1<\/span> of <span class='gf_step_page_count'>10<\/span>\n        \t<\/p>\n            <div class='gf_progressbar gf_progressbar_blue' aria-hidden='true'>\n                <div class='gf_progressbar_percentage percentbar_blue percentbar_10' style='width:10%;'><span>10%<\/span><\/div>\n            <\/div><\/div>\n                        <div class='gform-body gform_body'><div id='gform_page_9_1' class='gform_page ' data-js='page-field-id-74' >\n                                    <div class='gform_page_fields'><div id='gform_fields_9' class='gform_fields top_label form_sublabel_below description_below'><fieldset id=\"field_9_7\"  class=\"gfield gfield--type-radio gfield--type-choice gfield--width-half gfield_contains_required field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_9_7\"><legend class='gfield_label gform-field-label'  >\u0646\u0627\u0633\u0646\u0627\u0645\u06d5\u06cc \u0695\u06d5\u06af\u06d5\u0632\u06cc\u062a \u0686\u06cc\u06cc\u06d5\u061f<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_9_7'>\n\t\t\t<div class='gchoice gchoice_9_7_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_7' type='radio' value='\u0626\u0627\u0641\u0631\u06d5\u062a'  id='choice_9_7_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_9_7_0' id='label_9_7_0' class='gform-field-label gform-field-label--type-inline'>\u0626\u0627\u0641\u0631\u06d5\u062a<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_9_7_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_7' type='radio' value='\u067e\u06cc\u0627\u0648'  id='choice_9_7_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_9_7_1' id='label_9_7_1' class='gform-field-label gform-field-label--type-inline'>\u067e\u06cc\u0627\u0648<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_9_7_2'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_7' type='radio' value='gf_other_choice'  id='choice_9_7_2' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_9_7_2' id='label_9_7_2' class='gform-field-label gform-field-label--type-inline'>Other<\/label><br \/><input id='input_9_7_other' class='gchoice_other_control' name='input_7_other' type='text' value='Other' aria-label='Other Choice, please specify'  disabled='disabled' \/>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_9_12\"  class=\"gfield gfield--type-select gfield--width-half gfield_contains_required field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_9_12\"><label class='gfield_label gform-field-label' for='input_9_12' >\u062a\u06d5\u0645\u06d5\u0646\u062a \u0686\u06d5\u0646\u062f \u0633\u0627\u06b5\u06d5\u061f<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/label><div class='ginput_container ginput_container_select'><select name='input_12' id='input_9_12' class='large gfield_select'    aria-required=\"true\" aria-invalid=\"false\" ><option value='13' >13<\/option><option value='14' >14<\/option><option value='15' >15<\/option><option value='16' >16<\/option><option value='17' >17<\/option><option value='18' >18<\/option><option value='19' >19<\/option><option value='20' >20<\/option><option value='21' >21<\/option><option value='22' >22<\/option><option value='23' >23<\/option><option value='24' >24<\/option><option value='25' >25<\/option><option value='26' >26<\/option><option value='27' >27<\/option><option value='28' >28<\/option><option value='29' >29<\/option><option value='30' >30<\/option><option value='31' >31<\/option><option value='32' >32<\/option><option value='33' >33<\/option><option value='34' >34<\/option><option value='35' >35<\/option><option value='36' >36<\/option><option value='37' >37<\/option><option value='38' >38<\/option><option value='39' >39<\/option><option value='40' >40<\/option><option value='41' >41<\/option><option value='42' >42<\/option><option value='43' >43<\/option><option value='44' >44<\/option><option value='45' >45<\/option><option value='46' >46<\/option><option value='47' >47<\/option><option value='48' >48<\/option><option value='49' >49<\/option><option value='50' >50<\/option><option value='51' >51<\/option><option value='52' >52<\/option><option value='53' >53<\/option><option value='54' >54<\/option><option value='55' >55<\/option><option value='56' >56<\/option><option value='57' >57<\/option><option value='58' >58<\/option><option value='59' >59<\/option><option value='60' >60<\/option><option value='61' >61<\/option><option value='62' >62<\/option><option value='63' >63<\/option><option value='64' >64<\/option><option value='65' >65<\/option><option value='66' >66<\/option><option value='67' >67<\/option><option value='68' >68<\/option><option value='69' >69<\/option><option value='70' >70<\/option><option value='71' >71<\/option><option value='72' >72<\/option><option value='73' >73<\/option><option value='74' >74<\/option><option value='75' >75<\/option><option value='76' >76<\/option><option value='77' >77<\/option><option value='78' >78<\/option><option value='79' >79<\/option><option value='80' >80<\/option><option value='81' >81<\/option><option value='82' >82<\/option><option value='83' >83<\/option><option value='84' >84<\/option><option value='85' >85<\/option><option value='86' >86<\/option><option value='87' >87<\/option><option value='88' >88<\/option><option value='89' >89<\/option><option value='90' >90<\/option><option value='91' >91<\/option><option value='92' >92<\/option><option value='93' >93<\/option><option value='94' >94<\/option><option value='95' >95<\/option><option value='96' >96<\/option><option value='97' >97<\/option><option value='98' >98<\/option><option value='99' >99<\/option><\/select><\/div><\/div><fieldset id=\"field_9_14\"  class=\"gfield gfield--type-radio gfield--type-choice gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_9_14\"><legend class='gfield_label gform-field-label'  >\u0686\u06c6\u0646 \u062f\u06d5\u0646\u0627\u0633\u06cc\u062a\u06d5\u0648\u06d5\u061f<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_9_14'>\n\t\t\t<div class='gchoice gchoice_9_14_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_14' type='radio' value='\u0695\u0627\u0633\u062a\u06d5\u0648\u062e\u06c6'  id='choice_9_14_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_9_14_0' id='label_9_14_0' class='gform-field-label gform-field-label--type-inline'>\u0695\u0627\u0633\u062a\u06d5\u0648\u062e\u06c6<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_9_14_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_14' type='radio' value='\u0647\u0627\u0648\u0695\u06d5\u06af\u06d5\u0632\u0628\u0627\u0632'  id='choice_9_14_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_9_14_1' id='label_9_14_1' class='gform-field-label gform-field-label--type-inline'>\u0647\u0627\u0648\u0695\u06d5\u06af\u06d5\u0632\u0628\u0627\u0632<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_9_14_2'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_14' type='radio' value='\u0698\u0646\u06ce\u06a9 \u0647\u0627\u0648\u0695\u06d5\u06af\u06d5\u0632\u0628\u0627\u0632'  id='choice_9_14_2' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_9_14_2' id='label_9_14_2' class='gform-field-label gform-field-label--type-inline'>\u0698\u0646\u06ce\u06a9 \u0647\u0627\u0648\u0695\u06d5\u06af\u06d5\u0632\u0628\u0627\u0632<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_9_14_3'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_14' type='radio' value='\u062f\u0648\u0648\u0695\u06d5\u06af\u06d5\u0632 \u0648 \u067e\u0627\u0646\u0633\u06ce\u06a9\u0633\u0648\u0627\u0644'  id='choice_9_14_3' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_9_14_3' id='label_9_14_3' class='gform-field-label gform-field-label--type-inline'>\u062f\u0648\u0648\u0695\u06d5\u06af\u06d5\u0632 \u0648 \u067e\u0627\u0646\u0633\u06ce\u06a9\u0633\u0648\u0627\u0644<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_9_14_4'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_14' type='radio' value='\u067e\u06ce\u062a \u0628\u0627\u0634\u06d5 \u0646\u06d5\u06b5\u06ce\u06cc\u062a'  id='choice_9_14_4' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_9_14_4' id='label_9_14_4' class='gform-field-label gform-field-label--type-inline'>\u067e\u06ce\u062a \u0628\u0627\u0634\u06d5 \u0646\u06d5\u06b5\u06ce\u06cc\u062a<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_9_14_5'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_14' type='radio' value='gf_other_choice'  id='choice_9_14_5' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_9_14_5' id='label_9_14_5' class='gform-field-label gform-field-label--type-inline'>Other<\/label><br \/><input id='input_9_14_other' class='gchoice_other_control' name='input_14_other' type='text' value='Other' aria-label='Other Choice, please specify'  disabled='disabled' \/>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_9_23\"  class=\"gfield gfield--type-radio gfield--type-choice gfield--width-half gfield_contains_required field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_9_23\"><legend class='gfield_label gform-field-label'  >\u0626\u0627\u06cc\u0627 \u062e\u06c6\u062a \u0628\u06d5 \u0626\u0627\u06cc\u0646\u06cc \u062f\u06d5\u0632\u0627\u0646\u06cc\u062a\u061f<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_9_23'>\n\t\t\t<div class='gchoice gchoice_9_23_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_23' type='radio' value='\u0628\u06d5\u06b5\u06ce'  id='choice_9_23_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_9_23_0' id='label_9_23_0' class='gform-field-label gform-field-label--type-inline'>\u0628\u06d5\u06b5\u06ce<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_9_23_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_23' type='radio' value='\u0646\u06d5\u062e\u06ce\u0631'  id='choice_9_23_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_9_23_1' id='label_9_23_1' class='gform-field-label gform-field-label--type-inline'>\u0646\u06d5\u062e\u06ce\u0631<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_9_23_2'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_23' type='radio' value='\u067e\u06ce\u062a \u0628\u0627\u0634\u06d5 \u0646\u06d5\u06b5\u06ce\u06cc\u062a'  id='choice_9_23_2' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_9_23_2' id='label_9_23_2' class='gform-field-label gform-field-label--type-inline'>\u067e\u06ce\u062a \u0628\u0627\u0634\u06d5 \u0646\u06d5\u06b5\u06ce\u06cc\u062a<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_9_22\"  class=\"gfield gfield--type-radio gfield--type-choice gfield--width-half gfield_contains_required field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_9_22\"><legend class='gfield_label gform-field-label'  >\u0626\u0627\u06cc\u0627 \u062e\u06c6\u062a \u0628\u06d5 \u0695\u06c6\u062d\u06cc \u062f\u06d5\u0632\u0627\u0646\u06cc\u062a\u061f<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_9_22'>\n\t\t\t<div class='gchoice gchoice_9_22_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_22' type='radio' value='\u0628\u06d5\u06b5\u06ce'  id='choice_9_22_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_9_22_0' id='label_9_22_0' class='gform-field-label gform-field-label--type-inline'>\u0628\u06d5\u06b5\u06ce<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_9_22_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_22' type='radio' value='\u0646\u06d5\u062e\u06ce\u0631'  id='choice_9_22_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_9_22_1' id='label_9_22_1' class='gform-field-label