{"id":613,"date":"2021-05-07T18:37:21","date_gmt":"2021-05-07T18:37:21","guid":{"rendered":"https:\/\/web.saumag.edu\/counseling\/?page_id=613"},"modified":"2021-06-16T20:27:23","modified_gmt":"2021-06-16T20:27:23","slug":"intake-information-form","status":"publish","type":"page","link":"https:\/\/web.saumag.edu\/counseling\/intake-information-form\/","title":{"rendered":"Intake Information Form"},"content":{"rendered":"<script type=\"text\/javascript\">\n\/* <![CDATA[ *\/\nvar gform;gform||(document.addEventListener(\"gform_main_scripts_loaded\",function(){gform.scriptsLoaded=!0}),document.addEventListener(\"gform\/theme\/scripts_loaded\",function(){gform.themeScriptsLoaded=!0}),window.addEventListener(\"DOMContentLoaded\",function(){gform.domLoaded=!0}),gform={domLoaded:!1,scriptsLoaded:!1,themeScriptsLoaded:!1,isFormEditor:()=>\"function\"==typeof 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gfield_visibility_hidden\"  ><div class=\"admin-hidden-markup\"><i class=\"gform-icon gform-icon--hidden\" aria-hidden=\"true\" title=\"This field is hidden when viewing the form\"><\/i><span>This field is hidden when viewing the form<\/span><\/div><label class='gfield_label gform-field-label' for='input_5_40'>Date<\/label><div class='ginput_container ginput_container_date'>\n                            <input name='input_40' id='input_5_40' type='text' value='11\/02\/2025' class='datepicker gform-datepicker mdy datepicker_no_icon gdatepicker-no-icon'   placeholder='mm\/dd\/yyyy' aria-describedby=\"input_5_40_date_format\" aria-invalid=\"false\" \/>\n                            <span id='input_5_40_date_format' class='screen-reader-text'>MM slash DD slash YYYY<\/span>\n                        <\/div>\n                        <input type='hidden' id='gforms_calendar_icon_input_5_40' class='gform_hidden' value='https:\/\/web.saumag.edu\/counseling\/wp-content\/plugins\/gravityforms\/images\/datepicker\/datepicker.svg'\/><\/div><fieldset id=\"field_5_38\" class=\"gfield gfield--type-radio gfield--type-choice gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >Are you completing this form for yourself or on behalf of someone else?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_5_38'>\n\t\t\t<div class='gchoice gchoice_5_38_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_38' type='radio' value='For myself'  id='choice_5_38_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_5_38_0' id='label_5_38_0' class='gform-field-label gform-field-label--type-inline'>For myself<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_5_38_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_38' type='radio' value='On behalf of someone else'  id='choice_5_38_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_5_38_1' id='label_5_38_1' class='gform-field-label gform-field-label--type-inline'>On behalf of someone else<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_5_39\" class=\"gfield gfield--type-name gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Your Name<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class='ginput_complex ginput_container ginput_container--name no_prefix has_first_name no_middle_name has_last_name no_suffix gf_name_has_2 ginput_container_name gform-grid-row' id='input_5_39'>\n                            \n                            <span id='input_5_39_3_container' class='name_first gform-grid-col gform-grid-col--size-auto' >\n                                                    <input type='text' name='input_39.3' id='input_5_39_3' value=''   aria-required='true'     \/>\n                                                    <label for='input_5_39_3' class='gform-field-label gform-field-label--type-sub '>First<\/label>\n                                                <\/span>\n                            \n                            <span id='input_5_39_6_container' class='name_last gform-grid-col gform-grid-col--size-auto' >\n                                                    <input type='text' name='input_39.6' id='input_5_39_6' value=''   aria-required='true'     \/>\n                                                    <label for='input_5_39_6' class='gform-field-label gform-field-label--type-sub '>Last<\/label>\n                                                <\/span>\n                            \n                        <\/div><\/fieldset><fieldset id=\"field_5_1\" class=\"gfield gfield--type-name gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Student\/Patient Name<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class='ginput_complex ginput_container ginput_container--name no_prefix has_first_name no_middle_name has_last_name no_suffix gf_name_has_2 ginput_container_name gform-grid-row' id='input_5_1'>\n                            \n                            <span id='input_5_1_3_container' class='name_first gform-grid-col gform-grid-col--size-auto' >\n                                                    <input type='text' name='input_1.3' id='input_5_1_3' value=''   aria-required='true'     \/>\n                                                    <label for='input_5_1_3' class='gform-field-label gform-field-label--type-sub '>First<\/label>\n                                                <\/span>\n                            \n                            <span id='input_5_1_6_container' class='name_last gform-grid-col gform-grid-col--size-auto' >\n                                                    <input type='text' name='input_1.6' id='input_5_1_6' value=''   aria-required='true'     \/>\n                                                    <label for='input_5_1_6' class='gform-field-label gform-field-label--type-sub '>Last<\/label>\n                                                <\/span>\n                            \n                        <\/div><\/fieldset><div id=\"field_5_2\" class=\"gfield gfield--type-date gfield--input-type-datepicker gfield--datepicker-no-icon gf_left_half gfield--width-half gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_5_2'>Date of Birth<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_date'>\n                            <input name='input_2' id='input_5_2' type='text' value='' class='datepicker gform-datepicker mdy datepicker_no_icon gdatepicker-no-icon'   placeholder='mm\/dd\/yyyy' aria-describedby=\"input_5_2_date_format\" aria-invalid=\"false\" aria-required=\"true\"\/>\n                            <span id='input_5_2_date_format' class='screen-reader-text'>MM slash DD slash YYYY<\/span>\n                        <\/div>\n                        <input type='hidden' id='gforms_calendar_icon_input_5_2' class='gform_hidden' value='https:\/\/web.saumag.edu\/counseling\/wp-content\/plugins\/gravityforms\/images\/datepicker\/datepicker.svg'\/><\/div><div id=\"field_5_3\" class=\"gfield gfield--type-number gf_right_half gfield--width-half gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_5_3'>Age<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_number'><input name='input_3' id='input_5_3' type='number' step='any'   value='' class='medium'     aria-required=\"true\" aria-invalid=\"false\"  \/><\/div><\/div><fieldset id=\"field_5_4\" class=\"gfield gfield--type-radio gfield--type-choice gf_left_half gfield--width-half gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >Sex<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_5_4'>\n\t\t\t<div class='gchoice gchoice_5_4_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_4' type='radio' value='Male'  id='choice_5_4_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_5_4_0' id='label_5_4_0' class='gform-field-label gform-field-label--type-inline'>Male<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_5_4_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_4' type='radio' value='Female'  id='choice_5_4_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_5_4_1' id='label_5_4_1' class='gform-field-label gform-field-label--type-inline'>Female<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_5_4_2'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_4' type='radio' value='Other'  id='choice_5_4_2' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_5_4_2' id='label_5_4_2' class='gform-field-label gform-field-label--type-inline'>Other<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_5_5\" class=\"gfield gfield--type-radio gfield--type-choice gf_right_half gfield--width-half gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >Do you live on-campus?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_5_5'>\n\t\t\t<div class='gchoice gchoice_5_5_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_5' type='radio' value='Yes'  id='choice_5_5_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_5_5_0' id='label_5_5_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_5_5_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_5' type='radio' value='No'  id='choice_5_5_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_5_5_1' id='label_5_5_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_5_6\" class=\"gfield gfield--type-text gf_left_half gfield--width-half gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_5_6'>Residence Hall<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_6' id='input_5_6' type='text' value='' class='medium'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_5_7\" class=\"gfield gfield--type-text gf_right_half gfield--width-half gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_5_7'>Room Number<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_7' id='input_5_7' type='text' value='' class='medium'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><fieldset id=\"field_5_8\" class=\"gfield gfield--type-address gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Home Address<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend>    \n                    <div class='ginput_complex ginput_container has_street has_street2 has_city has_state has_zip ginput_container_address gform-grid-row' id='input_5_8' >\n                         <span class='ginput_full address_line_1 ginput_address_line_1 gform-grid-col' id='input_5_8_1_container' >\n                                        <input type='text' name='input_8.1' id='input_5_8_1' value=''    aria-required='true'    \/>\n                                        <label for='input_5_8_1' id='input_5_8_1_label' class='gform-field-label gform-field-label--type-sub '>Street Address<\/label>\n                                    <\/span><span