{"id":668,"date":"2024-08-23T14:45:39","date_gmt":"2024-08-23T19:45:39","guid":{"rendered":"https:\/\/web.saumag.edu\/counseling\/?page_id=668"},"modified":"2024-09-30T12:38:13","modified_gmt":"2024-09-30T17:38:13","slug":"screening-survey","status":"publish","type":"page","link":"https:\/\/web.saumag.edu\/counseling\/screening-survey\/","title":{"rendered":"Self-Rated Cross Screening Survey"},"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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gform_body'><div id='gform_page_7_1' class='gform_page ' data-js='page-field-id-0' >\n\t\t\t\t\t<div class='gform_page_fields'><div id='gform_fields_7' class='gform_fields top_label form_sublabel_below description_below validation_below'><div id=\"field_7_7\" class=\"gfield gfield--type-html gfield--input-type-html gfield--width-full 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>Informed Content<\/h3>\n<p>The Southern Arkansas University Athletic Department has partnered with the University Counseling Center and implemented a self-rated screening tool to support mental health and promote well-being among student athletes. The purpose of the survey is to screen for psychological distress at least once annually using a validated screening tool and offer mental health support to student athletes, in accordance with the NCAA Mental Health Best Practices. The content submitted in the Self-Rated Cross Screening Survey is confidential and will only be accessed by the Counseling Center staff. The only information to be released by the counseling center to the athletic department is whether you, the athlete, have or have not completed the yearly screening.<\/p><\/div><fieldset id=\"field_7_8\" class=\"gfield gfield--type-consent gfield--type-choice gfield--input-type-consent 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' >Consent<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/legend><div class='ginput_container ginput_container_consent'><input name='input_8.1' id='input_7_8_1' type='checkbox' value='1'   aria-required=\"true\" aria-invalid=\"false\"   \/> <label class=\"gform-field-label gform-field-label--type-inline gfield_consent_label\" for='input_7_8_1' >I have read and consent to the above informed consent statement and understand that a counselor will reach out to offer counseling services if a possible need is identified. I further understand that participation in counseling is optional and cannot be mandated by the counseling center.<\/label><input type='hidden' name='input_8.2' value='I have read and consent to the above informed consent statement and understand that a counselor will reach out to offer counseling services if a possible need is identified. I further understand that participation in counseling is optional and cannot be mandated by the counseling center.' class='gform_hidden' \/><input type='hidden' name='input_8.3' value='4' class='gform_hidden' \/><\/div><\/fieldset><fieldset id=\"field_7_1\" class=\"gfield gfield--type-name gfield--input-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' >Name<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/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_7_1'>\n                            \n                            <span id='input_7_1_3_container' class='name_first gform-grid-col gform-grid-col--size-auto' >\n                                                    <input type='text' name='input_1.3' id='input_7_1_3' value=''   aria-required='true'     \/>\n                                                    <label for='input_7_1_3' class='gform-field-label gform-field-label--type-sub '>First<\/label>\n                                                <\/span>\n                            \n                            <span id='input_7_1_6_container' class='name_last gform-grid-col gform-grid-col--size-auto' >\n                                                    <input type='text' name='input_1.6' id='input_7_1_6' value=''   aria-required='true'     \/>\n                                                    <label for='input_7_1_6' class='gform-field-label gform-field-label--type-sub '>Last<\/label>\n                                                <\/span>\n                            \n                        <\/div><\/fieldset><div id=\"field_7_3\" class=\"gfield gfield--type-number gfield--input-type-number 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_7_3'>Age<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/label><div class='ginput_container ginput_container_number'><input name='input_3' id='input_7_3' type='number' step='any' min='17' max='99' value='' class='large'     aria-required=\"true\" aria-invalid=\"false\" aria-describedby=\"gfield_instruction_7_3\" \/><div class='gfield_description instruction ' id='gfield_instruction_7_3'>Please enter a number from <strong>17<\/strong> to <strong>99<\/strong>.