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</head>



@yield('cl_content')




<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
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													<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
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															<li class='gchoice gchoice_1_26_2'> <input
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																	type='checkbox'
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																	family, or significant other)</label></li>
															<li class='gchoice gchoice_1_26_3'> <input
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															<li class='gchoice gchoice_1_26_4'> <input
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															</li>
															<li class='gchoice gchoice_1_26_5'> <input
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															<li class='gchoice gchoice_1_26_6'> <input
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																	type='checkbox' value='Financial problems'
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															<li class='gchoice gchoice_1_26_7'> <input
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																	type='checkbox' value='Loneliness or isolation'
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															</li>
															<li class='gchoice gchoice_1_26_8'> <input
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															<li class='gchoice gchoice_1_26_9'> <input
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																	or discrimination</label></li>
															<li class='gchoice gchoice_1_26_11'> <input
																	class='gfield-choice-input' name='input_26.11'
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																	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
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															class='medium' placeholder='Enter other...'
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												<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.)'
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																	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'
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															<li class='gchoice gchoice_1_30_6'> <input
																	class='gfield-choice-input' name='input_30.6'
																	type='checkbox'
																	value='COPD or other lung conditions'
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																	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.)'
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																	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"
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						<p>&nbsp;</p>
						<hr />
						<p><a href="https://screening.mhanational.org/screening-tools/depression-spanish/">The
								Depression Test is also available in Spanish.</a></p>
						<p><a href="https://screening.mhanational.org/screening-tools/postpartum-depression/">Click here
								to test for postpartum depression (new <em>and</em> expecting parents).</a></p>
						<h4>Source:</h4>
						
					</div>
				</div>
			</article>
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