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													autocomplete="username" class="input" value="" size="20" /></p>
											<p class="login-password float-label"> <label
													for="user_pass">Password</label> <input type="password" name="pwd"
													id="user_pass" autocomplete="current-password" class="input"
													value="" size="20" /></p>
											<p class="login-remember"><label><input name="rememberme" type="checkbox"
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					<!-- <div class="bubble round-tl mobile-wide mint"><div class="inner"><h1>Take a Mental Health Test</h1><div class="text"><p>Online screening is one of the quickest and easiest ways to determine whether you are experiencing symptoms of a mental health condition.</p><p><strong>Mental health conditions, such as depression or anxiety, are real, common and treatable. And recovery is possible.</strong></p></div></div></div> -->
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						<h1 class="entry-title">Diagnosa Tingkat Depresi</h1>
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						<div class='gf_browser_safari gform_wrapper gform_legacy_markup_wrapper' id='gform_wrapper_1'
							style='display:none'>
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								<h3 class="gform_title">Tes Depresi</h3> <span class='gform_description'></span>
							</div>
							<form method='post' enctype='multipart/form-data' id='gform_1' action="{{ route('spk.store') }}" novalidate>
								@csrf
								<ol class="screen-progress-bar clearfix step-2-of-3">
									<li class="step-1"><span>Informasi<br />Tes</span></li>
									<li class="step-2"><span>Pertanyaan<br />Tes</span></li>
									<li class="step-3"><span>Hasil<br />Anda</span></li>
								</ol>
								<div class='gform_body gform-body '>
									<div id='gform_page_1_1' class='gform_page'>
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													data-js-reload="field_1_4">
													<p><strong>Dalam 2 minggu terakhir</strong>, seberapa sering masalah-masalah berikut ini mengganggu kamu?</p>
													<p>Tidak semua field harus diisi, jadi pastikan untuk memberikan jawaban yang tepat sesuai dengan pengalamanmu.</p>
												</li>
												<li id="field_1_38"
													class="gfield gform_hidden field_sublabel_below field_description_above gfield_visibility_visible"
													data-js-reload="field_1_38">
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													class="gfield gform_hidden field_sublabel_below field_description_above gfield_visibility_visible"
													data-js-reload="field_1_39"><input name="input_39" id="input_1_39"
														type="hidden" class="gform_hidden" aria-invalid="false"
														value="22"></li>
												<li id="field_1_40"
													class="gfield gform_hidden field_sublabel_below field_description_above gfield_visibility_visible"
													data-js-reload="field_1_40"><input name="input_40" id="input_1_40"
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													data-js-reload="field_1_41">
													<div class='ginput_container ginput_container_text'><input
															name='input_41' id='input_1_41' type='hidden'
															class='gform_hidden' aria-invalid="false" value='' /></div>
												</li>
												<li id="field_1_47"
													class="gfield gform_hidden field_sublabel_below field_description_above gfield_visibility_visible"
													data-js-reload="field_1_47">
													<div class='ginput_container ginput_container_text'><input
															name='input_47' id='input_1_47' type='hidden'
															class='gform_hidden' aria-invalid="false" value='' /></div>
												</li>
												<li id="field_1_58"
													class="gfield gform_hidden field_sublabel_below field_description_above gfield_visibility_visible"
													data-js-reload="field_1_58">
													<div class='ginput_container ginput_container_text'><input
															name='input_58' id='input_1_58' type='hidden'
															class='gform_hidden' aria-invalid="false" value='' /></div>
												</li>
												<li id="field_1_59"
													class="gfield gform_hidden field_sublabel_below field_description_above gfield_visibility_visible"
													data-js-reload="field_1_59">
													<div class='ginput_container ginput_container_text'><input
															name='input_59' id='input_1_59' type='hidden'
															class='gform_hidden' aria-invalid="false" value='' /></div>
												</li>
												<li id="field_1_60"
													class="gfield gform_hidden field_sublabel_below field_description_above gfield_visibility_visible"
													data-js-reload="field_1_60">
													<div class='ginput_container ginput_container_text'><input
															name='input_60' id='input_1_60' type='hidden'
															class='gform_hidden' aria-invalid="false" value='' /></div>
												</li>



												@foreach($gejala as $item)
<li id="field_{{ $loop->iteration }}" class="gfield question gfield_contains_required field_sublabel_below field_description_above gfield_visibility_visible" data-js-reload="field_{{ $loop->iteration }}">
	<label class='gfield_label'>{{ $loop->iteration }}. Apakah anda merasa {{ $item->gejala }}?<span class="gfield_required"><span class="gfield_required gfield_required_asterisk">*</span></span></label>
	<div class='ginput_container ginput_container_radio'>
		<ul class='gfield_radio' id='input_{{ $loop->iteration }}'>
			@foreach($kondisi_user as $kondisi)
				<li style='font-size: 14px;' class='gchoice gchoice_{{ $loop->parent->iteration }}_{{ $loop->iteration }}'>
					<input name='input_{{ $loop->parent->iteration }}' type='radio' value='{{ $kondisi->nilai }}' id='choice_{{ $loop->parent->iteration }}_{{ $loop->iteration }}'
					onchange="document.getElementById('kondisi_{{ $item->kode_gejala }}{{ $loop->parent->iteration }}').value = this.value" />
					<label for='choice_{{ $loop->parent->iteration }}_{{ $loop->iteration }}' id='label_{{ $loop->parent->iteration }}_{{ $loop->iteration }}'>{{ $kondisi->kondisi }}</label>
				</li>
				@endforeach
				<input type="hidden" name="kondisi[{{ $item->kode_gejala }}]" id="kondisi_{{ $item->kode_gejala }}{{ $loop->iteration }}" value="" />
		</ul>
	</div>
</li>
@endforeach






												<div class='gform_page_footer top_label'>
													<button type="submit" class='gform_next_button button'>Submit</button>
													{{-- <a href="/form-faq" class='gform_cancel_button button'>Batal</a> --}}

												</div>

											</ul>
										</div>
										<div class='gform_page_footer top_label'> <input type='button'
												id='gform_next_button_1_17' class='gform_next_button button'
												value='Next'
												onclick='jQuery("#gform_target_page_number_1").val("2");  jQuery("#gform_1").trigger("submit",[true]); '
												onkeypress='if( event.keyCode == 13 ){ jQuery("#gform_target_page_number_1").val("2");  jQuery("#gform_1").trigger("submit",[true]); } ' />
										</div>
									</div>
									<div id='gform_page_1_2' class='gform_page demographics' style='display:none;'>
										<div class='gform_page_fields'>
											<ul id='gform_fields_1_2'
												class='gform_fields top_label form_sublabel_below description_above'>
												<li id="field_1_18"
													class="gfield gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below field_description_above gfield_visibility_visible"
													data-js-reload="field_1_18">
													<p>Please take a moment to answer the following
														<strong>optional</strong> questions. Your answers are totally
														anonymous—we won't be able to identify you based on this
														information. Your answers help us provide better information and
														support for people like you.</p>
													<p>You can answer as many or as few questions as you would like.