<\/div><\/div><\/div><fieldset id=\"field_7_4\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-half field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >Gender<\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_7_4'>\n\t\t\t<div class='gchoice gchoice_7_4_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_4' type='radio' value='Male'  id='choice_7_4_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_7_4_0' id='label_7_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_7_4_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_4' type='radio' value='Female'  id='choice_7_4_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_7_4_1' id='label_7_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_7_4_2'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_4' type='radio' value='Prefer not to say'  id='choice_7_4_2' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_7_4_2' id='label_7_4_2' class='gform-field-label gform-field-label--type-inline'>Prefer not to say<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><\/div>\n                    <\/div>\n                    <div class='gform-page-footer gform_page_footer top_label'>\n                         <input type='button' id='gform_next_button_7_6' class='gform_next_button gform-theme-button button' onclick='gform.submission.handleButtonClick(this);' data-submission-type='next' value='Next'  \/> \n                    <\/div>\n                <\/div>\n                <div id='gform_page_7_2' class='gform_page' data-js='page-field-id-6' style='display:none;'>\n                    <div class='gform_page_fields'>\n                        <div id='gform_fields_7_2' class='gform_fields top_label form_sublabel_below description_below validation_below'><div id=\"field_7_5\" class=\"gfield gfield--type-survey gfield--input-type-likert gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible gsurvey-survey-field \"  data-field-class=\"gsurvey-survey-field\" ><label class='gfield_label gform-field-label gfield_label_before_complex' >During the past two weeks, how much (or how often) have you been bothered by the following problems?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/label><div class='ginput_container ginput_container_likert'><table aria-label='During the past two weeks, how much (or how often) have you been bothered by the following problems?' class='gsurvey-likert' id='input_7_5'><thead><tr><td scope='col' class='gsurvey-likert-row-label'><\/td><th id='likert_col_1_7_5' scope='col'  class='gsurvey-likert-choice-label'>Not at all<\/th><th id='likert_col_2_7_5' scope='col'  class='gsurvey-likert-choice-label'>Slight, less than a day or two<\/th><th id='likert_col_3_7_5' scope='col'  class='gsurvey-likert-choice-label'>Mild, several days<\/th><th id='likert_col_4_7_5' scope='col'  class='gsurvey-likert-choice-label'>Moderate, more than half the days<\/th><th id='likert_col_5_7_5' scope='col'  class='gsurvey-likert-choice-label'>Severe, nearly every day<\/th><\/tr><\/thead><tbody><tr><td id='likert_row_1_7_5' data-label='' class='gsurvey-likert-row-label'>Little interest or pleasure in doing things?<\/td><td data-label='Not at all' class='gsurvey-likert-choice'><input name='input_5.1' type='radio' value='glikertrow1761a90c:glikertcol5c9346de1'  id='choice_7_5_1_1'    aria-labelledby='likert_row_1_7_5 likert_col_1_7_5'\/><\/td><td data-label='Slight, less than a day or two' class='gsurvey-likert-choice'><input name='input_5.1' type='radio' value='glikertrow1761a90c:glikertcol560f07384'  id='choice_7_5_1_2'    aria-labelledby='likert_row_1_7_5 likert_col_2_7_5'\/><\/td><td data-label='Mild, several days' class='gsurvey-likert-choice'><input name='input_5.1' type='radio' value='glikertrow1761a90c:glikertcol5afe8c30c'  id='choice_7_5_1_3'    aria-labelledby='likert_row_1_7_5 likert_col_3_7_5'\/><\/td><td data-label='Moderate, more than half the days' class='gsurvey-likert-choice'><input name='input_5.1' type='radio' value='glikertrow1761a90c:glikertcol5caef96a4'  id='choice_7_5_1_4'    aria-labelledby='likert_row_1_7_5 likert_col_4_7_5'\/><\/td><td data-label='Severe, nearly every day' class='gsurvey-likert-choice'><input name='input_5.1' type='radio' value='glikertrow1761a90c:glikertcol581c8ec79'  id='choice_7_5_1_5'    aria-labelledby='likert_row_1_7_5 likert_col_5_7_5'\/><\/td><\/tr><tr><td id='likert_row_2_7_5' data-label='' class='gsurvey-likert-row-label'>Feeling down, depressed, or hopeless?