class='ginput_full address_line_2 ginput_address_line_2 gform-grid-col' id='input_5_8_2_container' >\n                                        <input type='text' name='input_8.2' id='input_5_8_2' value=''     aria-required='false'   \/>\n                                        <label for='input_5_8_2' id='input_5_8_2_label' class='gform-field-label gform-field-label--type-sub '>Address Line 2<\/label>\n                                    <\/span><span class='ginput_left address_city ginput_address_city gform-grid-col' id='input_5_8_3_container' >\n                                    <input type='text' name='input_8.3' id='input_5_8_3' value=''    aria-required='true'    \/>\n                                    <label for='input_5_8_3' id='input_5_8_3_label' class='gform-field-label gform-field-label--type-sub '>City<\/label>\n                                 <\/span><span class='ginput_right address_state ginput_address_state gform-grid-col' id='input_5_8_4_container' >\n                                        <select name='input_8.4' id='input_5_8_4'     aria-required='true'    ><option value='' ><\/option><option value='Alabama' >Alabama<\/option><option value='Alaska' >Alaska<\/option><option value='American Samoa' >American Samoa<\/option><option value='Arizona' >Arizona<\/option><option value='Arkansas' selected='selected'>Arkansas<\/option><option value='California' >California<\/option><option value='Colorado' >Colorado<\/option><option value='Connecticut' >Connecticut<\/option><option value='Delaware' >Delaware<\/option><option value='District of Columbia' >District of Columbia<\/option><option value='Florida' >Florida<\/option><option value='Georgia' >Georgia<\/option><option value='Guam' >Guam<\/option><option value='Hawaii' >Hawaii<\/option><option value='Idaho' >Idaho<\/option><option value='Illinois' >Illinois<\/option><option value='Indiana' >Indiana<\/option><option value='Iowa' >Iowa<\/option><option value='Kansas' >Kansas<\/option><option value='Kentucky' >Kentucky<\/option><option value='Louisiana' >Louisiana<\/option><option value='Maine' >Maine<\/option><option value='Maryland' >Maryland<\/option><option value='Massachusetts' >Massachusetts<\/option><option value='Michigan' >Michigan<\/option><option value='Minnesota' >Minnesota<\/option><option value='Mississippi' >Mississippi<\/option><option value='Missouri' >Missouri<\/option><option value='Montana' >Montana<\/option><option value='Nebraska' >Nebraska<\/option><option value='Nevada' >Nevada<\/option><option value='New Hampshire' >New Hampshire<\/option><option value='New Jersey' >New Jersey<\/option><option value='New Mexico' >New Mexico<\/option><option value='New York' >New York<\/option><option value='North Carolina' >North Carolina<\/option><option value='North Dakota' >North Dakota<\/option><option value='Northern Mariana Islands' >Northern Mariana Islands<\/option><option value='Ohio' >Ohio<\/option><option value='Oklahoma' >Oklahoma<\/option><option value='Oregon' >Oregon<\/option><option value='Pennsylvania' >Pennsylvania<\/option><option value='Puerto Rico' >Puerto Rico<\/option><option value='Rhode Island' >Rhode Island<\/option><option value='South Carolina' >South Carolina<\/option><option value='South Dakota' >South Dakota<\/option><option value='Tennessee' >Tennessee<\/option><option value='Texas' >Texas<\/option><option value='Utah' >Utah<\/option><option value='U.S. Virgin Islands' >U.S. Virgin Islands<\/option><option value='Vermont' >Vermont<\/option><option value='Virginia' >Virginia<\/option><option value='Washington' >Washington<\/option><option value='West Virginia' >West Virginia<\/option><option value='Wisconsin' >Wisconsin<\/option><option value='Wyoming' >Wyoming<\/option><option value='Armed Forces Americas' >Armed Forces Americas<\/option><option value='Armed Forces Europe' >Armed Forces Europe<\/option><option value='Armed Forces Pacific' >Armed Forces Pacific<\/option><\/select>\n                                        <label for='input_5_8_4' id='input_5_8_4_label' class='gform-field-label gform-field-label--type-sub '>State<\/label>\n                                      <\/span><span class='ginput_left address_zip ginput_address_zip gform-grid-col' id='input_5_8_5_container' >\n                                    <input type='text' name='input_8.5' id='input_5_8_5' value=''    aria-required='true'    \/>\n                                    <label for='input_5_8_5' id='input_5_8_5_label' class='gform-field-label gform-field-label--type-sub '>ZIP Code<\/label>\n                                <\/span><input type='hidden' class='gform_hidden' name='input_8.6' id='input_5_8_6' value='United States' \/>\n                    <div class='gf_clear gf_clear_complex'><\/div>\n                <\/div><\/fieldset><div id=\"field_5_27\" class=\"gfield gfield--type-phone gf_left_half gfield--width-half gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_5_27'>Phone<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_phone'><input name='input_27' id='input_5_27' type='tel' value='' class='medium'   aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><fieldset id=\"field_5_32\" class=\"gfield gfield--type-radio gfield--type-choice gf_right_half gfield--width-half gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >Can we leave a message?