{"id":8,"date":"2026-05-13T19:48:10","date_gmt":"2026-05-13T14:18:10","guid":{"rendered":"https:\/\/innerglance.com.au\/admin\/?page_id=8"},"modified":"2026-05-14T18:26:25","modified_gmt":"2026-05-14T12:56:25","slug":"counseling","status":"publish","type":"page","link":"https:\/\/innerglance.com.au\/adminwp\/counseling\/","title":{"rendered":"Counseling"},"content":{"rendered":"\t\t<div data-elementor-type=\"wp-page\" data-elementor-id=\"8\" class=\"elementor elementor-8\">\n\t\t\t\t<div class=\"elementor-element elementor-element-fb5ca0c e-flex e-con-boxed e-con e-parent\" data-id=\"fb5ca0c\" data-element_type=\"container\" data-e-type=\"container\">\n\t\t\t\t\t<div class=\"e-con-inner\">\n\t\t\t\t<div class=\"elementor-element elementor-element-0579773 elementor-widget elementor-widget-shortcode\" data-id=\"0579773\" data-element_type=\"widget\" data-e-type=\"widget\" data-widget_type=\"shortcode.default\">\n\t\t\t\t\t\t\t<div class=\"elementor-shortcode\"><div class='fluentform ff-default fluentform_wrapper_3 ffs_custom_wrap'><form data-form_id=\"3\" id=\"fluentform_3\" class=\"frm-fluent-form fluent_form_3 ff-el-form-top ff_form_instance_3_1 ff-form-loading ff-form-has-steps ffs_custom\" data-form_instance=\"ff_form_instance_3_1\" method=\"POST\" ><fieldset  style=\"border: none!important;margin: 0!important;padding: 0!important;background-color: transparent!important;box-shadow: none!important;outline: none!important; min-inline-size: 100%;\">\n                    <legend class=\"ff_screen_reader_title\" style=\"display: block; margin: 0!important;padding: 0!important;height: 0!important;text-indent: -999999px;width: 0!important;overflow:hidden;\">Counselling<\/legend><input type='hidden' name='__fluent_form_embded_post_id' value='8' \/><input type=\"hidden\" id=\"_fluentform_3_fluentformnonce\" name=\"_fluentform_3_fluentformnonce\" value=\"e687d51690\" \/><input type=\"hidden\" name=\"_wp_http_referer\" value=\"\/adminwp\/wp-json\/wp\/v2\/pages\/8\" \/><div class='ff-step-container' data-name=\"step_start-3_13\" data-disable_auto_focus=\"no\" data-enable_auto_slider=\"no\" data-enable_step_data_persistency=\"yes\" data-enable_step_page_resume=\"yes\" data-animation_type=\"slide\" ><div class='ff-step-header'><div class='ff-el-progress-status' aria-live='polite'><\/div>\n            <div class='ff-el-progress'>\n                <div role='progressbar'  class='ff-el-progress-bar'><span><\/span><\/div>\n            <\/div>\n            <ul style='display: none' class='ff-el-progress-title'>\n                <li>Inner Glance<\/li><li>Patient Info<\/li><li>Employer & Status<\/li><li>Emergency Contact<\/li><li>Health and Medical Info<\/li><li>Personal & Family<\/li><li>Symptom Assessment<\/li><li>Financial Agreement<\/li><li>Consent for Treatment<\/li><li>Health Release Consent<\/li>\n            <\/ul><\/div><span class='ff_step_start'><\/span><div class='ff-step-body'><div class=\"fluentform-step active\" data-name=\"step_start-3_13\" data-disable_auto_focus=\"no\" data-enable_auto_slider=\"no\" data-enable_step_data_persistency=\"yes\" data-enable_step_page_resume=\"yes\" data-animation_type=\"slide\" ><div data-name=\"ff_cn_id_1\"  class='ff-t-container ff-column-container ff_columns_total_2 '><div class='ff-t-cell ff-t-column-1' style='flex-basis: 50%;'><div class='ff-el-group'><div class=\"ff-el-input--label ff-el-is-required asterisk-right\"><label for='ff_3_patientname' id='label_ff_3_patientname' >Patient Name :<\/label><\/div><div class='ff-el-input--content'><input type=\"text\" name=\"patientname\" class=\"ff-el-form-control\" placeholder=\"Enter Patient Name\" data-name=\"patientname\" id=\"ff_3_patientname\"  aria-invalid=\"false\" aria-required=true><\/div><\/div><\/div><div class='ff-t-cell ff-t-column-2' style='flex-basis: 50%;'><div class='ff-el-group'><div class=\"ff-el-input--label ff-el-is-required asterisk-right\"><label for='ff_3_datetime' id='label_ff_3_datetime' aria-label=\"Select Date :\">Select Date :<\/label><\/div><div class='ff-el-input--content'><input  aria-label='Select Date : Use arrow keys to navigate dates. Press enter to select a date.'  aria-haspopup='dialog' data-type-datepicker data-format='d\/m\/Y' type=\"text\" name=\"datetime\" id=\"ff_3_datetime\" class=\"ff-el-form-control ff-el-datepicker\" placeholder=\"Select Date\" data-name=\"datetime\"  aria-invalid='false' aria-required=true><\/div><\/div><\/div><\/div><div class='ff-el-group  ff_list_inline'><div class=\"ff-el-input--label ff-el-is-required asterisk-right\"><label   aria-label=\"Type of counseling I am seeking :\">Type of counseling I am seeking :<\/label><\/div><div class='ff-el-input--content'><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for='input_radio_48bb6a88b1cc6b00b09b1c528f5f895d'><input  type=\"radio\" name=\"input_radio\" data-name=\"input_radio\" class=\"ff-el-form-check-input ff-el-form-check-radio\" value=\"Individual\"  id='input_radio_48bb6a88b1cc6b00b09b1c528f5f895d' aria-label='Individual' aria-invalid='false' aria-required=true> <span>Individual<\/span><\/label><\/div><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for='input_radio_312bd5c82d2d16c7286d232a783c9530'><input  type=\"radio\" name=\"input_radio\" data-name=\"input_radio\" class=\"ff-el-form-check-input ff-el-form-check-radio\" value=\"Couple\"  id='input_radio_312bd5c82d2d16c7286d232a783c9530' aria-label='Couple' aria-invalid='false' aria-required=true> <span>Couple<\/span><\/label><\/div><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for='input_radio_07ae7be876ec80e915fda3e5cc1f9167'><input  type=\"radio\" name=\"input_radio\" data-name=\"input_radio\" class=\"ff-el-form-check-input ff-el-form-check-radio\" value=\"Group Therapy\"  id='input_radio_07ae7be876ec80e915fda3e5cc1f9167' aria-label='Group Therapy' aria-invalid='false' aria-required=true> <span>Group Therapy<\/span><\/label><\/div><\/div><\/div><div class='step-nav ff_step_nav_last'><button style='float: left;'  type='button' data-action='prev' class='ff-btn ff-btn-prev ff-btn-secondary' aria-label='Previous'>Previous<\/button><button style='float: right;'  type='button' data-action='next' class='ff-float-right ff-btn ff-btn-next ff-btn-secondary' aria-label='Next'>Next<\/button><\/div><\/div><div style='display: none;' class=\" fluentform-step\" data-name=\"form_step-3_1\" ><div data-name=\"ff_cn_id_2\"  class='ff-t-container ff-column-container ff_columns_total_3 '><div class='ff-t-cell ff-t-column-1' style='flex-basis: 33.33%;'><div class='ff-el-group'><div class=\"ff-el-input--label ff-el-is-required asterisk-right\"><label for='ff_3_dateofbirth' id='label_ff_3_dateofbirth' aria-label=\"Date of Birth :\">Date of Birth :<\/label><\/div><div class='ff-el-input--content'><input  aria-label='Date of Birth : Use arrow keys to navigate dates. Press enter to select a date.'  aria-haspopup='dialog' data-type-datepicker data-format='d\/m\/Y' type=\"text\" name=\"dateofbirth\" id=\"ff_3_dateofbirth\" class=\"ff-el-form-control ff-el-datepicker\" placeholder=\"Enter Date of Birth\" data-name=\"dateofbirth\"  aria-invalid='false' aria-required=true><\/div><\/div><\/div><div class='ff-t-cell ff-t-column-2' style='flex-basis: 33.33%;'><div class='ff-el-group'><div class=\"ff-el-input--label ff-el-is-required asterisk-right\"><label for='ff_3_legal_name' id='label_ff_3_legal_name' >Legal Name :<\/label><\/div><div class='ff-el-input--content'><input type=\"text\" name=\"legal_name\" class=\"ff-el-form-control\" placeholder=\"Enter Legal Name\" data-name=\"legal_name\" id=\"ff_3_legal_name\"  aria-invalid=\"false\" aria-required=true><\/div><\/div><\/div><div class='ff-t-cell ff-t-column-3' style='flex-basis: 33.33%;'><div class='ff-el-group'><div class=\"ff-el-input--label ff-el-is-required asterisk-right\"><label for='ff_3_preferred_name' id='label_ff_3_preferred_name' >Preferred Name :<\/label><\/div><div class='ff-el-input--content'><input type=\"text\" name=\"preferred_name\" class=\"ff-el-form-control\" placeholder=\"Enter Preferred Name\" data-name=\"preferred_name\" id=\"ff_3_preferred_name\"  aria-invalid=\"false\" aria-required=true><\/div><\/div><\/div><\/div><div data-name=\"ff_cn_id_3\"  class='ff-t-container ff-column-container ff_columns_total_2 '><div class='ff-t-cell ff-t-column-1' style='flex-basis: 50%;'><div class='ff-el-group'><div class=\"ff-el-input--label ff-el-is-required asterisk-right\"><label for='ff_3_gender' id='label_ff_3_gender' aria-label=\"Select Gender :\">Select Gender :<\/label><\/div><div class='ff-el-input--content'><select name=\"gender\" id=\"ff_3_gender\" class=\"ff-el-form-control\" data-name=\"gender\" data-calc_value=\"0\"  aria-invalid=\"false\" aria-required=\"true\" aria-labelledby=\"label_ff_3_gender\"><option value=\"\">- Select -<\/option><option value=\"Male\"  >Male<\/option><option value=\"Female\"  >Female<\/option><\/select><\/div><\/div><\/div><div class='ff-t-cell ff-t-column-2' style='flex-basis: 50%;'><div class='ff-el-group'><div class=\"ff-el-input--label ff-el-is-required asterisk-right\"><label for='ff_3_preferred_gender' id='label_ff_3_preferred_gender' aria-label=\"Preferred Gender Pronouns :\">Preferred Gender Pronouns :<\/label><\/div><div class='ff-el-input--content'><input type=\"text\" name=\"preferred_gender\" class=\"ff-el-form-control\" placeholder=\"Enter Preferred Gender Pronouns\" data-name=\"preferred_gender\" id=\"ff_3_preferred_gender\"  aria-invalid=\"false\" aria-required=true><\/div><\/div><\/div><\/div><div class=\"ff-name-address-wrapper fluent-address\" data-type=\"address-element\" data-name=\"address\" ><div class='ff-el-input--content'><div class='ff-t-container'><div class='ff-t-cell'><div class='ff-el-group'><div class=\"ff-el-input--label ff-el-is-required asterisk-right\"><label for='ff_3_address_address_line_1_' id='label_ff_3_address_address_line_1_' aria-label=\"Address\">Address<\/label><\/div><div class='ff-el-input--content'><input type=\"text\" name=\"address[address_line_1]\" id=\"ff_3_address_address_line_1_\" class=\"ff-el-form-control\" placeholder=\"Enter Address\" data-key_name=\"address_line_1\"  aria-invalid=\"false\" aria-required=true><\/div><\/div><\/div><div class='ff-t-cell'><div class='ff-el-group'><div class=\"ff-el-input--label ff-el-is-required asterisk-right\"><label for='ff_3_address_city_' id='label_ff_3_address_city_' aria-label=\"City\">City<\/label><\/div><div class='ff-el-input--content'><input type=\"text\" name=\"address[city]\" id=\"ff_3_address_city_\" class=\"ff-el-form-control\" placeholder=\"Enter City\" data-key_name=\"city\"  aria-invalid=\"false\" aria-required=true><\/div><\/div><\/div><\/div><div class='ff-t-container'><div class='ff-t-cell'><div class='ff-el-group'><div class=\"ff-el-input--label ff-el-is-required asterisk-right\"><label for='ff_3_address_state_' id='label_ff_3_address_state_' aria-label=\"State\">State<\/label><\/div><div class='ff-el-input--content'><input type=\"text\" name=\"address[state]\" id=\"ff_3_address_state_\" class=\"ff-el-form-control\" placeholder=\"Enter State\" data-key_name=\"state\"  aria-invalid=\"false\" aria-required=true><\/div><\/div><\/div><div class='ff-t-cell'><div class='ff-el-group'><div class=\"ff-el-input--label ff-el-is-required asterisk-right\"><label for='ff_3_address_zip_' id='label_ff_3_address_zip_' aria-label=\"Zip Code\">Zip Code<\/label><\/div><div class='ff-el-input--content'><input type=\"text\" name=\"address[zip]\" id=\"ff_3_address_zip_\" class=\"ff-el-form-control\" placeholder=\"Enter Zip Code\" data-key_name=\"zip\"  aria-invalid=\"false\" aria-required=true><\/div><\/div><\/div><\/div><\/div><\/div><div data-name=\"ff_cn_id_4\"  class='ff-t-container ff-column-container ff_columns_total_2 '><div class='ff-t-cell ff-t-column-1' style='flex-basis: 50%;'><div class='ff-el-group'><div class=\"ff-el-input--label ff-el-is-required asterisk-right\"><label for='ff_3_email' id='label_ff_3_email' aria-label=\"Email Address :\">Email Address :<\/label><\/div><div class='ff-el-input--content'><input type=\"email\" name=\"email\" id=\"ff_3_email\" class=\"ff-el-form-control\" placeholder=\"Enter Email Address\" data-name=\"email\"  aria-invalid=\"false\" aria-required=true><\/div><\/div><\/div><div class='ff-t-cell ff-t-column-2' style='flex-basis: 50%;'><div class='ff-el-group'><div class=\"ff-el-input--label ff-el-is-required asterisk-right\"><label for='ff_3_phone' id='label_ff_3_phone' aria-label=\"Preferred Phone :\">Preferred Phone :<\/label><\/div><div class='ff-el-input--content'><input name=\"phone\" class=\"ff-el-form-control ff-el-phone ff_el_with_extended_validation\" type=\"tel\" placeholder=\"Enter Preferred Phone Number\" data-name=\"phone\" id=\"ff_3_phone\" inputmode=\"tel\"  aria-invalid='false' aria-required=true><\/div><\/div><\/div><\/div><div class='step-nav ff_step_nav_last'><button style='float: left;'  type='button' data-action='prev' class='ff-btn ff-btn-prev ff-btn-secondary' aria-label='Previous'>Previous<\/button><button style='float: right;'  type='button' data-action='next' class='ff-float-right ff-btn ff-btn-next ff-btn-secondary' aria-label='Next'>Next<\/button><\/div><\/div><div style='display: none;' class=\" fluentform-step\" data-name=\"form_step-3_2\" ><div data-name=\"ff_cn_id_5\"  class='ff-t-container ff-column-container ff_columns_total_3 '><div class='ff-t-cell ff-t-column-1' style='flex-basis: 33.33%;'><div class='ff-el-group'><div class=\"ff-el-input--label ff-el-is-required asterisk-right\"><label for='ff_3_occupation' id='label_ff_3_occupation' aria-label=\"Occupation :\">Occupation :<\/label><\/div><div class='ff-el-input--content'><input type=\"text\" name=\"occupation\" class=\"ff-el-form-control\" placeholder=\"Enter Occupation\" data-name=\"occupation\" id=\"ff_3_occupation\"  aria-invalid=\"false\" aria-required=true><\/div><\/div><\/div><div class='ff-t-cell ff-t-column-2' style='flex-basis: 33.33%;'><div class='ff-el-group'><div class=\"ff-el-input--label ff-el-is-required asterisk-right\"><label for='ff_3_industry' id='label_ff_3_industry' aria-label=\"Industry :\">Industry :<\/label><\/div><div class='ff-el-input--content'><input type=\"text\" name=\"industry\" class=\"ff-el-form-control\" placeholder=\"Enter Industry\" data-name=\"industry\" id=\"ff_3_industry\"  aria-invalid=\"false\" aria-required=true><\/div><\/div><\/div><div class='ff-t-cell ff-t-column-3' style='flex-basis: 33.33%;'><div class='ff-el-group'><div class=\"ff-el-input--label ff-el-is-required asterisk-right\"><label for='ff_3_company_name' id='label_ff_3_company_name' >Company Name :<\/label><\/div><div class='ff-el-input--content'><input type=\"text\" name=\"company_name\" class=\"ff-el-form-control\" placeholder=\"Enter Company Name\" data-name=\"company_name\" id=\"ff_3_company_name\"  aria-invalid=\"false\" aria-required=true><\/div><\/div><\/div><\/div><div class=\"ff-name-address-wrapper fluent-address\" data-type=\"address-element\" data-name=\"company_address\" ><div class='ff-el-input--content'><div class='ff-t-container'><div class='ff-t-cell'><div class='ff-el-group'><div class=\"ff-el-input--label ff-el-is-required asterisk-right\"><label for='ff_3_company_address_address_line_1_' id='label_ff_3_company_address_address_line_1_' aria-label=\"Company Address :\">Company Address :<\/label><\/div><div class='ff-el-input--content'><input type=\"text\" name=\"company_address[address_line_1]\" id=\"ff_3_company_address_address_line_1_\" class=\"ff-el-form-control\" placeholder=\"Enter Company Address\" data-key_name=\"address_line_1\"  aria-invalid=\"false\" aria-required=true><\/div><\/div><\/div><div class='ff-t-cell'><div class='ff-el-group'><div class=\"ff-el-input--label ff-el-is-required asterisk-right\"><label for='ff_3_company_address_city_' id='label_ff_3_company_address_city_' aria-label=\"City\">City<\/label><\/div><div class='ff-el-input--content'><input type=\"text\" name=\"company_address[city]\" id=\"ff_3_company_address_city_\" class=\"ff-el-form-control\" placeholder=\"Enter City\" data-key_name=\"city\"  aria-invalid=\"false\" aria-required=true><\/div><\/div><\/div><\/div><div class='ff-t-container'><div class='ff-t-cell'><div class='ff-el-group'><div class=\"ff-el-input--label ff-el-is-required asterisk-right\"><label for='ff_3_company_address_state_' id='label_ff_3_company_address_state_' aria-label=\"State\">State<\/label><\/div><div class='ff-el-input--content'><input type=\"text\" name=\"company_address[state]\" id=\"ff_3_company_address_state_\" class=\"ff-el-form-control\" placeholder=\"Enter State\" data-key_name=\"state\"  aria-invalid=\"false\" aria-required=true><\/div><\/div><\/div><div class='ff-t-cell'><div class='ff-el-group'><div class=\"ff-el-input--label ff-el-is-required asterisk-right\"><label for='ff_3_company_address_zip_' id='label_ff_3_company_address_zip_' aria-label=\"Zip Code\">Zip Code<\/label><\/div><div class='ff-el-input--content'><input type=\"text\" name=\"company_address[zip]\" id=\"ff_3_company_address_zip_\" class=\"ff-el-form-control\" placeholder=\"Enter Zip Code\" data-key_name=\"zip\"  aria-invalid=\"false\" aria-required=true><\/div><\/div><\/div><\/div><\/div><\/div><div class='ff-el-group  ff_list_inline'><div class=\"ff-el-input--label ff-el-is-required asterisk-right\"><label   aria-label=\"Employment Type :\">Employment Type :<\/label><\/div><div