														When you are done, scroll to the bottom of the survey and click
														"submit" to receive your screening results.</p>
												</li>
												<li id="field_1_61"
													class="gfield gfield--width-full gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below field_description_above gfield_visibility_visible"
													data-js-reload="field_1_61">
													<hr />
												</li>
												<li id="field_1_62"
													class="gfield gfield--width-full field_sublabel_below field_description_above gfield_visibility_visible"
													data-js-reload="field_1_62"><label class='gfield_label'>Are you
														taking this test for yourself or for someone else?</label>
													<div class='ginput_container ginput_container_radio'>
														<ul class='gfield_radio' id='input_1_62'>
															<li class='gchoice gchoice_1_62_0'> <input name='input_62'
																	type='radio' value='For myself'
																	id='choice_1_62_0' /> <label for='choice_1_62_0'
																	id='label_1_62_0'>For myself</label></li>
															<li class='gchoice gchoice_1_62_1'> <input name='input_62'
																	type='radio' value='For someone else'
																	id='choice_1_62_1' /> <label for='choice_1_62_1'
																	id='label_1_62_1'>For someone else</label></li>
														</ul>
													</div>
												</li>
												<li id="field_1_63"
													class="gfield gfield--width-full gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below field_description_above gfield_visibility_visible"
													data-js-reload="field_1_63">If you are taking this test for someone
													else, <strong>please use that person's information</strong> for the
													questions below, or leave them blank if you don't know the answer.
													Remember, <em>these questions are optional</em>.</li>
												<li id="field_1_42"
													class="gfield section-title gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below field_description_above gfield_visibility_visible"
													data-js-reload="field_1_42">
													<h2>About You</h2>
												</li>
												<li id="field_1_19"
													class="gfield optional taxonomy indent field_sublabel_below field_description_above gfield_visibility_visible"
													data-js-reload="field_1_19"><label class='gfield_label'
														for='input_1_19'>Age Range</label>
													<div class='ginput_container ginput_container_select'><select
															name='input_19' id='input_1_19' class='medium gfield_select'
															aria-invalid="false">
															<option value=''></option>
															<option value='8-10'>8-10</option>
															<option value='11-13'>11-13</option>
															<option value='14-15'>14-15</option>
															<option value='16-17'>16-17</option>
															<option value='18-24'>18-24</option>
															<option value='25-34'>25-34</option>
															<option value='35-44'>35-44</option>
															<option value='45-54'>45-54</option>
															<option value='55-64'>55-64</option>
															<option value='65+'>65+</option>
														</select></div>
												</li>
												<li id="field_1_46"
													class="gfield optional indent mb-2 short field_sublabel_below field_description_above gfield_visibility_visible"
													data-js-reload="field_1_46"><label
														class='gfield_label'>Gender</label>
													<div class='ginput_container ginput_container_radio'>
														<ul class='gfield_radio' id='input_1_46'>
															<li class='gchoice gchoice_1_46_0'> <input name='input_46'
																	type='radio' value='Female' id='choice_1_46_0' />
																<label for='choice_1_46_0'
																	id='label_1_46_0'>Female</label></li>
															<li class='gchoice gchoice_1_46_1'> <input name='input_46'
																	type='radio' value='Male' id='choice_1_46_1' />
																<label for='choice_1_46_1'
																	id='label_1_46_1'>Male</label></li>
															<li class='gchoice gchoice_1_46_2'> <input name='input_46'
																	type='radio' value='Non-Binary'
																	id='choice_1_46_2' /> <label for='choice_1_46_2'
																	id='label_1_46_2'>Non-Binary</label></li>
														</ul>
													</div>
												</li>
												<li id="field_1_48"
													class="gfield optional field_sublabel_below field_description_above hidden_label gfield_visibility_visible"
													data-js-reload="field_1_48"><label class='gfield_label'
														for='input_1_48'>Enter Gender</label>
													<div class='ginput_container ginput_container_text'><input
															name='input_48' id='input_1_48' type='text' value=''
															class='small'
															placeholder='How would you describe your gender?'
															aria-invalid="false" /></div>
												</li>
												<li id="field_1_21"
													class="gfield optional traditional indent field_sublabel_below field_description_above hidden_label gfield_visibility_visible"
													data-js-reload="field_1_21"><label
														class='gfield_label gfield_label_before_complex'>Please check
														this box if you identify as transgender.</label>
													<div class='ginput_container ginput_container_checkbox'>
														<ul class='gfield_checkbox' id='input_1_21'>
															<li class='gchoice gchoice_1_21_1'> <input
																	class='gfield-choice-input' name='input_21.1'
																	type='checkbox' value='1' id='choice_1_21_1' />
																<label for='choice_1_21_1' id='label_1_21_1'>Please
																	check this box if you identify as
																	transgender.</label></li>
														</ul>
													</div>
												</li>
												<li id="field_1_22"
													class="gfield optional field_sublabel_below field_description_above gfield_visibility_visible"
													data-js-reload="field_1_22"><label class='gfield_label'
														for='input_1_22'>Race/Ethnicity</label>
													<div class='ginput_container ginput_container_select'><select
															name='input_22' id='input_1_22' class='medium gfield_select'
															aria-invalid="false">
															<option value=''></option>
															<option value='American Indian or Alaska Native'>American
																Indian or Alaska Native</option>
															<option value='Asian'>Asian</option>
															<option value='Black or African American (non-Hispanic)'>
																Black or African American (non-Hispanic)</option>
															<option value='Hispanic or Latino'>Hispanic or Latino
															</option>
															<option value='Middle Eastern or North African'>Middle
																Eastern or North African</option>
															<option value='Native Hawaiian or other Pacific Islander'>
																Native Hawaiian or other Pacific Islander</option>
															<option value='White (non-Hispanic)'>White (non-Hispanic)
															</option>
															<option value='More than one of the above'>More than one of
																the above</option>
															<option value='Other'>Other</option>
														</select></div>
												</li>
												<li id="field_1_23"
													class="gfield optional field_sublabel_below field_description_above gfield_visibility_visible"
													data-js-reload="field_1_23"><label class='gfield_label'
														for='input_1_23'>Household Income</label>
													<div class='ginput_container ginput_container_select'><select
															name='input_23' id='input_1_23' class='medium gfield_select'
															aria-invalid="false">
															<option value=''></option>
															<option value='Less than $20,000'>Less than $20,000</option>
															<option value='$20,000 - $39,999'>$20,000 - $39,999</option>
															<option value='$40,000 - $59,999'>$40,000 - $59,999</option>
															<option value='$60,000 - $79,999'>$60,000 - $79,999</option>
															<option value='$80,000 - $99,999'>$80,000 - $99,999</option>
															<option value='$100,000 - $149,999'>$100,000 - $149,999
															</option>
															<option value='$150,000+'>$150,000+</option>
														</select></div>
												</li>
												<li id="field_1_64"
													class="gfield gfield--width-full field_sublabel_below field_description_above gfield_visibility_visible"
													data-js-reload="field_1_64"><label class='gfield_label'>Do you live
														in the United States or another country?</label>
													<div class='ginput_container ginput_container_radio'>
														<ul class='gfield_radio' id='input_1_64'>
															<li class='gchoice gchoice_1_64_0'> <input name='input_64'
																	type='radio' value='I live in the United States'
																	id='choice_1_64_0' /> <label for='choice_1_64_0'
																	id='label_1_64_0'>I live in the United
																	States</label></li>
															<li class='gchoice gchoice_1_64_1'> <input name='input_64'
																	type='radio' value='I live in another country'
																	id='choice_1_64_1' /> <label for='choice_1_64_1'
																	id='label_1_64_1'>I live in another country</label>
															</li>
														</ul>
													</div>
												</li>
												<li id="field_1_32"
													class="gfield gfield--width-full optional field_sublabel_below field_description_above gfield_visibility_visible"
													data-js-reload="field_1_32"><label class='gfield_label'
														for='input_1_32'>State</label>
													<div class='ginput_container ginput_container_select'><select
															name='input_32' id='input_1_32' class='medium gfield_select'
															aria-invalid="false">
															<option value=''></option>
															<option value='Alabama'>Alabama</option>
															<option value='Alaska'>Alaska</option>
															<option value='Arizona'>Arizona</option>
															<option value='Arkansas'>Arkansas</option>
															<option value='California'>California</option>
															<option value='Colorado'>Colorado</option>
															<option value='Connecticut'>Connecticut</option>
															<option value='Delaware'>Delaware</option>
															<option value='District of Columbia'>District of Columbia
															</option>
															<option value='Florida'>Florida</option>
															<option value='Georgia'>Georgia</option>
															<option value='Hawaii'>Hawaii</option>
															<option value='Idaho'>Idaho</option>
															<option value='Illinois'>Illinois</option>
															<option value='Indiana'>Indiana</option>
															<option value='Iowa'>Iowa</option>
															<option value='Kansas'>Kansas</option>
															<option value='Kentucky'>Kentucky</option>
															<option value='Louisiana'>Louisiana</option>
															<option value='Maine'>Maine</option>
															<option value='Maryland'>Maryland</option>
															<option value='Massachusetts'>Massachusetts</option>
															<option value='Michigan'>Michigan</option>
															<option value='Minnesota'>Minnesota</option>
															<option value='Mississippi'>Mississippi</option>
															<option value='Missouri'>Missouri</option>
															<option value='Montana'>Montana</option>
															<option value='Nebraska'>Nebraska</option>
															<option value='Nevada'>Nevada</option>
															<option value='New Hampshire'>New Hampshire</option>
															<option value='New Jersey'>New Jersey</option>
															<option value='New Mexico'>New Mexico</option>
															<option value='New York'>New York</option>
															<option value='North Carolina'>North Carolina</option>
															<option value='North Dakota'>North Dakota</option>
															<option value='Ohio'>Ohio</option>
															<option value='Oklahoma'>Oklahoma</option>
															<option value='Oregon'>Oregon</option>
															<option value='Pennsylvania'>Pennsylvania</option>
															<option value='Rhode Island'>Rhode Island</option>
															<option value='South Carolina'>South Carolina</option>
															<option value='South Dakota'>South Dakota</option>
															<option value='Tennessee'>Tennessee</option>
															<option value='Texas'>Texas</option>
															<option value='Utah'>Utah</option>
															<option value='Vermont'>Vermont</option>
															<option value='Virginia'>Virginia</option>
															<option value='Washington'>Washington</option>
															<option value='West Virginia'>West Virginia</option>
															<option value='Wisconsin'>Wisconsin</option>
															<option value='Wyoming'>Wyoming</option>
															<option value='I live in a U.S. Territory'>I live in a U.S.
