{"id":63,"date":"2011-09-28T21:12:24","date_gmt":"2011-09-28T21:12:24","guid":{"rendered":"https:\/\/www.ndutime.org\/beta\/?page_id=63"},"modified":"2011-12-07T20:46:15","modified_gmt":"2011-12-07T20:46:15","slug":"referrals","status":"publish","type":"page","link":"https:\/\/www.ndutime.org\/?page_id=63","title":{"rendered":"Referrals"},"content":{"rendered":"<p><strong>IMPORTANT<\/strong> To submit a referral for Therapeutic Group Homes, please fill out our <a href=\"\/beta\/contact\/group-home-referrals\/\">Therapeutic Group Homes Referral<\/a>. For all other referrals, please use the form below.<\/p>\n<script type=\"text\/javascript\">var gform;gform||(document.addEventListener(\"gform_main_scripts_loaded\",function(){gform.scriptsLoaded=!0}),window.addEventListener(\"DOMContentLoaded\",function(){gform.domLoaded=!0}),gform={domLoaded:!1,scriptsLoaded:!1,initializeOnLoaded:function(o){gform.domLoaded&&gform.scriptsLoaded?o():!gform.domLoaded&&gform.scriptsLoaded?window.addEventListener(\"DOMContentLoaded\",o):document.addEventListener(\"gform_main_scripts_loaded\",o)},hooks:{action:{},filter:{}},addAction:function(o,n,r,t){gform.addHook(\"action\",o,n,r,t)},addFilter:function(o,n,r,t){gform.addHook(\"filter\",o,n,r,t)},doAction:function(o){gform.doHook(\"action\",o,arguments)},applyFilters:function(o){return gform.doHook(\"filter\",o,arguments)},removeAction:function(o,n){gform.removeHook(\"action\",o,n)},removeFilter:function(o,n,r){gform.removeHook(\"filter\",o,n,r)},addHook:function(o,n,r,t,i){null==gform.hooks[o][n]&&(gform.hooks[o][n]=[]);var e=gform.hooks[o][n];null==i&&(i=n+\"_\"+e.length),gform.hooks[o][n].push({tag:i,callable:r,priority:t=null==t?10:t})},doHook:function(n,o,r){var t;if(r=Array.prototype.slice.call(r,1),null!=gform.hooks[n][o]&&((o=gform.hooks[n][o]).sort(function(o,n){return o.priority-n.priority}),o.forEach(function(o){\"function\"!=typeof(t=o.callable)&&(t=window[t]),\"action\"==n?t.apply(null,r):r[0]=t.apply(null,r)})),\"filter\"==n)return r[0]},removeHook:function(o,n,t,i){var r;null!=gform.hooks[o][n]&&(r=(r=gform.hooks[o][n]).filter(function(o,n,r){return!!(null!=i&&i!=o.tag||null!=t&&t!=o.priority)}),gform.hooks[o][n]=r)}});<\/script>\n                <div class='gf_browser_gecko gform_wrapper gform_legacy_markup_wrapper gform-theme--no-framework' data-form-theme='legacy' data-form-index='0' id='gform_wrapper_3' ><form method='post' enctype='multipart\/form-data'  id='gform_3'  action='\/index.php?rest_route=%2Fwp%2Fv2%2Fpages%2F63' data-formid='3' >\n                        <div class='gform-body gform_body'><ul id='gform_fields_3' class='gform_fields top_label form_sublabel_below description_below'><li id=\"field_3_5\"  class=\"gfield gfield--type-section gsection field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_3_5\"><h2 class=\"gsection_title\">Identifying Information<\/h2><\/li><li id=\"field_3_1\"  class=\"gfield gfield--type-name gfield_contains_required field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_3_1\"><label class='gfield_label gform-field-label gfield_label_before_complex'  >Name<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><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_3_1'>\n                            <span id='input_3_1_3_container' class='name_first gform-grid-col' >\n                                                    <input type='text' name='input_1.3' id='input_3_1_3' value=''   aria-required='true'    \/>\n                                                    <label for='input_3_1_3' class='gform-field-label gform-field-label--type-sub '>First<\/label>\n                                               <\/span>\n                            <span id='input_3_1_6_container' class='name_last gform-grid-col' >\n                                                    <input type='text' name='input_1.6' id='input_3_1_6' value=''   aria-required='true'    \/>\n                                                    <label for='input_3_1_6' class='gform-field-label gform-field-label--type-sub '>Last<\/label>\n                                                <\/span>\n                            <div class='gf_clear gf_clear_complex'><\/div>\n                        <\/div><\/li><li id=\"field_3_16\"  class=\"gfield gfield--type-date gfield--input-type- gfield_contains_required field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_3_16\"><label