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_5_32'>\n\t\t\t<div class='gchoice gchoice_5_32_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_32' type='radio' value='Yes'  id='choice_5_32_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_5_32_0' id='label_5_32_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_5_32_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_32' type='radio' value='No'  id='choice_5_32_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_5_32_1' id='label_5_32_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_5_28\" class=\"gfield gfield--type-email gf_left_half gfield--width-half gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_5_28'>Email<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_email'>\n                            <input name='input_28' id='input_5_28' type='email' value='' class='medium'    aria-required=\"true\" aria-invalid=\"false\"  \/>\n                        <\/div><\/div><fieldset id=\"field_5_33\" class=\"gfield gfield--type-radio gfield--type-choice gf_right_half gfield--width-half gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >Can we email?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_5_33'>\n\t\t\t<div class='gchoice gchoice_5_33_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_33' type='radio' value='Yes'  id='choice_5_33_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_5_33_0' id='label_5_33_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_5_33_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_33' type='radio' value='No'  id='choice_5_33_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_5_33_1' id='label_5_33_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_5_29\" class=\"gfield gfield--type-text field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_5_29'>Major<\/label><div class='ginput_container ginput_container_text'><input name='input_29' id='input_5_29' type='text' value='' class='medium'      aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_5_30\" class=\"gfield gfield--type-text field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_5_30'>Minor<\/label><div class='ginput_container ginput_container_text'><input name='input_30' id='input_5_30' type='text' value='' class='medium'      aria-invalid=\"false\"   \/><\/div><\/div><fieldset id=\"field_5_31\" class=\"gfield gfield--type-radio gfield--type-choice field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >Are you a full-time or part-time student?<\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_5_31'>\n\t\t\t<div class='gchoice gchoice_5_31_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_31' type='radio' value='Full-time'  id='choice_5_31_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_5_31_0' id='label_5_31_0' class='gform-field-label gform-field-label--type-inline'>Full-time<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_5_31_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_31' type='radio' value='Part-time'  id='choice_5_31_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_5_31_1' id='label_5_31_1' class='gform-field-label gform-field-label--type-inline'>Part-time<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_5_9\" class=\"gfield gfield--type-radio gfield--type-choice gf_left_half gfield--width-half gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >Marital Status<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_5_9'>\n\t\t\t<div class='gchoice gchoice_5_9_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_9' type='radio' value='Single'  id='choice_5_9_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_5_9_0' id='label_5_9_0' class='gform-field-label gform-field-label--type-inline'>Single<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_5_9_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_9' type='radio' value='Divorced'  id='choice_5_9_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_5_9_1' id='label_5_9_1' class='gform-field-label gform-field-label--type-inline'>Divorced<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_5_9_2'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_9' type='radio' value='Widowed'  id='choice_5_9_2' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_5_9_2' id='label_5_9_2' class='gform-field-label gform-field-label--type-inline'>Widowed<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_5_9_3'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_9' type='radio' value='Married'  id='choice_5_9_3' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_5_9_3' id='label_5_9_3' class='gform-field-label gform-field-label--type-inline'>Married<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_5_9_4'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_9' type='radio' value='Separated'  id='choice_5_9_4' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_5_9_4' id='label_5_9_4' class='gform-field-label gform-field-label--type-inline'>Separated<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_5_10\" class=\"gfield gfield--type-radio gfield--type-choice gf_right_half gfield--width-half gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >Ethnicity<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_5_10'>\n\t\t\t<div class='gchoice gchoice_5_10_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_10' type='radio' value='Asian'  id='choice_5_10_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_5_10_0' id='label_5_10_0' class='gform-field-label gform-field-label--type-inline'>Asian<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_5_10_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_10' type='radio' value='African American'  id='choice_5_10_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_5_10_1' id='label_5_10_1' class='gform-field-label gform-field-label--type-inline'>African American<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_5_10_2'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_10' type='radio' value='Bi-Racial'  id='choice_5_10_2' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_5_10_2' id='label_5_10_2' class='gform-field-label gform-field-label--type-inline'>Bi-Racial<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_5_10_3'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_10' type='radio' value='Caucasian'  id='choice_5_10_3' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_5_10_3' id='label_5_10_3' class='gform-field-label gform-field-label--type-inline'>Caucasian<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_5_10_4'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_10' type='radio' value='Hispanic'  id='choice_5_10_4' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_5_10_4' id='label_5_10_4' class='gform-field-label gform-field-label--type-inline'>Hispanic<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_5_10_5'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_10' type='radio' value='Other'  id='choice_5_10_5' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_5_10_5' id='label_5_10_5' class='gform-field-label gform-field-label--type-inline'>Other<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_5_11\" class=\"gfield gfield--type-radio gfield--type-choice gf_left_third gfield--width-third gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >Are you a veteran?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_5_11'>\n\t\t\t<div class='gchoice gchoice_5_11_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_11' type='radio' value='Yes'  id='choice_5_11_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_5_11_0' id='label_5_11_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_5_11_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_11' type='radio' value='No'  id='choice_5_11_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_5_11_1' id='label_5_11_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_5_12\" class=\"gfield gfield--type-radio gfield--type-choice gf_middle_third gfield--width-third gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >Student Classification<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_5_12'>\n\t\t\t<div class='gchoice gchoice_5_12_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_12' type='radio' value='Freshman'  id='choice_5_12_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_5_12_0' id='label_5_12_0' class='gform-field-label gform-field-label--type-inline'>Freshman<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_5_12_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_12' type='radio' value='Sophomore'  id='choice_5_12_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_5_12_1' id='label_5_12_1' class='gform-field-label gform-field-label--type-inline'>Sophomore<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_5_12_2'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_12' type='radio' value='Junior'  id='choice_5_12_2' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_5_12_2' id='label_5_12_2' class='gform-field-label gform-field-label--type-inline'>Junior<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_5_12_3'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_12' type='radio' value='Senior'  id='choice_5_12_3' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_5_12_3' id='label_5_12_3' class='gform-field-label gform-field-label--type-inline'>Senior<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_5_12_4'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_12' type='radio' value='Graduate'  id='choice_5_12_4' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_5_12_4' id='label_5_12_4' class='gform-field-label gform-field-label--type-inline'>Graduate<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_5_12_5'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_12' type='radio' value='Other'  id='choice_5_12_5' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_5_12_5' id='label_5_12_5' class='gform-field-label gform-field-label--type-inline'>Other<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_5_13\" class=\"gfield gfield--type-checkbox gfield--type-choice gf_right_third gfield--width-third field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Who referred you?