																Territory</option>
														</select></div>
												</li>
												<li id="field_1_36"
													class="gfield gfield--width-full optional field_sublabel_below field_description_above gfield_visibility_visible"
													data-js-reload="field_1_36"><label class='gfield_label'
														for='input_1_36'>What country do you live in?</label>
													<div class='ginput_container ginput_container_select'><select
															name='input_36' id='input_1_36' class='medium gfield_select'
															aria-invalid="false">
															<option value=''></option>
															<option value='Afghanistan'>Afghanistan</option>
															<option value='Albania'>Albania</option>
															<option value='Algeria'>Algeria</option>
															<option value='American Samoa'>American Samoa</option>
															<option value='Andorra'>Andorra</option>
															<option value='Angola'>Angola</option>
															<option value='Anguilla'>Anguilla</option>
															<option value='Antarctica'>Antarctica</option>
															<option value='Antigua and Barbuda'>Antigua and Barbuda
															</option>
															<option value='Argentina'>Argentina</option>
															<option value='Armenia'>Armenia</option>
															<option value='Aruba'>Aruba</option>
															<option value='Australia'>Australia</option>
															<option value='Austria'>Austria</option>
															<option value='Azerbaijan'>Azerbaijan</option>
															<option value='Bahamas'>Bahamas</option>
															<option value='Bahrain'>Bahrain</option>
															<option value='Bangladesh'>Bangladesh</option>
															<option value='Barbados'>Barbados</option>
															<option value='Belarus'>Belarus</option>
															<option value='Belgium'>Belgium</option>
															<option value='Belize'>Belize</option>
															<option value='Benin'>Benin</option>
															<option value='Bermuda'>Bermuda</option>
															<option value='Bhutan'>Bhutan</option>
															<option value='Bolivia'>Bolivia</option>
															<option value='Bonaire, Sint Eustatius and Saba'>Bonaire,
																Sint Eustatius and Saba</option>
															<option value='Bosnia and Herzegovina'>Bosnia and
																Herzegovina</option>
															<option value='Botswana'>Botswana</option>
															<option value='Bouvet Island'>Bouvet Island</option>
															<option value='Brazil'>Brazil</option>
															<option value='British Indian Ocean Territory'>British
																Indian Ocean Territory</option>
															<option value='Brunei Darussalam'>Brunei Darussalam</option>
															<option value='Bulgaria'>Bulgaria</option>
															<option value='Burkina Faso'>Burkina Faso</option>
															<option value='Burundi'>Burundi</option>
															<option value='Cambodia'>Cambodia</option>
															<option value='Cameroon'>Cameroon</option>
															<option value='Canada'>Canada</option>
															<option value='Cape Verde'>Cape Verde</option>
															<option value='Cayman Islands'>Cayman Islands</option>
															<option value='Central African Republic'>Central African
																Republic</option>
															<option value='Chad'>Chad</option>
															<option value='Chile'>Chile</option>
															<option value='China'>China</option>
															<option value='Christmas Island'>Christmas Island</option>
															<option value='Cocos Islands'>Cocos Islands</option>
															<option value='Colombia'>Colombia</option>
															<option value='Comoros'>Comoros</option>
															<option value='Congo, Democratic Republic of the'>Congo,
																Democratic Republic of the</option>
															<option value='Congo, Republic of the'>Congo, Republic of
																the</option>
															<option value='Cook Islands'>Cook Islands</option>
															<option value='Costa Rica'>Costa Rica</option>
															<option value='Croatia'>Croatia</option>
															<option value='Cuba'>Cuba</option>
															<option value='Curaçao'>Curaçao</option>
															<option value='Cyprus'>Cyprus</option>
															<option value='Czech Republic'>Czech Republic</option>
															<option value='Côte d&#039;Ivoire'>Côte d&#039;Ivoire
															</option>
															<option value='Denmark'>Denmark</option>
															<option value='Djibouti'>Djibouti</option>
															<option value='Dominica'>Dominica</option>
															<option value='Dominican Republic'>Dominican Republic
															</option>
															<option value='Ecuador'>Ecuador</option>
															<option value='Egypt'>Egypt</option>
															<option value='El Salvador'>El Salvador</option>
															<option value='Equatorial Guinea'>Equatorial Guinea</option>
															<option value='Eritrea'>Eritrea</option>
															<option value='Estonia'>Estonia</option>
															<option value='Eswatini (Swaziland)'>Eswatini (Swaziland)
															</option>
															<option value='Ethiopia'>Ethiopia</option>
															<option value='Falkland Islands'>Falkland Islands</option>
															<option value='Faroe Islands'>Faroe Islands</option>
															<option value='Fiji'>Fiji</option>
															<option value='Finland'>Finland</option>
															<option value='France'>France</option>
															<option value='French Guiana'>French Guiana</option>
															<option value='French Polynesia'>French Polynesia</option>
															<option value='French Southern Territories'>French Southern
																Territories</option>
															<option value='Gabon'>Gabon</option>
															<option value='Gambia'>Gambia</option>
															<option value='Georgia'>Georgia</option>
															<option value='Germany'>Germany</option>
															<option value='Ghana'>Ghana</option>
															<option value='Gibraltar'>Gibraltar</option>
															<option value='Greece'>Greece</option>
															<option value='Greenland'>Greenland</option>
															<option value='Grenada'>Grenada</option>
															<option value='Guadeloupe'>Guadeloupe</option>
															<option value='Guam'>Guam</option>
															<option value='Guatemala'>Guatemala</option>
															<option value='Guernsey'>Guernsey</option>
															<option value='Guinea'>Guinea</option>
															<option value='Guinea-Bissau'>Guinea-Bissau</option>
															<option value='Guyana'>Guyana</option>
															<option value='Haiti'>Haiti</option>
															<option value='Heard and McDonald Islands'>Heard and
																McDonald Islands</option>
															<option value='Holy See'>Holy See</option>
															<option value='Honduras'>Honduras</option>
															<option value='Hong Kong'>Hong Kong</option>
															<option value='Hungary'>Hungary</option>
															<option value='Iceland'>Iceland</option>
															<option value='India'>India</option>
															<option value='Indonesia'>Indonesia</option>
															<option value='Iran'>Iran</option>
															<option value='Iraq'>Iraq</option>
															<option value='Ireland'>Ireland</option>
															<option value='Isle of Man'>Isle of Man</option>
															<option value='Israel'>Israel</option>
															<option value='Italy'>Italy</option>
															<option value='Jamaica'>Jamaica</option>
															<option value='Japan'>Japan</option>
															<option value='Jersey'>Jersey</option>
															<option value='Jordan'>Jordan</option>
															<option value='Kazakhstan'>Kazakhstan</option>
															<option value='Kenya'>Kenya</option>
															<option value='Kiribati'>Kiribati</option>