class='ff-el-input--content'><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for='employment_type_d3384ab75e034bb5ddfdbe9554f45516'><input  type=\"radio\" name=\"employment_type\" data-name=\"employment_type\" class=\"ff-el-form-check-input ff-el-form-check-radio\" value=\"Employed\"  id='employment_type_d3384ab75e034bb5ddfdbe9554f45516' aria-label='Employed' aria-invalid='false' aria-required=true> <span>Employed<\/span><\/label><\/div><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for='employment_type_922e9cc960eb424e5a51d70d9622f714'><input  type=\"radio\" name=\"employment_type\" data-name=\"employment_type\" class=\"ff-el-form-check-input ff-el-form-check-radio\" value=\"Self-Employed\"  id='employment_type_922e9cc960eb424e5a51d70d9622f714' aria-label='Self-Employed' aria-invalid='false' aria-required=true> <span>Self-Employed<\/span><\/label><\/div><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for='employment_type_1874a0366fede9d5a80fcfed8a855b3b'><input  type=\"radio\" name=\"employment_type\" data-name=\"employment_type\" class=\"ff-el-form-check-input ff-el-form-check-radio\" value=\"Unemployed\"  id='employment_type_1874a0366fede9d5a80fcfed8a855b3b' aria-label='Unemployed' aria-invalid='false' aria-required=true> <span>Unemployed<\/span><\/label><\/div><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for='employment_type_6857f767a38f664514bac8ae3f31ac18'><input  type=\"radio\" name=\"employment_type\" data-name=\"employment_type\" class=\"ff-el-form-check-input ff-el-form-check-radio\" value=\"Other\"  id='employment_type_6857f767a38f664514bac8ae3f31ac18' aria-label='Other' aria-invalid='false' aria-required=true> <span>Other<\/span><\/label><\/div><\/div><\/div><div class='step-nav ff_step_nav_last'><button style='float: left;'  type='button' data-action='prev' class='ff-btn ff-btn-prev ff-btn-secondary' aria-label='Previous'>Previous<\/button><button style='float: right;'  type='button' data-action='next' class='ff-float-right ff-btn ff-btn-next ff-btn-secondary' aria-label='Next'>Next<\/button><\/div><\/div><div style='display: none;' class=\" fluentform-step\" data-name=\"form_step-3_3\" ><div data-type=\"name-element\" data-name=\"names\" class=\" ff-field_container ff-name-field-wrapper\" ><div class='ff-t-container'><div class='ff-t-cell '><div class='ff-el-group ff-el-form-top'><div class=\"ff-el-input--label ff-el-is-required asterisk-right\"><label for='ff_3_names_first_name_' id='label_ff_3_names_first_name_' >First Name<\/label><\/div><div class='ff-el-input--content'><input type=\"text\" name=\"names[first_name]\" id=\"ff_3_names_first_name_\" class=\"ff-el-form-control\" placeholder=\"Enter Your First Name\" aria-invalid=\"false\" aria-required=true><\/div><\/div><\/div><div class='ff-t-cell '><div class='ff-el-group ff-el-form-top'><div class=\"ff-el-input--label ff-el-is-required asterisk-right\"><label for='ff_3_names_last_name_' id='label_ff_3_names_last_name_' >Last Name<\/label><\/div><div class='ff-el-input--content'><input type=\"text\" name=\"names[last_name]\" id=\"ff_3_names_last_name_\" class=\"ff-el-form-control\" placeholder=\"Enter Your Last Name\" aria-invalid=\"false\" aria-required=true><\/div><\/div><\/div><\/div><\/div><div data-name=\"ff_cn_id_6\"  class='ff-t-container ff-column-container ff_columns_total_2 '><div class='ff-t-cell ff-t-column-1' style='flex-basis: 50%;'><div class='ff-el-group'><div class=\"ff-el-input--label ff-el-is-required asterisk-right\"><label for='ff_3_emergency_phone' id='label_ff_3_emergency_phone' aria-label=\"Phone Number :\">Phone Number :<\/label><\/div><div class='ff-el-input--content'><input name=\"emergency_phone\" class=\"ff-el-form-control ff-el-phone ff_el_with_extended_validation\" type=\"tel\" placeholder=\"Enter Phone Number\" data-name=\"emergency_phone\" id=\"ff_3_emergency_phone\" inputmode=\"tel\"  aria-invalid='false' aria-required=true><\/div><\/div><\/div><div class='ff-t-cell ff-t-column-2' style='flex-basis: 50%;'><div class='ff-el-group'><div class=\"ff-el-input--label ff-el-is-required asterisk-right\"><label for='ff_3_relationship_to_you' id='label_ff_3_relationship_to_you' aria-label=\"Relationship to You :\">Relationship to You :<\/label><\/div><div class='ff-el-input--content'><input type=\"text\" name=\"relationship_to_you\" class=\"ff-el-form-control\" placeholder=\"Enter Relationship to You\" data-name=\"relationship_to_you\" id=\"ff_3_relationship_to_you\"  aria-invalid=\"false\" aria-required=true><\/div><\/div><\/div><\/div><div class='step-nav ff_step_nav_last'><button style='float: left;'  type='button' data-action='prev' class='ff-btn ff-btn-prev ff-btn-secondary' aria-label='Previous'>Previous<\/button><button style='float: right;'  type='button' data-action='next' class='ff-float-right ff-btn ff-btn-next ff-btn-secondary' aria-label='Next'>Next<\/button><\/div><\/div><div style='display: none;' class=\" fluentform-step\" data-name=\"form_step-3_4\" ><div data-name=\"ff_cn_id_7\"  class='ff-t-container ff-column-container ff_columns_total_2 '><div class='ff-t-cell ff-t-column-1' style='flex-basis: 50%;'><div class='ff-el-group'><div class=\"ff-el-input--label ff-el-is-required asterisk-right\"><label for='ff_3_primary_care_physician' id='label_ff_3_primary_care_physician' aria-label=\"Primary Care Physician :\">Primary Care Physician :<\/label><\/div><div class='ff-el-input--content'><input type=\"text\" name=\"primary_care_physician\" class=\"ff-el-form-control\" placeholder=\"Enter Primary Care Physician\" data-name=\"primary_care_physician\" id=\"ff_3_primary_care_physician\"  aria-invalid=\"false\" aria-required=true><\/div><\/div><\/div><div class='ff-t-cell ff-t-column-2' style='flex-basis: 50%;'><div class='ff-el-group'><div class=\"ff-el-input--label ff-el-is-required asterisk-right\"><label for='ff_3_psychiatrist__phone' id='label_ff_3_psychiatrist__phone' aria-label=\"Phone Number :\">Phone Number :<\/label><\/div><div class='ff-el-input--content'><input name=\"psychiatrist__phone\" class=\"ff-el-form-control ff-el-phone ff_el_with_extended_validation\" type=\"tel\" placeholder=\"Enter Phone Number\" data-name=\"psychiatrist__phone\" id=\"ff_3_psychiatrist__phone\" inputmode=\"tel\"  aria-invalid='false' aria-required=true><\/div><\/div><\/div><\/div><div data-name=\"ff_cn_id_8\"  class='ff-t-container ff-column-container ff_columns_total_2 '><div class='ff-t-cell ff-t-column-1' style='flex-basis: 50%;'><div class='ff-el-group'><div class=\"ff-el-input--label ff-el-is-required asterisk-right\"><label for='ff_3_psychiatrist' id='label_ff_3_psychiatrist' aria-label=\"Psychiatrist :\">Psychiatrist :<\/label><\/div><div class='ff-el-input--content'><input type=\"text\" name=\"psychiatrist\" class=\"ff-el-form-control\" placeholder=\"Enter Psychiatrist\" data-name=\"psychiatrist\" id=\"ff_3_psychiatrist\"  aria-invalid=\"false\" aria-required=true><\/div><\/div><\/div><div class='ff-t-cell ff-t-column-2' style='flex-basis: 50%;'><div class='ff-el-group'><div class=\"ff-el-input--label ff-el-is-required asterisk-right\"><label for='ff_3_primary_care_physician_phone_1' id='label_ff_3_primary_care_physician_phone_1' aria-label=\"Phone Number :\">Phone Number :<\/label><\/div><div class='ff-el-input--content'><input name=\"primary_care_physician_phone_1\" class=\"ff-el-form-control ff-el-phone ff_el_with_extended_validation\" type=\"tel\" placeholder=\"Enter Phone Number\" data-name=\"primary_care_physician_phone_1\" id=\"ff_3_primary_care_physician_phone_1\" inputmode=\"tel\"  aria-invalid='false' aria-required=true><\/div><\/div><\/div><\/div><div class='ff-el-group'><div class=\"ff-el-input--label ff-el-is-required asterisk-right\"><label for='ff_3_medical_problems' id='label_ff_3_medical_problems' aria-label=\"Please list any medical problems :\">Please list any medical problems :<\/label><\/div><div class='ff-el-input--content'><textarea aria-required=\"true\" aria-labelledby=\"label_ff_3_medical_problems\" name=\"medical_problems\" id=\"ff_3_medical_problems\" class=\"ff-el-form-control\" placeholder=\"Please enter list any medical problems\" rows=\"3\" cols=\"2\" data-name=\"medical_problems\" ><\/textarea><\/div><\/div><div class='ff-el-group'><div class=\"ff-el-input--label ff-el-is-required asterisk-right\"><label for='ff_3_current_medications' id='label_ff_3_current_medications' aria-label=\"Please list any current medications :\">Please list any current medications :<\/label><\/div><div class='ff-el-input--content'><textarea aria-required=\"true\" aria-labelledby=\"label_ff_3_current_medications\" name=\"current_medications\" id=\"ff_3_current_medications\" class=\"ff-el-form-control\" placeholder=\"Please enter list any current medications\" rows=\"3\" cols=\"2\" data-name=\"current_medications\" ><\/textarea><\/div><\/div><div class='step-nav ff_step_nav_last'><button style='float: left;'  type='button' data-action='prev' class='ff-btn ff-btn-prev ff-btn-secondary' aria-label='Previous'>Previous<\/button><button style='float: right;'  type='button' data-action='next' class='ff-float-right ff-btn ff-btn-next ff-btn-secondary' aria-label='Next'>Next<\/button><\/div><\/div><div style='display: none;' class=\" fluentform-step\" data-name=\"form_step-3_5\" ><div data-name=\"ff_cn_id_9\"  class='ff-t-container ff-column-container ff_columns_total_2 '><div class='ff-t-cell ff-t-column-1' style='flex-basis: 50%;'><div class='ff-el-group'><div class=\"ff-el-input--label ff-el-is-required asterisk-right\"><label for='ff_3_ethnicity' id='label_ff_3_ethnicity' aria-label=\"What is your ethnicity?\">What is your ethnicity?<\/label><\/div><div class='ff-el-input--content'><select name=\"ethnicity\" id=\"ff_3_ethnicity\" class=\"ff-el-form-control\" data-name=\"ethnicity\" data-calc_value=\"0\"  aria-invalid=\"false\" aria-required=\"true\" aria-labelledby=\"label_ff_3_ethnicity\"><option value=\"\">- Select -<\/option><option value=\"White\"  >White<\/option><option value=\"Hispanic\"  >Hispanic<\/option><option value=\"Black or African American\"  >Black or African American<\/option><option value=\"Asian\"  >Asian<\/option><option value=\"Other\"  >Other<\/option><\/select><\/div><\/div><\/div><div class='ff-t-cell ff-t-column-2' style='flex-basis: 50%;'><div class='ff-el-group'><div class=\"ff-el-input--label ff-el-is-required asterisk-right\"><label for='ff_3_marriage_status' id='label_ff_3_marriage_status' aria-label=\"What is your marriage status?\">What is your marriage status?<\/label><\/div><div class='ff-el-input--content'><select name=\"marriage_status\" id=\"ff_3_marriage_status\" class=\"ff-el-form-control\" data-name=\"marriage_status\" data-calc_value=\"0\"  aria-invalid=\"false\" aria-required=\"true\" aria-labelledby=\"label_ff_3_marriage_status\"><option value=\"\">- Select -<\/option><option value=\"Single\"  >Single<\/option><option value=\"Married\"  >Married<\/option><option value=\"Un-Married\"  >Un-Married<\/option><option value=\"Divorced\"  >Divorced<\/option><option value=\"Widowed\"  >Widowed<\/option><\/select><\/div><\/div><\/div><\/div><div data-name=\"ff_cn_id_10\"  class='ff-t-container ff-column-container ff_columns_total_2 '><div class='ff-t-cell ff-t-column-1' style='flex-basis: 50%;'><div class='ff-el-group'><div class=\"ff-el-input--label ff-el-is-required asterisk-right\"><label for='ff_3_poeple_household' id='label_ff_3_poeple_household' aria-label=\"How many people are in your household?\">How many people are in your household?<\/label><\/div><div class='ff-el-input--content'><input type=\"number\" name=\"poeple_household\" id=\"ff_3_poeple_household\" class=\"ff-el-form-control\" placeholder=\"Enter How many people are in your household?\" data-name=\"poeple_household\" inputmode=\"numeric\" step=\"any\"  aria-invalid=\"false\" aria-required=true><\/div><\/div><\/div><div class='ff-t-cell ff-t-column-2' style='flex-basis: 50%;'><div class='ff-el-group'><div class=\"ff-el-input--label ff-el-is-required asterisk-right\"><label for='ff_3_income_level' id='label_ff_3_income_level' aria-label=\"What is your income level?\">What is your income level?<\/label><\/div><div class='ff-el-input--content'><select name=\"income_level\" id=\"ff_3_income_level\" class=\"ff-el-form-control\" data-name=\"income_level\" data-calc_value=\"0\"  aria-invalid=\"false\" aria-required=\"true\" aria-labelledby=\"label_ff_3_income_level\"><option value=\"\">- Select -<\/option><option value=\"Less than $1500\"  >Less than $1500<\/option><option value=\"$1500 - $3000\"  >$1500 - $3000<\/option><option value=\"$3000 - $4500\"  >$3000 - $4500<\/option><option value=\"$4500 - $5500\"  >$4500 - $5500<\/option><option value=\"More than $5500\"  >More than $5500<\/option><\/select><\/div><\/div><\/div><\/div><div class='ff-el-group'><div class=\"ff-el-input--label ff-el-is-required asterisk-right\"><label for='ff_3_highest_education' id='label_ff_3_highest_education' aria-label=\"What is the highest education level you\u2019ve completed?\">What is the highest education level you\u2019ve completed?<\/label><\/div><div class='ff-el-input--content'><select name=\"highest_education\" id=\"ff_3_highest_education\" class=\"ff-el-form-control\" data-name=\"highest_education\" data-calc_value=\"0\"  aria-invalid=\"false\" aria-required=\"true\" aria-labelledby=\"label_ff_3_highest_education\"><option value=\"\">- Select -<\/option><option value=\"Less Than High School Diploma\"  >Less Than High School Diploma<\/option><option value=\"High School Diploma or GED\"  >High School Diploma or GED<\/option><option value=\"Some College But No Degree\"  >Some College But No Degree<\/option><option value=\"Bachelor&#039;s Degree\"  >Bachelor's Degree<\/option><option value=\"Master&#039;s Degree\"  >Master's Degree<\/option><option value=\"Doctorate\"  >Doctorate<\/option><\/select><\/div><\/div><div data-name=\"ff_cn_id_11\"  class='ff-t-container ff-column-container ff_columns_total_2 '><div class='ff-t-cell ff-t-column-1' style='flex-basis: 50%;'><div class='ff-el-group  ff_list_inline'><div class=\"ff-el-input--label ff-el-is-required asterisk-right\"><label   aria-label=\"Have you ever been hospitalized for a psychiatric illness?\">Have you ever been hospitalized for a psychiatric illness?<\/label><\/div><div class='ff-el-input--content'><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for='psychiatric_illness_b5f153bd489c03cb5b49b4da14d2cf3e'><input  type=\"radio\" name=\"psychiatric_illness\" data-name=\"psychiatric_illness\" class=\"ff-el-form-check-input ff-el-form-check-radio\" value=\"Yes\"  id='psychiatric_illness_b5f153bd489c03cb5b49b4da14d2cf3e' aria-label='Yes' aria-invalid='false' aria-required=true> <span>Yes<\/span><\/label><\/div><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for='psychiatric_illness_cbe3ad79a158e3afb068fe3959ddd129'><input  type=\"radio\" name=\"psychiatric_illness\" data-name=\"psychiatric_illness\" class=\"ff-el-form-check-input ff-el-form-check-radio\" value=\"No\"  id='psychiatric_illness_cbe3ad79a158e3afb068fe3959ddd129' aria-label='No' aria-invalid='false' aria-required=true> <span>No<\/span><\/label><\/div><\/div><\/div><\/div><div class='ff-t-cell ff-t-column-2' style='flex-basis: 50%;'><div class='ff-el-group  ff_list_inline'><div class=\"ff-el-input--label ff-el-is-required asterisk-right\"><label   aria-label=\"Has a family member ever been hospitalized for a psychiatric illness?\">Has a family member ever been hospitalized for a psychiatric illness?<\/label><\/div><div class='ff-el-input--content'><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for='family_psychiatric_illness_8367e6caaab0900e6176afe241de0f4c'><input  type=\"radio\" name=\"family_psychiatric_illness\" data-name=\"family_psychiatric_illness\" class=\"ff-el-form-check-input ff-el-form-check-radio\" value=\"Yes\"  id='family_psychiatric_illness_8367e6caaab0900e6176afe241de0f4c' aria-label='Yes' aria-invalid='false' aria-required=true> <span>Yes<\/span><\/label><\/div><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for='family_psychiatric_illness_58f40aaa7e9e739f957ae171e9b65d77'><input  type=\"radio\" name=\"family_psychiatric_illness\" data-name=\"family_psychiatric_illness\" class=\"ff-el-form-check-input ff-el-form-check-radio\" value=\"No\"  id='family_psychiatric_illness_58f40aaa7e9e739f957ae171e9b65d77' aria-label='No' aria-invalid='false' aria-required=true> <span>No<\/span><\/label><\/div><\/div><\/div><\/div><\/div><div data-name=\"ff_cn_id_12\"  class='ff-t-container ff-column-container ff_columns_total_2 '><div class='ff-t-cell ff-t-column-1' style='flex-basis: 50%;'><div class='ff-el-group  ff_list_inline'><div class=\"ff-el-input--label ff-el-is-required asterisk-right\"><label   aria-label=\"Does anyone in your family have a history of mental illness?\">Does anyone in your family have a history of mental illness?