gform-field-label--type-inline'>\u0646\u06d5\u062e\u06ce\u0631<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_9_22_2'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_22' type='radio' value='\u067e\u06ce\u062a \u0628\u0627\u0634\u06d5 \u0646\u06d5\u06b5\u06ce\u06cc\u062a'  id='choice_9_22_2' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_9_22_2' id='label_9_22_2' class='gform-field-label gform-field-label--type-inline'>\u067e\u06ce\u062a \u0628\u0627\u0634\u06d5 \u0646\u06d5\u06b5\u06ce\u06cc\u062a<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><\/div>\n                    <\/div>\n                    <div class='gform_page_footer top_label'>\n                         <input type='button' id='gform_next_button_9_62' class='gform_next_button gform-theme-button button' value='Next'  onclick='jQuery(\"#gform_target_page_number_9\").val(\"2\");  jQuery(\"#gform_9\").trigger(\"submit\",[true]); ' onkeypress='if( event.keyCode == 13 ){ jQuery(\"#gform_target_page_number_9\").val(\"2\");  jQuery(\"#gform_9\").trigger(\"submit\",[true]); } ' \/> \n                    <\/div>\n                <\/div>\n                <div id='gform_page_9_2' class='gform_page' data-js='page-field-id-62' style='display:none;'>\n                    <div class='gform_page_fields'>\n                        <div id='gform_fields_9_2' class='gform_fields top_label form_sublabel_below description_below'><fieldset id=\"field_9_24\"  class=\"gfield gfield--type-checkbox gfield--type-choice gfield--width-half gfield_contains_required field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_9_24\"><legend class='gfield_label gform-field-label gfield_label_before_complex'  >\u0686\u06cc \u0648\u0627\u06cc \u0644\u06ce\u06a9\u0631\u062f\u06cc\u062a \u0626\u06d5\u0645\u0695\u06c6 \u0628\u06cc\u0631 \u0644\u06d5 \u0686\u0627\u0631\u06d5\u0633\u06d5\u0631\u06a9\u0631\u062f\u0646 \u0628\u06a9\u06d5\u06cc\u062a\u06d5\u0648\u06d5\u061f<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox' id='input_9_24'><div class='gchoice gchoice_9_24_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_24.1' type='checkbox'  value='\u0647\u06d5\u0633\u062a\u0645 \u0628\u06d5 \u062e\u06d5\u0645\u06c6\u06a9\u06cc \u06a9\u0631\u062f\u0648\u0648\u06d5'  id='choice_9_24_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_9_24_1' id='label_9_24_1' class='gform-field-label gform-field-label--type-inline'>\u0647\u06d5\u0633\u062a\u0645 \u0628\u06d5 \u062e\u06d5\u0645\u06c6\u06a9\u06cc \u06a9\u0631\u062f\u0648\u0648\u06d5<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_9_24_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_24.2' type='checkbox'  value='\u0647\u06d5\u0633\u062a \u0628\u06d5 \u062f\u06b5\u06d5\u0695\u0627\u0648\u06a9\u06ce\u06cc \u062f\u06b5\u06d5\u0695\u0627\u0648\u06a9\u06ce \u06cc\u0627\u0646 \u0633\u06d5\u0631\u06a9\u0648\u062a\u06a9\u0631\u062f\u0646 \u062f\u06d5\u06a9\u06d5\u0645'  id='choice_9_24_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_9_24_2' id='label_9_24_2' class='gform-field-label gform-field-label--type-inline'>\u0647\u06d5\u0633\u062a \u0628\u06d5 \u062f\u06b5\u06d5\u0695\u0627\u0648\u06a9\u06ce\u06cc \u062f\u06b5\u06d5\u0695\u0627\u0648\u06a9\u06ce \u06cc\u0627\u0646 \u0633\u06d5\u0631\u06a9\u0648\u062a\u06a9\u0631\u062f\u0646 \u062f\u06d5\u06a9\u06d5\u0645<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_9_24_3'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_24.3' type='checkbox'  value='\u0628\u0627\u0631\u06cc \u062f\u06d5\u0631\u0648\u0648\u0646\u06cc\u0645 \u062f\u06d5\u0633\u062a\u0648\u06d5\u0631\u062f\u0627\u0646 \u062f\u06d5\u06a9\u0627\u062a \u0644\u06d5 \u0626\u06d5\u062f\u0627\u06cc \u06a9\u0627\u0631\u06d5\u06a9\u06d5\u0645\/\u0642\u0648\u062a\u0627\u0628\u062e\u0627\u0646\u06d5\u06a9\u06d5\u0645'  id='choice_9_24_3'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_9_24_3' id='label_9_24_3' class='gform-field-label gform-field-label--type-inline'>\u0628\u0627\u0631\u06cc \u062f\u06d5\u0631\u0648\u0648\u0646\u06cc\u0645 \u062f\u06d5\u0633\u062a\u0648\u06d5\u0631\u062f\u0627\u0646 \u062f\u06d5\u06a9\u0627\u062a \u0644\u06d5 \u0626\u06d5\u062f\u0627\u06cc \u06a9\u0627\u0631\u06d5\u06a9\u06d5\u0645\/\u0642\u0648\u062a\u0627\u0628\u062e\u0627\u0646\u06d5\u06a9\u06d5\u0645<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_9_24_4'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_24.4' type='checkbox'  value='\u0645\u0646 \u06a9\u06ce\u0634\u06d5\u0645 \u0644\u06d5\u06af\u06d5\u06b5 \u062f\u0631\u0648\u0633\u062a\u06a9\u0631\u062f\u0646 \u06cc\u0627\u0646 \u067e\u0627\u0631\u0627\u0633\u062a\u0646\u06cc \u067e\u06d5\u06cc\u0648\u06d5\u0646\u062f\u06cc\u06cc\u06d5\u06a9\u0627\u0646 \u0647\u06d5\u06cc\u06d5'  id='choice_9_24_4'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_9_24_4' id='label_9_24_4' class='gform-field-label gform-field-label--type-inline'>\u0645\u0646 \u06a9\u06ce\u0634\u06d5\u0645 \u0644\u06d5\u06af\u06d5\u06b5 \u062f\u0631\u0648\u0633\u062a\u06a9\u0631\u062f\u0646 \u06cc\u0627\u0646 \u067e\u0627\u0631\u0627\u0633\u062a\u0646\u06cc \u067e\u06d5\u06cc\u0648\u06d5\u0646\u062f\u06cc\u06cc\u06d5\u06a9\u0627\u0646 \u0647\u06d5\u06cc\u06d5<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_9_24_5'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_24.5' type='checkbox'  value='\u0646\u0627\u062a\u0648\u0627\u0646\u0645 \u0626\u0627\u0645\u0627\u0646\u062c \u0648 \u0645\u0627\u0646\u0627 \u0644\u06d5 \u0698\u06cc\u0627\u0646\u0645\u062f\u0627 \u0628\u062f\u06c6\u0632\u0645\u06d5\u0648\u06d5'  id='choice_9_24_5'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_9_24_5' id='label_9_24_5' class='gform-field-label gform-field-label--type-inline'>\u0646\u0627\u062a\u0648\u0627\u0646\u0645 \u0626\u0627\u0645\u0627\u0646\u062c \u0648 \u0645\u0627\u0646\u0627 \u0644\u06d5 \u0698\u06cc\u0627\u0646\u0645\u062f\u0627 \u0628\u062f\u06c6\u0632\u0645\u06d5\u0648\u06d5<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_9_24_6'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_24.6' type='checkbox'  value=''  id='choice_9_24_6'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_9_24_6' id='label_9_24_6' class='gform-field-label gform-field-label--type-inline'><\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_9_24_7'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_24.7' type='checkbox'  value='I have experienced trauma'  id='choice_9_24_7'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_9_24_7' id='label_9_24_7' class='gform-field-label gform-field-label--type-inline'>I have experienced trauma<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_9_24_8'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_24.8' type='checkbox'  value='I need to talk through a specific challenge'  id='choice_9_24_8'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_9_24_8' id='label_9_24_8' class='gform-field-label gform-field-label--type-inline'>I need to talk through a specific challenge<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_9_24_9'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_24.9' type='checkbox'  value='I want to gain self confidence'  id='choice_9_24_9'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_9_24_9' id='label_9_24_9' class='gform-field-label gform-field-label--type-inline'>I want to gain self confidence<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_9_24_11'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_24.11' type='checkbox'  value='I want to improve myself but i don&#039;t know where to start'  id='choice_9_24_11'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_9_24_11' id='label_9_24_11' class='gform-field-label gform-field-label--type-inline'>I want to improve myself but i don't know where to start<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_9_24_12'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_24.12' type='checkbox'  value='recommended to me (friend, family, doctor)'  id='choice_9_24_12'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_9_24_12' id='label_9_24_12' class='gform-field-label gform-field-label--type-inline'>recommended to me (friend, family, doctor)<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_9_24_13'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_24.13' type='checkbox'  value='Just exploring'  id='choice_9_24_13'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_9_24_13' id='label_9_24_13' class='gform-field-label gform-field-label--type-inline'>Just exploring<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_9_21\"  class=\"gfield gfield--type-radio gfield--type-choice gfield--width-half gfield_contains_required field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_9_21\"><legend class='gfield_label gform-field-label'  >Have you ever been in therapy before?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_9_21'>\n\t\t\t<div class='gchoice gchoice_9_21_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_21' type='radio' value='Yes'  id='choice_9_21_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_9_21_0' id='label_9_21_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_9_21_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_21' type='radio' value='No'  id='choice_9_21_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_9_21_1' id='label_9_21_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><\/div>\n                    <\/div>\n                    <div class='gform_page_footer top_label'>\n                        <input type='button' id='gform_previous_button_9_69' class='gform_previous_button gform-theme-button gform-theme-button--secondary button' value='Previous'  onclick='jQuery(\"#gform_target_page_number_9\").val(\"1\");  jQuery(\"#gform_9\").trigger(\"submit\",[true]); ' onkeypress='if( event.keyCode == 13 ){ jQuery(\"#gform_target_page_number_9\").val(\"1\");  jQuery(\"#gform_9\").trigger(\"submit\",[true]); } ' \/> <input type='button' id='gform_next_button_9_69' class='gform_next_button gform-theme-button button' value='Next'  onclick='jQuery(\"#gform_target_page_number_9\").val(\"3\");  jQuery(\"#gform_9\").trigger(\"submit\",[true]); ' onkeypress='if( event.keyCode == 13 ){ jQuery(\"#gform_target_page_number_9\").val(\"3\");  jQuery(\"#gform_9\").trigger(\"submit\",[true]); } ' \/> \n                    <\/div>\n                <\/div>\n                <div id='gform_page_9_3' class='gform_page' data-js='page-field-id-69' style='display:none;'>\n                    <div class='gform_page_fields'>\n                        <div id='gform_fields_9_3' class='gform_fields top_label form_sublabel_below description_below'><fieldset id=\"field_9_25\"  class=\"gfield gfield--type-checkbox gfield--type-choice gfield--width-half gfield_contains_required field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_9_25\"><legend class='gfield_label gform-field-label gfield_label_before_complex'  >What are your expectations from your therapist? A therapist who ...