<\/legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox ' id='input_5_13'><div class='gchoice gchoice_5_13_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_13.1' type='checkbox'  value='Self'  id='choice_5_13_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_5_13_1' id='label_5_13_1' class='gform-field-label gform-field-label--type-inline'>Self<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_5_13_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_13.2' type='checkbox'  value='RA'  id='choice_5_13_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_5_13_2' id='label_5_13_2' class='gform-field-label gform-field-label--type-inline'>RA<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_5_13_3'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_13.3' type='checkbox'  value='Advisor'  id='choice_5_13_3'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_5_13_3' id='label_5_13_3' class='gform-field-label gform-field-label--type-inline'>Advisor<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_5_13_4'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_13.4' type='checkbox'  value='Professor'  id='choice_5_13_4'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_5_13_4' id='label_5_13_4' class='gform-field-label gform-field-label--type-inline'>Professor<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_5_13_5'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_13.5' type='checkbox'  value='Family'  id='choice_5_13_5'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_5_13_5' id='label_5_13_5' class='gform-field-label gform-field-label--type-inline'>Family<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_5_13_6'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_13.6' type='checkbox'  value='Friend'  id='choice_5_13_6'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_5_13_6' id='label_5_13_6' class='gform-field-label gform-field-label--type-inline'>Friend<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_5_13_7'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_13.7' type='checkbox'  value='Other'  id='choice_5_13_7'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_5_13_7' id='label_5_13_7' class='gform-field-label gform-field-label--type-inline'>Other<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_5_25\" class=\"gfield gfield--type-section gsection field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><h3 class=\"gsection_title\">Medical History<\/h3><\/div><fieldset id=\"field_5_14\" class=\"gfield gfield--type-checkbox gfield--type-choice gf_right_third gfield--width-third gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Presenting Problem<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox ' id='input_5_14'><div class='gchoice gchoice_5_14_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_14.1' type='checkbox'  value='Depression'  id='choice_5_14_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_5_14_1' id='label_5_14_1' class='gform-field-label gform-field-label--type-inline'>Depression<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_5_14_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_14.2' type='checkbox'  value='Anxiety'  id='choice_5_14_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_5_14_2' id='label_5_14_2' class='gform-field-label gform-field-label--type-inline'>Anxiety<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_5_14_3'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_14.3' type='checkbox'  value='Suicidal thoughts'  id='choice_5_14_3'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_5_14_3' id='label_5_14_3' class='gform-field-label gform-field-label--type-inline'>Suicidal thoughts<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_5_14_4'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_14.4' type='checkbox'  value='Stress'  id='choice_5_14_4'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_5_14_4' id='label_5_14_4' class='gform-field-label gform-field-label--type-inline'>Stress<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_5_14_5'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_14.5' type='checkbox'  value='Conflict with others'  id='choice_5_14_5'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_5_14_5' id='label_5_14_5' class='gform-field-label gform-field-label--type-inline'>Conflict with others<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_5_14_6'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_14.6' type='checkbox'  value='Decision making'  id='choice_5_14_6'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_5_14_6' id='label_5_14_6' class='gform-field-label gform-field-label--type-inline'>Decision making<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_5_14_7'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_14.7' type='checkbox'  value='Other'  id='choice_5_14_7'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_5_14_7' id='label_5_14_7' class='gform-field-label gform-field-label--type-inline'>Other<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_5_15\" class=\"gfield gfield--type-text gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_5_15'>Other presenting problem<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_15' id='input_5_15' type='text' value='' class='medium'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><fieldset id=\"field_5_16\" class=\"gfield gfield--type-radio gfield--type-choice gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >Have you ever taken medications?