<\/label><\/div><div class='ff-el-input--content'><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for='mental_illness_53208dbe6ade6e1b677ad4960a9b8094'><input  type=\"radio\" name=\"mental_illness\" data-name=\"mental_illness\" class=\"ff-el-form-check-input ff-el-form-check-radio\" value=\"Yes\"  id='mental_illness_53208dbe6ade6e1b677ad4960a9b8094' aria-label='Yes' aria-invalid='false' aria-required=true> <span>Yes<\/span><\/label><\/div><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for='mental_illness_265dc468262457c1e720b02dd3983694'><input  type=\"radio\" name=\"mental_illness\" data-name=\"mental_illness\" class=\"ff-el-form-check-input ff-el-form-check-radio\" value=\"No\"  id='mental_illness_265dc468262457c1e720b02dd3983694' aria-label='No' aria-invalid='false' aria-required=true> <span>No<\/span><\/label><\/div><\/div><\/div><\/div><div class='ff-t-cell ff-t-column-2' style='flex-basis: 50%;'><div class='ff-el-group  ff_list_inline'><div class=\"ff-el-input--label ff-el-is-required asterisk-right\"><label   aria-label=\"Have you ever attempted suicide?\">Have you ever attempted suicide?<\/label><\/div><div class='ff-el-input--content'><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for='suicide_c6a09144dfc86ffa748811359a28838e'><input  type=\"radio\" name=\"suicide\" data-name=\"suicide\" class=\"ff-el-form-check-input ff-el-form-check-radio\" value=\"Yes\"  id='suicide_c6a09144dfc86ffa748811359a28838e' aria-label='Yes' aria-invalid='false' aria-required=true> <span>Yes<\/span><\/label><\/div><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for='suicide_5ab83bd6a473fa3583db82c32bb9314c'><input  type=\"radio\" name=\"suicide\" data-name=\"suicide\" class=\"ff-el-form-check-input ff-el-form-check-radio\" value=\"No\"  id='suicide_5ab83bd6a473fa3583db82c32bb9314c' aria-label='No' aria-invalid='false' aria-required=true> <span>No<\/span><\/label><\/div><\/div><\/div><\/div><\/div><div data-name=\"ff_cn_id_13\"  class='ff-t-container ff-column-container ff_columns_total_2 '><div class='ff-t-cell ff-t-column-1' style='flex-basis: 50%;'><div class='ff-el-group  ff_list_inline'><div class=\"ff-el-input--label ff-el-is-required asterisk-right\"><label   aria-label=\"Has anyone in your family attempted or committed suicide?\">Has anyone in your family attempted or committed suicide?<\/label><\/div><div class='ff-el-input--content'><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for='family_suicide_e6d565d842354866f755c1aab2e3aa41'><input  type=\"radio\" name=\"family_suicide\" data-name=\"family_suicide\" class=\"ff-el-form-check-input ff-el-form-check-radio\" value=\"Yes\"  id='family_suicide_e6d565d842354866f755c1aab2e3aa41' aria-label='Yes' aria-invalid='false' aria-required=true> <span>Yes<\/span><\/label><\/div><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for='family_suicide_4091464d6ec119ff1a786f771920c282'><input  type=\"radio\" name=\"family_suicide\" data-name=\"family_suicide\" class=\"ff-el-form-check-input ff-el-form-check-radio\" value=\"No\"  id='family_suicide_4091464d6ec119ff1a786f771920c282' aria-label='No' aria-invalid='false' aria-required=true> <span>No<\/span><\/label><\/div><\/div><\/div><\/div><div class='ff-t-cell ff-t-column-2' style='flex-basis: 50%;'><div class='ff-el-group  ff_list_inline'><div class=\"ff-el-input--label ff-el-is-required asterisk-right\"><label   aria-label=\"Do you have substance abuse problems?\">Do you have substance abuse problems?<\/label><\/div><div class='ff-el-input--content'><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for='abuse_problems_fb8ade67b615ddea2e872a17d722c909'><input  type=\"radio\" name=\"abuse_problems\" data-name=\"abuse_problems\" class=\"ff-el-form-check-input ff-el-form-check-radio\" value=\"Yes\"  id='abuse_problems_fb8ade67b615ddea2e872a17d722c909' aria-label='Yes' aria-invalid='false' aria-required=true> <span>Yes<\/span><\/label><\/div><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for='abuse_problems_f5aa181be3992eecb0b1fecd0dfd1ac2'><input  type=\"radio\" name=\"abuse_problems\" data-name=\"abuse_problems\" class=\"ff-el-form-check-input ff-el-form-check-radio\" value=\"No\"  id='abuse_problems_f5aa181be3992eecb0b1fecd0dfd1ac2' aria-label='No' aria-invalid='false' aria-required=true> <span>No<\/span><\/label><\/div><\/div><\/div><\/div><\/div><div data-name=\"ff_cn_id_14\"  class='ff-t-container ff-column-container ff_columns_total_2 '><div class='ff-t-cell ff-t-column-1' style='flex-basis: 50%;'><div class='ff-el-group  ff_list_inline'><div class=\"ff-el-input--label ff-el-is-required asterisk-right\"><label   aria-label=\"Does anyone in your family have substance abuse problems?\">Does anyone in your family have substance abuse problems?<\/label><\/div><div class='ff-el-input--content'><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for='family_abuse_problems_d4640573b4733ccfbbd9e0d876c3a98d'><input  type=\"radio\" name=\"family_abuse_problems\" data-name=\"family_abuse_problems\" class=\"ff-el-form-check-input ff-el-form-check-radio\" value=\"Yes\"  id='family_abuse_problems_d4640573b4733ccfbbd9e0d876c3a98d' aria-label='Yes' aria-invalid='false' aria-required=true> <span>Yes<\/span><\/label><\/div><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for='family_abuse_problems_2d976698d48f4416c257a5eb53917edf'><input  type=\"radio\" name=\"family_abuse_problems\" data-name=\"family_abuse_problems\" class=\"ff-el-form-check-input ff-el-form-check-radio\" value=\"No\"  id='family_abuse_problems_2d976698d48f4416c257a5eb53917edf' aria-label='No' aria-invalid='false' aria-required=true> <span>No<\/span><\/label><\/div><\/div><\/div><\/div><div class='ff-t-cell ff-t-column-2' style='flex-basis: 50%;'><div class='ff-el-group  ff_list_inline'><div class=\"ff-el-input--label ff-el-is-required asterisk-right\"><label   aria-label=\"Have you ever been arrested?\">Have you ever been arrested?<\/label><\/div><div class='ff-el-input--content'><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for='arrested_74f70c19f09810936da35f96b9e77215'><input  type=\"radio\" name=\"arrested\" data-name=\"arrested\" class=\"ff-el-form-check-input ff-el-form-check-radio\" value=\"Yes\"  id='arrested_74f70c19f09810936da35f96b9e77215' aria-label='Yes' aria-invalid='false' aria-required=true> <span>Yes<\/span><\/label><\/div><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for='arrested_51026d3a8ee2fb9b21469fc9c4405c50'><input  type=\"radio\" name=\"arrested\" data-name=\"arrested\" class=\"ff-el-form-check-input ff-el-form-check-radio\" value=\"No\"  id='arrested_51026d3a8ee2fb9b21469fc9c4405c50' aria-label='No' aria-invalid='false' aria-required=true> <span>No<\/span><\/label><\/div><\/div><\/div><\/div><\/div><div data-name=\"ff_cn_id_15\"  class='ff-t-container ff-column-container ff_columns_total_2 '><div class='ff-t-cell ff-t-column-1' style='flex-basis: 50%;'><div class='ff-el-group  ff_list_inline'><div class=\"ff-el-input--label ff-el-is-required asterisk-right\"><label   aria-label=\"How well are you doing at your job?\">How well are you doing at your job?<\/label><\/div><div class='ff-el-input--content'><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for='doing_at_job_4c76adbdac810008f62c480dd6e911cf'><input  type=\"radio\" name=\"doing_at_job\" data-name=\"doing_at_job\" class=\"ff-el-form-check-input ff-el-form-check-radio\" value=\"Not working\"  id='doing_at_job_4c76adbdac810008f62c480dd6e911cf' aria-label='Not working' aria-invalid='false' aria-required=true> <span>Not working<\/span><\/label><\/div><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for='doing_at_job_5fa2e0a714d4a809f55a85c0bd382935'><input  type=\"radio\" name=\"doing_at_job\" data-name=\"doing_at_job\" class=\"ff-el-form-check-input ff-el-form-check-radio\" value=\"Cannot Function\"  id='doing_at_job_5fa2e0a714d4a809f55a85c0bd382935' aria-label='Cannot Function' aria-invalid='false' aria-required=true> <span>Cannot Function<\/span><\/label><\/div><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for='doing_at_job_bc9b9d5e2f11a4ec49dfea8a289c210d'><input  type=\"radio\" name=\"doing_at_job\" data-name=\"doing_at_job\" class=\"ff-el-form-check-input ff-el-form-check-radio\" value=\"Serious Problems\"  id='doing_at_job_bc9b9d5e2f11a4ec49dfea8a289c210d' aria-label='Serious Problems' aria-invalid='false' aria-required=true> <span>Serious Problems<\/span><\/label><\/div><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for='doing_at_job_ac5db3ad9b8376baf896fd360d125c0b'><input  type=\"radio\" name=\"doing_at_job\" data-name=\"doing_at_job\" class=\"ff-el-form-check-input ff-el-form-check-radio\" value=\"Mild Problems\"  id='doing_at_job_ac5db3ad9b8376baf896fd360d125c0b' aria-label='Mild Problems' aria-invalid='false' aria-required=true> <span>Mild Problems<\/span><\/label><\/div><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for='doing_at_job_df4235142974c7cc3ad9d0a52aec03d9'><input  type=\"radio\" name=\"doing_at_job\" data-name=\"doing_at_job\" class=\"ff-el-form-check-input ff-el-form-check-radio\" value=\"No Problems\"  id='doing_at_job_df4235142974c7cc3ad9d0a52aec03d9' aria-label='No Problems' aria-invalid='false' aria-required=true> <span>No Problems<\/span><\/label><\/div><\/div><\/div><\/div><div class='ff-t-cell ff-t-column-2' style='flex-basis: 50%;'><div class='ff-el-group  ff_list_inline'><div class=\"ff-el-input--label ff-el-is-required asterisk-right\"><label   aria-label=\"How well are you doing in your marital or with your significant other?\">How well are you doing in your marital or with your significant other?<\/label><\/div><div class='ff-el-input--content'><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for='doing_in_your_marital_0c91a93bb0b810c366ab75c3af3a5c49'><input  type=\"radio\" name=\"doing_in_your_marital\" data-name=\"doing_in_your_marital\" class=\"ff-el-form-check-input ff-el-form-check-radio\" value=\"Not working\"  id='doing_in_your_marital_0c91a93bb0b810c366ab75c3af3a5c49' aria-label='Not working' aria-invalid='false' aria-required=true> <span>Not working<\/span><\/label><\/div><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for='doing_in_your_marital_fc6795011ab45c945c086a3cdb80c7b7'><input  type=\"radio\" name=\"doing_in_your_marital\" data-name=\"doing_in_your_marital\" class=\"ff-el-form-check-input ff-el-form-check-radio\" value=\"Cannot Function\"  id='doing_in_your_marital_fc6795011ab45c945c086a3cdb80c7b7' aria-label='Cannot Function' aria-invalid='false' aria-required=true> <span>Cannot Function<\/span><\/label><\/div><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for='doing_in_your_marital_1b7d64726022bc38bc0192b49bd46efe'><input  type=\"radio\" name=\"doing_in_your_marital\" data-name=\"doing_in_your_marital\" class=\"ff-el-form-check-input ff-el-form-check-radio\" value=\"Serious Problems\"  id='doing_in_your_marital_1b7d64726022bc38bc0192b49bd46efe' aria-label='Serious Problems' aria-invalid='false' aria-required=true> <span>Serious Problems<\/span><\/label><\/div><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for='doing_in_your_marital_547ff0026b8cd1a0b71c06ebf451da88'><input  type=\"radio\" name=\"doing_in_your_marital\" data-name=\"doing_in_your_marital\" class=\"ff-el-form-check-input ff-el-form-check-radio\" value=\"Mild Problems\"  id='doing_in_your_marital_547ff0026b8cd1a0b71c06ebf451da88' aria-label='Mild Problems' aria-invalid='false' aria-required=true> <span>Mild Problems<\/span><\/label><\/div><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for='doing_in_your_marital_132381f32acc0a0111b291785fb8d063'><input  type=\"radio\" name=\"doing_in_your_marital\" data-name=\"doing_in_your_marital\" class=\"ff-el-form-check-input ff-el-form-check-radio\" value=\"No Problems\"  id='doing_in_your_marital_132381f32acc0a0111b291785fb8d063' aria-label='No Problems' aria-invalid='false' aria-required=true> <span>No Problems<\/span><\/label><\/div><\/div><\/div><\/div><\/div><div data-name=\"ff_cn_id_16\"  class='ff-t-container ff-column-container ff_columns_total_2 '><div class='ff-t-cell ff-t-column-1' style='flex-basis: 50%;'><div class='ff-el-group  ff_list_inline'><div class=\"ff-el-input--label ff-el-is-required asterisk-right\"><label   aria-label=\"How well are you doing with family relationships?\">How well are you doing with family relationships?<\/label><\/div><div class='ff-el-input--content'><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for='relationships_with_family_48bcb8e40700cf11834f8c6f98416913'><input  type=\"radio\" name=\"relationships_with_family\" data-name=\"relationships_with_family\" class=\"ff-el-form-check-input ff-el-form-check-radio\" value=\"Not working\"  id='relationships_with_family_48bcb8e40700cf11834f8c6f98416913' aria-label='Not working' aria-invalid='false' aria-required=true> <span>Not working<\/span><\/label><\/div><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for='relationships_with_family_2082dd17b393e5aff463b015c08a2ba0'><input  type=\"radio\" name=\"relationships_with_family\" data-name=\"relationships_with_family\" class=\"ff-el-form-check-input ff-el-form-check-radio\" value=\"Cannot Function\"  id='relationships_with_family_2082dd17b393e5aff463b015c08a2ba0' aria-label='Cannot Function' aria-invalid='false' aria-required=true> <span>Cannot Function<\/span><\/label><\/div><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for='relationships_with_family_ccdc6d9c4e4dcfa346ea5b85f9c3c537'><input  type=\"radio\" name=\"relationships_with_family\" data-name=\"relationships_with_family\" class=\"ff-el-form-check-input ff-el-form-check-radio\" value=\"Serious Problems\"  id='relationships_with_family_ccdc6d9c4e4dcfa346ea5b85f9c3c537' aria-label='Serious Problems' aria-invalid='false' aria-required=true> <span>Serious Problems<\/span><\/label><\/div><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for='relationships_with_family_534df192f731003483b6f0f339ee3e77'><input  type=\"radio\" name=\"relationships_with_family\" data-name=\"relationships_with_family\" class=\"ff-el-form-check-input ff-el-form-check-radio\" value=\"Mild Problems\"  id='relationships_with_family_534df192f731003483b6f0f339ee3e77' aria-label='Mild Problems' aria-invalid='false' aria-required=true> <span>Mild Problems<\/span><\/label><\/div><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for='relationships_with_family_5d4e217506a0ed1861f3f51a618ff8aa'><input  type=\"radio\" name=\"relationships_with_family\" data-name=\"relationships_with_family\" class=\"ff-el-form-check-input ff-el-form-check-radio\" value=\"No Problems\"  id='relationships_with_family_5d4e217506a0ed1861f3f51a618ff8aa' aria-label='No Problems' aria-invalid='false' aria-required=true> <span>No Problems<\/span><\/label><\/div><\/div><\/div><\/div><div class='ff-t-cell ff-t-column-2' style='flex-basis: 50%;'><div class='ff-el-group  ff_list_inline'><div class=\"ff-el-input--label ff-el-is-required asterisk-right\"><label   aria-label=\"How well are you doing in relationships with non-family members?\">How well are you doing in relationships with non-family members? <\/label><\/div><div class='ff-el-input--content'><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for='relationships_with_non_family_ca8c069109e50052a6633d2a1ec9702e'><input  type=\"radio\" name=\"relationships_with_non_family\" data-name=\"relationships_with_non_family\" class=\"ff-el-form-check-input ff-el-form-check-radio\" value=\"Not working\"  id='relationships_with_non_family_ca8c069109e50052a6633d2a1ec9702e' aria-label='Not working' aria-invalid='false' aria-required=true> <span>Not working<\/span><\/label><\/div><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for='relationships_with_non_family_a74973f5f3f281bb479b1bf23579a3b1'><input  type=\"radio\" name=\"relationships_with_non_family\" data-name=\"relationships_with_non_family\" class=\"ff-el-form-check-input ff-el-form-check-radio\" value=\"Cannot Function\"  id='relationships_with_non_family_a74973f5f3f281bb479b1bf23579a3b1' aria-label='Cannot Function' aria-invalid='false' aria-required=true> <span>Cannot Function<\/span><\/label><\/div><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for='relationships_with_non_family_1841544d0be91a2e0d9ae9e1a2df33f7'><input  type=\"radio\" name=\"relationships_with_non_family\" data-name=\"relationships_with_non_family\" class=\"ff-el-form-check-input ff-el-form-check-radio\" value=\"Serious Problems\"  id='relationships_with_non_family_1841544d0be91a2e0d9ae9e1a2df33f7' aria-label='Serious Problems' aria-invalid='false' aria-required=true> <span>Serious Problems<\/span><\/label><\/div><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for='relationships_with_non_family_452a0078ddadfaf3ec9fb133842359ae'><input  type=\"radio\" name=\"relationships_with_non_family\" data-name=\"relationships_with_non_family\" class=\"ff-el-form-check-input ff-el-form-check-radio\" value=\"Mild Problems\"  id='relationships_with_non_family_452a0078ddadfaf3ec9fb133842359ae' aria-label='Mild Problems' aria-invalid='false' aria-required=true> <span>Mild Problems<\/span><\/label><\/div><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for='relationships_with_non_family_3a36f809b15245f9300cea2437541813'><input  type=\"radio\" name=\"relationships_with_non_family\" data-name=\"relationships_with_non_family\" class=\"ff-el-form-check-input ff-el-form-check-radio\" value=\"No Problems\"  id='relationships_with_non_family_3a36f809b15245f9300cea2437541813' aria-label='No Problems' aria-invalid='false' aria-required=true> <span>No Problems<\/span><\/label><\/div><\/div><\/div><\/div><\/div><div data-name=\"ff_cn_id_17\"  class='ff-t-container ff-column-container ff_columns_total_2 '><div class='ff-t-cell ff-t-column-1' style='flex-basis: 50%;'><div class='ff-el-group  ff_list_inline'><div class=\"ff-el-input--label ff-el-is-required asterisk-right\"><label   aria-label=\"How is your current health?