<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox' id='input_9_25'><div class='gchoice gchoice_9_25_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_25.1' type='checkbox'  value='Listens'  id='choice_9_25_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_9_25_1' id='label_9_25_1' class='gform-field-label gform-field-label--type-inline'>Listens<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_9_25_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_25.2' type='checkbox'  value='Explores my past'  id='choice_9_25_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_9_25_2' id='label_9_25_2' class='gform-field-label gform-field-label--type-inline'>Explores my past<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_9_25_3'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_25.3' type='checkbox'  value='Teaches me new skills'  id='choice_9_25_3'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_9_25_3' id='label_9_25_3' class='gform-field-label gform-field-label--type-inline'>Teaches me new skills<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_9_25_4'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_25.4' type='checkbox'  value='Challenges my beliefs'  id='choice_9_25_4'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_9_25_4' id='label_9_25_4' class='gform-field-label gform-field-label--type-inline'>Challenges my beliefs<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_9_25_5'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_25.5' type='checkbox'  value='Assigns me homework'  id='choice_9_25_5'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_9_25_5' id='label_9_25_5' class='gform-field-label gform-field-label--type-inline'>Assigns me homework<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_9_25_6'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_25.6' type='checkbox'  value='Guides me to set goals'  id='choice_9_25_6'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_9_25_6' id='label_9_25_6' class='gform-field-label gform-field-label--type-inline'>Guides me to set goals<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_9_25_7'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_25.7' type='checkbox'  value='Proactively checks in with me'  id='choice_9_25_7'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_9_25_7' id='label_9_25_7' class='gform-field-label gform-field-label--type-inline'>Proactively checks in with me<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_9_25_8'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_25.8' type='checkbox'  value='I don&#039;t know'  id='choice_9_25_8'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_9_25_8' id='label_9_25_8' class='gform-field-label gform-field-label--type-inline'>I don't know<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_9_18\"  class=\"gfield gfield--type-radio gfield--type-choice gfield--width-half gfield_contains_required field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_9_18\"><legend class='gfield_label gform-field-label'  >Are you currently experiencing overwhelming sadness, grief, or depression?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_9_18'>\n\t\t\t<div class='gchoice gchoice_9_18_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_18' type='radio' value='Yes'  id='choice_9_18_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_9_18_0' id='label_9_18_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_9_18_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_18' type='radio' value='No'  id='choice_9_18_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_9_18_1' id='label_9_18_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_9_20\"  class=\"gfield gfield--type-radio gfield--type-choice gfield--width-half gfield_contains_required field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_9_20\"><legend class='gfield_label gform-field-label'  >How would you rate your current physical health?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_9_20'>\n\t\t\t<div class='gchoice gchoice_9_20_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_20' type='radio' value='Good'  id='choice_9_20_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_9_20_0' id='label_9_20_0' class='gform-field-label gform-field-label--type-inline'>Good<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_9_20_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_20' type='radio' value='Fair'  id='choice_9_20_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_9_20_1' id='label_9_20_1' class='gform-field-label gform-field-label--type-inline'>Fair<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_9_20_2'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_20' type='radio' value='Poor'  id='choice_9_20_2' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_9_20_2' id='label_9_20_2' class='gform-field-label gform-field-label--type-inline'>Poor<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_9_19\"  class=\"gfield gfield--type-radio gfield--type-choice gfield--width-half gfield_contains_required field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_9_19\"><legend class='gfield_label gform-field-label'  >How would you rate your current eating habits?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_9_19'>\n\t\t\t<div class='gchoice gchoice_9_19_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_19' type='radio' value='Good'  id='choice_9_19_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_9_19_0' id='label_9_19_0' class='gform-field-label gform-field-label--type-inline'>Good<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_9_19_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_19' type='radio' value='Fair'  id='choice_9_19_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_9_19_1' id='label_9_19_1' class='gform-field-label gform-field-label--type-inline'>Fair<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_9_19_2'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_19' type='radio' value='Poor'  id='choice_9_19_2' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_9_19_2' id='label_9_19_2' class='gform-field-label gform-field-label--type-inline'>Poor<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><\/div>\n                    <\/div>\n                    <div class='gform_page_footer top_label'>\n                        <input type='button' id='gform_previous_button_9_73' class='gform_previous_button gform-theme-button gform-theme-button--secondary button' value='Previous'  onclick='jQuery(\"#gform_target_page_number_9\").val(\"2\");  jQuery(\"#gform_9\").trigger(\"submit\",[true]); ' onkeypress='if( event.keyCode == 13 ){ jQuery(\"#gform_target_page_number_9\").val(\"2\");  jQuery(\"#gform_9\").trigger(\"submit\",[true]); } ' \/> <input type='button' id='gform_next_button_9_73' class='gform_next_button gform-theme-button button' value='Next'  onclick='jQuery(\"#gform_target_page_number_9\").val(\"4\");  jQuery(\"#gform_9\").trigger(\"submit\",[true]); ' onkeypress='if( event.keyCode == 13 ){ jQuery(\"#gform_target_page_number_9\").val(\"4\");  jQuery(\"#gform_9\").trigger(\"submit\",[true]); } ' \/> \n                    <\/div>\n                <\/div>\n                <div id='gform_page_9_4' class='gform_page' data-js='page-field-id-73' style='display:none;'>\n                    <div class='gform_page_fields'>\n                        <div id='gform_fields_9_4' class='gform_fields top_label form_sublabel_below description_below'><div id=\"field_9_27\"  class=\"gfield gfield--type-html gfield--width-full gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_9_27\">over past 2 weeks, how often have you been bothered by any of the following problems:<\/div><fieldset id=\"field_9_16\"  class=\"gfield gfield--type-radio gfield--type-choice gfield--width-half gfield_contains_required field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_9_16\"><legend class='gfield_label gform-field-label'  >Moving or speaking so slowly that other people could have noticed? Or the opposite - being so fidgety or restless that you have been moving around a lot more than usual.<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_9_16'>\n\t\t\t<div class='gchoice gchoice_9_16_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_16' type='radio' value='Not at all'  id='choice_9_16_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_9_16_0' id='label_9_16_0' class='gform-field-label gform-field-label--type-inline'>Not at all<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_9_16_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_16' type='radio' value='Several days'  id='choice_9_16_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_9_16_1' id='label_9_16_1' class='gform-field-label gform-field-label--type-inline'>Several days<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_9_16_2'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_16' type='radio' value='More than half the days'  id='choice_9_16_2' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_9_16_2' id='label_9_16_2' class='gform-field-label gform-field-label--type-inline'>More than half the days<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_9_16_3'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_16' type='radio' value='Nearly every day'  id='choice_9_16_3' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_9_16_3' id='label_9_16_3' class='gform-field-label gform-field-label--type-inline'>Nearly every day<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_9_30\"  class=\"gfield gfield--type-radio gfield--type-choice gfield--width-half gfield_contains_required field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_9_30\"><legend class='gfield_label gform-field-label'  >Feeling tired or having little energy.<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_9_30'>\n\t\t\t<div class='gchoice gchoice_9_30_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_30' type='radio' value='Not at all'  id='choice_9_30_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_9_30_0' id='label_9_30_0' class='gform-field-label gform-field-label--type-inline'>Not at all<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_9_30_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_30' type='radio' value='Several days'  id='choice_9_30_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_9_30_1' id='label_9_30_1' class='gform-field-label gform-field-label--type-inline'>Several days<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_9_30_2'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_30' type='radio' value='More than half the days'  id='choice_9_30_2' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_9_30_2' id='label_9_30_2' class='gform-field-label gform-field-label--type-inline'>More than half the days<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_9_30_3'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_30' type='radio' value='Nearly every day'  id='choice_9_30_3' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_9_30_3' id='label_9_30_3' class='gform-field-label gform-field-label--type-inline'>Nearly every day<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_9_17\"  class=\"gfield gfield--type-radio gfield--type-choice gfield--width-third gfield_contains_required field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_9_17\"><legend class='gfield_label gform-field-label'  >Little interest or pleasure in doing things.