															<option value='Kuwait'>Kuwait</option>
															<option value='Kyrgyzstan'>Kyrgyzstan</option>
															<option value='Lao People&#039;s Democratic Republic'>Lao
																People&#039;s Democratic Republic</option>
															<option value='Latvia'>Latvia</option>
															<option value='Lebanon'>Lebanon</option>
															<option value='Lesotho'>Lesotho</option>
															<option value='Liberia'>Liberia</option>
															<option value='Libya'>Libya</option>
															<option value='Liechtenstein'>Liechtenstein</option>
															<option value='Lithuania'>Lithuania</option>
															<option value='Luxembourg'>Luxembourg</option>
															<option value='Macau'>Macau</option>
															<option value='Macedonia'>Macedonia</option>
															<option value='Madagascar'>Madagascar</option>
															<option value='Malawi'>Malawi</option>
															<option value='Malaysia'>Malaysia</option>
															<option value='Maldives'>Maldives</option>
															<option value='Mali'>Mali</option>
															<option value='Malta'>Malta</option>
															<option value='Marshall Islands'>Marshall Islands</option>
															<option value='Martinique'>Martinique</option>
															<option value='Mauritania'>Mauritania</option>
															<option value='Mauritius'>Mauritius</option>
															<option value='Mayotte'>Mayotte</option>
															<option value='Mexico'>Mexico</option>
															<option value='Micronesia'>Micronesia</option>
															<option value='Moldova'>Moldova</option>
															<option value='Monaco'>Monaco</option>
															<option value='Mongolia'>Mongolia</option>
															<option value='Montenegro'>Montenegro</option>
															<option value='Montserrat'>Montserrat</option>
															<option value='Morocco'>Morocco</option>
															<option value='Mozambique'>Mozambique</option>
															<option value='Myanmar'>Myanmar</option>
															<option value='Namibia'>Namibia</option>
															<option value='Nauru'>Nauru</option>
															<option value='Nepal'>Nepal</option>
															<option value='Netherlands'>Netherlands</option>
															<option value='New Caledonia'>New Caledonia</option>
															<option value='New Zealand'>New Zealand</option>
															<option value='Nicaragua'>Nicaragua</option>
															<option value='Niger'>Niger</option>
															<option value='Nigeria'>Nigeria</option>
															<option value='Niue'>Niue</option>
															<option value='Norfolk Island'>Norfolk Island</option>
															<option value='North Korea'>North Korea</option>
															<option value='Northern Mariana Islands'>Northern Mariana
																Islands</option>
															<option value='Norway'>Norway</option>
															<option value='Oman'>Oman</option>
															<option value='Pakistan'>Pakistan</option>
															<option value='Palau'>Palau</option>
															<option value='Palestine, State of'>Palestine, State of
															</option>
															<option value='Panama'>Panama</option>
															<option value='Papua New Guinea'>Papua New Guinea</option>
															<option value='Paraguay'>Paraguay</option>
															<option value='Peru'>Peru</option>
															<option value='Philippines'>Philippines</option>
															<option value='Pitcairn'>Pitcairn</option>
															<option value='Poland'>Poland</option>
															<option value='Portugal'>Portugal</option>
															<option value='Puerto Rico'>Puerto Rico</option>
															<option value='Qatar'>Qatar</option>
															<option value='Romania'>Romania</option>
															<option value='Russia'>Russia</option>
															<option value='Rwanda'>Rwanda</option>
															<option value='Réunion'>Réunion</option>
															<option value='Saint Barthélemy'>Saint Barthélemy</option>
															<option value='Saint Helena'>Saint Helena</option>
															<option value='Saint Kitts and Nevis'>Saint Kitts and Nevis
															</option>
															<option value='Saint Lucia'>Saint Lucia</option>
															<option value='Saint Martin'>Saint Martin</option>
															<option value='Saint Pierre and Miquelon'>Saint Pierre and
																Miquelon</option>
															<option value='Saint Vincent and the Grenadines'>Saint
																Vincent and the Grenadines</option>
															<option value='Samoa'>Samoa</option>
															<option value='San Marino'>San Marino</option>
															<option value='Sao Tome and Principe'>Sao Tome and Principe
															</option>
															<option value='Saudi Arabia'>Saudi Arabia</option>
															<option value='Senegal'>Senegal</option>
															<option value='Serbia'>Serbia</option>
															<option value='Seychelles'>Seychelles</option>
															<option value='Sierra Leone'>Sierra Leone</option>
															<option value='Singapore'>Singapore</option>
															<option value='Sint Maarten'>Sint Maarten</option>
															<option value='Slovakia'>Slovakia</option>
															<option value='Slovenia'>Slovenia</option>
															<option value='Solomon Islands'>Solomon Islands</option>
															<option value='Somalia'>Somalia</option>
															<option value='South Africa'>South Africa</option>
															<option value='South Georgia'>South Georgia</option>
															<option value='South Korea'>South Korea</option>
															<option value='South Sudan'>South Sudan</option>
															<option value='Spain'>Spain</option>
															<option value='Sri Lanka'>Sri Lanka</option>
															<option value='Sudan'>Sudan</option>
															<option value='Suriname'>Suriname</option>
															<option value='Svalbard and Jan Mayen Islands'>Svalbard and
																Jan Mayen Islands</option>
															<option value='Sweden'>Sweden</option>
															<option value='Switzerland'>Switzerland</option>
															<option value='Syria'>Syria</option>
															<option value='Taiwan'>Taiwan</option>
															<option value='Tajikistan'>Tajikistan</option>
															<option value='Tanzania'>Tanzania</option>
															<option value='Thailand'>Thailand</option>
															<option value='Timor-Leste'>Timor-Leste</option>
															<option value='Togo'>Togo</option>
															<option value='Tokelau'>Tokelau</option>
															<option value='Tonga'>Tonga</option>
															<option value='Trinidad and Tobago'>Trinidad and Tobago
															</option>
															<option value='Tunisia'>Tunisia</option>
															<option value='Turkey'>Turkey</option>
															<option value='Turkmenistan'>Turkmenistan</option>
															<option value='Turks and Caicos Islands'>Turks and Caicos
																Islands</option>
															<option value='Tuvalu'>Tuvalu</option>
															<option value='US Minor Outlying Islands'>US Minor Outlying
																Islands</option>
															<option value='Uganda'>Uganda</option>
															<option value='Ukraine'>Ukraine</option>
															<option value='United Arab Emirates'>United Arab Emirates
															</option>
															<option value='United Kingdom'>United Kingdom</option>
															<option value='Uruguay'>Uruguay</option>
															<option value='Uzbekistan'>Uzbekistan</option>
															<option value='Vanuatu'>Vanuatu</option>
															<option value='Venezuela'>Venezuela</option>
															<option value='Vietnam'>Vietnam</option>
															<option value='Virgin Islands, British'>Virgin Islands,
																British</option>
															<option value='Virgin Islands, U.S.'>Virgin Islands, U.S.