\">How is your current health?<\/label><\/div><div class='ff-el-input--content'><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for='your_current_health_23665a86f9d245c5cb6177ffd589805f'><input  type=\"radio\" name=\"your_current_health\" data-name=\"your_current_health\" class=\"ff-el-form-check-input ff-el-form-check-radio\" value=\"Not working\"  id='your_current_health_23665a86f9d245c5cb6177ffd589805f' aria-label='Not working' aria-invalid='false' aria-required=true> <span>Not working<\/span><\/label><\/div><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for='your_current_health_6c627b7d0a6a653932d57c4c1824960f'><input  type=\"radio\" name=\"your_current_health\" data-name=\"your_current_health\" class=\"ff-el-form-check-input ff-el-form-check-radio\" value=\"Cannot Function\"  id='your_current_health_6c627b7d0a6a653932d57c4c1824960f' aria-label='Cannot Function' aria-invalid='false' aria-required=true> <span>Cannot Function<\/span><\/label><\/div><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for='your_current_health_7ffab6bd1d5e9e870554d7dced5ec707'><input  type=\"radio\" name=\"your_current_health\" data-name=\"your_current_health\" class=\"ff-el-form-check-input ff-el-form-check-radio\" value=\"Serious Problems\"  id='your_current_health_7ffab6bd1d5e9e870554d7dced5ec707' aria-label='Serious Problems' aria-invalid='false' aria-required=true> <span>Serious Problems<\/span><\/label><\/div><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for='your_current_health_b8f52fc375643113fdabf2a44c4c9dea'><input  type=\"radio\" name=\"your_current_health\" data-name=\"your_current_health\" class=\"ff-el-form-check-input ff-el-form-check-radio\" value=\"Mild Problems\"  id='your_current_health_b8f52fc375643113fdabf2a44c4c9dea' aria-label='Mild Problems' aria-invalid='false' aria-required=true> <span>Mild Problems<\/span><\/label><\/div><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for='your_current_health_bd493d1c880535b438a6366d30bd0139'><input  type=\"radio\" name=\"your_current_health\" data-name=\"your_current_health\" class=\"ff-el-form-check-input ff-el-form-check-radio\" value=\"No Problems\"  id='your_current_health_bd493d1c880535b438a6366d30bd0139' aria-label='No Problems' aria-invalid='false' aria-required=true> <span>No Problems<\/span><\/label><\/div><\/div><\/div><\/div><div class='ff-t-cell ff-t-column-2' style='flex-basis: 50%;'><div class='ff-el-group  ff_list_inline'><div class=\"ff-el-input--label ff-el-is-required asterisk-right\"><label   aria-label=\"How is your general happiness and well-being?\">How is your general happiness and well-being?<\/label><\/div><div class='ff-el-input--content'><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for='general_happiness_3b135747a2874a9954571a792eeaa073'><input  type=\"radio\" name=\"general_happiness\" data-name=\"general_happiness\" class=\"ff-el-form-check-input ff-el-form-check-radio\" value=\"Not working\"  id='general_happiness_3b135747a2874a9954571a792eeaa073' aria-label='Not working' aria-invalid='false' aria-required=true> <span>Not working<\/span><\/label><\/div><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for='general_happiness_4bf0955d81145b724c437dc7e0b4525a'><input  type=\"radio\" name=\"general_happiness\" data-name=\"general_happiness\" class=\"ff-el-form-check-input ff-el-form-check-radio\" value=\"Cannot Function\"  id='general_happiness_4bf0955d81145b724c437dc7e0b4525a' aria-label='Cannot Function' aria-invalid='false' aria-required=true> <span>Cannot Function<\/span><\/label><\/div><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for='general_happiness_159b0c78378f43678abd94e5fa95f29c'><input  type=\"radio\" name=\"general_happiness\" data-name=\"general_happiness\" class=\"ff-el-form-check-input ff-el-form-check-radio\" value=\"Serious Problems\"  id='general_happiness_159b0c78378f43678abd94e5fa95f29c' aria-label='Serious Problems' aria-invalid='false' aria-required=true> <span>Serious Problems<\/span><\/label><\/div><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for='general_happiness_6d8666e6caffabb327aabe24c458df67'><input  type=\"radio\" name=\"general_happiness\" data-name=\"general_happiness\" class=\"ff-el-form-check-input ff-el-form-check-radio\" value=\"Mild Problems\"  id='general_happiness_6d8666e6caffabb327aabe24c458df67' aria-label='Mild Problems' aria-invalid='false' aria-required=true> <span>Mild Problems<\/span><\/label><\/div><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for='general_happiness_22a4df91c1c88ac9258a6eb415ac16d7'><input  type=\"radio\" name=\"general_happiness\" data-name=\"general_happiness\" class=\"ff-el-form-check-input ff-el-form-check-radio\" value=\"No Problems\"  id='general_happiness_22a4df91c1c88ac9258a6eb415ac16d7' aria-label='No Problems' aria-invalid='false' aria-required=true> <span>No Problems<\/span><\/label><\/div><\/div><\/div><\/div><\/div><div class='step-nav ff_step_nav_last'><button style='float: left;'  type='button' data-action='prev' class='ff-btn ff-btn-prev ff-btn-secondary' aria-label='Previous'>Previous<\/button><button style='float: right;'  type='button' data-action='next' class='ff-float-right ff-btn ff-btn-next ff-btn-secondary' aria-label='Next'>Next<\/button><\/div><\/div><div style='display: none;' class=\" fluentform-step\" data-name=\"form_step-3_6\" ><div data-type='tabular-element' data-name='i_am_experiencing' class='ff-el-group'><div class='ff-el-input--label ff-el-is-required asterisk-right'><label aria-label='I AM EXPERIENCING' for=''>I AM EXPERIENCING<\/label><\/div><div class='ff-el-input--content'><table class='ff-table ff-checkable-grids ff_flexible_table' role='table'><thead><tr><th><\/th><th>Never<\/th><th>Rarely<\/th><th>Often<\/th><th>Always<\/th><th>How Long?<\/th><\/tr><\/thead><tbody><tr role=\"row\"\"><td class='ff_grid_header' role='cell'>Frequent worry or tension<\/td><td data-label='Never'><input aria-label=\"Frequent worry or tension-Never\" name=\"i_am_experiencing[Frequent worry or tension]\" type=\"radio\" value=\"Never\"   aria-invalid='false' aria-required=true><\/td><td data-label='Rarely'><input aria-label=\"Frequent worry or tension-Rarely\" name=\"i_am_experiencing[Frequent worry or tension]\" type=\"radio\" value=\"Rarely\"   aria-invalid='false' aria-required=true><\/td><td data-label='Often'><input aria-label=\"Frequent worry or tension-Often\" name=\"i_am_experiencing[Frequent worry or tension]\" type=\"radio\" value=\"Often\"   aria-invalid='false' aria-required=true><\/td><td data-label='Always'><input aria-label=\"Frequent worry or tension-Always\" name=\"i_am_experiencing[Frequent worry or tension]\" type=\"radio\" value=\"Always\"   aria-invalid='false' aria-required=true><\/td><td data-label='How Long?'><input aria-label=\"Frequent worry or tension-How Long?\" name=\"i_am_experiencing[Frequent worry or tension]\" type=\"radio\" value=\"How Long?\"   aria-invalid='false' aria-required=true><\/td><\/tr><tr role=\"row\"\"><td class='ff_grid_header' role='cell'>Fear of many things<\/td><td data-label='Never'><input aria-label=\"Fear of many things-Never\" name=\"i_am_experiencing[Fear of many things]\" type=\"radio\" value=\"Never\"   aria-invalid='false' aria-required=true><\/td><td data-label='Rarely'><input aria-label=\"Fear of many things-Rarely\" name=\"i_am_experiencing[Fear of many things]\" type=\"radio\" value=\"Rarely\"   aria-invalid='false' aria-required=true><\/td><td data-label='Often'><input aria-label=\"Fear of many things-Often\" name=\"i_am_experiencing[Fear of many things]\" type=\"radio\" value=\"Often\"   aria-invalid='false' aria-required=true><\/td><td data-label='Always'><input aria-label=\"Fear of many things-Always\" name=\"i_am_experiencing[Fear of many things]\" type=\"radio\" value=\"Always\"   aria-invalid='false' aria-required=true><\/td><td data-label='How Long?'><input aria-label=\"Fear of many things-How Long?\" name=\"i_am_experiencing[Fear of many things]\" type=\"radio\" value=\"How Long?\"   aria-invalid='false' aria-required=true><\/td><\/tr><tr role=\"row\"\"><td class='ff_grid_header' role='cell'>Discomfort in social situations<\/td><td data-label='Never'><input aria-label=\"Discomfort in social situations-Never\" name=\"i_am_experiencing[Discomfort in social situations]\" type=\"radio\" value=\"Never\"   aria-invalid='false' aria-required=true><\/td><td data-label='Rarely'><input aria-label=\"Discomfort in social situations-Rarely\" name=\"i_am_experiencing[Discomfort in social situations]\" type=\"radio\" value=\"Rarely\"   aria-invalid='false' aria-required=true><\/td><td data-label='Often'><input aria-label=\"Discomfort in social situations-Often\" name=\"i_am_experiencing[Discomfort in social situations]\" type=\"radio\" value=\"Often\"   aria-invalid='false' aria-required=true><\/td><td data-label='Always'><input aria-label=\"Discomfort in social situations-Always\" name=\"i_am_experiencing[Discomfort in social situations]\" type=\"radio\" value=\"Always\"   aria-invalid='false' aria-required=true><\/td><td data-label='How Long?'><input aria-label=\"Discomfort in social situations-How Long?\" name=\"i_am_experiencing[Discomfort in social situations]\" type=\"radio\" value=\"How Long?\"   aria-invalid='false' aria-required=true><\/td><\/tr><tr role=\"row\"\"><td class='ff_grid_header' role='cell'>Feelings of guilt<\/td><td data-label='Never'><input aria-label=\"Feelings of guilt-Never\" name=\"i_am_experiencing[Feelings of guilt]\" type=\"radio\" value=\"Never\"   aria-invalid='false' aria-required=true><\/td><td data-label='Rarely'><input aria-label=\"Feelings of guilt-Rarely\" name=\"i_am_experiencing[Feelings of guilt]\" type=\"radio\" value=\"Rarely\"   aria-invalid='false' aria-required=true><\/td><td data-label='Often'><input aria-label=\"Feelings of guilt-Often\" name=\"i_am_experiencing[Feelings of guilt]\" type=\"radio\" value=\"Often\"   aria-invalid='false' aria-required=true><\/td><td data-label='Always'><input aria-label=\"Feelings of guilt-Always\" name=\"i_am_experiencing[Feelings of guilt]\" type=\"radio\" value=\"Always\"   aria-invalid='false' aria-required=true><\/td><td data-label='How Long?'><input aria-label=\"Feelings of guilt-How Long?\" name=\"i_am_experiencing[Feelings of guilt]\" type=\"radio\" value=\"How Long?\"   aria-invalid='false' aria-required=true><\/td><\/tr><tr role=\"row\"\"><td class='ff_grid_header' role='cell'>Phobias: unusual fears about specific things<\/td><td data-label='Never'><input aria-label=\"Phobias: unusual fears about specific things-Never\" name=\"i_am_experiencing[Phobias: unusual fears about specific things]\" type=\"radio\" value=\"Never\"   aria-invalid='false' aria-required=true><\/td><td data-label='Rarely'><input aria-label=\"Phobias: unusual fears about specific things-Rarely\" name=\"i_am_experiencing[Phobias: unusual fears about specific things]\" type=\"radio\" value=\"Rarely\"   aria-invalid='false' aria-required=true><\/td><td data-label='Often'><input aria-label=\"Phobias: unusual fears about specific things-Often\" name=\"i_am_experiencing[Phobias: unusual fears about specific things]\" type=\"radio\" value=\"Often\"   aria-invalid='false' aria-required=true><\/td><td data-label='Always'><input aria-label=\"Phobias: unusual fears about specific things-Always\" name=\"i_am_experiencing[Phobias: unusual fears about specific things]\" type=\"radio\" value=\"Always\"   aria-invalid='false' aria-required=true><\/td><td data-label='How Long?'><input aria-label=\"Phobias: unusual fears about specific things-How Long?\" name=\"i_am_experiencing[Phobias: unusual fears about specific things]\" type=\"radio\" value=\"How Long?\"   aria-invalid='false' aria-required=true><\/td><\/tr><tr role=\"row\"\"><td class='ff_grid_header' role='cell'>Panic attacks: Sweating, trembling, shortness of breath, heart palpitations<\/td><td data-label='Never'><input aria-label=\"Panic attacks: Sweating, trembling, shortness of breath, heart palpitations-Never\" name=\"i_am_experiencing[Panic attacks: Sweating, trembling, shortness of breath, heart palpitations]\" type=\"radio\" value=\"Never\"   aria-invalid='false' aria-required=true><\/td><td data-label='Rarely'><input aria-label=\"Panic attacks: Sweating, trembling, shortness of breath, heart palpitations-Rarely\" name=\"i_am_experiencing[Panic attacks: Sweating, trembling, shortness of breath, heart palpitations]\" type=\"radio\" value=\"Rarely\"   aria-invalid='false' aria-required=true><\/td><td data-label='Often'><input aria-label=\"Panic attacks: Sweating, trembling, shortness of breath, heart palpitations-Often\" name=\"i_am_experiencing[Panic attacks: Sweating, trembling, shortness of breath, heart palpitations]\" type=\"radio\" value=\"Often\"   aria-invalid='false' aria-required=true><\/td><td data-label='Always'><input aria-label=\"Panic attacks: Sweating, trembling, shortness of breath, heart palpitations-Always\" name=\"i_am_experiencing[Panic attacks: Sweating, trembling, shortness of breath, heart palpitations]\" type=\"radio\" value=\"Always\"   aria-invalid='false' aria-required=true><\/td><td data-label='How Long?'><input aria-label=\"Panic attacks: Sweating, trembling, shortness of breath, heart palpitations-How Long?\" name=\"i_am_experiencing[Panic attacks: Sweating, trembling, shortness of breath, heart palpitations]\" type=\"radio\" value=\"How Long?\"   aria-invalid='false' aria-required=true><\/td><\/tr><tr role=\"row\"\"><td class='ff_grid_header' role='cell'>Recurring, distressing thoughts about a trauma<\/td><td data-label='Never'><input aria-label=\"Recurring, distressing thoughts about a trauma-Never\" name=\"i_am_experiencing[Recurring, distressing thoughts about a trauma]\" type=\"radio\" value=\"Never\"   aria-invalid='false' aria-required=true><\/td><td data-label='Rarely'><input aria-label=\"Recurring, distressing thoughts about a trauma-Rarely\" name=\"i_am_experiencing[Recurring, distressing thoughts about a trauma]\" type=\"radio\" value=\"Rarely\"   aria-invalid='false' aria-required=true><\/td><td data-label='Often'><input aria-label=\"Recurring, distressing thoughts about a trauma-Often\" name=\"i_am_experiencing[Recurring, distressing thoughts about a trauma]\" type=\"radio\" value=\"Often\"   aria-invalid='false' aria-required=true><\/td><td data-label='Always'><input aria-label=\"Recurring, distressing thoughts about a trauma-Always\" name=\"i_am_experiencing[Recurring, distressing thoughts about a trauma]\" type=\"radio\" value=\"Always\"   aria-invalid='false' aria-required=true><\/td><td data-label='How Long?'><input aria-label=\"Recurring, distressing thoughts about a trauma-How Long?\" name=\"i_am_experiencing[Recurring, distressing thoughts about a trauma]\" type=\"radio\" value=\"How Long?\"   aria-invalid='false' aria-required=true><\/td><\/tr><tr role=\"row\"\"><td class='ff_grid_header' role='cell'>\u201cFlashbacks\u201d as if reliving the traumatic event<\/td><td data-label='Never'><input aria-label=\"\u201cFlashbacks\u201d as if reliving the traumatic event-Never\" name=\"i_am_experiencing[\u201cFlashbacks\u201d as if reliving the traumatic event]\" type=\"radio\" value=\"Never\"   aria-invalid='false' aria-required=true><\/td><td data-label='Rarely'><input aria-label=\"\u201cFlashbacks\u201d as if reliving the traumatic event-Rarely\" name=\"i_am_experiencing[\u201cFlashbacks\u201d as if reliving the traumatic event]\" type=\"radio\" value=\"Rarely\"   aria-invalid='false' aria-required=true><\/td><td data-label='Often'><input aria-label=\"\u201cFlashbacks\u201d as if reliving the traumatic event-Often\" name=\"i_am_experiencing[\u201cFlashbacks\u201d as if reliving the traumatic event]\" type=\"radio\" value=\"Often\"   aria-invalid='false' aria-required=true><\/td><td data-label='Always'><input aria-label=\"\u201cFlashbacks\u201d as if reliving the traumatic event-Always\" name=\"i_am_experiencing[\u201cFlashbacks\u201d as if reliving the traumatic event]\" type=\"radio\" value=\"Always\"   aria-invalid='false' aria-required=true><\/td><td data-label='How Long?'><input aria-label=\"\u201cFlashbacks\u201d as if reliving the traumatic event-How Long?\" name=\"i_am_experiencing[\u201cFlashbacks\u201d as if reliving the traumatic event]\" type=\"radio\" value=\"How Long?\"   aria-invalid='false' aria-required=true><\/td><\/tr><tr role=\"row\"\"><td class='ff_grid_header' role='cell'>Avoiding people\/places associated with trauma<\/td><td data-label='Never'><input aria-label=\"Avoiding people\/places associated with trauma-Never\" name=\"i_am_experiencing[Avoiding people\/places associated with trauma]\" type=\"radio\" value=\"Never\"   aria-invalid='false' aria-required=true><\/td><td data-label='Rarely'><input aria-label=\"Avoiding people\/places associated with trauma-Rarely\" name=\"i_am_experiencing[Avoiding people\/places associated with trauma]\" type=\"radio\" value=\"Rarely\"   aria-invalid='false' aria-required=true><\/td><td data-label='Often'><input aria-label=\"Avoiding people\/places associated with trauma-Often\" name=\"i_am_experiencing[Avoiding people\/places associated with trauma]\" type=\"radio\" value=\"Often\"   aria-invalid='false' aria-required=true><\/td><td data-label='Always'><input aria-label=\"Avoiding people\/places associated with trauma-Always\" name=\"i_am_experiencing[Avoiding people\/places associated with trauma]\" type=\"radio\" value=\"Always\"   aria-invalid='false' aria-required=true><\/td><td data-label='How Long?'