<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_9_17'>\n\t\t\t<div class='gchoice gchoice_9_17_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_17' type='radio' value='Not at all'  id='choice_9_17_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_9_17_0' id='label_9_17_0' class='gform-field-label gform-field-label--type-inline'>Not at all<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_9_17_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_17' type='radio' value='Several days'  id='choice_9_17_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_9_17_1' id='label_9_17_1' class='gform-field-label gform-field-label--type-inline'>Several days<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_9_17_2'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_17' type='radio' value='More than half the days'  id='choice_9_17_2' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_9_17_2' id='label_9_17_2' class='gform-field-label gform-field-label--type-inline'>More than half the days<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_9_17_3'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_17' type='radio' value='Nearly every day'  id='choice_9_17_3' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_9_17_3' id='label_9_17_3' class='gform-field-label gform-field-label--type-inline'>Nearly every day<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_9_29\"  class=\"gfield gfield--type-radio gfield--type-choice gfield--width-third gfield_contains_required field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_9_29\"><legend class='gfield_label gform-field-label'  >Trouble falling asleep, staying asleep, or sleeping too much.<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_9_29'>\n\t\t\t<div class='gchoice gchoice_9_29_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_29' type='radio' value='Not at all'  id='choice_9_29_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_9_29_0' id='label_9_29_0' class='gform-field-label gform-field-label--type-inline'>Not at all<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_9_29_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_29' type='radio' value='Several days'  id='choice_9_29_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_9_29_1' id='label_9_29_1' class='gform-field-label gform-field-label--type-inline'>Several days<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_9_29_2'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_29' type='radio' value='More than half the days'  id='choice_9_29_2' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_9_29_2' id='label_9_29_2' class='gform-field-label gform-field-label--type-inline'>More than half the days<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_9_29_3'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_29' type='radio' value='Nearly every day'  id='choice_9_29_3' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_9_29_3' id='label_9_29_3' class='gform-field-label gform-field-label--type-inline'>Nearly every day<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_9_28\"  class=\"gfield gfield--type-radio gfield--type-choice gfield--width-third gfield_contains_required field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_9_28\"><legend class='gfield_label gform-field-label'  >Feeling down, depressed or hopeless.<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_9_28'>\n\t\t\t<div class='gchoice gchoice_9_28_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_28' type='radio' value='Not at all'  id='choice_9_28_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_9_28_0' id='label_9_28_0' class='gform-field-label gform-field-label--type-inline'>Not at all<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_9_28_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_28' type='radio' value='Several days'  id='choice_9_28_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_9_28_1' id='label_9_28_1' class='gform-field-label gform-field-label--type-inline'>Several days<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_9_28_2'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_28' type='radio' value='More than half the days'  id='choice_9_28_2' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_9_28_2' id='label_9_28_2' class='gform-field-label gform-field-label--type-inline'>More than half the days<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_9_28_3'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_28' type='radio' value='Nearly every day'  id='choice_9_28_3' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_9_28_3' id='label_9_28_3' class='gform-field-label gform-field-label--type-inline'>Nearly every day<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><\/div>\n                    <\/div>\n                    <div class='gform_page_footer top_label'>\n                        <input type='button' id='gform_previous_button_9_70' class='gform_previous_button gform-theme-button gform-theme-button--secondary button' value='Previous'  onclick='jQuery(\"#gform_target_page_number_9\").val(\"3\");  jQuery(\"#gform_9\").trigger(\"submit\",[true]); ' onkeypress='if( event.keyCode == 13 ){ jQuery(\"#gform_target_page_number_9\").val(\"3\");  jQuery(\"#gform_9\").trigger(\"submit\",[true]); } ' \/> <input type='button' id='gform_next_button_9_70' class='gform_next_button gform-theme-button button' value='Next'  onclick='jQuery(\"#gform_target_page_number_9\").val(\"5\");  jQuery(\"#gform_9\").trigger(\"submit\",[true]); ' onkeypress='if( event.keyCode == 13 ){ jQuery(\"#gform_target_page_number_9\").val(\"5\");  jQuery(\"#gform_9\").trigger(\"submit\",[true]); } ' \/> \n                    <\/div>\n                <\/div>\n                <div id='gform_page_9_5' class='gform_page' data-js='page-field-id-70' style='display:none;'>\n                    <div class='gform_page_fields'>\n                        <div id='gform_fields_9_5' class='gform_fields top_label form_sublabel_below description_below'><fieldset id=\"field_9_31\"  class=\"gfield gfield--type-radio gfield--type-choice gfield--width-third gfield_contains_required field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_9_31\"><legend class='gfield_label gform-field-label'  >Poor appetite or overeating.<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_9_31'>\n\t\t\t<div class='gchoice gchoice_9_31_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_31' type='radio' value='Not at all'  id='choice_9_31_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_9_31_0' id='label_9_31_0' class='gform-field-label gform-field-label--type-inline'>Not at all<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_9_31_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_31' type='radio' value='Several days'  id='choice_9_31_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_9_31_1' id='label_9_31_1' class='gform-field-label gform-field-label--type-inline'>Several days<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_9_31_2'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_31' type='radio' value='More than half the days'  id='choice_9_31_2' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_9_31_2' id='label_9_31_2' class='gform-field-label gform-field-label--type-inline'>More than half the days<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_9_31_3'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_31' type='radio' value='Nearly every day'  id='choice_9_31_3' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_9_31_3' id='label_9_31_3' class='gform-field-label gform-field-label--type-inline'>Nearly every day<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_9_32\"  class=\"gfield gfield--type-radio gfield--type-choice gfield--width-third gfield_contains_required field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_9_32\"><legend class='gfield_label gform-field-label'  >Feeling bad about yourself - or that you are a failure or have let yourself or your family down.<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_9_32'>\n\t\t\t<div class='gchoice gchoice_9_32_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_32' type='radio' value='Not at all'  id='choice_9_32_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_9_32_0' id='label_9_32_0' class='gform-field-label gform-field-label--type-inline'>Not at all<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_9_32_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_32' type='radio' value='Several days'  id='choice_9_32_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_9_32_1' id='label_9_32_1' class='gform-field-label gform-field-label--type-inline'>Several days<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_9_32_2'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_32' type='radio' value='More than half the days'  id='choice_9_32_2' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_9_32_2' id='label_9_32_2' class='gform-field-label gform-field-label--type-inline'>More than half the days<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_9_32_3'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_32' type='radio' value='Nearly every day'  id='choice_9_32_3' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_9_32_3' id='label_9_32_3' class='gform-field-label gform-field-label--type-inline'>Nearly every day<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_9_33\"  class=\"gfield gfield--type-radio gfield--type-choice gfield--width-third gfield_contains_required field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_9_33\"><legend class='gfield_label gform-field-label'  >Trouble concentrating on things, such as reading the newspaper or watching television.<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_9_33'>\n\t\t\t<div class='gchoice gchoice_9_33_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_33' type='radio' value='Not at all'  id='choice_9_33_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_9_33_0' id='label_9_33_0' class='gform-field-label gform-field-label--type-inline'>Not at all<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_9_33_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_33' type='radio' value='Several days'  id='choice_9_33_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_9_33_1' id='label_9_33_1' class='gform-field-label gform-field-label--type-inline'>Several days<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_9_33_2'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_33' type='radio' value='More than half the days'  id='choice_9_33_2' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_9_33_2' id='label_9_33_2' class='gform-field-label gform-field-label--type-inline'>More than half the days<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_9_33_3'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_33' type='radio' value='Nearly every day'  id='choice_9_33_3' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_9_33_3' id='label_9_33_3' class='gform-field-label gform-field-label--type-inline'>Nearly every day<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_9_34\"  class=\"gfield gfield--type-radio gfield--type-choice gfield--width-half gfield_contains_required field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_9_34\"><legend class='gfield_label gform-field-label'  >How difficult have these problems made it for you to do your work, take care of things at home, or get along with other people?