															</option>
															<option value='Wallis and Futuna'>Wallis and Futuna</option>
															<option value='Western Sahara'>Western Sahara</option>
															<option value='Yemen'>Yemen</option>
															<option value='Zambia'>Zambia</option>
															<option value='Zimbabwe'>Zimbabwe</option>
															<option value='Åland Islands'>Åland Islands</option>
														</select></div>
												</li>
												<li id="field_1_34"
													class="gfield gfield--width-full optional field_sublabel_below field_description_above gfield_visibility_visible"
													data-js-reload="field_1_34"><label class='gfield_label'
														for='input_1_34'>Zip/Postal Code</label>
													<div class='ginput_container ginput_container_text'><input
															name='input_34' id='input_1_34' type='text' value=''
															class='small' aria-invalid="false" /></div>
												</li>
												<li id="field_1_28"
													class="gfield optional traditional field_sublabel_below field_description_above gfield_visibility_visible"
													data-js-reload="field_1_28"><label
														class='gfield_label gfield_label_before_complex'>Which of the
														following populations describes you?</label>
													<div class='gfield_description' id='gfield_description_1_28'>Select
														all that apply.</div>
													<div class='ginput_container ginput_container_checkbox'>
														<ul class='gfield_checkbox' id='input_1_28'>
															<li class='gchoice gchoice_1_28_1'> <input
																	class='gfield-choice-input' name='input_28.1'
																	type='checkbox'
																	value='Veteran or active-duty military'
																	id='choice_1_28_1'
																	aria-describedby="gfield_description_1_28" /> <label
																	for='choice_1_28_1' id='label_1_28_1'>Veteran or
																	active-duty military</label></li>
															<li class='gchoice gchoice_1_28_2'> <input
																	class='gfield-choice-input' name='input_28.2'
																	type='checkbox'
																	value='Caregiver of someone living with emotional or physical illness'
																	id='choice_1_28_2' /> <label for='choice_1_28_2'
																	id='label_1_28_2'>Caregiver of someone living with
																	emotional or physical illness</label></li>
															<li class='gchoice gchoice_1_28_3'> <input
																	class='gfield-choice-input' name='input_28.3'
																	type='checkbox' value='LGBTQ+' id='choice_1_28_3' />
																<label for='choice_1_28_3'
																	id='label_1_28_3'>LGBTQ+</label></li>
															<li class='gchoice gchoice_1_28_4'> <input
																	class='gfield-choice-input' name='input_28.4'
																	type='checkbox' value='Student'
																	id='choice_1_28_4' /> <label for='choice_1_28_4'
																	id='label_1_28_4'>Student</label></li>
															<li class='gchoice gchoice_1_28_5'> <input
																	class='gfield-choice-input' name='input_28.5'
																	type='checkbox' value='Trauma survivor'
																	id='choice_1_28_5' /> <label for='choice_1_28_5'
																	id='label_1_28_5'>Trauma survivor</label></li>
															<li class='gchoice gchoice_1_28_6'> <input
																	class='gfield-choice-input' name='input_28.6'
																	type='checkbox' value='New or expecting parent'
																	id='choice_1_28_6' /> <label for='choice_1_28_6'
																	id='label_1_28_6'>New or expecting parent</label>
															</li>
															<li class='gchoice gchoice_1_28_7'> <input
																	class='gfield-choice-input' name='input_28.7'
																	type='checkbox' value='Healthcare worker'
																	id='choice_1_28_7' /> <label for='choice_1_28_7'
																	id='label_1_28_7'>Healthcare worker</label></li>
														</ul>
													</div>
												</li>
												<li id="field_1_55"
													class="gfield optional traditional limit-1 field_sublabel_below field_description_above gfield_visibility_hidden"
													data-js-reload="field_1_55">
													<div class='admin-hidden-markup'><i
															class='gform-icon gform-icon--hidden'></i><span>Hidden</span>
													</div><label class='gfield_label gfield_label_before_complex'>As a
														caregiver, what supports do you need?</label>
													<div class='ginput_container ginput_container_checkbox'>
														<ul class='gfield_checkbox' id='input_1_55'>
															<li class='gchoice gchoice_1_55_1'> <input
																	class='gfield-choice-input' name='input_55.1'
																	type='checkbox'
																	value='The person I&#039;m helping is getting treatment but is getting worse (meds or therapy stopped working)'
																	id='choice_1_55_1' /> <label for='choice_1_55_1'
																	id='label_1_55_1'>The person I'm helping is getting
																	treatment but is getting worse (meds or therapy
																	stopped working)</label></li>
															<li class='gchoice gchoice_1_55_2'> <input
																	class='gfield-choice-input' name='input_55.2'
																	type='checkbox'
																	value='The person I&#039;m helping is getting treatment but also needs something else (side effects cause other problems, not sure what else to do)'
																	id='choice_1_55_2' /> <label for='choice_1_55_2'
																	id='label_1_55_2'>The person I'm helping is getting
																	treatment but also needs something else (side
																	effects cause other problems, not sure what else to
																	do)</label></li>
															<li class='gchoice gchoice_1_55_3'> <input
																	class='gfield-choice-input' name='input_55.3'
																	type='checkbox'
																	value='The person I&#039;m helping doesn&#039;t want treatment and I want to figure out how to help them'
																	id='choice_1_55_3' /> <label for='choice_1_55_3'
																	id='label_1_55_3'>The person I'm helping doesn't
																	want treatment and I want to figure out how to help
																	them</label></li>
															<li class='gchoice gchoice_1_55_4'> <input
																	class='gfield-choice-input' name='input_55.4'
																	type='checkbox'
																	value='I need help because the stress of caretaking is hard'
																	id='choice_1_55_4' /> <label for='choice_1_55_4'
																	id='label_1_55_4'>I need help because the stress of
																	caretaking is hard</label></li>
															<li class='gchoice gchoice_1_55_5'> <input
																	class='gfield-choice-input' name='input_55.5'
																	type='checkbox' value='Other...'
																	id='choice_1_55_5' /> <label for='choice_1_55_5'
																	id='label_1_55_5'>Other...</label></li>
														</ul>
													</div>
												</li>
												<li id="field_1_56"
													class="gfield optional field_sublabel_below field_description_above hidden_label gfield_visibility_hidden"
													data-js-reload="field_1_56">
													<div class='admin-hidden-markup'><i
															class='gform-icon gform-icon--hidden'></i><span>Hidden</span>
													</div><label class='gfield_label' for='input_1_56'>Caregiver Support
														- Other</label>
													<div class='ginput_container ginput_container_text'><input
															name='input_56' id='input_1_56' type='text' value=''
															class='medium' placeholder='Enter other...'
															aria-invalid="false" /></div>
												</li>
												<li id="field_1_65"
													class="gfield gfield--width-full traditional field_sublabel_below field_description_above gfield_visibility_visible"
													data-js-reload="field_1_65"><label class='gfield_label'>Are you
														caring for someone with a mental or physical health
														condition?</label>
													<div class='ginput_container ginput_container_radio'>
														<ul class='gfield_radio' id='input_1_65'>
															<li class='gchoice gchoice_1_65_0'> <input name='input_65'
																	type='radio' value='Mental health condition'
																	id='choice_1_65_0' /> <label for='choice_1_65_0'
																	id='label_1_65_0'>Mental health condition</label>
															</li>
															<li class='gchoice gchoice_1_65_1'> <input name='input_65'
																	type='radio' value='Physical health condition'
																	id='choice_1_65_1' /> <label for='choice_1_65_1'
																	id='label_1_65_1'>Physical health condition</label>
															</li>
															<li class='gchoice gchoice_1_65_2'> <input name='input_65'
																	type='radio'
																	value='Both mental and physical health conditions'
																	id='choice_1_65_2' /> <label for='choice_1_65_2'
																	id='label_1_65_2'>Both mental and physical health
																	conditions</label></li>
														</ul>
													</div>
												</li>
												<li id="field_1_49"
													class="gfield optional traditional limit-1 field_sublabel_below field_description_above gfield_visibility_hidden"
													data-js-reload="field_1_49">
													<div class='admin-hidden-markup'><i
															class='gform-icon gform-icon--hidden'></i><span>Hidden</span>
													</div><label class='gfield_label gfield_label_before_complex'>Which
														of the following best describes your sexual orientation?