><input aria-label=\"Avoiding people\/places associated with trauma-How Long?\" name=\"i_am_experiencing[Avoiding people\/places associated with trauma]\" type=\"radio\" value=\"How Long?\"   aria-invalid='false' aria-required=true><\/td><\/tr><tr role=\"row\"\"><td class='ff_grid_header' role='cell'>Nightmares about traumatic experience<\/td><td data-label='Never'><input aria-label=\"Nightmares about traumatic experience-Never\" name=\"i_am_experiencing[Nightmares about traumatic experience]\" type=\"radio\" value=\"Never\"   aria-invalid='false' aria-required=true><\/td><td data-label='Rarely'><input aria-label=\"Nightmares about traumatic experience-Rarely\" name=\"i_am_experiencing[Nightmares about traumatic experience]\" type=\"radio\" value=\"Rarely\"   aria-invalid='false' aria-required=true><\/td><td data-label='Often'><input aria-label=\"Nightmares about traumatic experience-Often\" name=\"i_am_experiencing[Nightmares about traumatic experience]\" type=\"radio\" value=\"Often\"   aria-invalid='false' aria-required=true><\/td><td data-label='Always'><input aria-label=\"Nightmares about traumatic experience-Always\" name=\"i_am_experiencing[Nightmares about traumatic experience]\" type=\"radio\" value=\"Always\"   aria-invalid='false' aria-required=true><\/td><td data-label='How Long?'><input aria-label=\"Nightmares about traumatic experience-How Long?\" name=\"i_am_experiencing[Nightmares about traumatic experience]\" type=\"radio\" value=\"How Long?\"   aria-invalid='false' aria-required=true><\/td><\/tr><\/tbody><\/table><\/div><\/div><div data-type='tabular-element' data-name='i_am_feeling' class='ff-el-group'><div class='ff-el-input--label ff-el-is-required asterisk-right'><label aria-label='I AM FEELING' for=''>I AM FEELING<\/label><\/div><div class='ff-el-input--content'><table class='ff-table ff-checkable-grids ff_flexible_table' role='table'><thead><tr><th><\/th><th>Never<\/th><th>Rarely<\/th><th>Often<\/th><th>Always<\/th><th>How Long?<\/th><\/tr><\/thead><tbody><tr role=\"row\"\"><td class='ff_grid_header' role='cell'>Decreased interest in pleasurable activities<\/td><td data-label='Never'><input aria-label=\"Decreased interest in pleasurable activities-Never\" name=\"i_am_feeling[Decreased interest in pleasurable activities]\" type=\"radio\" value=\"Never\"   aria-invalid='false' aria-required=true><\/td><td data-label='Rarely'><input aria-label=\"Decreased interest in pleasurable activities-Rarely\" name=\"i_am_feeling[Decreased interest in pleasurable activities]\" type=\"radio\" value=\"Rarely\"   aria-invalid='false' aria-required=true><\/td><td data-label='Often'><input aria-label=\"Decreased interest in pleasurable activities-Often\" name=\"i_am_feeling[Decreased interest in pleasurable activities]\" type=\"radio\" value=\"Often\"   aria-invalid='false' aria-required=true><\/td><td data-label='Always'><input aria-label=\"Decreased interest in pleasurable activities-Always\" name=\"i_am_feeling[Decreased interest in pleasurable activities]\" type=\"radio\" value=\"Always\"   aria-invalid='false' aria-required=true><\/td><td data-label='How Long?'><input aria-label=\"Decreased interest in pleasurable activities-How Long?\" name=\"i_am_feeling[Decreased interest in pleasurable activities]\" type=\"radio\" value=\"How Long?\"   aria-invalid='false' aria-required=true><\/td><\/tr><tr role=\"row\"\"><td class='ff_grid_header' role='cell'>Social isolation, loneliness<\/td><td data-label='Never'><input aria-label=\"Social isolation, loneliness-Never\" name=\"i_am_feeling[Social isolation, loneliness]\" type=\"radio\" value=\"Never\"   aria-invalid='false' aria-required=true><\/td><td data-label='Rarely'><input aria-label=\"Social isolation, loneliness-Rarely\" name=\"i_am_feeling[Social isolation, loneliness]\" type=\"radio\" value=\"Rarely\"   aria-invalid='false' aria-required=true><\/td><td data-label='Often'><input aria-label=\"Social isolation, loneliness-Often\" name=\"i_am_feeling[Social isolation, loneliness]\" type=\"radio\" value=\"Often\"   aria-invalid='false' aria-required=true><\/td><td data-label='Always'><input aria-label=\"Social isolation, loneliness-Always\" name=\"i_am_feeling[Social isolation, loneliness]\" type=\"radio\" value=\"Always\"   aria-invalid='false' aria-required=true><\/td><td data-label='How Long?'><input aria-label=\"Social isolation, loneliness-How Long?\" name=\"i_am_feeling[Social isolation, loneliness]\" type=\"radio\" value=\"How Long?\"   aria-invalid='false' aria-required=true><\/td><\/tr><tr role=\"row\"\"><td class='ff_grid_header' role='cell'>Suicidal thoughts<\/td><td data-label='Never'><input aria-label=\"Suicidal thoughts-Never\" name=\"i_am_feeling[Suicidal thoughts]\" type=\"radio\" value=\"Never\"   aria-invalid='false' aria-required=true><\/td><td data-label='Rarely'><input aria-label=\"Suicidal thoughts-Rarely\" name=\"i_am_feeling[Suicidal thoughts]\" type=\"radio\" value=\"Rarely\"   aria-invalid='false' aria-required=true><\/td><td data-label='Often'><input aria-label=\"Suicidal thoughts-Often\" name=\"i_am_feeling[Suicidal thoughts]\" type=\"radio\" value=\"Often\"   aria-invalid='false' aria-required=true><\/td><td data-label='Always'><input aria-label=\"Suicidal thoughts-Always\" name=\"i_am_feeling[Suicidal thoughts]\" type=\"radio\" value=\"Always\"   aria-invalid='false' aria-required=true><\/td><td data-label='How Long?'><input aria-label=\"Suicidal thoughts-How Long?\" name=\"i_am_feeling[Suicidal thoughts]\" type=\"radio\" value=\"How Long?\"   aria-invalid='false' aria-required=true><\/td><\/tr><tr role=\"row\"\"><td class='ff_grid_header' role='cell'>Bereavement or feelings of loss<\/td><td data-label='Never'><input aria-label=\"Bereavement or feelings of loss-Never\" name=\"i_am_feeling[Bereavement or feelings of loss]\" type=\"radio\" value=\"Never\"   aria-invalid='false' aria-required=true><\/td><td data-label='Rarely'><input aria-label=\"Bereavement or feelings of loss-Rarely\" name=\"i_am_feeling[Bereavement or feelings of loss]\" type=\"radio\" value=\"Rarely\"   aria-invalid='false' aria-required=true><\/td><td data-label='Often'><input aria-label=\"Bereavement or feelings of loss-Often\" name=\"i_am_feeling[Bereavement or feelings of loss]\" type=\"radio\" value=\"Often\"   aria-invalid='false' aria-required=true><\/td><td data-label='Always'><input aria-label=\"Bereavement or feelings of loss-Always\" name=\"i_am_feeling[Bereavement or feelings of loss]\" type=\"radio\" value=\"Always\"   aria-invalid='false' aria-required=true><\/td><td data-label='How Long?'><input aria-label=\"Bereavement or feelings of loss-How Long?\" name=\"i_am_feeling[Bereavement or feelings of loss]\" type=\"radio\" value=\"How Long?\"   aria-invalid='false' aria-required=true><\/td><\/tr><tr role=\"row\"\"><td class='ff_grid_header' role='cell'>Changes in sleep (too much or not enough)<\/td><td data-label='Never'><input aria-label=\"Changes in sleep (too much or not enough)-Never\" name=\"i_am_feeling[Changes in sleep (too much or not enough)]\" type=\"radio\" value=\"Never\"   aria-invalid='false' aria-required=true><\/td><td data-label='Rarely'><input aria-label=\"Changes in sleep (too much or not enough)-Rarely\" name=\"i_am_feeling[Changes in sleep (too much or not enough)]\" type=\"radio\" value=\"Rarely\"   aria-invalid='false' aria-required=true><\/td><td data-label='Often'><input aria-label=\"Changes in sleep (too much or not enough)-Often\" name=\"i_am_feeling[Changes in sleep (too much or not enough)]\" type=\"radio\" value=\"Often\"   aria-invalid='false' aria-required=true><\/td><td data-label='Always'><input aria-label=\"Changes in sleep (too much or not enough)-Always\" name=\"i_am_feeling[Changes in sleep (too much or not enough)]\" type=\"radio\" value=\"Always\"   aria-invalid='false' aria-required=true><\/td><td data-label='How Long?'><input aria-label=\"Changes in sleep (too much or not enough)-How Long?\" name=\"i_am_feeling[Changes in sleep (too much or not enough)]\" type=\"radio\" value=\"How Long?\"   aria-invalid='false' aria-required=true><\/td><\/tr><tr role=\"row\"\"><td class='ff_grid_header' role='cell'>Normal, daily tasks require more effort<\/td><td data-label='Never'><input aria-label=\"Normal, daily tasks require more effort-Never\" name=\"i_am_feeling[Normal, daily tasks require more effort]\" type=\"radio\" value=\"Never\"   aria-invalid='false' aria-required=true><\/td><td data-label='Rarely'><input aria-label=\"Normal, daily tasks require more effort-Rarely\" name=\"i_am_feeling[Normal, daily tasks require more effort]\" type=\"radio\" value=\"Rarely\"   aria-invalid='false' aria-required=true><\/td><td data-label='Often'><input aria-label=\"Normal, daily tasks require more effort-Often\" name=\"i_am_feeling[Normal, daily tasks require more effort]\" type=\"radio\" value=\"Often\"   aria-invalid='false' aria-required=true><\/td><td data-label='Always'><input aria-label=\"Normal, daily tasks require more effort-Always\" name=\"i_am_feeling[Normal, daily tasks require more effort]\" type=\"radio\" value=\"Always\"   aria-invalid='false' aria-required=true><\/td><td data-label='How Long?'><input aria-label=\"Normal, daily tasks require more effort-How Long?\" name=\"i_am_feeling[Normal, daily tasks require more effort]\" type=\"radio\" value=\"How Long?\"   aria-invalid='false' aria-required=true><\/td><\/tr><tr role=\"row\"\"><td class='ff_grid_header' role='cell'>Sad, hopeless about future<\/td><td data-label='Never'><input aria-label=\"Sad, hopeless about future-Never\" name=\"i_am_feeling[Sad, hopeless about future]\" type=\"radio\" value=\"Never\"   aria-invalid='false' aria-required=true><\/td><td data-label='Rarely'><input aria-label=\"Sad, hopeless about future-Rarely\" name=\"i_am_feeling[Sad, hopeless about future]\" type=\"radio\" value=\"Rarely\"   aria-invalid='false' aria-required=true><\/td><td data-label='Often'><input aria-label=\"Sad, hopeless about future-Often\" name=\"i_am_feeling[Sad, hopeless about future]\" type=\"radio\" value=\"Often\"   aria-invalid='false' aria-required=true><\/td><td data-label='Always'><input aria-label=\"Sad, hopeless about future-Always\" name=\"i_am_feeling[Sad, hopeless about future]\" type=\"radio\" value=\"Always\"   aria-invalid='false' aria-required=true><\/td><td data-label='How Long?'><input aria-label=\"Sad, hopeless about future-How Long?\" name=\"i_am_feeling[Sad, hopeless about future]\" type=\"radio\" value=\"How Long?\"   aria-invalid='false' aria-required=true><\/td><\/tr><tr role=\"row\"\"><td class='ff_grid_header' role='cell'>Excessive feelings of guilt<\/td><td data-label='Never'><input aria-label=\"Excessive feelings of guilt-Never\" name=\"i_am_feeling[Excessive feelings of guilt]\" type=\"radio\" value=\"Never\"   aria-invalid='false' aria-required=true><\/td><td data-label='Rarely'><input aria-label=\"Excessive feelings of guilt-Rarely\" name=\"i_am_feeling[Excessive feelings of guilt]\" type=\"radio\" value=\"Rarely\"   aria-invalid='false' aria-required=true><\/td><td data-label='Often'><input aria-label=\"Excessive feelings of guilt-Often\" name=\"i_am_feeling[Excessive feelings of guilt]\" type=\"radio\" value=\"Often\"   aria-invalid='false' aria-required=true><\/td><td data-label='Always'><input aria-label=\"Excessive feelings of guilt-Always\" name=\"i_am_feeling[Excessive feelings of guilt]\" type=\"radio\" value=\"Always\"   aria-invalid='false' aria-required=true><\/td><td data-label='How Long?'><input aria-label=\"Excessive feelings of guilt-How Long?\" name=\"i_am_feeling[Excessive feelings of guilt]\" type=\"radio\" value=\"How Long?\"   aria-invalid='false' aria-required=true><\/td><\/tr><tr role=\"row\"\"><td class='ff_grid_header' role='cell'>Low self-esteem<\/td><td data-label='Never'><input aria-label=\"Low self-esteem-Never\" name=\"i_am_feeling[Low self-esteem]\" type=\"radio\" value=\"Never\"   aria-invalid='false' aria-required=true><\/td><td data-label='Rarely'><input aria-label=\"Low self-esteem-Rarely\" name=\"i_am_feeling[Low self-esteem]\" type=\"radio\" value=\"Rarely\"   aria-invalid='false' aria-required=true><\/td><td data-label='Often'><input aria-label=\"Low self-esteem-Often\" name=\"i_am_feeling[Low self-esteem]\" type=\"radio\" value=\"Often\"   aria-invalid='false' aria-required=true><\/td><td data-label='Always'><input aria-label=\"Low self-esteem-Always\" name=\"i_am_feeling[Low self-esteem]\" type=\"radio\" value=\"Always\"   aria-invalid='false' aria-required=true><\/td><td data-label='How Long?'><input aria-label=\"Low self-esteem-How Long?\" name=\"i_am_feeling[Low self-esteem]\" type=\"radio\" value=\"How Long?\"   aria-invalid='false' aria-required=true><\/td><\/tr><\/tbody><\/table><\/div><\/div><div data-type='tabular-element' data-name='i_notice' class='ff-el-group'><div class='ff-el-input--label ff-el-is-required asterisk-right'><label aria-label='I NOTICE' for=''>I NOTICE<\/label><\/div><div class='ff-el-input--content'><table class='ff-table ff-checkable-grids ff_flexible_table' role='table'><thead><tr><th><\/th><th>Never<\/th><th>Rarely<\/th><th>Often<\/th><th>Always<\/th><th>How Long?<\/th><\/tr><\/thead><tbody><tr role=\"row\"\"><td class='ff_grid_header' role='cell'>I am angry, Irritable, hostile<\/td><td data-label='Never'><input aria-label=\"I am angry, Irritable, hostile-Never\" name=\"i_notice[I am angry, Irritable, hostile]\" type=\"radio\" value=\"Never\"   aria-invalid='false' aria-required=true><\/td><td data-label='Rarely'><input aria-label=\"I am angry, Irritable, hostile-Rarely\" name=\"i_notice[I am angry, Irritable, hostile]\" type=\"radio\" value=\"Rarely\"   aria-invalid='false' aria-required=true><\/td><td data-label='Often'><input aria-label=\"I am angry, Irritable, hostile-Often\" name=\"i_notice[I am angry, Irritable, hostile]\" type=\"radio\" value=\"Often\"   aria-invalid='false' aria-required=true><\/td><td data-label='Always'><input aria-label=\"I am angry, Irritable, hostile-Always\" name=\"i_notice[I am angry, Irritable, hostile]\" type=\"radio\" value=\"Always\"   aria-invalid='false' aria-required=true><\/td><td data-label='How Long?'><input aria-label=\"I am angry, Irritable, hostile-How Long?\" name=\"i_notice[I am angry, Irritable, hostile]\" type=\"radio\" value=\"How Long?\"   aria-invalid='false' aria-required=true><\/td><\/tr><tr role=\"row\"\"><td class='ff_grid_header' role='cell'>I feel euphoric, energized and highly optimistic<\/td><td data-label='Never'><input aria-label=\"I feel euphoric, energized and highly optimistic-Never\" name=\"i_notice[I feel euphoric, energized and highly optimistic]\" type=\"radio\" value=\"Never\"   aria-invalid='false' aria-required=true><\/td><td data-label='Rarely'><input aria-label=\"I feel euphoric, energized and highly optimistic-Rarely\" name=\"i_notice[I feel euphoric, energized and highly optimistic]\" type=\"radio\" value=\"Rarely\"   aria-invalid='false' aria-required=true><\/td><td data-label='Often'><input aria-label=\"I feel euphoric, energized and highly optimistic-Often\" name=\"i_notice[I feel euphoric, energized and highly optimistic]\" type=\"radio\" value=\"Often\"   aria-invalid='false' aria-required=true><\/td><td data-label='Always'><input aria-label=\"I feel euphoric, energized and highly optimistic-Always\" name=\"i_notice[I feel euphoric, energized and highly optimistic]\" type=\"radio\" value=\"Always\"   aria-invalid='false' aria-required=true><\/td><td data-label='How Long?'><input aria-label=\"I feel euphoric, energized and highly optimistic-How Long?\" name=\"i_notice[I feel euphoric, energized and highly optimistic]\" type=\"radio\" value=\"How Long?\"   aria-invalid='false' aria-required=true><\/td><\/tr><tr role=\"row\"\"><td class='ff_grid_header' role='cell'>I have racing thoughts<\/td><td data-label='Never'><input aria-label=\"I have racing thoughts-Never\" name=\"i_notice[I have racing thoughts]\" type=\"radio\" value=\"Never\"   aria-invalid='false' aria-required=true><\/td><td data-label='Rarely'><input aria-label=\"I have racing thoughts-Rarely\" name=\"i_notice[I have racing thoughts]\" type=\"radio\" value=\"Rarely\"   aria-invalid='false' aria-required=true><\/td><td data-label='Often'><input aria-label=\"I have racing thoughts-Often\" name=\"i_notice[I have racing thoughts]\" type=\"radio\" value=\"Often\"   aria-invalid='false' aria-required=true><\/td><td data-label='Always'><input aria-label=\"I have racing thoughts-Always\" name=\"i_notice[I have racing thoughts]\" type=\"radio\" value=\"Always\"   aria-invalid='false' aria-required=true><\/td><td data-label='How Long?'><input aria-label=\"I have racing thoughts-How Long?\" name=\"i_notice[I have racing thoughts]\" type=\"radio\" value=\"How Long?\"   aria-invalid='false' aria-required=true><\/td><\/tr><tr role=\"row\"\"><td class='ff_grid_header' role='cell'>I need less sleep than usual<\/td><td data-label='Never'><input aria-label=\"I need less sleep than usual-Never\" name=\"i_notice[I need less sleep than usual]\" type=\"radio\" value=\"Never\"   aria-invalid='false' aria-required=true><\/td><td data-label='Rarely'><input aria-label=\"I need less sleep than usual-Rarely\" name=\"i_notice[I need less sleep than usual]\" type=\"radio\" value=\"Rarely\"   aria-invalid='false' aria-required=true><\/td><td data-label='Often'><input aria-label=\"I need less sleep than usual-Often\" name=\"i_notice[I need less sleep than usual]\" type=\"radio\" value=\"Often\"   aria-invalid='false' aria-required=true><\/td><td data-label='Always'><input aria-label=\"I need less sleep than usual-Always\" name=\"i_notice[I need less sleep than usual]\" type=\"radio\" value=\"Always\"   aria-invalid='false' aria-required=true><\/td><td data-label='How Long?'