<\/td><td data-label='Not at all' class='gsurvey-likert-choice'><input name='input_5.2' type='radio' value='glikertrow0949032d:glikertcol5c9346de1'  id='choice_7_5_2_1'    aria-labelledby='likert_row_2_7_5 likert_col_1_7_5'\/><\/td><td data-label='Slight, less than a day or two' class='gsurvey-likert-choice'><input name='input_5.2' type='radio' value='glikertrow0949032d:glikertcol560f07384'  id='choice_7_5_2_2'    aria-labelledby='likert_row_2_7_5 likert_col_2_7_5'\/><\/td><td data-label='Mild, several days' class='gsurvey-likert-choice'><input name='input_5.2' type='radio' value='glikertrow0949032d:glikertcol5afe8c30c'  id='choice_7_5_2_3'    aria-labelledby='likert_row_2_7_5 likert_col_3_7_5'\/><\/td><td data-label='Moderate, more than half the days' class='gsurvey-likert-choice'><input name='input_5.2' type='radio' value='glikertrow0949032d:glikertcol5caef96a4'  id='choice_7_5_2_4'    aria-labelledby='likert_row_2_7_5 likert_col_4_7_5'\/><\/td><td data-label='Severe, nearly every day' class='gsurvey-likert-choice'><input name='input_5.2' type='radio' value='glikertrow0949032d:glikertcol581c8ec79'  id='choice_7_5_2_5'    aria-labelledby='likert_row_2_7_5 likert_col_5_7_5'\/><\/td><\/tr><tr><td id='likert_row_3_7_5' data-label='' class='gsurvey-likert-row-label'>Feeling more irritated, grouchy, or angry than usual?<\/td><td data-label='Not at all' class='gsurvey-likert-choice'><input name='input_5.3' type='radio' value='glikertrow6c3a534a:glikertcol5c9346de1'  id='choice_7_5_3_1'    aria-labelledby='likert_row_3_7_5 likert_col_1_7_5'\/><\/td><td data-label='Slight, less than a day or two' class='gsurvey-likert-choice'><input name='input_5.3' type='radio' value='glikertrow6c3a534a:glikertcol560f07384'  id='choice_7_5_3_2'    aria-labelledby='likert_row_3_7_5 likert_col_2_7_5'\/><\/td><td data-label='Mild, several days' class='gsurvey-likert-choice'><input name='input_5.3' type='radio' value='glikertrow6c3a534a:glikertcol5afe8c30c'  id='choice_7_5_3_3'    aria-labelledby='likert_row_3_7_5 likert_col_3_7_5'\/><\/td><td data-label='Moderate, more than half the days' class='gsurvey-likert-choice'><input name='input_5.3' type='radio' value='glikertrow6c3a534a:glikertcol5caef96a4'  id='choice_7_5_3_4'    aria-labelledby='likert_row_3_7_5 likert_col_4_7_5'\/><\/td><td data-label='Severe, nearly every day' class='gsurvey-likert-choice'><input name='input_5.3' type='radio' value='glikertrow6c3a534a:glikertcol581c8ec79'  id='choice_7_5_3_5'    aria-labelledby='likert_row_3_7_5 likert_col_5_7_5'\/><\/td><\/tr><tr><td id='likert_row_4_7_5' data-label='' class='gsurvey-likert-row-label'>Sleeping less than usual, but still have a lot of energy?<\/td><td data-label='Not at all' class='gsurvey-likert-choice'><input name='input_5.4' type='radio' value='glikertrowdea9de99:glikertcol5c9346de1'  id='choice_7_5_4_1'    aria-labelledby='likert_row_4_7_5 likert_col_1_7_5'\/><\/td><td data-label='Slight, less than a day or two' class='gsurvey-likert-choice'><input name='input_5.4' type='radio' value='glikertrowdea9de99:glikertcol560f07384'  id='choice_7_5_4_2'    aria-labelledby='likert_row_4_7_5 likert_col_2_7_5'\/><\/td><td data-label='Mild, several days' class='gsurvey-likert-choice'><input name='input_5.4' type='radio' value='glikertrowdea9de99:glikertcol5afe8c30c'  id='choice_7_5_4_3'    aria-labelledby='likert_row_4_7_5 likert_col_3_7_5'\/><\/td><td data-label='Moderate, more than half the days' class='gsurvey-likert-choice'><input name='input_5.4' type='radio' value='glikertrowdea9de99:glikertcol5caef96a4'  id='choice_7_5_4_4'    aria-labelledby='likert_row_4_7_5 likert_col_4_7_5'\/><\/td><td data-label='Severe, nearly every day' class='gsurvey-likert-choice'><input name='input_5.4' type='radio' value='glikertrowdea9de99:glikertcol581c8ec79'  id='choice_7_5_4_5'    aria-labelledby='likert_row_4_7_5 likert_col_5_7_5'\/><\/td><\/tr><tr><td id='likert_row_5_7_5' data-label='' class='gsurvey-likert-row-label'>Starting lots more projects than usual or doing more risky things than usual?<\/td><td data-label='Not at all' class='gsurvey-likert-choice'><input name='input_5.5' type='radio' value='glikertrow6c0f22ce:glikertcol5c9346de1'  id='choice_7_5_5_1'    aria-labelledby='likert_row_5_7_5 likert_col_1_7_5'\/><\/td><td data-label='Slight, less than a day or two' class='gsurvey-likert-choice'><input name='input_5.5' type='radio' value='glikertrow6c0f22ce:glikertcol560f07384'  id='choice_7_5_5_2'    aria-labelledby='likert_row_5_7_5 likert_col_2_7_5'\/><\/td><td data-label='Mild, several days' class='gsurvey-likert-choice'><input name='input_5.5' type='radio' value='glikertrow6c0f22ce:glikertcol5afe8c30c'  id='choice_7_5_5_3'    aria-labelledby='likert_row_5_7_5 likert_col_3_7_5'\/><\/td><td data-label='Moderate, more than half the days' class='gsurvey-likert-choice'><input name='input_5.5' type='radio' value='glikertrow6c0f22ce:glikertcol5caef96a4'  id='choice_7_5_5_4'    aria-labelledby='likert_row_5_7_5 likert_col_4_7_5'\/><\/td><td data-label='Severe, nearly every day' class='gsurvey-likert-choice'><input name='input_5.5' type='radio' value='glikertrow6c0f22ce:glikertcol581c8ec79'  id='choice_7_5_5_5'    aria-labelledby='likert_row_5_7_5 likert_col_5_7_5'\/><\/td><\/tr><tr><td id='likert_row_6_7_5' data-label='' class='gsurvey-likert-row-label'>Feeling nervous, anxious, frightened, worried, or an edge?