														(old)</label>
													<div class='ginput_container ginput_container_checkbox'>
														<ul class='gfield_checkbox' id='input_1_49'>
															<li class='gchoice gchoice_1_49_1'> <input
																	class='gfield-choice-input' name='input_49.1'
																	type='checkbox' value='Lesbian'
																	id='choice_1_49_1' /> <label for='choice_1_49_1'
																	id='label_1_49_1'>Lesbian</label></li>
															<li class='gchoice gchoice_1_49_2'> <input
																	class='gfield-choice-input' name='input_49.2'
																	type='checkbox' value='Gay' id='choice_1_49_2' />
																<label for='choice_1_49_2' id='label_1_49_2'>Gay</label>
															</li>
															<li class='gchoice gchoice_1_49_3'> <input
																	class='gfield-choice-input' name='input_49.3'
																	type='checkbox' value='Bisexual'
																	id='choice_1_49_3' /> <label for='choice_1_49_3'
																	id='label_1_49_3'>Bisexual</label></li>
															<li class='gchoice gchoice_1_49_4'> <input
																	class='gfield-choice-input' name='input_49.4'
																	type='checkbox' value='Queer' id='choice_1_49_4' />
																<label for='choice_1_49_4'
																	id='label_1_49_4'>Queer</label></li>
															<li class='gchoice gchoice_1_49_5'> <input
																	class='gfield-choice-input' name='input_49.5'
																	type='checkbox' value='Pansexual'
																	id='choice_1_49_5' /> <label for='choice_1_49_5'
																	id='label_1_49_5'>Pansexual</label></li>
															<li class='gchoice gchoice_1_49_6'> <input
																	class='gfield-choice-input' name='input_49.6'
																	type='checkbox' value='Asexual'
																	id='choice_1_49_6' /> <label for='choice_1_49_6'
																	id='label_1_49_6'>Asexual</label></li>
															<li class='gchoice gchoice_1_49_7'> <input
																	class='gfield-choice-input' name='input_49.7'
																	type='checkbox' value='Other...'
																	id='choice_1_49_7' /> <label for='choice_1_49_7'
																	id='label_1_49_7'>Other...</label></li>
														</ul>
													</div>
												</li>
												<li id="field_1_66"
													class="gfield gfield--width-full field_sublabel_below field_description_above gfield_visibility_visible"
													data-js-reload="field_1_66"><label class='gfield_label'
														for='input_1_66'>Which of the following best describes your
														sexual orientation?</label>
													<div class='ginput_container ginput_container_select'><select
															name='input_66' id='input_1_66' class='medium gfield_select'
															aria-invalid="false">
															<option value=''></option>
															<option value='Lesbian or Gay'>Lesbian or Gay</option>
															<option value='Bisexual'>Bisexual</option>
															<option value='Queer'>Queer</option>
															<option value='Pansexual'>Pansexual</option>
															<option value='Asexual'>Asexual</option>
															<option value='Other...'>Other...</option>
														</select></div>
												</li>
												<li id="field_1_50"
													class="gfield optional field_sublabel_below field_description_above hidden_label gfield_visibility_visible"
													data-js-reload="field_1_50"><label class='gfield_label'
														for='input_1_50'>Sexual Orientation - Other</label>
													<div class='ginput_container ginput_container_text'><input
															name='input_50' id='input_1_50' type='text' value=''
															class='small' placeholder='Enter sexual orientation...'
															aria-invalid="false" /></div>
												</li>
												<li id="field_1_67"
													class="gfield gfield--width-full traditional field_sublabel_below field_description_above gfield_visibility_visible"
													data-js-reload="field_1_67"><label
														class='gfield_label gfield_label_before_complex'>Which of the
														following describe your experience of trauma?</label>
													<div class='ginput_container ginput_container_checkbox'>
														<ul class='gfield_checkbox' id='input_1_67'>
															<li class='gchoice gchoice_1_67_1'> <input
																	class='gfield-choice-input' name='input_67.1'
																	type='checkbox' value='Child abuse/violence'
																	id='choice_1_67_1' /> <label for='choice_1_67_1'
																	id='label_1_67_1'>Child abuse/violence</label></li>
															<li class='gchoice gchoice_1_67_2'> <input
																	class='gfield-choice-input' name='input_67.2'
																	type='checkbox' value='Intimate partner violence'
																	id='choice_1_67_2' /> <label for='choice_1_67_2'
																	id='label_1_67_2'>Intimate partner violence</label>
															</li>
															<li class='gchoice gchoice_1_67_3'> <input
																	class='gfield-choice-input' name='input_67.3'
																	type='checkbox' value='Sexual assault/violence'
																	id='choice_1_67_3' /> <label for='choice_1_67_3'
																	id='label_1_67_3'>Sexual assault/violence</label>
															</li>
															<li class='gchoice gchoice_1_67_4'> <input
																	class='gfield-choice-input' name='input_67.4'
																	type='checkbox'
																	value='Serious illness/injury/assault'
																	id='choice_1_67_4' /> <label for='choice_1_67_4'
																	id='label_1_67_4'>Serious
																	illness/injury/assault</label></li>
															<li class='gchoice gchoice_1_67_5'> <input
																	class='gfield-choice-input' name='input_67.5'
																	type='checkbox'
																	value='Family conflict (identity acceptance/separation/divorce)'
																	id='choice_1_67_5' /> <label for='choice_1_67_5'
																	id='label_1_67_5'>Family conflict (identity
																	acceptance/separation/divorce)</label></li>
															<li class='gchoice gchoice_1_67_6'> <input
																	class='gfield-choice-input' name='input_67.6'
																	type='checkbox'
																	value='Traumatic event (natural disaster, accident, witnessing violence, etc.)'
																	id='choice_1_67_6' /> <label for='choice_1_67_6'
																	id='label_1_67_6'>Traumatic event (natural disaster,
																	accident, witnessing violence, etc.)</label></li>
															<li class='gchoice gchoice_1_67_7'> <input
																	class='gfield-choice-input' name='input_67.7'
																	type='checkbox' value='Death of a loved one'
																	id='choice_1_67_7' /> <label for='choice_1_67_7'
																	id='label_1_67_7'>Death of a loved one</label></li>
															<li class='gchoice gchoice_1_67_8'> <input
																	class='gfield-choice-input' name='input_67.8'
																	type='checkbox'
																	value='Other and/or tell us more about your trauma'
																	id='choice_1_67_8' /> <label for='choice_1_67_8'
																	id='label_1_67_8'>Other and/or tell us more about
																	your trauma</label></li>
														</ul>
													</div>
												</li>
												<li id="field_1_68"
													class="gfield gfield--width-full field_sublabel_below field_description_above hidden_label gfield_visibility_visible"
													data-js-reload="field_1_68"><label class='gfield_label'
														for='input_1_68'>Trauma - Other</label>
													<div class='ginput_container ginput_container_text'><input
															name='input_68' id='input_1_68' type='text' value=''
															class='medium'
															placeholder='Tell us more about your trauma...'