><input aria-label=\"I need less sleep than usual-How Long?\" name=\"i_notice[I need less sleep than usual]\" type=\"radio\" value=\"How Long?\"   aria-invalid='false' aria-required=true><\/td><\/tr><tr role=\"row\"\"><td class='ff_grid_header' role='cell'>I am more talkative<\/td><td data-label='Never'><input aria-label=\"I am more talkative-Never\" name=\"i_notice[I am more talkative]\" type=\"radio\" value=\"Never\"   aria-invalid='false' aria-required=true><\/td><td data-label='Rarely'><input aria-label=\"I am more talkative-Rarely\" name=\"i_notice[I am more talkative]\" type=\"radio\" value=\"Rarely\"   aria-invalid='false' aria-required=true><\/td><td data-label='Often'><input aria-label=\"I am more talkative-Often\" name=\"i_notice[I am more talkative]\" type=\"radio\" value=\"Often\"   aria-invalid='false' aria-required=true><\/td><td data-label='Always'><input aria-label=\"I am more talkative-Always\" name=\"i_notice[I am more talkative]\" type=\"radio\" value=\"Always\"   aria-invalid='false' aria-required=true><\/td><td data-label='How Long?'><input aria-label=\"I am more talkative-How Long?\" name=\"i_notice[I am more talkative]\" type=\"radio\" value=\"How Long?\"   aria-invalid='false' aria-required=true><\/td><\/tr><tr role=\"row\"\"><td class='ff_grid_header' role='cell'>My moods fluctuate: go up and down<\/td><td data-label='Never'><input aria-label=\"My moods fluctuate: go up and down-Never\" name=\"i_notice[My moods fluctuate: go up and down]\" type=\"radio\" value=\"Never\"   aria-invalid='false' aria-required=true><\/td><td data-label='Rarely'><input aria-label=\"My moods fluctuate: go up and down-Rarely\" name=\"i_notice[My moods fluctuate: go up and down]\" type=\"radio\" value=\"Rarely\"   aria-invalid='false' aria-required=true><\/td><td data-label='Often'><input aria-label=\"My moods fluctuate: go up and down-Often\" name=\"i_notice[My moods fluctuate: go up and down]\" type=\"radio\" value=\"Often\"   aria-invalid='false' aria-required=true><\/td><td data-label='Always'><input aria-label=\"My moods fluctuate: go up and down-Always\" name=\"i_notice[My moods fluctuate: go up and down]\" type=\"radio\" value=\"Always\"   aria-invalid='false' aria-required=true><\/td><td data-label='How Long?'><input aria-label=\"My moods fluctuate: go up and down-How Long?\" name=\"i_notice[My moods fluctuate: go up and down]\" type=\"radio\" value=\"How Long?\"   aria-invalid='false' aria-required=true><\/td><\/tr><tr role=\"row\"\"><td class='ff_grid_header' role='cell'>Memory problems or trouble concentrating<\/td><td data-label='Never'><input aria-label=\"Memory problems or trouble concentrating-Never\" name=\"i_notice[Memory problems or trouble concentrating]\" type=\"radio\" value=\"Never\"   aria-invalid='false' aria-required=true><\/td><td data-label='Rarely'><input aria-label=\"Memory problems or trouble concentrating-Rarely\" name=\"i_notice[Memory problems or trouble concentrating]\" type=\"radio\" value=\"Rarely\"   aria-invalid='false' aria-required=true><\/td><td data-label='Often'><input aria-label=\"Memory problems or trouble concentrating-Often\" name=\"i_notice[Memory problems or trouble concentrating]\" type=\"radio\" value=\"Often\"   aria-invalid='false' aria-required=true><\/td><td data-label='Always'><input aria-label=\"Memory problems or trouble concentrating-Always\" name=\"i_notice[Memory problems or trouble concentrating]\" type=\"radio\" value=\"Always\"   aria-invalid='false' aria-required=true><\/td><td data-label='How Long?'><input aria-label=\"Memory problems or trouble concentrating-How Long?\" name=\"i_notice[Memory problems or trouble concentrating]\" type=\"radio\" value=\"How Long?\"   aria-invalid='false' aria-required=true><\/td><\/tr><tr role=\"row\"\"><td class='ff_grid_header' role='cell'>Trouble explaining myself to others<\/td><td data-label='Never'><input aria-label=\"Trouble explaining myself to others-Never\" name=\"i_notice[Trouble explaining myself to others]\" type=\"radio\" value=\"Never\"   aria-invalid='false' aria-required=true><\/td><td data-label='Rarely'><input aria-label=\"Trouble explaining myself to others-Rarely\" name=\"i_notice[Trouble explaining myself to others]\" type=\"radio\" value=\"Rarely\"   aria-invalid='false' aria-required=true><\/td><td data-label='Often'><input aria-label=\"Trouble explaining myself to others-Often\" name=\"i_notice[Trouble explaining myself to others]\" type=\"radio\" value=\"Often\"   aria-invalid='false' aria-required=true><\/td><td data-label='Always'><input aria-label=\"Trouble explaining myself to others-Always\" name=\"i_notice[Trouble explaining myself to others]\" type=\"radio\" value=\"Always\"   aria-invalid='false' aria-required=true><\/td><td data-label='How Long?'><input aria-label=\"Trouble explaining myself to others-How Long?\" name=\"i_notice[Trouble explaining myself to others]\" type=\"radio\" value=\"How Long?\"   aria-invalid='false' aria-required=true><\/td><\/tr><tr role=\"row\"\"><td class='ff_grid_header' role='cell'>Problems understanding what others tell me<\/td><td data-label='Never'><input aria-label=\"Problems understanding what others tell me-Never\" name=\"i_notice[Problems understanding what others tell me]\" type=\"radio\" value=\"Never\"   aria-invalid='false' aria-required=true><\/td><td data-label='Rarely'><input aria-label=\"Problems understanding what others tell me-Rarely\" name=\"i_notice[Problems understanding what others tell me]\" type=\"radio\" value=\"Rarely\"   aria-invalid='false' aria-required=true><\/td><td data-label='Often'><input aria-label=\"Problems understanding what others tell me-Often\" name=\"i_notice[Problems understanding what others tell me]\" type=\"radio\" value=\"Often\"   aria-invalid='false' aria-required=true><\/td><td data-label='Always'><input aria-label=\"Problems understanding what others tell me-Always\" name=\"i_notice[Problems understanding what others tell me]\" type=\"radio\" value=\"Always\"   aria-invalid='false' aria-required=true><\/td><td data-label='How Long?'><input aria-label=\"Problems understanding what others tell me-How Long?\" name=\"i_notice[Problems understanding what others tell me]\" type=\"radio\" value=\"How Long?\"   aria-invalid='false' aria-required=true><\/td><\/tr><tr role=\"row\"\"><td class='ff_grid_header' role='cell'>Intrusive or strange thoughts<\/td><td data-label='Never'><input aria-label=\"Intrusive or strange thoughts-Never\" name=\"i_notice[Intrusive or strange thoughts]\" type=\"radio\" value=\"Never\"   aria-invalid='false' aria-required=true><\/td><td data-label='Rarely'><input aria-label=\"Intrusive or strange thoughts-Rarely\" name=\"i_notice[Intrusive or strange thoughts]\" type=\"radio\" value=\"Rarely\"   aria-invalid='false' aria-required=true><\/td><td data-label='Often'><input aria-label=\"Intrusive or strange thoughts-Often\" name=\"i_notice[Intrusive or strange thoughts]\" type=\"radio\" value=\"Often\"   aria-invalid='false' aria-required=true><\/td><td data-label='Always'><input aria-label=\"Intrusive or strange thoughts-Always\" name=\"i_notice[Intrusive or strange thoughts]\" type=\"radio\" value=\"Always\"   aria-invalid='false' aria-required=true><\/td><td data-label='How Long?'><input aria-label=\"Intrusive or strange thoughts-How Long?\" name=\"i_notice[Intrusive or strange thoughts]\" type=\"radio\" value=\"How Long?\"   aria-invalid='false' aria-required=true><\/td><\/tr><tr role=\"row\"\"><td class='ff_grid_header' role='cell'>Obsessive thoughts<\/td><td data-label='Never'><input aria-label=\"Obsessive thoughts-Never\" name=\"i_notice[Obsessive thoughts]\" type=\"radio\" value=\"Never\"   aria-invalid='false' aria-required=true><\/td><td data-label='Rarely'><input aria-label=\"Obsessive thoughts-Rarely\" name=\"i_notice[Obsessive thoughts]\" type=\"radio\" value=\"Rarely\"   aria-invalid='false' aria-required=true><\/td><td data-label='Often'><input aria-label=\"Obsessive thoughts-Often\" name=\"i_notice[Obsessive thoughts]\" type=\"radio\" value=\"Often\"   aria-invalid='false' aria-required=true><\/td><td data-label='Always'><input aria-label=\"Obsessive thoughts-Always\" name=\"i_notice[Obsessive thoughts]\" type=\"radio\" value=\"Always\"   aria-invalid='false' aria-required=true><\/td><td data-label='How Long?'><input aria-label=\"Obsessive thoughts-How Long?\" name=\"i_notice[Obsessive thoughts]\" type=\"radio\" value=\"How Long?\"   aria-invalid='false' aria-required=true><\/td><\/tr><tr role=\"row\"\"><td class='ff_grid_header' role='cell'>Been hearing voices when alone<\/td><td data-label='Never'><input aria-label=\"Been hearing voices when alone-Never\" name=\"i_notice[Been hearing voices when alone]\" type=\"radio\" value=\"Never\"   aria-invalid='false' aria-required=true><\/td><td data-label='Rarely'><input aria-label=\"Been hearing voices when alone-Rarely\" name=\"i_notice[Been hearing voices when alone]\" type=\"radio\" value=\"Rarely\"   aria-invalid='false' aria-required=true><\/td><td data-label='Often'><input aria-label=\"Been hearing voices when alone-Often\" name=\"i_notice[Been hearing voices when alone]\" type=\"radio\" value=\"Often\"   aria-invalid='false' aria-required=true><\/td><td data-label='Always'><input aria-label=\"Been hearing voices when alone-Always\" name=\"i_notice[Been hearing voices when alone]\" type=\"radio\" value=\"Always\"   aria-invalid='false' aria-required=true><\/td><td data-label='How Long?'><input aria-label=\"Been hearing voices when alone-How Long?\" name=\"i_notice[Been hearing voices when alone]\" type=\"radio\" value=\"How Long?\"   aria-invalid='false' aria-required=true><\/td><\/tr><tr role=\"row\"\"><td class='ff_grid_header' role='cell'>Problems with my speech<\/td><td data-label='Never'><input aria-label=\"Problems with my speech-Never\" name=\"i_notice[Problems with my speech]\" type=\"radio\" value=\"Never\"   aria-invalid='false' aria-required=true><\/td><td data-label='Rarely'><input aria-label=\"Problems with my speech-Rarely\" name=\"i_notice[Problems with my speech]\" type=\"radio\" value=\"Rarely\"   aria-invalid='false' aria-required=true><\/td><td data-label='Often'><input aria-label=\"Problems with my speech-Often\" name=\"i_notice[Problems with my speech]\" type=\"radio\" value=\"Often\"   aria-invalid='false' aria-required=true><\/td><td data-label='Always'><input aria-label=\"Problems with my speech-Always\" name=\"i_notice[Problems with my speech]\" type=\"radio\" value=\"Always\"   aria-invalid='false' aria-required=true><\/td><td data-label='How Long?'><input aria-label=\"Problems with my speech-How Long?\" name=\"i_notice[Problems with my speech]\" type=\"radio\" value=\"How Long?\"   aria-invalid='false' aria-required=true><\/td><\/tr><tr role=\"row\"\"><td class='ff_grid_header' role='cell'>Risk taking behaviors<\/td><td data-label='Never'><input aria-label=\"Risk taking behaviors-Never\" name=\"i_notice[Risk taking behaviors]\" type=\"radio\" value=\"Never\"   aria-invalid='false' aria-required=true><\/td><td data-label='Rarely'><input aria-label=\"Risk taking behaviors-Rarely\" name=\"i_notice[Risk taking behaviors]\" type=\"radio\" value=\"Rarely\"   aria-invalid='false' aria-required=true><\/td><td data-label='Often'><input aria-label=\"Risk taking behaviors-Often\" name=\"i_notice[Risk taking behaviors]\" type=\"radio\" value=\"Often\"   aria-invalid='false' aria-required=true><\/td><td data-label='Always'><input aria-label=\"Risk taking behaviors-Always\" name=\"i_notice[Risk taking behaviors]\" type=\"radio\" value=\"Always\"   aria-invalid='false' aria-required=true><\/td><td data-label='How Long?'><input aria-label=\"Risk taking behaviors-How Long?\" name=\"i_notice[Risk taking behaviors]\" type=\"radio\" value=\"How Long?\"   aria-invalid='false' aria-required=true><\/td><\/tr><tr role=\"row\"\"><td class='ff_grid_header' role='cell'>Compulsive or repetitive behaviors<\/td><td data-label='Never'><input aria-label=\"Compulsive or repetitive behaviors-Never\" name=\"i_notice[Compulsive or repetitive behaviors]\" type=\"radio\" value=\"Never\"   aria-invalid='false' aria-required=true><\/td><td data-label='Rarely'><input aria-label=\"Compulsive or repetitive behaviors-Rarely\" name=\"i_notice[Compulsive or repetitive behaviors]\" type=\"radio\" value=\"Rarely\"   aria-invalid='false' aria-required=true><\/td><td data-label='Often'><input aria-label=\"Compulsive or repetitive behaviors-Often\" name=\"i_notice[Compulsive or repetitive behaviors]\" type=\"radio\" value=\"Often\"   aria-invalid='false' aria-required=true><\/td><td data-label='Always'><input aria-label=\"Compulsive or repetitive behaviors-Always\" name=\"i_notice[Compulsive or repetitive behaviors]\" type=\"radio\" value=\"Always\"   aria-invalid='false' aria-required=true><\/td><td data-label='How Long?'><input aria-label=\"Compulsive or repetitive behaviors-How Long?\" name=\"i_notice[Compulsive or repetitive behaviors]\" type=\"radio\" value=\"How Long?\"   aria-invalid='false' aria-required=true><\/td><\/tr><tr role=\"row\"\"><td class='ff_grid_header' role='cell'>Been acting without concern for consequence<\/td><td data-label='Never'><input aria-label=\"Been acting without concern for consequence-Never\" name=\"i_notice[Been acting without concern for consequence]\" type=\"radio\" value=\"Never\"   aria-invalid='false' aria-required=true><\/td><td data-label='Rarely'><input aria-label=\"Been acting without concern for consequence-Rarely\" name=\"i_notice[Been acting without concern for consequence]\" type=\"radio\" value=\"Rarely\"   aria-invalid='false' aria-required=true><\/td><td data-label='Often'><input aria-label=\"Been acting without concern for consequence-Often\" name=\"i_notice[Been acting without concern for consequence]\" type=\"radio\" value=\"Often\"   aria-invalid='false' aria-required=true><\/td><td data-label='Always'><input aria-label=\"Been acting without concern for consequence-Always\" name=\"i_notice[Been acting without concern for consequence]\" type=\"radio\" value=\"Always\"   aria-invalid='false' aria-required=true><\/td><td data-label='How Long?'><input aria-label=\"Been acting without concern for consequence-How Long?\" name=\"i_notice[Been acting without concern for consequence]\" type=\"radio\" value=\"How Long?\"   aria-invalid='false' aria-required=true><\/td><\/tr><tr role=\"row\"\"><td class='ff_grid_header' role='cell'>Been physically harming myself<\/td><td data-label='Never'><input aria-label=\"Been physically harming myself-Never\" name=\"i_notice[Been physically harming myself]\" type=\"radio\" value=\"Never\"   aria-invalid='false' aria-required=true><\/td><td data-label='Rarely'><input aria-label=\"Been physically harming myself-Rarely\" name=\"i_notice[Been physically harming myself]\" type=\"radio\" value=\"Rarely\"   aria-invalid='false' aria-required=true><\/td><td data-label='Often'><input aria-label=\"Been physically harming myself-Often\" name=\"i_notice[Been physically harming myself]\" type=\"radio\" value=\"Often\"   aria-invalid='false' aria-required=true><\/td><td data-label='Always'><input aria-label=\"Been physically harming myself-Always\" name=\"i_notice[Been physically harming myself]\" type=\"radio\" value=\"Always\"   aria-invalid='false' aria-required=true><\/td><td data-label='How Long?'><input aria-label=\"Been physically harming myself-How Long?\" name=\"i_notice[Been physically harming myself]\" type=\"radio\" value=\"How Long?\"   aria-invalid='false' aria-required=true><\/td><\/tr><tr role=\"row\"\"><td class='ff_grid_header' role='cell'>Been violent toward other(s)<\/td><td data-label='Never'><input aria-label=\"Been violent toward other(s)-Never\" name=\"i_notice[Been violent toward other(s)]\" type=\"radio\" value=\"Never\"   aria-invalid='false' aria-required=true><\/td><td data-label='Rarely'><input aria-label=\"Been violent toward other(s)-Rarely\" name=\"i_notice[Been violent toward other(s)]\" type=\"radio\" value=\"Rarely\"   aria-invalid='false' aria-required=true><\/td><td data-label='Often'><input aria-label=\"Been violent toward other(s)-Often\" name=\"i_notice[Been violent toward other(s)]\" type=\"radio\" value=\"Often\"   aria-invalid='false' aria-required=true><\/td><td data-label='Always'><input aria-label=\"Been violent toward other(s)-Always\" name=\"i_notice[Been violent toward other(s)]\" type=\"radio\" value=\"Always\"   aria-invalid='false' aria-required=true><\/td><td data-label='How Long?'><input aria-label=\"Been violent toward other(s)-How Long?\" name=\"i_notice[Been violent toward other(s)]\" type=\"radio\" value=\"How Long?\"   aria-invalid='false' aria-required=true><\/td><\/tr><\/tbody><\/table><\/div><\/div><div data-type='tabular-element' data-name='i_use_the_following' class='ff-el-group'><div class='ff-el-input--label ff-el-is-required asterisk-right'><label aria-label='I USE THE FOLLOWING' for=''>I USE THE FOLLOWING<\/label><\/div><div class='ff-el-input--content'><table class='ff-table ff-checkable-grids ff_flexible_table' role='table'><thead><tr><th><\/th><th>Never<\/th><th>Rarely<\/th><th>Often<\/th><th>Always<\/th><th>How Long?