<\/td><td data-label='Not at all' class='gsurvey-likert-choice'><input name='input_5.6' type='radio' value='glikertrow47480206:glikertcol5c9346de1'  id='choice_7_5_6_1'    aria-labelledby='likert_row_6_7_5 likert_col_1_7_5'\/><\/td><td data-label='Slight, less than a day or two' class='gsurvey-likert-choice'><input name='input_5.6' type='radio' value='glikertrow47480206:glikertcol560f07384'  id='choice_7_5_6_2'    aria-labelledby='likert_row_6_7_5 likert_col_2_7_5'\/><\/td><td data-label='Mild, several days' class='gsurvey-likert-choice'><input name='input_5.6' type='radio' value='glikertrow47480206:glikertcol5afe8c30c'  id='choice_7_5_6_3'    aria-labelledby='likert_row_6_7_5 likert_col_3_7_5'\/><\/td><td data-label='Moderate, more than half the days' class='gsurvey-likert-choice'><input name='input_5.6' type='radio' value='glikertrow47480206:glikertcol5caef96a4'  id='choice_7_5_6_4'    aria-labelledby='likert_row_6_7_5 likert_col_4_7_5'\/><\/td><td data-label='Severe, nearly every day' class='gsurvey-likert-choice'><input name='input_5.6' type='radio' value='glikertrow47480206:glikertcol581c8ec79'  id='choice_7_5_6_5'    aria-labelledby='likert_row_6_7_5 likert_col_5_7_5'\/><\/td><\/tr><tr><td id='likert_row_7_7_5' data-label='' class='gsurvey-likert-row-label'>Feeling panic or being frightened?<\/td><td data-label='Not at all' class='gsurvey-likert-choice'><input name='input_5.7' type='radio' value='glikertrow51e9e355:glikertcol5c9346de1'  id='choice_7_5_7_1'    aria-labelledby='likert_row_7_7_5 likert_col_1_7_5'\/><\/td><td data-label='Slight, less than a day or two' class='gsurvey-likert-choice'><input name='input_5.7' type='radio' value='glikertrow51e9e355:glikertcol560f07384'  id='choice_7_5_7_2'    aria-labelledby='likert_row_7_7_5 likert_col_2_7_5'\/><\/td><td data-label='Mild, several days' class='gsurvey-likert-choice'><input name='input_5.7' type='radio' value='glikertrow51e9e355:glikertcol5afe8c30c'  id='choice_7_5_7_3'    aria-labelledby='likert_row_7_7_5 likert_col_3_7_5'\/><\/td><td data-label='Moderate, more than half the days' class='gsurvey-likert-choice'><input name='input_5.7' type='radio' value='glikertrow51e9e355:glikertcol5caef96a4'  id='choice_7_5_7_4'    aria-labelledby='likert_row_7_7_5 likert_col_4_7_5'\/><\/td><td data-label='Severe, nearly every day' class='gsurvey-likert-choice'><input name='input_5.7' type='radio' value='glikertrow51e9e355:glikertcol581c8ec79'  id='choice_7_5_7_5'    aria-labelledby='likert_row_7_7_5 likert_col_5_7_5'\/><\/td><\/tr><tr><td id='likert_row_8_7_5' data-label='' class='gsurvey-likert-row-label'>Avoiding situations that make you anxious?<\/td><td data-label='Not at all' class='gsurvey-likert-choice'><input name='input_5.8' type='radio' value='glikertrow90f94d9a:glikertcol5c9346de1'  id='choice_7_5_8_1'    aria-labelledby='likert_row_8_7_5 likert_col_1_7_5'\/><\/td><td data-label='Slight, less than a day or two' class='gsurvey-likert-choice'><input name='input_5.8' type='radio' value='glikertrow90f94d9a:glikertcol560f07384'  id='choice_7_5_8_2'    aria-labelledby='likert_row_8_7_5 likert_col_2_7_5'\/><\/td><td data-label='Mild, several days' class='gsurvey-likert-choice'><input name='input_5.8' type='radio' value='glikertrow90f94d9a:glikertcol5afe8c30c'  id='choice_7_5_8_3'    aria-labelledby='likert_row_8_7_5 likert_col_3_7_5'\/><\/td><td data-label='Moderate, more than half the days' class='gsurvey-likert-choice'><input name='input_5.8' type='radio' value='glikertrow90f94d9a:glikertcol5caef96a4'  id='choice_7_5_8_4'    aria-labelledby='likert_row_8_7_5 likert_col_4_7_5'\/><\/td><td data-label='Severe, nearly every day' class='gsurvey-likert-choice'><input name='input_5.8' type='radio' value='glikertrow90f94d9a:glikertcol581c8ec79'  id='choice_7_5_8_5'    aria-labelledby='likert_row_8_7_5 likert_col_5_7_5'\/><\/td><\/tr><tr><td id='likert_row_9_7_5' data-label='' class='gsurvey-likert-row-label'>Unexplained aches and pains (e.g., head, back, joints, abdomen, legs)?<\/td><td data-label='Not at all' class='gsurvey-likert-choice'><input name='input_5.9' type='radio' value='glikertrowc50581fc:glikertcol5c9346de1'  id='choice_7_5_9_1'    aria-labelledby='likert_row_9_7_5 likert_col_1_7_5'\/><\/td><td data-label='Slight, less than a day or two' class='gsurvey-likert-choice'><input name='input_5.9' type='radio' value='glikertrowc50581fc:glikertcol560f07384'  id='choice_7_5_9_2'    aria-labelledby='likert_row_9_7_5 likert_col_2_7_5'\/><\/td><td data-label='Mild, several days' class='gsurvey-likert-choice'><input name='input_5.9' type='radio' value='glikertrowc50581fc:glikertcol5afe8c30c'  id='choice_7_5_9_3'    aria-labelledby='likert_row_9_7_5 likert_col_3_7_5'\/><\/td><td data-label='Moderate, more than half the days' class='gsurvey-likert-choice'><input name='input_5.9' type='radio' value='glikertrowc50581fc:glikertcol5caef96a4'  id='choice_7_5_9_4'    aria-labelledby='likert_row_9_7_5 likert_col_4_7_5'\/><\/td><td data-label='Severe, nearly every day' class='gsurvey-likert-choice'><input name='input_5.9' type='radio' value='glikertrowc50581fc:glikertcol581c8ec79'  id='choice_7_5_9_5'    aria-labelledby='likert_row_9_7_5 likert_col_5_7_5'\/><\/td><\/tr><tr><td id='likert_row_10_7_5' data-label='' class='gsurvey-likert-row-label'>Feeling that your illnesses are not being taken seriously enough?