															aria-invalid="false" /></div>
												</li>
												<li id="field_1_43"
													class="gfield section-title gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below field_description_above gfield_visibility_visible"
													data-js-reload="field_1_43">
													<h2>About Your Mental Health</h2>
												</li>
												<li id="field_1_24"
													class="gfield optional short field_sublabel_below field_description_above gfield_visibility_hidden"
													data-js-reload="field_1_24">
													<div class='admin-hidden-markup'><i
															class='gform-icon gform-icon--hidden'></i><span>Hidden</span>
													</div><label class='gfield_label'>Have you ever been diagnosed with
														a mental health condition by a professional (doctor, therapist,
														etc.)?</label>
													<div class='ginput_container ginput_container_radio'>
														<ul class='gfield_radio' id='input_1_24'>
															<li class='gchoice gchoice_1_24_0'> <input name='input_24'
																	type='radio' value='Yes' id='choice_1_24_0' />
																<label for='choice_1_24_0' id='label_1_24_0'>Yes</label>
															</li>
															<li class='gchoice gchoice_1_24_1'> <input name='input_24'
																	type='radio' value='No' id='choice_1_24_1' /> <label
																	for='choice_1_24_1' id='label_1_24_1'>No</label>
															</li>
														</ul>
													</div>
												</li>
												<li id="field_1_25"
													class="gfield optional short field_sublabel_below field_description_above gfield_visibility_visible"
													data-js-reload="field_1_25"><label class='gfield_label'>Have you
														ever received treatment/support for a mental health
														problem?</label>
													<div class='ginput_container ginput_container_radio'>
														<ul class='gfield_radio' id='input_1_25'>
															<li class='gchoice gchoice_1_25_0'> <input name='input_25'
																	type='radio' value='Yes' id='choice_1_25_0' />
																<label for='choice_1_25_0' id='label_1_25_0'>Yes</label>
															</li>
															<li class='gchoice gchoice_1_25_1'> <input name='input_25'
																	type='radio' value='No' id='choice_1_25_1' /> <label
																	for='choice_1_25_1' id='label_1_25_1'>No</label>
															</li>
														</ul>
													</div>
												</li>
												<li id="field_1_57"
													class="gfield optional short field_sublabel_below field_description_above gfield_visibility_visible"
													data-js-reload="field_1_57"><label class='gfield_label'>Are you
														receiving treatment/support now?</label>
													<div class='ginput_container ginput_container_radio'>
														<ul class='gfield_radio' id='input_1_57'>
															<li class='gchoice gchoice_1_57_0'> <input name='input_57'
																	type='radio' value='Yes' id='choice_1_57_0' />
																<label for='choice_1_57_0' id='label_1_57_0'>Yes</label>
															</li>
															<li class='gchoice gchoice_1_57_1'> <input name='input_57'
																	type='radio' value='No' id='choice_1_57_1' /> <label
																	for='choice_1_57_1' id='label_1_57_1'>No</label>
															</li>
														</ul>
													</div>
												</li>
												<li id="field_1_26"
													class="gfield optional traditional limit-3 field_sublabel_below field_description_above gfield_visibility_visible"
													data-js-reload="field_1_26"><label
														class='gfield_label gfield_label_before_complex'>Think about
														your mental health test. What are the main things contributing
														to your mental health problems right now?</label>
													<div class='gfield_description' id='gfield_description_1_26'>Choose
														up to 3.</div>
													<div class='ginput_container ginput_container_checkbox'>
														<ul class='gfield_checkbox' id='input_1_26'>
															<li class='gchoice gchoice_1_26_1'> <input
																	class='gfield-choice-input' name='input_26.1'
																	type='checkbox' value='Abuse or violence'
																	id='choice_1_26_1'
																	aria-describedby="gfield_description_1_26" /> <label
																	for='choice_1_26_1' id='label_1_26_1'>Abuse or
																	violence</label></li>
															<li class='gchoice gchoice_1_26_2'> <input
																	class='gfield-choice-input' name='input_26.2'
																	type='checkbox'
																	value='Relationship problems (friends, family, or significant other)'
																	id='choice_1_26_2' /> <label for='choice_1_26_2'
																	id='label_1_26_2'>Relationship problems (friends,
																	family, or significant other)</label></li>
															<li class='gchoice gchoice_1_26_3'> <input
																	class='gfield-choice-input' name='input_26.3'
																	type='checkbox' value='Body image or self-image'
																	id='choice_1_26_3' /> <label for='choice_1_26_3'
																	id='label_1_26_3'>Body image or self-image</label>
															</li>
															<li class='gchoice gchoice_1_26_4'> <input
																	class='gfield-choice-input' name='input_26.4'
																	type='checkbox' value='School or work problems'
																	id='choice_1_26_4' /> <label for='choice_1_26_4'
																	id='label_1_26_4'>School or work problems</label>
															</li>
															<li class='gchoice gchoice_1_26_5'> <input
																	class='gfield-choice-input' name='input_26.5'
																	type='checkbox'
																	value='Basic needs (no food or housing)'
																	id='choice_1_26_5' /> <label for='choice_1_26_5'
																	id='label_1_26_5'>Basic needs (no food or
																	housing)</label></li>
															<li class='gchoice gchoice_1_26_6'> <input
																	class='gfield-choice-input' name='input_26.6'
																	type='checkbox' value='Financial problems'
																	id='choice_1_26_6' /> <label for='choice_1_26_6'
																	id='label_1_26_6'>Financial problems</label></li>
															<li class='gchoice gchoice_1_26_7'> <input
																	class='gfield-choice-input' name='input_26.7'
																	type='checkbox' value='Loneliness or isolation'
																	id='choice_1_26_7' /> <label for='choice_1_26_7'
																	id='label_1_26_7'>Loneliness or isolation</label>
															</li>
															<li class='gchoice gchoice_1_26_8'> <input
																	class='gfield-choice-input' name='input_26.8'
																	type='checkbox'
																	value='Grief or loss of someone or something'
																	id='choice_1_26_8' /> <label for='choice_1_26_8'
																	id='label_1_26_8'>Grief or loss of someone or
																	something</label></li>
															<li class='gchoice gchoice_1_26_9'> <input
																	class='gfield-choice-input' name='input_26.9'
																	type='checkbox'
																	value='Racism, homophobia, transphobia, or discrimination'
																	id='choice_1_26_9' /> <label for='choice_1_26_9'
																	id='label_1_26_9'>Racism, homophobia, transphobia,
																	or discrimination</label></li>
															<li class='gchoice gchoice_1_26_11'> <input
																	class='gfield-choice-input' name='input_26.11'
																	type='checkbox' value='Other...'
																	id='choice_1_26_11' /> <label for='choice_1_26_11'
																	id='label_1_26_11'>Other...</label></li>
														</ul>
													</div>
												</li>
												<li id="field_1_27"
													class="gfield optional field_sublabel_below field_description_above hidden_label gfield_visibility_visible"
													data-js-reload="field_1_27"><label class='gfield_label'
														for='input_1_27'>Mental Health Problems - Other</label>
													<div class='ginput_container ginput_container_text'><input
															name='input_27' id='input_1_27' type='text' value=''
															class='medium' placeholder='Enter other...'