<\/th><\/tr><\/thead><tbody><tr role=\"row\"\"><td class='ff_grid_header' role='cell'>Alcohol<\/td><td data-label='Never'><input aria-label=\"Alcohol-Never\" name=\"i_use_the_following[Alcohol]\" type=\"radio\" value=\"Never\"   aria-invalid='false' aria-required=true><\/td><td data-label='Rarely'><input aria-label=\"Alcohol-Rarely\" name=\"i_use_the_following[Alcohol]\" type=\"radio\" value=\"Rarely\"   aria-invalid='false' aria-required=true><\/td><td data-label='Often'><input aria-label=\"Alcohol-Often\" name=\"i_use_the_following[Alcohol]\" type=\"radio\" value=\"Often\"   aria-invalid='false' aria-required=true><\/td><td data-label='Always'><input aria-label=\"Alcohol-Always\" name=\"i_use_the_following[Alcohol]\" type=\"radio\" value=\"Always\"   aria-invalid='false' aria-required=true><\/td><td data-label='How Long?'><input aria-label=\"Alcohol-How Long?\" name=\"i_use_the_following[Alcohol]\" type=\"radio\" value=\"How Long?\"   aria-invalid='false' aria-required=true><\/td><\/tr><tr role=\"row\"\"><td class='ff_grid_header' role='cell'>Nicotine (Cigarettes)<\/td><td data-label='Never'><input aria-label=\"Nicotine (Cigarettes)-Never\" name=\"i_use_the_following[Nicotine (Cigarettes)]\" type=\"radio\" value=\"Never\"   aria-invalid='false' aria-required=true><\/td><td data-label='Rarely'><input aria-label=\"Nicotine (Cigarettes)-Rarely\" name=\"i_use_the_following[Nicotine (Cigarettes)]\" type=\"radio\" value=\"Rarely\"   aria-invalid='false' aria-required=true><\/td><td data-label='Often'><input aria-label=\"Nicotine (Cigarettes)-Often\" name=\"i_use_the_following[Nicotine (Cigarettes)]\" type=\"radio\" value=\"Often\"   aria-invalid='false' aria-required=true><\/td><td data-label='Always'><input aria-label=\"Nicotine (Cigarettes)-Always\" name=\"i_use_the_following[Nicotine (Cigarettes)]\" type=\"radio\" value=\"Always\"   aria-invalid='false' aria-required=true><\/td><td data-label='How Long?'><input aria-label=\"Nicotine (Cigarettes)-How Long?\" name=\"i_use_the_following[Nicotine (Cigarettes)]\" type=\"radio\" value=\"How Long?\"   aria-invalid='false' aria-required=true><\/td><\/tr><tr role=\"row\"\"><td class='ff_grid_header' role='cell'>Marijuana<\/td><td data-label='Never'><input aria-label=\"Marijuana-Never\" name=\"i_use_the_following[Marijuana]\" type=\"radio\" value=\"Never\"   aria-invalid='false' aria-required=true><\/td><td data-label='Rarely'><input aria-label=\"Marijuana-Rarely\" name=\"i_use_the_following[Marijuana]\" type=\"radio\" value=\"Rarely\"   aria-invalid='false' aria-required=true><\/td><td data-label='Often'><input aria-label=\"Marijuana-Often\" name=\"i_use_the_following[Marijuana]\" type=\"radio\" value=\"Often\"   aria-invalid='false' aria-required=true><\/td><td data-label='Always'><input aria-label=\"Marijuana-Always\" name=\"i_use_the_following[Marijuana]\" type=\"radio\" value=\"Always\"   aria-invalid='false' aria-required=true><\/td><td data-label='How Long?'><input aria-label=\"Marijuana-How Long?\" name=\"i_use_the_following[Marijuana]\" type=\"radio\" value=\"How Long?\"   aria-invalid='false' aria-required=true><\/td><\/tr><tr role=\"row\"\"><td class='ff_grid_header' role='cell'>Cocaine<\/td><td data-label='Never'><input aria-label=\"Cocaine-Never\" name=\"i_use_the_following[Cocaine]\" type=\"radio\" value=\"Never\"   aria-invalid='false' aria-required=true><\/td><td data-label='Rarely'><input aria-label=\"Cocaine-Rarely\" name=\"i_use_the_following[Cocaine]\" type=\"radio\" value=\"Rarely\"   aria-invalid='false' aria-required=true><\/td><td data-label='Often'><input aria-label=\"Cocaine-Often\" name=\"i_use_the_following[Cocaine]\" type=\"radio\" value=\"Often\"   aria-invalid='false' aria-required=true><\/td><td data-label='Always'><input aria-label=\"Cocaine-Always\" name=\"i_use_the_following[Cocaine]\" type=\"radio\" value=\"Always\"   aria-invalid='false' aria-required=true><\/td><td data-label='How Long?'><input aria-label=\"Cocaine-How Long?\" name=\"i_use_the_following[Cocaine]\" type=\"radio\" value=\"How Long?\"   aria-invalid='false' aria-required=true><\/td><\/tr><tr role=\"row\"\"><td class='ff_grid_header' role='cell'>Opiates<\/td><td data-label='Never'><input aria-label=\"Opiates-Never\" name=\"i_use_the_following[Opiates]\" type=\"radio\" value=\"Never\"   aria-invalid='false' aria-required=true><\/td><td data-label='Rarely'><input aria-label=\"Opiates-Rarely\" name=\"i_use_the_following[Opiates]\" type=\"radio\" value=\"Rarely\"   aria-invalid='false' aria-required=true><\/td><td data-label='Often'><input aria-label=\"Opiates-Often\" name=\"i_use_the_following[Opiates]\" type=\"radio\" value=\"Often\"   aria-invalid='false' aria-required=true><\/td><td data-label='Always'><input aria-label=\"Opiates-Always\" name=\"i_use_the_following[Opiates]\" type=\"radio\" value=\"Always\"   aria-invalid='false' aria-required=true><\/td><td data-label='How Long?'><input aria-label=\"Opiates-How Long?\" name=\"i_use_the_following[Opiates]\" type=\"radio\" value=\"How Long?\"   aria-invalid='false' aria-required=true><\/td><\/tr><tr role=\"row\"\"><td class='ff_grid_header' role='cell'>Sedatives<\/td><td data-label='Never'><input aria-label=\"Sedatives-Never\" name=\"i_use_the_following[Sedatives]\" type=\"radio\" value=\"Never\"   aria-invalid='false' aria-required=true><\/td><td data-label='Rarely'><input aria-label=\"Sedatives-Rarely\" name=\"i_use_the_following[Sedatives]\" type=\"radio\" value=\"Rarely\"   aria-invalid='false' aria-required=true><\/td><td data-label='Often'><input aria-label=\"Sedatives-Often\" name=\"i_use_the_following[Sedatives]\" type=\"radio\" value=\"Often\"   aria-invalid='false' aria-required=true><\/td><td data-label='Always'><input aria-label=\"Sedatives-Always\" name=\"i_use_the_following[Sedatives]\" type=\"radio\" value=\"Always\"   aria-invalid='false' aria-required=true><\/td><td data-label='How Long?'><input aria-label=\"Sedatives-How Long?\" name=\"i_use_the_following[Sedatives]\" type=\"radio\" value=\"How Long?\"   aria-invalid='false' aria-required=true><\/td><\/tr><tr role=\"row\"\"><td class='ff_grid_header' role='cell'>Hallucinogens<\/td><td data-label='Never'><input aria-label=\"Hallucinogens-Never\" name=\"i_use_the_following[Hallucinogens]\" type=\"radio\" value=\"Never\"   aria-invalid='false' aria-required=true><\/td><td data-label='Rarely'><input aria-label=\"Hallucinogens-Rarely\" name=\"i_use_the_following[Hallucinogens]\" type=\"radio\" value=\"Rarely\"   aria-invalid='false' aria-required=true><\/td><td data-label='Often'><input aria-label=\"Hallucinogens-Often\" name=\"i_use_the_following[Hallucinogens]\" type=\"radio\" value=\"Often\"   aria-invalid='false' aria-required=true><\/td><td data-label='Always'><input aria-label=\"Hallucinogens-Always\" name=\"i_use_the_following[Hallucinogens]\" type=\"radio\" value=\"Always\"   aria-invalid='false' aria-required=true><\/td><td data-label='How Long?'><input aria-label=\"Hallucinogens-How Long?\" name=\"i_use_the_following[Hallucinogens]\" type=\"radio\" value=\"How Long?\"   aria-invalid='false' aria-required=true><\/td><\/tr><tr role=\"row\"\"><td class='ff_grid_header' role='cell'>Stimulants<\/td><td data-label='Never'><input aria-label=\"Stimulants-Never\" name=\"i_use_the_following[Stimulants]\" type=\"radio\" value=\"Never\"   aria-invalid='false' aria-required=true><\/td><td data-label='Rarely'><input aria-label=\"Stimulants-Rarely\" name=\"i_use_the_following[Stimulants]\" type=\"radio\" value=\"Rarely\"   aria-invalid='false' aria-required=true><\/td><td data-label='Often'><input aria-label=\"Stimulants-Often\" name=\"i_use_the_following[Stimulants]\" type=\"radio\" value=\"Often\"   aria-invalid='false' aria-required=true><\/td><td data-label='Always'><input aria-label=\"Stimulants-Always\" name=\"i_use_the_following[Stimulants]\" type=\"radio\" value=\"Always\"   aria-invalid='false' aria-required=true><\/td><td data-label='How Long?'><input aria-label=\"Stimulants-How Long?\" name=\"i_use_the_following[Stimulants]\" type=\"radio\" value=\"How Long?\"   aria-invalid='false' aria-required=true><\/td><\/tr><tr role=\"row\"\"><td class='ff_grid_header' role='cell'>Methamphetamines<\/td><td data-label='Never'><input aria-label=\"Methamphetamines-Never\" name=\"i_use_the_following[Methamphetamines]\" type=\"radio\" value=\"Never\"   aria-invalid='false' aria-required=true><\/td><td data-label='Rarely'><input aria-label=\"Methamphetamines-Rarely\" name=\"i_use_the_following[Methamphetamines]\" type=\"radio\" value=\"Rarely\"   aria-invalid='false' aria-required=true><\/td><td data-label='Often'><input aria-label=\"Methamphetamines-Often\" name=\"i_use_the_following[Methamphetamines]\" type=\"radio\" value=\"Often\"   aria-invalid='false' aria-required=true><\/td><td data-label='Always'><input aria-label=\"Methamphetamines-Always\" name=\"i_use_the_following[Methamphetamines]\" type=\"radio\" value=\"Always\"   aria-invalid='false' aria-required=true><\/td><td data-label='How Long?'><input aria-label=\"Methamphetamines-How Long?\" name=\"i_use_the_following[Methamphetamines]\" type=\"radio\" value=\"How Long?\"   aria-invalid='false' aria-required=true><\/td><\/tr><tr role=\"row\"\"><td class='ff_grid_header' role='cell'>Other<\/td><td data-label='Never'><input aria-label=\"Other-Never\" name=\"i_use_the_following[Other]\" type=\"radio\" value=\"Never\"   aria-invalid='false' aria-required=true><\/td><td data-label='Rarely'><input aria-label=\"Other-Rarely\" name=\"i_use_the_following[Other]\" type=\"radio\" value=\"Rarely\"   aria-invalid='false' aria-required=true><\/td><td data-label='Often'><input aria-label=\"Other-Often\" name=\"i_use_the_following[Other]\" type=\"radio\" value=\"Often\"   aria-invalid='false' aria-required=true><\/td><td data-label='Always'><input aria-label=\"Other-Always\" name=\"i_use_the_following[Other]\" type=\"radio\" value=\"Always\"   aria-invalid='false' aria-required=true><\/td><td data-label='How Long?'><input aria-label=\"Other-How Long?\" name=\"i_use_the_following[Other]\" type=\"radio\" value=\"How Long?\"   aria-invalid='false' aria-required=true><\/td><\/tr><\/tbody><\/table><\/div><\/div><div data-type='tabular-element' data-name='my_eating_involves' class='ff-el-group'><div class='ff-el-input--label ff-el-is-required asterisk-right'><label aria-label='MY EATING INVOLVES' for=''>MY EATING INVOLVES<\/label><\/div><div class='ff-el-input--content'><table class='ff-table ff-checkable-grids ff_flexible_table' role='table'><thead><tr><th><\/th><th>Never<\/th><th>Rarely<\/th><th>Often<\/th><th>Always<\/th><th>How Long?<\/th><\/tr><\/thead><tbody><tr role=\"row\"\"><td class='ff_grid_header' role='cell'>Restriction of food consumption<\/td><td data-label='Never'><input aria-label=\"Restriction of food consumption-Never\" name=\"my_eating_involves[Restriction of food consumption]\" type=\"radio\" value=\"Never\"   aria-invalid='false' aria-required=true><\/td><td data-label='Rarely'><input aria-label=\"Restriction of food consumption-Rarely\" name=\"my_eating_involves[Restriction of food consumption]\" type=\"radio\" value=\"Rarely\"   aria-invalid='false' aria-required=true><\/td><td data-label='Often'><input aria-label=\"Restriction of food consumption-Often\" name=\"my_eating_involves[Restriction of food consumption]\" type=\"radio\" value=\"Often\"   aria-invalid='false' aria-required=true><\/td><td data-label='Always'><input aria-label=\"Restriction of food consumption-Always\" name=\"my_eating_involves[Restriction of food consumption]\" type=\"radio\" value=\"Always\"   aria-invalid='false' aria-required=true><\/td><td data-label='How Long?'><input aria-label=\"Restriction of food consumption-How Long?\" name=\"my_eating_involves[Restriction of food consumption]\" type=\"radio\" value=\"How Long?\"   aria-invalid='false' aria-required=true><\/td><\/tr><tr role=\"row\"\"><td class='ff_grid_header' role='cell'>Bingeing and purging<\/td><td data-label='Never'><input aria-label=\"Bingeing and purging-Never\" name=\"my_eating_involves[Bingeing and purging]\" type=\"radio\" value=\"Never\"   aria-invalid='false' aria-required=true><\/td><td data-label='Rarely'><input aria-label=\"Bingeing and purging-Rarely\" name=\"my_eating_involves[Bingeing and purging]\" type=\"radio\" value=\"Rarely\"   aria-invalid='false' aria-required=true><\/td><td data-label='Often'><input aria-label=\"Bingeing and purging-Often\" name=\"my_eating_involves[Bingeing and purging]\" type=\"radio\" value=\"Often\"   aria-invalid='false' aria-required=true><\/td><td data-label='Always'><input aria-label=\"Bingeing and purging-Always\" name=\"my_eating_involves[Bingeing and purging]\" type=\"radio\" value=\"Always\"   aria-invalid='false' aria-required=true><\/td><td data-label='How Long?'><input aria-label=\"Bingeing and purging-How Long?\" name=\"my_eating_involves[Bingeing and purging]\" type=\"radio\" value=\"How Long?\"   aria-invalid='false' aria-required=true><\/td><\/tr><tr role=\"row\"\"><td class='ff_grid_header' role='cell'>Binge eating<\/td><td data-label='Never'><input aria-label=\"Binge eating-Never\" name=\"my_eating_involves[Binge eating]\" type=\"radio\" value=\"Never\"   aria-invalid='false' aria-required=true><\/td><td data-label='Rarely'><input aria-label=\"Binge eating-Rarely\" name=\"my_eating_involves[Binge eating]\" type=\"radio\" value=\"Rarely\"   aria-invalid='false' aria-required=true><\/td><td data-label='Often'><input aria-label=\"Binge eating-Often\" name=\"my_eating_involves[Binge eating]\" type=\"radio\" value=\"Often\"   aria-invalid='false' aria-required=true><\/td><td data-label='Always'><input aria-label=\"Binge eating-Always\" name=\"my_eating_involves[Binge eating]\" type=\"radio\" value=\"Always\"   aria-invalid='false' aria-required=true><\/td><td data-label='How Long?'><input aria-label=\"Binge eating-How Long?\" name=\"my_eating_involves[Binge eating]\" type=\"radio\" value=\"How Long?\"   aria-invalid='false' aria-required=true><\/td><\/tr><tr role=\"row\"\"><td class='ff_grid_header' role='cell'>A lot of weight loss or gain<\/td><td data-label='Never'><input aria-label=\"A lot of weight loss or gain-Never\" name=\"my_eating_involves[A lot of weight loss or gain]\" type=\"radio\" value=\"Never\"   aria-invalid='false' aria-required=true><\/td><td data-label='Rarely'><input aria-label=\"A lot of weight loss or gain-Rarely\" name=\"my_eating_involves[A lot of weight loss or gain]\" type=\"radio\" value=\"Rarely\"   aria-invalid='false' aria-required=true><\/td><td data-label='Often'><input aria-label=\"A lot of weight loss or gain-Often\" name=\"my_eating_involves[A lot of weight loss or gain]\" type=\"radio\" value=\"Often\"   aria-invalid='false' aria-required=true><\/td><td data-label='Always'><input aria-label=\"A lot of weight loss or gain-Always\" name=\"my_eating_involves[A lot of weight loss or gain]\" type=\"radio\" value=\"Always\"   aria-invalid='false' aria-required=true><\/td><td data-label='How Long?'><input aria-label=\"A lot of weight loss or gain-How Long?\" name=\"my_eating_involves[A lot of weight loss or gain]\" type=\"radio\" value=\"How Long?\"   aria-invalid='false' aria-required=true><\/td><\/tr><\/tbody><\/table><\/div><\/div><div data-type='tabular-element' data-name='i_have' class='ff-el-group'><div class='ff-el-input--label ff-el-is-required asterisk-right'><label aria-label='I HAVE' for=''>I HAVE<\/label><\/div><div class='ff-el-input--content'><table class='ff-table ff-checkable-grids ff_flexible_table' role='table'><thead><tr><th><\/th><th>Never<\/th><th>Rarely<\/th><th>Often<\/th><th>Always<\/th><th>How Long?<\/th><\/tr><\/thead><tbody><tr role=\"row\"\"><td class='ff_grid_header' role='cell'>Concern about my sexual function<\/td><td data-label='Never'><input aria-label=\"Concern about my sexual function-Never\" name=\"i_have[Concern about my sexual function]\" type=\"radio\" value=\"Never\"   aria-invalid='false' aria-required=true><\/td><td data-label='Rarely'><input aria-label=\"Concern about my sexual function-Rarely\" name=\"i_have[Concern about my sexual function]\" type=\"radio\" value=\"Rarely\"   aria-invalid='false' aria-required=true><\/td><td data-label='Often'><input aria-label=\"Concern about my sexual function-Often\" name=\"i_have[Concern about my sexual function]\" type=\"radio\" value=\"Often\"   aria-invalid='false' aria-required=true><\/td><td data-label='Always'><input aria-label=\"Concern about my sexual function-Always\" name=\"i_have[Concern about my sexual function]\" type=\"radio\" value=\"Always\"   aria-invalid='false' aria-required=true><\/td><td data-label='How Long?'><input aria-label=\"Concern about my sexual function-How Long?\" name=\"i_have[Concern about my sexual function]\" type=\"radio\" value=\"How Long?