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_5_16'>\n\t\t\t<div class='gchoice gchoice_5_16_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_16' type='radio' value='Yes'  id='choice_5_16_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_5_16_0' id='label_5_16_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_5_16_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_16' type='radio' value='No'  id='choice_5_16_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_5_16_1' id='label_5_16_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_5_17\" class=\"gfield gfield--type-radio gfield--type-choice gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >Are you currently taking any medications?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_5_17'>\n\t\t\t<div class='gchoice gchoice_5_17_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_17' type='radio' value='Yes'  id='choice_5_17_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_5_17_0' id='label_5_17_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_5_17_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_17' type='radio' value='No'  id='choice_5_17_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_5_17_1' id='label_5_17_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_5_18\" class=\"gfield gfield--type-text gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_5_18'>What medication(s) and dose?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_18' id='input_5_18' type='text' value='' class='medium'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><fieldset id=\"field_5_19\" class=\"gfield gfield--type-radio gfield--type-choice gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >Have you ever received counseling?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_5_19'>\n\t\t\t<div class='gchoice gchoice_5_19_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_19' type='radio' value='Yes'  id='choice_5_19_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_5_19_0' id='label_5_19_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_5_19_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_19' type='radio' value='No'  id='choice_5_19_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_5_19_1' id='label_5_19_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_5_20\" class=\"gfield gfield--type-text field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_5_20'>When and where have you received counseling?<\/label><div class='ginput_container ginput_container_text'><input name='input_20' id='input_5_20' type='text' value='' class='medium'      aria-invalid=\"false\"   \/><\/div><\/div><fieldset id=\"field_5_21\" class=\"gfield gfield--type-radio gfield--type-choice gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >Do you have a previous diagnosis?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_5_21'>\n\t\t\t<div class='gchoice gchoice_5_21_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_21' type='radio' value='Yes'  id='choice_5_21_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_5_21_0' id='label_5_21_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_5_21_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_21' type='radio' value='No'  id='choice_5_21_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_5_21_1' id='label_5_21_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_5_22\" class=\"gfield gfield--type-text field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_5_22'>What diagnosis?<\/label><div class='ginput_container ginput_container_text'><input name='input_22' id='input_5_22' type='text' value='' class='medium'      aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_5_23\" class=\"gfield gfield--type-textarea field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_5_23'>Any medical conditions?<\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_23' id='input_5_23' class='textarea medium'      aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/div><div id=\"field_5_24\" class=\"gfield gfield--type-section gsection field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><h3 class=\"gsection_title\">Emergency Contacts<\/h3><\/div><fieldset id=\"field_5_26\" class=\"gfield gfield--type-list field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Please list emergency contacts below<\/legend><div class='ginput_container ginput_container_list ginput_list ginput_container_list--columns'><div class='gfield_list gfield_list_container'><div class=\"gfield_list_header gform-grid-row\"><div class=\"gform-field-label gfield_header_item gform-grid-col\">Name<\/div><div class=\"gform-field-label gfield_header_item gform-grid-col\">Phone<\/div><div class=\"gform-field-label gfield_header_item gform-grid-col\">Relationship<\/div><div class=\"gfield_header_item gfield_header_item--icons gform-grid-col\">&nbsp;<\/div><\/div><div class=\"gfield_list_groups\"><div class='gfield_list_row_odd gfield_list_group gform-grid-row'><div class='gfield_list_group_item gfield_list_cell gfield_list_26_cell1 gform-grid-col' data-label='Name'><input aria-invalid='false'   aria-label='Name, Row 1' data-aria-label-template='Name, Row {0}' type='text' name='input_26[]' value=''   \/><\/div><div class='gfield_list_group_item gfield_list_cell gfield_list_26_cell2 gform-grid-col' data-label='Phone'><input aria-invalid='false'   aria-label='Phone, Row 1' data-aria-label-template='Phone, Row {0}' type='text' name='input_26[]' value=''   \/><\/div><div class='gfield_list_group_item gfield_list_cell gfield_list_26_cell3 gform-grid-col' data-label='Relationship'><input aria-invalid='false'   aria-label='Relationship, Row 1' data-aria-label-template='Relationship, Row {0}' type='text' name='input_26[]' value=''   \/><\/div><div class='gfield_list_icons gform-grid-col'>   <button type='button'  class='add_list_item ' aria-label='Add another row' onclick='gformAddListItem(this, 0)'>Add<\/button>   <button type='button'  class='delete_list_item' aria-label='Remove row 1' data-aria-label-template='Remove row {0}' onclick='gformDeleteListItem(this, 0)' style=\"visibility:hidden;\">Remove<\/button><\/div><\/div><\/div><\/div><\/div><\/fieldset><div id=\"field_5_34\" class=\"gfield gfield--type-html gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><h3><strong><u>Limits of Confidentiality<\/u><\/strong><\/h3>\n\n<p>Counseling services provided by the Counseling Center at SAU are confidential.\u00a0 No information can be shared with another party without the written consent of the student\/client.\u00a0 It is the policy of this office not to release any information about a student\/client without a signed release of information.\u00a0 There are exceptions to this as follows:<\/p>\n\n<strong><u>Duty to Warn and Protect<\/u><\/strong>\n\n<p>When a client discloses intentions or a plan to harm another person, the counselor is required to warn the intended victim and report this information to the legal authorities.\u00a0 In cases in which the client discloses or implies a plan for suicide, the counselor is required to notify legal authorities and make reasonable attempts to notify the family of the client.<\/p>\n\n<strong><u>Abuse of Children and Vulnerable Adults<\/u><\/strong>\n\n<p>If a student\/client reports or implies child abuse or abuse of a vulnerable adult, the counselor is required to report this information to the appropriate social service and\/or legal authorities.<\/p>\n\n<strong><u>Court Orders<\/u><\/strong>\n\n<p>Counselors are required to release records of students\/clients when a court order has been issued for such records.<\/p>\n\n<strong><u>Other<\/u><\/strong>\n\n<p>At the Center we utilize student workers. They have received confidentiality training.<\/p>\n\n<p>The Center also utilizes interns from the Counseling Department. They are training to be professional therapists and have received confidentiality training. Students have the right to refuse intern participation.<\/p>\n\n<p>All of our counselors are trained in Technology Assisted therapy.<\/p><\/div><fieldset id=\"field_5_35\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' >In the event in which someone from this office must contact a student\/client for purposes such as appointment cancellations or reminders, or to give\/receive other information, efforts are made to preserve confidentiality.  Please identify your preferred mode of contact?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox ' id='input_5_35'><div class='gchoice gchoice_5_35_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_35.1' type='checkbox'  value='Phone'  id='choice_5_35_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_5_35_1' id='label_5_35_1' class='gform-field-label gform-field-label--type-inline'>Phone<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_5_35_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_35.2' type='checkbox'  value='Email'  id='choice_5_35_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_5_35_2' id='label_5_35_2' class='gform-field-label gform-field-label--type-inline'>Email<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_5_35_3'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_35.3' type='checkbox'  value='None'  id='choice_5_35_3'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_5_35_3' id='label_5_35_3' class='gform-field-label gform-field-label--type-inline'>None<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_5_36\" class=\"gfield gfield--type-radio gfield--type-choice gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >Would you like a copy of Limits of Confidentiality?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_5_36'>\n\t\t\t<div class='gchoice gchoice_5_36_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_36' type='radio' value='Yes'  id='choice_5_36_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_5_36_0' id='label_5_36_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_5_36_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_36' type='radio' value='No'  id='choice_5_36_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_5_36_1' id='label_5_36_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_5_37\" class=\"gfield gfield--type-consent gfield--type-choice gfield--input-type-consent gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Consent<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class='ginput_container 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