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_9_34'>\n\t\t\t<div class='gchoice gchoice_9_34_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_34' type='radio' value='Not difficult at all'  id='choice_9_34_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_9_34_0' id='label_9_34_0' class='gform-field-label gform-field-label--type-inline'>Not difficult at all<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_9_34_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_34' type='radio' value='Somewhat difficult'  id='choice_9_34_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_9_34_1' id='label_9_34_1' class='gform-field-label gform-field-label--type-inline'>Somewhat difficult<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_9_34_2'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_34' type='radio' value='Very difficult'  id='choice_9_34_2' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_9_34_2' id='label_9_34_2' class='gform-field-label gform-field-label--type-inline'>Very difficult<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_9_34_3'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_34' type='radio' value='Extremely difficult'  id='choice_9_34_3' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_9_34_3' id='label_9_34_3' class='gform-field-label gform-field-label--type-inline'>Extremely difficult<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_9_36\"  class=\"gfield gfield--type-radio gfield--type-choice gfield--width-half gfield_contains_required field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_9_36\"><legend class='gfield_label gform-field-label'  >Thoughts that you would be better off dead or of hurting yourself in some way.<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_9_36'>\n\t\t\t<div class='gchoice gchoice_9_36_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_36' type='radio' value='Not at all'  id='choice_9_36_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_9_36_0' id='label_9_36_0' class='gform-field-label gform-field-label--type-inline'>Not at all<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_9_36_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_36' type='radio' value='Several days'  id='choice_9_36_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_9_36_1' id='label_9_36_1' class='gform-field-label gform-field-label--type-inline'>Several days<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_9_36_2'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_36' type='radio' value='More than half the days'  id='choice_9_36_2' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_9_36_2' id='label_9_36_2' class='gform-field-label gform-field-label--type-inline'>More than half the days<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_9_36_3'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_36' type='radio' value='Nearly every day'  id='choice_9_36_3' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_9_36_3' id='label_9_36_3' class='gform-field-label gform-field-label--type-inline'>Nearly every day<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><\/div>\n                    <\/div>\n                    <div class='gform_page_footer top_label'>\n                        <input type='button' id='gform_previous_button_9_64' class='gform_previous_button gform-theme-button gform-theme-button--secondary button' value='Previous'  onclick='jQuery(\"#gform_target_page_number_9\").val(\"4\");  jQuery(\"#gform_9\").trigger(\"submit\",[true]); ' onkeypress='if( event.keyCode == 13 ){ jQuery(\"#gform_target_page_number_9\").val(\"4\");  jQuery(\"#gform_9\").trigger(\"submit\",[true]); } ' \/> <input type='button' id='gform_next_button_9_64' class='gform_next_button gform-theme-button button' value='Next'  onclick='jQuery(\"#gform_target_page_number_9\").val(\"6\");  jQuery(\"#gform_9\").trigger(\"submit\",[true]); ' onkeypress='if( event.keyCode == 13 ){ jQuery(\"#gform_target_page_number_9\").val(\"6\");  jQuery(\"#gform_9\").trigger(\"submit\",[true]); } ' \/> \n                    <\/div>\n                <\/div>\n                <div id='gform_page_9_6' class='gform_page' data-js='page-field-id-64' style='display:none;'>\n                    <div class='gform_page_fields'>\n                        <div id='gform_fields_9_6' class='gform_fields top_label form_sublabel_below description_below'><div id=\"field_9_37\"  class=\"gfield gfield--type-html gfield--width-full gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_9_37\">Please fill out this short questionnaire to provide some background information about you and the issues you'd like to deal with in therapy. It would help us match you with the most suitable therapist for you. Your answers will also give this therapist a good starting point in getting to know you.<\/div><fieldset id=\"field_9_38\"  class=\"gfield gfield--type-radio gfield--type-choice gfield--width-third gfield_contains_required field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_9_38\"><legend class='gfield_label gform-field-label'  >Are you currently employed?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_9_38'>\n\t\t\t<div class='gchoice gchoice_9_38_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_38' type='radio' value='Yes'  id='choice_9_38_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_9_38_0' id='label_9_38_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_9_38_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_38' type='radio' value='No'  id='choice_9_38_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_9_38_1' id='label_9_38_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_9_39\"  class=\"gfield gfield--type-radio gfield--type-choice gfield--width-third gfield_contains_required field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_9_39\"><legend class='gfield_label gform-field-label'  >Do you have any problems or worries about intimacy?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_9_39'>\n\t\t\t<div class='gchoice gchoice_9_39_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_39' type='radio' value='Yes'  id='choice_9_39_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_9_39_0' id='label_9_39_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_9_39_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_39' type='radio' value='No'  id='choice_9_39_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_9_39_1' id='label_9_39_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_9_40\"  class=\"gfield gfield--type-radio gfield--type-choice gfield--width-third gfield_contains_required field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_9_40\"><legend class='gfield_label gform-field-label'  >How often do you drink alcohol?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_9_40'>\n\t\t\t<div class='gchoice gchoice_9_40_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_40' type='radio' value='Never'  id='choice_9_40_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_9_40_0' id='label_9_40_0' class='gform-field-label gform-field-label--type-inline'>Never<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_9_40_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_40' type='radio' value='Infrequently'  id='choice_9_40_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_9_40_1' id='label_9_40_1' class='gform-field-label gform-field-label--type-inline'>Infrequently<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_9_40_2'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_40' type='radio' value='Monthly'  id='choice_9_40_2' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_9_40_2' id='label_9_40_2' class='gform-field-label gform-field-label--type-inline'>Monthly<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_9_40_3'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_40' type='radio' value='Weekly'  id='choice_9_40_3' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_9_40_3' id='label_9_40_3' class='gform-field-label gform-field-label--type-inline'>Weekly<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_9_40_4'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_40' type='radio' value='Daily'  id='choice_9_40_4' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_9_40_4' id='label_9_40_4' class='gform-field-label gform-field-label--type-inline'>Daily<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_9_41\"  class=\"gfield gfield--type-radio gfield--type-choice gfield--width-third gfield_contains_required field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_9_41\"><legend class='gfield_label gform-field-label'  >When was the last time you thought about suicide?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_9_41'>\n\t\t\t<div class='gchoice gchoice_9_41_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_41' type='radio' value='Never'  id='choice_9_41_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_9_41_0' id='label_9_41_0' class='gform-field-label gform-field-label--type-inline'>Never<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_9_41_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_41' type='radio' value='Over a years ago'  id='choice_9_41_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_9_41_1' id='label_9_41_1' class='gform-field-label gform-field-label--type-inline'>Over a years ago<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_9_41_2'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_41' type='radio' value='Over a month ago'  id='choice_9_41_2' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_9_41_2' id='label_9_41_2' class='gform-field-label gform-field-label--type-inline'>Over a month ago<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_9_41_3'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_41' type='radio' value='Over a week ago'  id='choice_9_41_3' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_9_41_3' id='label_9_41_3' class='gform-field-label gform-field-label--type-inline'>Over a week ago<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_9_41_4'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_41' type='radio' value='Every day'  id='choice_9_41_4' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_9_41_4' id='label_9_41_4' class='gform-field-label gform-field-label--type-inline'>Every day<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_9_48\"  class=\"gfield gfield--type-radio gfield--type-choice gfield--width-third gfield_contains_required field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_9_48\"><legend class='gfield_label gform-field-label'  >How do you prefer to communicate with your therapist?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_9_48'>\n\t\t\t<div class='gchoice gchoice_9_48_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_48' type='radio' value='Mostly via messaging'  id='choice_9_48_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_9_48_0' id='label_9_48_0' class='gform-field-label gform-field-label--type-inline'>Mostly via messaging<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_9_48_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_48' type='radio' value='Mostly via messaging'  id='choice_9_48_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_9_48_1' id='label_9_48_1' class='gform-field-label gform-field-label--type-inline'>Mostly via messaging<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_9_48_2'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_48' type='radio' value='Not sure yet (decide later)'  id='choice_9_48_2' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_9_48_2' id='label_9_48_2' class='gform-field-label gform-field-label--type-inline'>Not sure yet (decide later)<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_9_42\"  class=\"gfield gfield--type-radio gfield--type-choice gfield--width-third gfield_contains_required field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_9_42\"><legend class='gfield_label gform-field-label'  >Are you currently experiencing anxiety, panic attacks or have any phobias?