\"   aria-invalid='false' aria-required=true><\/td><\/tr><tr role=\"row\"\"><td class='ff_grid_header' role='cell'>Discomfort engaging in sexual activity<\/td><td data-label='Never'><input aria-label=\"Discomfort engaging in sexual activity-Never\" name=\"i_have[Discomfort engaging in sexual activity]\" type=\"radio\" value=\"Never\"   aria-invalid='false' aria-required=true><\/td><td data-label='Rarely'><input aria-label=\"Discomfort engaging in sexual activity-Rarely\" name=\"i_have[Discomfort engaging in sexual activity]\" type=\"radio\" value=\"Rarely\"   aria-invalid='false' aria-required=true><\/td><td data-label='Often'><input aria-label=\"Discomfort engaging in sexual activity-Often\" name=\"i_have[Discomfort engaging in sexual activity]\" type=\"radio\" value=\"Often\"   aria-invalid='false' aria-required=true><\/td><td data-label='Always'><input aria-label=\"Discomfort engaging in sexual activity-Always\" name=\"i_have[Discomfort engaging in sexual activity]\" type=\"radio\" value=\"Always\"   aria-invalid='false' aria-required=true><\/td><td data-label='How Long?'><input aria-label=\"Discomfort engaging in sexual activity-How Long?\" name=\"i_have[Discomfort engaging in sexual activity]\" type=\"radio\" value=\"How Long?\"   aria-invalid='false' aria-required=true><\/td><\/tr><tr role=\"row\"\"><td class='ff_grid_header' role='cell'>Questions about my sexual orientation<\/td><td data-label='Never'><input aria-label=\"Questions about my sexual orientation-Never\" name=\"i_have[Questions about my sexual orientation]\" type=\"radio\" value=\"Never\"   aria-invalid='false' aria-required=true><\/td><td data-label='Rarely'><input aria-label=\"Questions about my sexual orientation-Rarely\" name=\"i_have[Questions about my sexual orientation]\" type=\"radio\" value=\"Rarely\"   aria-invalid='false' aria-required=true><\/td><td data-label='Often'><input aria-label=\"Questions about my sexual orientation-Often\" name=\"i_have[Questions about my sexual orientation]\" type=\"radio\" value=\"Often\"   aria-invalid='false' aria-required=true><\/td><td data-label='Always'><input aria-label=\"Questions about my sexual orientation-Always\" name=\"i_have[Questions about my sexual orientation]\" type=\"radio\" value=\"Always\"   aria-invalid='false' aria-required=true><\/td><td data-label='How Long?'><input aria-label=\"Questions about my sexual orientation-How Long?\" name=\"i_have[Questions about my sexual orientation]\" type=\"radio\" value=\"How Long?\"   aria-invalid='false' aria-required=true><\/td><\/tr><\/tbody><\/table><\/div><\/div><div data-type='tabular-element' data-name='employment_self_care' class='ff-el-group'><div class='ff-el-input--label ff-el-is-required asterisk-right'><label aria-label='EMPLOYMENT &amp; SELF CARE' for=''>EMPLOYMENT &amp; SELF CARE<\/label><\/div><div class='ff-el-input--content'><table class='ff-table ff-checkable-grids ff_flexible_table' role='table'><thead><tr><th><\/th><th>Never<\/th><th>Rarely<\/th><th>Often<\/th><th>Always<\/th><th>How Long?<\/th><\/tr><\/thead><tbody><tr role=\"row\"\"><td class='ff_grid_header' role='cell'>I have problems getting\/keeping a job<\/td><td data-label='Never'><input aria-label=\"I have problems getting\/keeping a job-Never\" name=\"employment_self_care[I have problems getting\/keeping a job]\" type=\"radio\" value=\"Never\"   aria-invalid='false' aria-required=true><\/td><td data-label='Rarely'><input aria-label=\"I have problems getting\/keeping a job-Rarely\" name=\"employment_self_care[I have problems getting\/keeping a job]\" type=\"radio\" value=\"Rarely\"   aria-invalid='false' aria-required=true><\/td><td data-label='Often'><input aria-label=\"I have problems getting\/keeping a job-Often\" name=\"employment_self_care[I have problems getting\/keeping a job]\" type=\"radio\" value=\"Often\"   aria-invalid='false' aria-required=true><\/td><td data-label='Always'><input aria-label=\"I have problems getting\/keeping a job-Always\" name=\"employment_self_care[I have problems getting\/keeping a job]\" type=\"radio\" value=\"Always\"   aria-invalid='false' aria-required=true><\/td><td data-label='How Long?'><input aria-label=\"I have problems getting\/keeping a job-How Long?\" name=\"employment_self_care[I have problems getting\/keeping a job]\" type=\"radio\" value=\"How Long?\"   aria-invalid='false' aria-required=true><\/td><\/tr><tr role=\"row\"\"><td class='ff_grid_header' role='cell'>I have problems paying for basic expenses<\/td><td data-label='Never'><input aria-label=\"I have problems paying for basic expenses-Never\" name=\"employment_self_care[I have problems paying for basic expenses]\" type=\"radio\" value=\"Never\"   aria-invalid='false' aria-required=true><\/td><td data-label='Rarely'><input aria-label=\"I have problems paying for basic expenses-Rarely\" name=\"employment_self_care[I have problems paying for basic expenses]\" type=\"radio\" value=\"Rarely\"   aria-invalid='false' aria-required=true><\/td><td data-label='Often'><input aria-label=\"I have problems paying for basic expenses-Often\" name=\"employment_self_care[I have problems paying for basic expenses]\" type=\"radio\" value=\"Often\"   aria-invalid='false' aria-required=true><\/td><td data-label='Always'><input aria-label=\"I have problems paying for basic expenses-Always\" name=\"employment_self_care[I have problems paying for basic expenses]\" type=\"radio\" value=\"Always\"   aria-invalid='false' aria-required=true><\/td><td data-label='How Long?'><input aria-label=\"I have problems paying for basic expenses-How Long?\" name=\"employment_self_care[I have problems paying for basic expenses]\" type=\"radio\" value=\"How Long?\"   aria-invalid='false' aria-required=true><\/td><\/tr><tr role=\"row\"\"><td class='ff_grid_header' role='cell'>I am afraid of becoming homeless<\/td><td data-label='Never'><input aria-label=\"I am afraid of becoming homeless-Never\" name=\"employment_self_care[I am afraid of becoming homeless]\" type=\"radio\" value=\"Never\"   aria-invalid='false' aria-required=true><\/td><td data-label='Rarely'><input aria-label=\"I am afraid of becoming homeless-Rarely\" name=\"employment_self_care[I am afraid of becoming homeless]\" type=\"radio\" value=\"Rarely\"   aria-invalid='false' aria-required=true><\/td><td data-label='Often'><input aria-label=\"I am afraid of becoming homeless-Often\" name=\"employment_self_care[I am afraid of becoming homeless]\" type=\"radio\" value=\"Often\"   aria-invalid='false' aria-required=true><\/td><td data-label='Always'><input aria-label=\"I am afraid of becoming homeless-Always\" name=\"employment_self_care[I am afraid of becoming homeless]\" type=\"radio\" value=\"Always\"   aria-invalid='false' aria-required=true><\/td><td data-label='How Long?'><input aria-label=\"I am afraid of becoming homeless-How Long?\" name=\"employment_self_care[I am afraid of becoming homeless]\" type=\"radio\" value=\"How Long?\"   aria-invalid='false' aria-required=true><\/td><\/tr><tr role=\"row\"\"><td class='ff_grid_header' role='cell'>I have problems accessing healthcare<\/td><td data-label='Never'><input aria-label=\"I have problems accessing healthcare-Never\" name=\"employment_self_care[I have problems accessing healthcare]\" type=\"radio\" value=\"Never\"   aria-invalid='false' aria-required=true><\/td><td data-label='Rarely'><input aria-label=\"I have problems accessing healthcare-Rarely\" name=\"employment_self_care[I have problems accessing healthcare]\" type=\"radio\" value=\"Rarely\"   aria-invalid='false' aria-required=true><\/td><td data-label='Often'><input aria-label=\"I have problems accessing healthcare-Often\" name=\"employment_self_care[I have problems accessing healthcare]\" type=\"radio\" value=\"Often\"   aria-invalid='false' aria-required=true><\/td><td data-label='Always'><input aria-label=\"I have problems accessing healthcare-Always\" name=\"employment_self_care[I have problems accessing healthcare]\" type=\"radio\" value=\"Always\"   aria-invalid='false' aria-required=true><\/td><td data-label='How Long?'><input aria-label=\"I have problems accessing healthcare-How Long?\" name=\"employment_self_care[I have problems accessing healthcare]\" type=\"radio\" value=\"How Long?\"   aria-invalid='false' aria-required=true><\/td><\/tr><\/tbody><\/table><\/div><\/div><div class='step-nav ff_step_nav_last'><button style='float: left;'  type='button' data-action='prev' class='ff-btn ff-btn-prev ff-btn-secondary' aria-label='Previous'>Previous<\/button><button style='float: right;'  type='button' data-action='next' class='ff-float-right ff-btn ff-btn-next ff-btn-secondary' aria-label='Next'>Next<\/button><\/div><\/div><div style='display: none;' class=\" fluentform-step\" data-name=\"form_step-3_7\" ><div class='ff-el-group  ff-custom_html' tabindex='-1' data-name=\"custom_html-3_8\" ><p><strong>Rates<\/strong><\/p>\n<p>Charges for individual counseling are:\u00a0<strong>$150<\/strong>\u00a0These sessions are\u00a0<strong>60<\/strong>\u00a0minutes in length.<\/p>\n<p>These rates are subject to change with the changing market and clients will be notified of any changes in rates. Group therapy rates vary by practitioner.<\/p>\n<p><strong>Insurance<\/strong><\/p>\n<p>We accept Private insurance from :<\/p>\n<p><img decoding=\"async\" class=\"alignnone wp-image-15 size-full\" src=\"https:\/\/innerglance.com.au\/adminwp\/wp-content\/uploads\/2026\/05\/Counseling-Intake-Form-insurance.jpg\" alt=\"\" width=\"500\" height=\"96\" srcset=\"https:\/\/innerglance.com.au\/adminwp\/wp-content\/uploads\/2026\/05\/Counseling-Intake-Form-insurance.jpg 500w, https:\/\/innerglance.com.au\/adminwp\/wp-content\/uploads\/2026\/05\/Counseling-Intake-Form-insurance-300x58.jpg 300w\" sizes=\"(max-width: 500px) 100vw, 500px\" \/><\/p>\n<p><strong>Payment<\/strong><\/p>\n<p>Cash\/ Bank Transfer prior to the session.<\/p>\n<p>Thank you for valuing our services by agreeing with these terms.<\/p><\/div><div class='step-nav ff_step_nav_last'><button style='float: left;'  type='button' data-action='prev' class='ff-btn ff-btn-prev ff-btn-secondary' aria-label='Previous'>Previous<\/button><button style='float: right;'  type='button' data-action='next' class='ff-float-right ff-btn ff-btn-next ff-btn-secondary' aria-label='Next'>Next<\/button><\/div><\/div><div style='display: none;' class=\" fluentform-step\" data-name=\"form_step-3_9\" ><div class='ff-el-group  ff-custom_html' tabindex='-1' data-name=\"custom_html-3_10\" ><p>Psychotherapy is a working cooperative relationship between you and your counselor. Each member of this cooperative<br \/>relationship has certain responsibilities. Your counselor will contribute their knowledge, expertise, and clinical skills. You,<br \/>as the client, have the responsibility to bring an attitude of collaboration and a commitment to the therapeutic process.<br \/>While there are no guarantees regarding the outcome of the treatment, your commitment may increase the likelihood of a<br \/>satisfactory experience.<\/p>\n<p><strong>Fees and Appointments<\/strong><\/p>\n<p>Appointments are 60\/45 minutes in length and take place on weekly\/fortnight basis. Your counselor holds your specific hour<br \/>for you each week\/fortnight. If you are unable to keep an appointment, please cancel as soon as possible. You will be<br \/>responsible for payment of missed sessions. If you are able to reschedule your appointment within xxx working days, it<br \/>will not count as a cancellation. We ask that you pay prior to your session each time. We reserve the right to suspend<br \/>therapy if services are rendered and not paid.<\/p>\n<p><strong>Confidentiality<\/strong><\/p>\n<p>Communication between you and your counselor is confidential. This means that your counselor will not discuss your<br \/>case orally or in writing without your expressed written permission (please see the following section on \u201cTraining and Supervision\u201d).<\/p>\n<p>Your counselor has an ethical and legal obligation to break confidentiality under the following circumstances :<\/p>\n<ol>\n<li>If there is a reason to believe there is an occurrence of child, elder, or dependent adult abuse or neglect.<\/li>\n<li>If there is reason to believe that you have serious intent to harm yourself, someone else, or property by a violent act you may commit.<\/li>\n<li>If you disclose that you knowingly develop, duplicate, print, download, stream, or access through any electronic or digital media or exchanges, a film, photograph, video in which a child is engaged in an act of obscene sexual conduct.<\/li>\n<li>If you introduce your emotional condition into a legal proceeding.<\/li>\n<li>If there is a court order for release of your records.<\/li>\n<\/ol>\n<p><strong>Availability and After Hours Emergencies<\/strong><\/p>\n<p>Counselors check for voice mail messages during normal business hours. Messages left outside of normal hours of operation will be picked up the next business day. If you have an emergency that needs immediate attention you may need to<br \/>seek assistance at the nearest emergency services department.<\/p>\n<p><strong>Child Care Release<\/strong><\/p>\n<p>We do not provide childcare and do not allow children inside the Counselling room.<\/p>\n<p><strong>Additional Rights and Responsibilities<\/strong><\/p>\n<p>In addition to your right to confidentiality, you have the right to end your counseling at any time, for whatever reason and without any obligation, with the exception of payment of fees for services already provided. You have the right to question any aspect of your treatment with your counselor.\u00a0<\/p>\n<p>You also have the right to expect that your counselor will maintain professional and ethical boundaries by not entering into<br \/>other personal, financial, or professional relationships with you.<\/p>\n<p>We reserve the right to discontinue counseling at any time including, but not limited to, a violation by you of this Consent for Treatment, a change or reevaluation of your therapeutic needs.<\/p>\n<p>Our ability to address those needs, or other circumstances that lead us to conclude in its sole and absolute discretion that your counseling needs would be better served at another counseling facility. Under such circumstances, we will suggest an appropriate counselor(s) or counseling agency.<\/p><\/div><div class='step-nav ff_step_nav_last'><button style='float: left;'  type='button' data-action='prev' class='ff-btn ff-btn-prev ff-btn-secondary' aria-label='Previous'>Previous<\/button><button style='float: right;'  type='button' data-action='next' class='ff-float-right ff-btn ff-btn-next ff-btn-secondary' aria-label='Next'>Next<\/button><\/div><\/div><div style='display: none;' class=\" fluentform-step\" data-name=\"form_step-3_11\" ><div class='ff-el-group  ff-custom_html' tabindex='-1' data-name=\"custom_html-3_12\" ><p><em>CONSENT TO USE OR DISCLOSE HEALTH INFORMATION FOR TREATMENT, PAYMENT, HEALTH CARE\u00a0<\/em><em>OPERATIONS, AND ACKNOWLEDGEMENT OF RECEIPT OF THE PRIVACY ACT 1988<\/em><\/p>\n<p>In the course of providing services to you, we may create, receive, and store individually identifiable information, including information that relates to health care and payment for health care (\u201cPersonal Information\u201d). It is often necessary to use and disclose this Personal Information in order to treat you, to obtain payment for our services, and to conduct health care operations involving our office.<\/p>\n<p>We have a The Privacy Act 1988 that describes these uses and disclosures. As described in our Notice of Privacy Practices, the use and disclosure of your Personal Information for treatment purposes not only includes care and services provided here, but also disclosures of your Personal Information as may be necessary or appropriate for you to receive follow-up care from another health care professional. Similarly, the use and disclosure of your Personal Information for purposes of payment may include, for example, the submission of this information to a billing agent for processing claims or obtaining payment and\/or submission of claims to insurers.<\/p>\n<p>When you sign this consent document, you expressly agree that we can and will use and disclose your personal Information to treat you, to obtain payment for our services, and to operate our practice. You can revoke this consent in writing at any time unless we have already treated you, sought payment for our services, or performed health care operations in reliance upon our ability to use or disclose your information in accordance with this consent. We can decline to serve you if you elect not to sign this consent form.<\/p>\n<p>You also acknowledge, by your signature below, that you have received a copy of our The Privacy Act 1988.<\/p>\n<p><strong>I HAVE READ THIS CONSENT AND UNDERSTAND IT. I CONSENT TO THE USE AND DISCLOSURE OF MY\u00a0<\/strong><strong>PERSONAL INFORMATION FOR PURPOSES OF TREATMENT, PAYMENT, AND HEALTH CARE OPERATIONS.<\/strong><\/p>\n<p><strong>I ALSO ACKNOWLEDGE THAT I HAVE RECEIVED A COPY OF THE PRIVACY ACT 1988.<\/strong><\/p><\/div>        <div class=\"ff-step-t-container ff-inner_submit_container ff-column-container ff_columns_total_2\">\n            <div class=\"ff-t-cell ff-t-column-1\"><div class='step-nav ff_step_nav_last'><button style='float: left;'  type='button' data-action='prev' class='ff-btn ff-btn-prev ff-btn-secondary' aria-label='Previous'>Previous<\/button><\/div><\/div>\n            <div class=\"ff-t-cell ff-t-column-2\">\n                <div class='ff-el-group ff-text-left ff_submit_btn_wrapper'><button type=\"submit\" class=\"ff-btn ff-btn-submit ff-btn-md ff_btn_style\"  aria-label=\"Submit Form\">Submit Form<\/button><\/div>            <\/div>\n        <\/div>\n        <\/div><\/div><\/div>\n        <\/fieldset><\/form><div 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