<\/td><td data-label='Not at all' class='gsurvey-likert-choice'><input name='input_5.11' type='radio' value='glikertrowf7c43923:glikertcol5c9346de1'  id='choice_7_5_11_1'    aria-labelledby='likert_row_10_7_5 likert_col_1_7_5'\/><\/td><td data-label='Slight, less than a day or two' class='gsurvey-likert-choice'><input name='input_5.11' type='radio' value='glikertrowf7c43923:glikertcol560f07384'  id='choice_7_5_11_2'    aria-labelledby='likert_row_10_7_5 likert_col_2_7_5'\/><\/td><td data-label='Mild, several days' class='gsurvey-likert-choice'><input name='input_5.11' type='radio' value='glikertrowf7c43923:glikertcol5afe8c30c'  id='choice_7_5_11_3'    aria-labelledby='likert_row_10_7_5 likert_col_3_7_5'\/><\/td><td data-label='Moderate, more than half the days' class='gsurvey-likert-choice'><input name='input_5.11' type='radio' value='glikertrowf7c43923:glikertcol5caef96a4'  id='choice_7_5_11_4'    aria-labelledby='likert_row_10_7_5 likert_col_4_7_5'\/><\/td><td data-label='Severe, nearly every day' class='gsurvey-likert-choice'><input name='input_5.11' type='radio' value='glikertrowf7c43923:glikertcol581c8ec79'  id='choice_7_5_11_5'    aria-labelledby='likert_row_10_7_5 likert_col_5_7_5'\/><\/td><\/tr><tr><td id='likert_row_11_7_5' data-label='' class='gsurvey-likert-row-label'>Thoughts of actually hurting yourself?<\/td><td data-label='Not at all' class='gsurvey-likert-choice'><input name='input_5.12' type='radio' value='glikertrowf4afd689:glikertcol5c9346de1'  id='choice_7_5_12_1'    aria-labelledby='likert_row_11_7_5 likert_col_1_7_5'\/><\/td><td data-label='Slight, less than a day or two' class='gsurvey-likert-choice'><input name='input_5.12' type='radio' value='glikertrowf4afd689:glikertcol560f07384'  id='choice_7_5_12_2'    aria-labelledby='likert_row_11_7_5 likert_col_2_7_5'\/><\/td><td data-label='Mild, several days' class='gsurvey-likert-choice'><input name='input_5.12' type='radio' value='glikertrowf4afd689:glikertcol5afe8c30c'  id='choice_7_5_12_3'    aria-labelledby='likert_row_11_7_5 likert_col_3_7_5'\/><\/td><td data-label='Moderate, more than half the days' class='gsurvey-likert-choice'><input name='input_5.12' type='radio' value='glikertrowf4afd689:glikertcol5caef96a4'  id='choice_7_5_12_4'    aria-labelledby='likert_row_11_7_5 likert_col_4_7_5'\/><\/td><td data-label='Severe, nearly every day' class='gsurvey-likert-choice'><input name='input_5.12' type='radio' value='glikertrowf4afd689:glikertcol581c8ec79'  id='choice_7_5_12_5'    aria-labelledby='likert_row_11_7_5 likert_col_5_7_5'\/><\/td><\/tr><tr><td id='likert_row_12_7_5' data-label='' class='gsurvey-likert-row-label'>Hearing things other people couldn\u2019t hear, such as voices even when no one was around?<\/td><td data-label='Not at all' class='gsurvey-likert-choice'><input name='input_5.13' type='radio' value='glikertrow5da093ea:glikertcol5c9346de1'  id='choice_7_5_13_1'    aria-labelledby='likert_row_12_7_5 likert_col_1_7_5'\/><\/td><td data-label='Slight, less than a day or two' class='gsurvey-likert-choice'><input name='input_5.13' type='radio' value='glikertrow5da093ea:glikertcol560f07384'  id='choice_7_5_13_2'    aria-labelledby='likert_row_12_7_5 likert_col_2_7_5'\/><\/td><td data-label='Mild, several days' class='gsurvey-likert-choice'><input name='input_5.13' type='radio' value='glikertrow5da093ea:glikertcol5afe8c30c'  id='choice_7_5_13_3'    aria-labelledby='likert_row_12_7_5 likert_col_3_7_5'\/><\/td><td data-label='Moderate, more than half the days' class='gsurvey-likert-choice'><input name='input_5.13' type='radio' value='glikertrow5da093ea:glikertcol5caef96a4'  id='choice_7_5_13_4'    aria-labelledby='likert_row_12_7_5 likert_col_4_7_5'\/><\/td><td data-label='Severe, nearly every day' class='gsurvey-likert-choice'><input name='input_5.13' type='radio' value='glikertrow5da093ea:glikertcol581c8ec79'  id='choice_7_5_13_5'    aria-labelledby='likert_row_12_7_5 likert_col_5_7_5'\/><\/td><\/tr><tr><td id='likert_row_13_7_5' data-label='' class='gsurvey-likert-row-label'>Feeling that someone could hear your thoughts, or that you could hear what another person was thinking?<\/td><td data-label='Not at all' class='gsurvey-likert-choice'><input name='input_5.14' type='radio' value='glikertrow3c992808:glikertcol5c9346de1'  id='choice_7_5_14_1'    aria-labelledby='likert_row_13_7_5 likert_col_1_7_5'\/><\/td><td data-label='Slight, less than a day or two' class='gsurvey-likert-choice'><input name='input_5.14' type='radio' value='glikertrow3c992808:glikertcol560f07384'  id='choice_7_5_14_2'    aria-labelledby='likert_row_13_7_5 likert_col_2_7_5'\/><\/td><td data-label='Mild, several days' class='gsurvey-likert-choice'><input name='input_5.14' type='radio' value='glikertrow3c992808:glikertcol5afe8c30c'  id='choice_7_5_14_3'    aria-labelledby='likert_row_13_7_5 likert_col_3_7_5'\/><\/td><td data-label='Moderate, more than half the days' class='gsurvey-likert-choice'><input name='input_5.14' type='radio' value='glikertrow3c992808:glikertcol5caef96a4'  id='choice_7_5_14_4'    aria-labelledby='likert_row_13_7_5 likert_col_4_7_5'\/><\/td><td data-label='Severe, nearly every day' class='gsurvey-likert-choice'><input name='input_5.14' type='radio' value='glikertrow3c992808:glikertcol581c8ec79'  id='choice_7_5_14_5'    aria-labelledby='likert_row_13_7_5 likert_col_5_7_5'\/><\/td><\/tr><tr><td id='likert_row_14_7_5' data-label='' class='gsurvey-likert-row-label'>Problems with sleep that affected your sleep quality over all?