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_9_42'>\n\t\t\t<div class='gchoice gchoice_9_42_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_42' type='radio' value='Yes'  id='choice_9_42_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_9_42_0' id='label_9_42_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_9_42_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_42' type='radio' value='No'  id='choice_9_42_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_9_42_1' id='label_9_42_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><\/div>\n                    <\/div>\n                    <div class='gform_page_footer top_label'>\n                        <input type='button' id='gform_previous_button_9_71' class='gform_previous_button gform-theme-button gform-theme-button--secondary button' value='Previous'  onclick='jQuery(\"#gform_target_page_number_9\").val(\"5\");  jQuery(\"#gform_9\").trigger(\"submit\",[true]); ' onkeypress='if( event.keyCode == 13 ){ jQuery(\"#gform_target_page_number_9\").val(\"5\");  jQuery(\"#gform_9\").trigger(\"submit\",[true]); } ' \/> <input type='button' id='gform_next_button_9_71' class='gform_next_button gform-theme-button button' value='Next'  onclick='jQuery(\"#gform_target_page_number_9\").val(\"7\");  jQuery(\"#gform_9\").trigger(\"submit\",[true]); ' onkeypress='if( event.keyCode == 13 ){ jQuery(\"#gform_target_page_number_9\").val(\"7\");  jQuery(\"#gform_9\").trigger(\"submit\",[true]); } ' \/> \n                    <\/div>\n                <\/div>\n                <div id='gform_page_9_7' class='gform_page' data-js='page-field-id-71' style='display:none;'>\n                    <div class='gform_page_fields'>\n                        <div id='gform_fields_9_7' class='gform_fields top_label form_sublabel_below description_below'><fieldset id=\"field_9_43\"  class=\"gfield gfield--type-radio gfield--type-choice gfield--width-third gfield_contains_required field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_9_43\"><legend class='gfield_label gform-field-label'  >Are you currently taking any medication?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_9_43'>\n\t\t\t<div class='gchoice gchoice_9_43_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_43' type='radio' value='Yes'  id='choice_9_43_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_9_43_0' id='label_9_43_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_9_43_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_43' type='radio' value='No'  id='choice_9_43_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_9_43_1' id='label_9_43_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_9_44\"  class=\"gfield gfield--type-radio gfield--type-choice gfield--width-third gfield_contains_required field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_9_44\"><legend class='gfield_label gform-field-label'  >Are you currently experiencing any chronic pain?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_9_44'>\n\t\t\t<div class='gchoice gchoice_9_44_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_44' type='radio' value='Yes'  id='choice_9_44_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_9_44_0' id='label_9_44_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_9_44_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_44' type='radio' value='No'  id='choice_9_44_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_9_44_1' id='label_9_44_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_9_46\"  class=\"gfield gfield--type-radio gfield--type-choice gfield--width-third gfield_contains_required field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_9_46\"><legend class='gfield_label gform-field-label'  >How would you rate your current financial status?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_9_46'>\n\t\t\t<div class='gchoice gchoice_9_46_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_46' type='radio' value='Good'  id='choice_9_46_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_9_46_0' id='label_9_46_0' class='gform-field-label gform-field-label--type-inline'>Good<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_9_46_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_46' type='radio' value='Fair'  id='choice_9_46_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_9_46_1' id='label_9_46_1' class='gform-field-label gform-field-label--type-inline'>Fair<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_9_46_2'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_46' type='radio' value='Poor'  id='choice_9_46_2' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_9_46_2' id='label_9_46_2' class='gform-field-label gform-field-label--type-inline'>Poor<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_9_47\"  class=\"gfield gfield--type-radio gfield--type-choice gfield--width-third gfield_contains_required field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_9_47\"><legend class='gfield_label gform-field-label'  >How would you rate your current sleeping habits?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_9_47'>\n\t\t\t<div class='gchoice gchoice_9_47_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_47' type='radio' value='Good'  id='choice_9_47_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_9_47_0' id='label_9_47_0' class='gform-field-label gform-field-label--type-inline'>Good<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_9_47_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_47' type='radio' value='Fair'  id='choice_9_47_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_9_47_1' id='label_9_47_1' class='gform-field-label gform-field-label--type-inline'>Fair<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_9_47_2'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_47' type='radio' value='Poor'  id='choice_9_47_2' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_9_47_2' id='label_9_47_2' class='gform-field-label gform-field-label--type-inline'>Poor<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_9_49\"  class=\"gfield gfield--type-checkbox gfield--type-choice gfield--width-third gfield_contains_required field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_9_49\"><legend class='gfield_label gform-field-label gfield_label_before_complex'  >Are there any specific preferences for your therapist?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox' id='input_9_49'><div class='gchoice gchoice_9_49_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_49.1' type='checkbox'  value='Male therapist'  id='choice_9_49_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_9_49_1' id='label_9_49_1' class='gform-field-label gform-field-label--type-inline'>Male therapist<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_9_49_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_49.2' type='checkbox'  value='Female therapist'  id='choice_9_49_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_9_49_2' id='label_9_49_2' class='gform-field-label gform-field-label--type-inline'>Female therapist<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_9_49_3'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_49.3' type='checkbox'  value='Christian-based therapy'  id='choice_9_49_3'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_9_49_3' id='label_9_49_3' class='gform-field-label gform-field-label--type-inline'>Christian-based therapy<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_9_49_4'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_49.4' type='checkbox'  value='Therapist from the LGBTQ+ community'  id='choice_9_49_4'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_9_49_4' id='label_9_49_4' class='gform-field-label gform-field-label--type-inline'>Therapist from the LGBTQ+ community<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_9_49_5'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_49.5' type='checkbox'  value='Older therapist (45+)'  id='choice_9_49_5'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_9_49_5' id='label_9_49_5' class='gform-field-label gform-field-label--type-inline'>Older therapist (45+)<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_9_49_6'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_49.6' type='checkbox'  value='Non-religious therapist'  id='choice_9_49_6'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_9_49_6' id='label_9_49_6' class='gform-field-label gform-field-label--type-inline'>Non-religious therapist<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_9_49_7'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_49.7' type='checkbox'  value='Therapist of color'  id='choice_9_49_7'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_9_49_7' id='label_9_49_7' class='gform-field-label gform-field-label--type-inline'>Therapist of color<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_9_50\"  class=\"gfield gfield--type-radio gfield--type-choice gfield--width-third gfield_contains_required field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_9_50\"><legend class='gfield_label gform-field-label'  >Who referred you to Avadaroon?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_9_50'>\n\t\t\t<div class='gchoice gchoice_9_50_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_50' type='radio' value='Celebrity'  id='choice_9_50_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_9_50_0' id='label_9_50_0' class='gform-field-label gform-field-label--type-inline'>Celebrity<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_9_50_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_50' type='radio' value='Youtube'  id='choice_9_50_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_9_50_1' id='label_9_50_1' class='gform-field-label gform-field-label--type-inline'>Youtube<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_9_50_2'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_50' type='radio' value='Tiktok'  id='choice_9_50_2' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_9_50_2' id='label_9_50_2' class='gform-field-label gform-field-label--type-inline'>Tiktok<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_9_50_3'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_50' type='radio' value='TV'  id='choice_9_50_3' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_9_50_3' id='label_9_50_3' class='gform-field-label gform-field-label--type-inline'>TV<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_9_50_4'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_50' type='radio' value='gf_other_choice'  id='choice_9_50_4' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_9_50_4' id='label_9_50_4' class='gform-field-label gform-field-label--type-inline'>Other<\/label><br \/><input id='input_9_50_other' class='gchoice_other_control' name='input_50_other' type='text' value='Other' aria-label='Other Choice, please specify'  disabled='disabled' \/>\n\t\t\t<\/div><\/div><\/div><\/fieldset><\/div>\n                    <\/div>\n                    <div class='gform_page_footer top_label'>\n                        <input type='button' id='gform_previous_button_9_67' class='gform_previous_button gform-theme-button gform-theme-button--secondary button' value='Previous'  onclick='jQuery(\"#gform_target_page_number_9\").val(\"6\");  jQuery(\"#gform_9\").trigger(\"submit\",[true]); ' onkeypress='if( event.keyCode == 13 ){ jQuery(\"#gform_target_page_number_9\").val(\"6\");  jQuery(\"#gform_9\").trigger(\"submit\",[true]); } ' \/> <input type='button' id='gform_next_button_9_67' class='gform_next_button gform-theme-button button' value='Next'  onclick='jQuery(\"#gform_target_page_number_9\").val(\"8\");  jQuery(\"#gform_9\").trigger(\"submit\",[true]); ' onkeypress='if( event.keyCode == 13 ){ jQuery(\"#gform_target_page_number_9\").val(\"8\");  jQuery(\"#gform_9\").trigger(\"submit\",[true]); } ' \/> \n                    <\/div>\n                <\/div>\n                <div id='gform_page_9_8' class='gform_page' data-js='page-field-id-67' style='display:none;'>\n                    <div class='gform_page_fields'>\n                        <div id='gform_fields_9_8' class='gform_fields top_label form_sublabel_below description_below'><div id=\"field_9_53\"  class=\"gfield gfield--type-text gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_9_53\"><label class='gfield_label gform-field-label' for='input_9_53' >Which country are you in?