															aria-invalid="false" /></div>
												</li>
												<li id="field_1_44"
													class="gfield section-title gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below field_description_above gfield_visibility_visible"
													data-js-reload="field_1_44">
													<h2>About Your Health</h2>
												</li>
												<li id="field_1_29"
													class="gfield optional short field_sublabel_below field_description_above gfield_visibility_visible"
													data-js-reload="field_1_29"><label class='gfield_label'>Do you
														currently have health insurance?</label>
													<div class='ginput_container ginput_container_radio'>
														<ul class='gfield_radio' id='input_1_29'>
															<li class='gchoice gchoice_1_29_0'> <input name='input_29'
																	type='radio' value='Yes' id='choice_1_29_0' />
																<label for='choice_1_29_0' id='label_1_29_0'>Yes</label>
															</li>
															<li class='gchoice gchoice_1_29_1'> <input name='input_29'
																	type='radio' value='No' id='choice_1_29_1' /> <label
																	for='choice_1_29_1' id='label_1_29_1'>No</label>
															</li>
														</ul>
													</div>
												</li>
												<li id="field_1_30"
													class="gfield optional traditional field_sublabel_below field_description_above gfield_visibility_visible"
													data-js-reload="field_1_30"><label
														class='gfield_label gfield_label_before_complex'>Do you have any
														of the following general health conditions?</label>
													<div class='gfield_description' id='gfield_description_1_30'>Select
														all that apply.</div>
													<div class='ginput_container ginput_container_checkbox'>
														<ul class='gfield_checkbox' id='input_1_30'>
															<li class='gchoice gchoice_1_30_1'> <input
																	class='gfield-choice-input' name='input_30.1'
																	type='checkbox' value='Heart disease'
																	id='choice_1_30_1'
																	aria-describedby="gfield_description_1_30" /> <label
																	for='choice_1_30_1' id='label_1_30_1'>Heart
																	disease</label></li>
															<li class='gchoice gchoice_1_30_2'> <input
																	class='gfield-choice-input' name='input_30.2'
																	type='checkbox'
																	value='Reproductive health concerns (PCOS, endometriosis, infertility, etc.)'
																	id='choice_1_30_2' /> <label for='choice_1_30_2'
																	id='label_1_30_2'>Reproductive health concerns
																	(PCOS, endometriosis, infertility, etc.)</label>
															</li>
															<li class='gchoice gchoice_1_30_3'> <input
																	class='gfield-choice-input' name='input_30.3'
																	type='checkbox' value='Diabetes'
																	id='choice_1_30_3' /> <label for='choice_1_30_3'
																	id='label_1_30_3'>Diabetes</label></li>
															<li class='gchoice gchoice_1_30_4'> <input
																	class='gfield-choice-input' name='input_30.4'
																	type='checkbox' value='Cancer' id='choice_1_30_4' />
																<label for='choice_1_30_4'
																	id='label_1_30_4'>Cancer</label></li>
															<li class='gchoice gchoice_1_30_5'> <input
																	class='gfield-choice-input' name='input_30.5'
																	type='checkbox'
																	value='Arthritis or other chronic pain'
																	id='choice_1_30_5' /> <label for='choice_1_30_5'
																	id='label_1_30_5'>Arthritis or other chronic
																	pain</label></li>
															<li class='gchoice gchoice_1_30_6'> <input
																	class='gfield-choice-input' name='input_30.6'
																	type='checkbox'
																	value='COPD or other lung conditions'
																	id='choice_1_30_6' /> <label for='choice_1_30_6'
																	id='label_1_30_6'>COPD or other lung
																	conditions</label></li>
															<li class='gchoice gchoice_1_30_7'> <input
																	class='gfield-choice-input' name='input_30.7'
																	type='checkbox'
																	value='Movement Disorders (involuntary tics, tardive dyskinesia, etc.)'
																	id='choice_1_30_7' /> <label for='choice_1_30_7'
																	id='label_1_30_7'>Movement Disorders (involuntary
																	tics, tardive dyskinesia, etc.)</label></li>
															<li class='gchoice gchoice_1_30_8'> <input
																	class='gfield-choice-input' name='input_30.8'
																	type='checkbox' value='Other...'
																	id='choice_1_30_8' /> <label for='choice_1_30_8'
																	id='label_1_30_8'>Other...</label></li>
														</ul>
													</div>
												</li>
												<li id="field_1_31"
													class="gfield optional field_sublabel_below field_description_above hidden_label gfield_visibility_visible"
													data-js-reload="field_1_31"><label class='gfield_label'
														for='input_1_31'>If &#039;Other&#039; please specify (for
														general health conditions)</label>
													<div class='ginput_container ginput_container_text'><input
															name='input_31' id='input_1_31' type='text' value=''
															class='large' placeholder='Enter other...'
															aria-invalid="false" /></div>
												</li>
												<li id="field_1_69"
													class="gfield gform_validation_container field_sublabel_below field_description_above gfield_visibility_visible"
													data-js-reload="field_1_69"><label class='gfield_label'
														for='input_1_69'>Email</label>
													<div class='gfield_description' id='gfield_description_1_69'>This
														field is for validation purposes and should be left unchanged.
													</div>
													<div class='ginput_container'><input name='input_69' id='input_1_69'
															type='text' value='' autocomplete='new-password' /></div>
												</li>
											</ul>
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										<div class='gform_page_footer top_label'><input type='submit'
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											<input type='submit' id='gform_submit_button_1' class='gform_button button'
												value='View Results'
												onclick='if(window["gf_submitting_1"]){return false;}  if( !jQuery("#gform_1")[0].checkValidity || jQuery("#gform_1")[0].checkValidity()){window["gf_submitting_1"]=true;}  '
												onkeypress='if( event.keyCode == 13 ){ if(window["gf_submitting_1"]){return false;} if( !jQuery("#gform_1")[0].checkValidity || jQuery("#gform_1")[0].checkValidity()){window["gf_submitting_1"]=true;}  jQuery("#gform_1").trigger("submit",[true]); }' />
											<input type='hidden' class='gform_hidden' name='is_submit_1' value='1' />
											<input type='hidden' class='gform_hidden' name='gform_submit' value='1' />
											<input type='hidden' class='gform_hidden' name='gform_unique_id' value='' />
											<input type='hidden' class='gform_hidden' name='state_1'
												value='WyJ7XCI2MlwiOltcIjU0ZTRiYTQ1ZTVmMmNiNjVjMTcwODkxNmU3ZmRhOGFjXCIsXCI1YzYyNGZhODRhY2I2ODE5NWU1OWQ0MmM5Y2YwYzc2NlwiXSxcIjY0XCI6W1wiOGY4NDk5NWQ0OTI2OGFmNWZhMjQzYzMyNWY3YzliYTlcIixcImFmZmE0ODNhODQ0NTNiOWUzYTZmODZiOGQxYzQzMTA1XCJdLFwiNjVcIjpbXCJkOTQ1Y2UwOWU2Y2NiYmVmMjE4YjRmODI5ODEyYmE0ZlwiLFwiMDE5NzI4ZmQ1MjMxZDJiMmZlOTQzMDU3YmQxYTk5NDlcIixcImZmNjk5ZjhiMjdiZTM0YjU5YzJhODhjM2U1OGMzNjg2XCJdfSIsIjMwMzNlNDM3MDA3YzNlNDI2YzdjZWI0NjdiOGQzNTcyIl0=' />
											<input type='hidden' class='gform_hidden' name='gform_target_page_number_1'
												id='gform_target_page_number_1' value='2' /> <input type='hidden'
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												id='gform_source_page_number_1' value='1' /> <input type='hidden'
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						<p>&nbsp;</p>
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														<div class='ginput_container'><input name='input_8'
																id='input_4_8' type='text' value=''
																autocomplete='new-password' /></div>
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															field is for validation purposes and should be left
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											<div class='gform_footer top_label'> <input type='submit'
													id='gform_submit_button_4' class='gform_button button'
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