<\/td><td data-label='Not at all' class='gsurvey-likert-choice'><input name='input_5.15' type='radio' value='glikertrow05e05bcd:glikertcol5c9346de1'  id='choice_7_5_15_1'    aria-labelledby='likert_row_14_7_5 likert_col_1_7_5'\/><\/td><td data-label='Slight, less than a day or two' class='gsurvey-likert-choice'><input name='input_5.15' type='radio' value='glikertrow05e05bcd:glikertcol560f07384'  id='choice_7_5_15_2'    aria-labelledby='likert_row_14_7_5 likert_col_2_7_5'\/><\/td><td data-label='Mild, several days' class='gsurvey-likert-choice'><input name='input_5.15' type='radio' value='glikertrow05e05bcd:glikertcol5afe8c30c'  id='choice_7_5_15_3'    aria-labelledby='likert_row_14_7_5 likert_col_3_7_5'\/><\/td><td data-label='Moderate, more than half the days' class='gsurvey-likert-choice'><input name='input_5.15' type='radio' value='glikertrow05e05bcd:glikertcol5caef96a4'  id='choice_7_5_15_4'    aria-labelledby='likert_row_14_7_5 likert_col_4_7_5'\/><\/td><td data-label='Severe, nearly every day' class='gsurvey-likert-choice'><input name='input_5.15' type='radio' value='glikertrow05e05bcd:glikertcol581c8ec79'  id='choice_7_5_15_5'    aria-labelledby='likert_row_14_7_5 likert_col_5_7_5'\/><\/td><\/tr><tr><td id='likert_row_15_7_5' data-label='' class='gsurvey-likert-row-label'>Problems with memory (e.g., learning new information) or with location (e.g., finding your way home)?<\/td><td data-label='Not at all' class='gsurvey-likert-choice'><input name='input_5.16' type='radio' value='glikertrowd340a304:glikertcol5c9346de1'  id='choice_7_5_16_1'    aria-labelledby='likert_row_15_7_5 likert_col_1_7_5'\/><\/td><td data-label='Slight, less than a day or two' class='gsurvey-likert-choice'><input name='input_5.16' type='radio' value='glikertrowd340a304:glikertcol560f07384'  id='choice_7_5_16_2'    aria-labelledby='likert_row_15_7_5 likert_col_2_7_5'\/><\/td><td data-label='Mild, several days' class='gsurvey-likert-choice'><input name='input_5.16' type='radio' value='glikertrowd340a304:glikertcol5afe8c30c'  id='choice_7_5_16_3'    aria-labelledby='likert_row_15_7_5 likert_col_3_7_5'\/><\/td><td data-label='Moderate, more than half the days' class='gsurvey-likert-choice'><input name='input_5.16' type='radio' value='glikertrowd340a304:glikertcol5caef96a4'  id='choice_7_5_16_4'    aria-labelledby='likert_row_15_7_5 likert_col_4_7_5'\/><\/td><td data-label='Severe, nearly every day' class='gsurvey-likert-choice'><input name='input_5.16' type='radio' value='glikertrowd340a304:glikertcol581c8ec79'  id='choice_7_5_16_5'    aria-labelledby='likert_row_15_7_5 likert_col_5_7_5'\/><\/td><\/tr><tr><td id='likert_row_16_7_5' data-label='' class='gsurvey-likert-row-label'>Unpleasant thoughts, urges, or images that repeatedly enter your mind?<\/td><td data-label='Not at all' class='gsurvey-likert-choice'><input name='input_5.17' type='radio' value='glikertrow2f00bb6d:glikertcol5c9346de1'  id='choice_7_5_17_1'    aria-labelledby='likert_row_16_7_5 likert_col_1_7_5'\/><\/td><td data-label='Slight, less than a day or two' class='gsurvey-likert-choice'><input name='input_5.17' type='radio' value='glikertrow2f00bb6d:glikertcol560f07384'  id='choice_7_5_17_2'    aria-labelledby='likert_row_16_7_5 likert_col_2_7_5'\/><\/td><td data-label='Mild, several days' class='gsurvey-likert-choice'><input name='input_5.17' type='radio' value='glikertrow2f00bb6d:glikertcol5afe8c30c'  id='choice_7_5_17_3'    aria-labelledby='likert_row_16_7_5 likert_col_3_7_5'\/><\/td><td data-label='Moderate, more than half the days' class='gsurvey-likert-choice'><input name='input_5.17' type='radio' value='glikertrow2f00bb6d:glikertcol5caef96a4'  id='choice_7_5_17_4'    aria-labelledby='likert_row_16_7_5 likert_col_4_7_5'\/><\/td><td data-label='Severe, nearly every day' class='gsurvey-likert-choice'><input name='input_5.17' type='radio' value='glikertrow2f00bb6d:glikertcol581c8ec79'  id='choice_7_5_17_5'    aria-labelledby='likert_row_16_7_5 likert_col_5_7_5'\/><\/td><\/tr><tr><td id='likert_row_17_7_5' data-label='' class='gsurvey-likert-row-label'>Feeling driven to perform certain behaviors or mental acts over and over again?