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_53' id='input_9_53' type='text' value='' class='large'     aria-required=\"true\" aria-invalid=\"false\"   \/> <\/div><\/div><div id=\"field_9_54\"  class=\"gfield gfield--type-text gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_9_54\"><label class='gfield_label gform-field-label' for='input_9_54' >What is your preferred language?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_54' id='input_9_54' type='text' value='' class='large'     aria-required=\"true\" aria-invalid=\"false\"   \/> <\/div><\/div><fieldset id=\"field_9_55\"  class=\"gfield gfield--type-checkbox gfield--type-choice gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_9_55\"><legend class='gfield_label gform-field-label gfield_label_before_complex'  >Please mark all that apply<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox' id='input_9_55'><div class='gchoice gchoice_9_55_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_55.1' type='checkbox'  value='I&#039;m a student'  id='choice_9_55_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_9_55_1' id='label_9_55_1' class='gform-field-label gform-field-label--type-inline'>I'm a student<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_9_55_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_55.2' type='checkbox'  value='I&#039;m a veteran'  id='choice_9_55_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_9_55_2' id='label_9_55_2' class='gform-field-label gform-field-label--type-inline'>I'm a veteran<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_9_55_3'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_55.3' type='checkbox'  value='I&#039;m disabled'  id='choice_9_55_3'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_9_55_3' id='label_9_55_3' class='gform-field-label gform-field-label--type-inline'>I'm disabled<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_9_55_4'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_55.4' type='checkbox'  value='I&#039;m unemployed'  id='choice_9_55_4'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_9_55_4' id='label_9_55_4' class='gform-field-label gform-field-label--type-inline'>I'm unemployed<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_9_55_5'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_55.5' type='checkbox'  value='I&#039;m employed but my income is low'  id='choice_9_55_5'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_9_55_5' id='label_9_55_5' class='gform-field-label gform-field-label--type-inline'>I'm employed but my income is low<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_9_55_6'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_55.6' type='checkbox'  value='I&#039;m financially impacted by the coronavirus outbreak'  id='choice_9_55_6'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_9_55_6' id='label_9_55_6' class='gform-field-label gform-field-label--type-inline'>I'm financially impacted by the coronavirus outbreak<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><\/div>\n                    <\/div>\n                    <div class='gform_page_footer top_label'>\n                        <input type='button' id='gform_previous_button_9_72' class='gform_previous_button gform-theme-button gform-theme-button--secondary button' value='Previous'  onclick='jQuery(\"#gform_target_page_number_9\").val(\"7\");  jQuery(\"#gform_9\").trigger(\"submit\",[true]); ' onkeypress='if( event.keyCode == 13 ){ jQuery(\"#gform_target_page_number_9\").val(\"7\");  jQuery(\"#gform_9\").trigger(\"submit\",[true]); } ' \/> <input type='button' id='gform_next_button_9_72' class='gform_next_button gform-theme-button button' value='Next'  onclick='jQuery(\"#gform_target_page_number_9\").val(\"9\");  jQuery(\"#gform_9\").trigger(\"submit\",[true]); ' onkeypress='if( event.keyCode == 13 ){ jQuery(\"#gform_target_page_number_9\").val(\"9\");  jQuery(\"#gform_9\").trigger(\"submit\",[true]); } ' \/> \n                    <\/div>\n                <\/div>\n                <div id='gform_page_9_9' class='gform_page' data-js='page-field-id-72' style='display:none;'>\n                    <div class='gform_page_fields'>\n                        <div id='gform_fields_9_9' class='gform_fields top_label form_sublabel_below description_below'><div id=\"field_9_65\"  class=\"gfield gfield--type-html gfield--width-full gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_9_65\">Are there any issues you'd like to focus on? We want to match you with a therapist who suits your needs.<\/div><fieldset id=\"field_9_58\"  class=\"gfield gfield--type-checkbox gfield--type-choice gfield--width-half gfield_contains_required field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_9_58\"><legend class='gfield_label gform-field-label gfield_label_before_complex'  >Additional focus areas I prefer<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox' id='input_9_58'><div class='gchoice gchoice_9_58_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_58.1' type='checkbox'  value='Communication Problems'  id='choice_9_58_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_9_58_1' id='label_9_58_1' class='gform-field-label gform-field-label--type-inline'>Communication Problems<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_9_58_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_58.2' type='checkbox'  value='Life Purpose'  id='choice_9_58_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_9_58_2' id='label_9_58_2' class='gform-field-label gform-field-label--type-inline'>Life Purpose<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_9_58_3'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_58.3' type='checkbox'  value='Isolation\/Loneliness'  id='choice_9_58_3'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_9_58_3' id='label_9_58_3' class='gform-field-label gform-field-label--type-inline'>Isolation\/Loneliness<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_9_58_4'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_58.4' type='checkbox'  value='Self-Love'  id='choice_9_58_4'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_9_58_4' id='label_9_58_4' class='gform-field-label gform-field-label--type-inline'>Self-Love<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_9_58_5'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_58.5' type='checkbox'  value='Social Anxiety and Phobia'  id='choice_9_58_5'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_9_58_5' id='label_9_58_5' class='gform-field-label gform-field-label--type-inline'>Social Anxiety and Phobia<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_9_58_6'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_58.6' type='checkbox'  value='Guilt and Shame'  id='choice_9_58_6'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_9_58_6' id='label_9_58_6' class='gform-field-label gform-field-label--type-inline'>Guilt and Shame<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_9_58_7'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_58.7' type='checkbox'  value='Post-traumatic Stress'  id='choice_9_58_7'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_9_58_7' id='label_9_58_7' class='gform-field-label gform-field-label--type-inline'>Post-traumatic Stress<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_9_58_8'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_58.8' type='checkbox'  value='Panic Disorder and Panic Attacks'  id='choice_9_58_8'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_9_58_8' id='label_9_58_8' class='gform-field-label gform-field-label--type-inline'>Panic Disorder and Panic Attacks<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_9_58_9'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_58.9' type='checkbox'  value='Control Issues'  id='choice_9_58_9'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_9_58_9' id='label_9_58_9' class='gform-field-label gform-field-label--type-inline'>Control Issues<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_9_58_11'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_58.11' type='checkbox'  value='Forgiveness'  id='choice_9_58_11'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_9_58_11' id='label_9_58_11' class='gform-field-label gform-field-label--type-inline'>Forgiveness<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_9_58_12'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_58.12' type='checkbox'  value='Caregiver Issues and Stress'  id='choice_9_58_12'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_9_58_12' id='label_9_58_12' class='gform-field-label gform-field-label--type-inline'>Caregiver Issues and Stress<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_9_58_13'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_58.13' type='checkbox'  value='Pregnancy and Childbirth'  id='choice_9_58_13'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_9_58_13' id='label_9_58_13' class='gform-field-label gform-field-label--type-inline'>Pregnancy and Childbirth<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_9_58_14'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_58.14' type='checkbox'  value='Divorce and Separation'  id='choice_9_58_14'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_9_58_14' id='label_9_58_14' class='gform-field-label gform-field-label--type-inline'>Divorce and Separation<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_9_58_15'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_58.15' type='checkbox'  value='Attachment Issues'  id='choice_9_58_15'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_9_58_15' id='label_9_58_15' class='gform-field-label gform-field-label--type-inline'>Attachment Issues<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_9_58_16'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_58.16' type='checkbox'  value='Abandonment'  id='choice_9_58_16'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_9_58_16' id='label_9_58_16' class='gform-field-label gform-field-label--type-inline'>Abandonment<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_9_58_17'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_58.17' type='checkbox'  value='Body Image'  id='choice_9_58_17'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_9_58_17' id='label_9_58_17' class='gform-field-label gform-field-label--type-inline'>Body Image<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_9_58_18'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_58.18' type='checkbox'  value='Mood Disorders'  id='choice_9_58_18'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_9_58_18' id='label_9_58_18' class='gform-field-label gform-field-label--type-inline'>Mood Disorders<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_9_58_19'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_58.19' type='checkbox'  value='Impulsivity'  id='choice_9_58_19'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_9_58_19' id='label_9_58_19' class='gform-field-label gform-field-label--type-inline'>Impulsivity<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_9_58_21'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_58.21' type='checkbox'  value='Workplace Issues'  id='choice_9_58_21'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_9_58_21' id='label_9_58_21' class='gform-field-label gform-field-label--type-inline'>Workplace Issues<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_9_58_22'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_58.22' type='checkbox'  value='Money and Financial Issues'  id='choice_9_58_22'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_9_58_22' id='label_9_58_22' class='gform-field-label gform-field-label--type-inline'>Money and Financial Issues<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_9_58_23'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_58.23' type='checkbox'  value='Chronic Pain Illness and Disability'  id='choice_9_58_23'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_9_58_23' id='label_9_58_23' class='gform-field-label gform-field-label--type-inline'>Chronic Pain Illness and Disability<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_9_58_24'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_58.24' type='checkbox'  value='Women&#039;s Issues'  id='choice_9_58_24'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_9_58_24' id='label_9_58_24' class='gform-field-label gform-field-label--type-inline'>Women's Issues<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_9_58_25'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_58.25' type='checkbox'  value='Men&#039;s Issues'  id='choice_9_58_25'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_9_58_25' id='label_9_58_25' class='gform-field-label gform-field-label--type-inline'>Men's Issues<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_9_58_26'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_58.26' type='checkbox'  value='Sexuality'  id='choice_9_58_26'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_9_58_26' id='label_9_58_26' class='gform-field-label gform-field-label--type-inline'>Sexuality<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_9_58_27'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_58.27' type='checkbox'  value='Midlife Crisis'  id='choice_9_58_27'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_9_58_27' id='label_9_58_27' class='gform-field-label gform-field-label--type-inline'>Midlife Crisis<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_9_58_28'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_58.28' type='checkbox'  value='Narcissism'  id='choice_9_58_28'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_9_58_28' id='label_9_58_28' class='gform-field-label gform-field-label--type-inline'>Narcissism<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_9_57\"  class=\"gfield gfield--type-checkbox gfield--type-choice gfield--width-half gfield_contains_required field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_9_57\"><legend class='gfield_label gform-field-label gfield_label_before_complex'  >I prefer a therapist with experience in...<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox' id='input_9_57'><div class='gchoice gchoice_9_57_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_57.1' type='checkbox'  value='Depression'  id='choice_9_57_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_9_57_1' id='label_9_57_1' class='gform-field-label gform-field-label--type-inline'>Depression<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_9_57_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_57.2' type='checkbox'  value='Stress and anxiety'  id='choice_9_57_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_9_57_2' id='label_9_57_2' class='gform-field-label gform-field-label--type-inline'>Stress and anxiety<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_9_57_3'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_57.3' type='checkbox'  value='Coping with addictions'  id='choice_9_57_3'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_9_57_3' id='label_9_57_3' class='gform-field-label gform-field-label--type-inline'>Coping with addictions<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_9_57_4'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_57.4' type='checkbox'  value='LGBT-related issues'  id='choice_9_57_4'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_9_57_4' id='label_9_57_4' class='gform-field-label gform-field-label--type-inline'>LGBT-related issues<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_9_57_5'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_57.5' type='checkbox'  value='Relationship issues'  id='choice_9_57_5'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_9_57_5' id='label_9_57_5' class='gform-field-label gform-field-label--type-inline'>Relationship issues<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_9_57_6'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_57.6' type='checkbox'  value='Family conflicts'  id='choice_9_57_6'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_9_57_6' id='label_9_57_6' class='gform-field-label gform-field-label--type-inline'>Family conflicts<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_9_57_7'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_57.7' type='checkbox'  value='Trauma and abuse'  id='choice_9_57_7'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_9_57_7' id='label_9_57_7' class='gform-field-label gform-field-label--type-inline'>Trauma and abuse<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_9_57_8'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_57.8' type='checkbox'  value='Coping with grief and loss'  id='choice_9_57_8'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_9_57_8' id='label_9_57_8' class='gform-field-label gform-field-label--type-inline'>Coping with grief and loss<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_9_57_9'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_57.9' type='checkbox'  value='Intimacy related issues'  id='choice_9_57_9'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_9_57_9' id='label_9_57_9' class='gform-field-label gform-field-label--type-inline'>Intimacy related issues<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_9_57_11'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_57.11' type='checkbox'  value='Eating disorders'  id='choice_9_57_11'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_9_57_11' id='label_9_57_11' class='gform-field-label gform-field-label--type-inline'>Eating disorders<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_9_57_12'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_57.12' type='checkbox'  value='Sleeping disorders'  id='choice_9_57_12'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_9_57_12' id='label_9_57_12' class='gform-field-label gform-field-label--type-inline'>Sleeping disorders<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_9_57_13'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_57.13' type='checkbox'  value='Parenting issues'  id='choice_9_57_13'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_9_57_13' id='label_9_57_13' class='gform-field-label gform-field-label--type-inline'>Parenting issues<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_9_57_14'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_57.14' type='checkbox'  value='Motivation, self esteem, and confidence'  id='choice_9_57_14'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_9_57_14' id='label_9_57_14' class='gform-field-label gform-field-label--type-inline'>Motivation, self esteem, and confidence<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_9_57_15'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_57.15' type='checkbox'  value='Anger management'  id='choice_9_57_15'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_9_57_15' id='label_9_57_15' class='gform-field-label gform-field-label--type-inline'>Anger management<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_9_57_16'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_57.16' type='checkbox'  value='Career difficulties'  id='choice_9_57_16'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_9_57_16' id='label_9_57_16' class='gform-field-label gform-field-label--type-inline'>Career difficulties<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_9_57_17'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_57.17' type='checkbox'  value='Bipolar disorder'  id='choice_9_57_17'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_9_57_17' id='label_9_57_17' class='gform-field-label gform-field-label--type-inline'>Bipolar disorder<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_9_57_18'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_57.18' type='checkbox'  value='Coping with life changes'  id='choice_9_57_18'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_9_57_18' id='label_9_57_18' class='gform-field-label gform-field-label--type-inline'>Coping with life changes<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_9_57_19'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_57.19' type='checkbox'  value='Executive and professional coaching'  id='choice_9_57_19'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_9_57_19' id='label_9_57_19' class='gform-field-label gform-field-label--type-inline'>Executive and professional 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class='gform_previous_button gform-theme-button gform-theme-button--secondary button' value='Previous'  onclick='jQuery(\"#gform_target_page_number_9\").val(\"8\");  jQuery(\"#gform_9\").trigger(\"submit\",[true]); ' onkeypress='if( event.keyCode == 13 ){ jQuery(\"#gform_target_page_number_9\").val(\"8\");  jQuery(\"#gform_9\").trigger(\"submit\",[true]); } ' \/> <input type='button' id='gform_next_button_9_74' class='gform_next_button gform-theme-button button' value='Next'  onclick='jQuery(\"#gform_target_page_number_9\").val(\"10\");  jQuery(\"#gform_9\").trigger(\"submit\",[true]); ' onkeypress='if( event.keyCode == 13 ){ jQuery(\"#gform_target_page_number_9\").val(\"10\");  jQuery(\"#gform_9\").trigger(\"submit\",[true]); } ' \/> \n                    <\/div>\n                <\/div>\n                <div id='gform_page_9_10' class='gform_page' data-js='page-field-id-74' style='display:none;'>\n                    <div class='gform_page_fields'>\n                        <div id='gform_fields_9_10' class='gform_fields top_label form_sublabel_below description_below'><div id=\"field_9_59\"  class=\"gfield gfield--type-html gfield--width-full gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_9_59\">Please specify (in a few sentences) why you'd like therapy. 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