<\/td><td data-label='Not at all' class='gsurvey-likert-choice'><input name='input_5.18' type='radio' value='glikertrow0c30d300:glikertcol5c9346de1'  id='choice_7_5_18_1'    aria-labelledby='likert_row_17_7_5 likert_col_1_7_5'\/><\/td><td data-label='Slight, less than a day or two' class='gsurvey-likert-choice'><input name='input_5.18' type='radio' value='glikertrow0c30d300:glikertcol560f07384'  id='choice_7_5_18_2'    aria-labelledby='likert_row_17_7_5 likert_col_2_7_5'\/><\/td><td data-label='Mild, several days' class='gsurvey-likert-choice'><input name='input_5.18' type='radio' value='glikertrow0c30d300:glikertcol5afe8c30c'  id='choice_7_5_18_3'    aria-labelledby='likert_row_17_7_5 likert_col_3_7_5'\/><\/td><td data-label='Moderate, more than half the days' class='gsurvey-likert-choice'><input name='input_5.18' type='radio' value='glikertrow0c30d300:glikertcol5caef96a4'  id='choice_7_5_18_4'    aria-labelledby='likert_row_17_7_5 likert_col_4_7_5'\/><\/td><td data-label='Severe, nearly every day' class='gsurvey-likert-choice'><input name='input_5.18' type='radio' value='glikertrow0c30d300:glikertcol581c8ec79'  id='choice_7_5_18_5'    aria-labelledby='likert_row_17_7_5 likert_col_5_7_5'\/><\/td><\/tr><tr><td id='likert_row_18_7_5' data-label='' class='gsurvey-likert-row-label'>Feeling detached or distant from yourself, your body, your physical surroundings, or your memories?<\/td><td data-label='Not at all' class='gsurvey-likert-choice'><input name='input_5.19' type='radio' value='glikertrowcc6279ff:glikertcol5c9346de1'  id='choice_7_5_19_1'    aria-labelledby='likert_row_18_7_5 likert_col_1_7_5'\/><\/td><td data-label='Slight, less than a day or two' class='gsurvey-likert-choice'><input name='input_5.19' type='radio' value='glikertrowcc6279ff:glikertcol560f07384'  id='choice_7_5_19_2'    aria-labelledby='likert_row_18_7_5 likert_col_2_7_5'\/><\/td><td data-label='Mild, several days' class='gsurvey-likert-choice'><input name='input_5.19' type='radio' value='glikertrowcc6279ff:glikertcol5afe8c30c'  id='choice_7_5_19_3'    aria-labelledby='likert_row_18_7_5 likert_col_3_7_5'\/><\/td><td data-label='Moderate, more than half the days' class='gsurvey-likert-choice'><input name='input_5.19' type='radio' value='glikertrowcc6279ff:glikertcol5caef96a4'  id='choice_7_5_19_4'    aria-labelledby='likert_row_18_7_5 likert_col_4_7_5'\/><\/td><td data-label='Severe, nearly every day' class='gsurvey-likert-choice'><input name='input_5.19' type='radio' value='glikertrowcc6279ff:glikertcol581c8ec79'  id='choice_7_5_19_5'    aria-labelledby='likert_row_18_7_5 likert_col_5_7_5'\/><\/td><\/tr><tr><td id='likert_row_19_7_5' data-label='' class='gsurvey-likert-row-label'>Not knowing who you really are or what you want out of life?<\/td><td data-label='Not at all' class='gsurvey-likert-choice'><input name='input_5.21' type='radio' value='glikertrowfe7c919f:glikertcol5c9346de1'  id='choice_7_5_21_1'    aria-labelledby='likert_row_19_7_5 likert_col_1_7_5'\/><\/td><td data-label='Slight, less than a day or two' class='gsurvey-likert-choice'><input name='input_5.21' type='radio' value='glikertrowfe7c919f:glikertcol560f07384'  id='choice_7_5_21_2'    aria-labelledby='likert_row_19_7_5 likert_col_2_7_5'\/><\/td><td data-label='Mild, several days' class='gsurvey-likert-choice'><input name='input_5.21' type='radio' value='glikertrowfe7c919f:glikertcol5afe8c30c'  id='choice_7_5_21_3'    aria-labelledby='likert_row_19_7_5 likert_col_3_7_5'\/><\/td><td data-label='Moderate, more than half the days' class='gsurvey-likert-choice'><input name='input_5.21' type='radio' value='glikertrowfe7c919f:glikertcol5caef96a4'  id='choice_7_5_21_4'    aria-labelledby='likert_row_19_7_5 likert_col_4_7_5'\/><\/td><td data-label='Severe, nearly every day' class='gsurvey-likert-choice'><input name='input_5.21' type='radio' value='glikertrowfe7c919f:glikertcol581c8ec79'  id='choice_7_5_21_5'    aria-labelledby='likert_row_19_7_5 likert_col_5_7_5'\/><\/td><\/tr><tr><td id='likert_row_20_7_5' data-label='' class='gsurvey-likert-row-label'>Not feeling close to other people or enjoying your relationships with them?<\/td><td data-label='Not at all' class='gsurvey-likert-choice'><input name='input_5.22' type='radio' value='glikertrow48e29253:glikertcol5c9346de1'  id='choice_7_5_22_1'    aria-labelledby='likert_row_20_7_5 likert_col_1_7_5'\/><\/td><td data-label='Slight, less than a day or two' class='gsurvey-likert-choice'><input name='input_5.22' type='radio' value='glikertrow48e29253:glikertcol560f07384'  id='choice_7_5_22_2'    aria-labelledby='likert_row_20_7_5 likert_col_2_7_5'\/><\/td><td data-label='Mild, several days' class='gsurvey-likert-choice'><input name='input_5.22' type='radio' value='glikertrow48e29253:glikertcol5afe8c30c'  id='choice_7_5_22_3'    aria-labelledby='likert_row_20_7_5 likert_col_3_7_5'\/><\/td><td data-label='Moderate, more than half the days' class='gsurvey-likert-choice'><input name='input_5.22' type='radio' value='glikertrow48e29253:glikertcol5caef96a4'  id='choice_7_5_22_4'    aria-labelledby='likert_row_20_7_5 likert_col_4_7_5'\/><\/td><td data-label='Severe, nearly every day' class='gsurvey-likert-choice'><input name='input_5.22' type='radio' value='glikertrow48e29253:glikertcol581c8ec79'  id='choice_7_5_22_5'    aria-labelledby='likert_row_20_7_5 likert_col_5_7_5'\/><\/td><\/tr><tr><td id='likert_row_21_7_5' data-label='' class='gsurvey-likert-row-label'>Drinking at least 4 drinks of any kind of alcohol in a single day?<\/td><td data-label='Not at all' class='gsurvey-likert-choice'><input name='input_5.23' type='radio' value='glikertrowda8e1d30:glikertcol5c9346de1'  id='choice_7_5_23_1'    aria-labelledby='likert_row_21_7_5 likert_col_1_7_5'\/><\/td><td data-label='Slight, less than a day or two' class='gsurvey-likert-choice'><input name='input_5.23' type='radio' value='glikertrowda8e1d30:glikertcol560f07384'  id='choice_7_5_23_2'    aria-labelledby='likert_row_21_7_5 likert_col_2_7_5'\/><\/td><td data-label='Mild, several days' class='gsurvey-likert-choice'><input name='input_5.23' type='radio' value='glikertrowda8e1d30:glikertcol5afe8c30c'  id='choice_7_5_23_3'    aria-labelledby='likert_row_21_7_5 likert_col_3_7_5'\/><\/td><td data-label='Moderate, more than half the days' class='gsurvey-likert-choice'><input name='input_5.23' type='radio' value='glikertrowda8e1d30:glikertcol5caef96a4'  id='choice_7_5_23_4'    aria-labelledby='likert_row_21_7_5 likert_col_4_7_5'\/><\/td><td data-label='Severe, nearly every day' class='gsurvey-likert-choice'><input name='input_5.23' type='radio' value='glikertrowda8e1d30:glikertcol581c8ec79'  id='choice_7_5_23_5'    aria-labelledby='likert_row_21_7_5 likert_col_5_7_5'\/><\/td><\/tr><tr><td id='likert_row_22_7_5' data-label='' class='gsurvey-likert-row-label'>Smoking any cigarettes, a cigar, or pipe, or using snuff or chewing tobacco?<\/td><td data-label='Not at all' class='gsurvey-likert-choice'><input name='input_5.24' type='radio' value='glikertrowd40e5a60:glikertcol5c9346de1'  id='choice_7_5_24_1'    aria-labelledby='likert_row_22_7_5 likert_col_1_7_5'\/><\/td><td data-label='Slight, less than a day or two' class='gsurvey-likert-choice'><input name='input_5.24' type='radio' value='glikertrowd40e5a60:glikertcol560f07384'  id='choice_7_5_24_2'    aria-labelledby='likert_row_22_7_5 likert_col_2_7_5'\/><\/td><td data-label='Mild, several days' class='gsurvey-likert-choice'><input name='input_5.24' type='radio' value='glikertrowd40e5a60:glikertcol5afe8c30c'  id='choice_7_5_24_3'    aria-labelledby='likert_row_22_7_5 likert_col_3_7_5'\/><\/td><td data-label='Moderate, more than half the days' class='gsurvey-likert-choice'><input name='input_5.24' type='radio' value='glikertrowd40e5a60:glikertcol5caef96a4'  id='choice_7_5_24_4'    aria-labelledby='likert_row_22_7_5 likert_col_4_7_5'\/><\/td><td data-label='Severe, nearly every day' class='gsurvey-likert-choice'><input name='input_5.24' type='radio' value='glikertrowd40e5a60:glikertcol581c8ec79'  id='choice_7_5_24_5'    aria-labelledby='likert_row_22_7_5 likert_col_5_7_5'\/><\/td><\/tr><tr><td id='likert_row_23_7_5' data-label='' class='gsurvey-likert-row-label'>Using any of the following medicines ON YOUR OWN, that is, without a doctor\u2019s prescription, in greater amounts or longer than prescribed [e.g., painkillers (like Vicodin), stimulants (like Ritalin or Adderall), sedatives or tranquilizers (like sleeping pills or Valium), or drugs like marijuana, cocaine or crack, club drugs (like ecstasy), hallucinogens (like LSD), heroin, inhalants or solvents (like glue), or methamphetamine (like speed)]?<\/td><td data-label='Not at all' class='gsurvey-likert-choice'><input name='input_5.25' type='radio' value='glikertrowad2a92e4:glikertcol5c9346de1'  id='choice_7_5_25_1'    aria-labelledby='likert_row_23_7_5 likert_col_1_7_5'\/><\/td><td data-label='Slight, less than a day or two' class='gsurvey-likert-choice'><input name='input_5.25' type='radio' value='glikertrowad2a92e4:glikertcol560f07384'  id='choice_7_5_25_2'    aria-labelledby='likert_row_23_7_5 likert_col_2_7_5'\/><\/td><td data-label='Mild, several days' class='gsurvey-likert-choice'><input name='input_5.25' type='radio' value='glikertrowad2a92e4:glikertcol5afe8c30c'  id='choice_7_5_25_3'    aria-labelledby='likert_row_23_7_5 likert_col_3_7_5'\/><\/td><td data-label='Moderate, more than half the days' class='gsurvey-likert-choice'><input name='input_5.25' type='radio' value='glikertrowad2a92e4:glikertcol5caef96a4'  id='choice_7_5_25_4'    aria-labelledby='likert_row_23_7_5 likert_col_4_7_5'\/><\/td><td data-label='Severe, nearly every day' class='gsurvey-likert-choice'><input name='input_5.25' type='radio' value='glikertrowad2a92e4:glikertcol581c8ec79'  id='choice_7_5_25_5'    aria-labelledby='likert_row_23_7_5 likert_col_5_7_5'\/><\/td><\/tr><\/tbody><\/table><\/div><\/div><\/div><\/div>\n        <div class='gform-page-footer gform_page_footer top_label'><input type='submit' id='gform_previous_button_7' class='gform_previous_button gform-theme-button gform-theme-button--secondary button' onclick='gform.submission.handleButtonClick(this);' data-submission-type='previous' value='Previous'  \/> <input type='submit' id='gform_submit_button_7' class='gform_button button' 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