class='gfield_label gform-field-label' for='input_3_16' >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_16' id='input_3_16' type='text' value='' class='datepicker gform-datepicker mdy datepicker_no_icon gdatepicker-no-icon'    aria-describedby=\"input_3_16_date_format\" aria-invalid=\"false\" aria-required=\"true\"\/>\n                            <span id='input_3_16_date_format' class='screen-reader-text'>MM slash DD slash YYYY<\/span>\n                        <\/div>\n                        <input type='hidden' id='gforms_calendar_icon_input_3_16' class='gform_hidden' value='https:\/\/www.ndutime.org\/wp-content\/plugins\/gravityforms\/images\/datepicker\/datepicker.svg'\/><\/li><li id=\"field_3_17\"  class=\"gfield gfield--type-number gfield_contains_required field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_3_17\"><label class='gfield_label gform-field-label' for='input_3_17' >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_17' id='input_3_17' type='text'    value='' class='medium'     aria-required=\"true\" aria-invalid=\"false\"  \/><\/div><\/li><li id=\"field_3_18\"  class=\"gfield gfield--type-text gfield_contains_required field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_3_18\"><label class='gfield_label gform-field-label' for='input_3_18' >Social Security 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_18' id='input_3_18' type='text' value='' class='medium'     aria-required=\"true\" aria-invalid=\"false\"   \/> <\/div><\/li><li id=\"field_3_19\"  class=\"gfield gfield--type-select gfield_contains_required field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_3_19\"><label class='gfield_label gform-field-label' for='input_3_19' >Gender<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_select'><select name='input_19' id='input_3_19' class='medium gfield_select'    aria-required=\"true\" aria-invalid=\"false\" ><option value='Male' >Male<\/option><option value='Female' >Female<\/option><\/select><\/div><\/li><li id=\"field_3_18\"  class=\"gfield gfield--type-text gfield_contains_required field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_3_18\"><label class='gfield_label gform-field-label' for='input_3_18' >Social Security 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_18' id='input_3_18' type='text' value='' class='medium'     aria-required=\"true\" aria-invalid=\"false\"   \/> <\/div><\/li><li id=\"field_3_36\"  class=\"gfield gfield--type-text gfield_contains_required field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_3_36\"><label class='gfield_label gform-field-label' for='input_3_36' >School<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_36' id='input_3_36' type='text' value='' class='medium'     aria-required=\"true\" aria-invalid=\"false\"   \/> <\/div><\/li><li id=\"field_3_23\"  class=\"gfield gfield--type-text gfield_contains_required field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_3_23\"><label class='gfield_label gform-field-label' for='input_3_23' >Grade<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_23' id='input_3_23' type='text' value='' class='medium'     aria-required=\"true\" aria-invalid=\"false\"   \/> <\/div><\/li><li id=\"field_3_21\"  class=\"gfield gfield--type-section gsection field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_3_21\"><h2 class=\"gsection_title\"><\/h2><\/li><li id=\"field_3_20\"  class=\"gfield gfield--type-number gfield_contains_required field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_3_20\"><label class='gfield_label gform-field-label' for='input_3_20' >Insurance Number<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_number'><input name='input_20' id='input_3_20' type='text'    value='' class='medium'     aria-required=\"true\" aria-invalid=\"false\"  \/><\/div><\/li><li id=\"field_3_37\"  class=\"gfield gfield--type-text gfield_contains_required field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_3_37\"><label class='gfield_label gform-field-label' for='input_3_37' >HMO \/ PPO Name<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_37' id='input_3_37' type='text' value='' class='medium'     aria-required=\"true\" aria-invalid=\"false\"   \/> <\/div><\/li><li id=\"field_3_21\"  class=\"gfield gfield--type-section gsection field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_3_21\"><h2 class=\"gsection_title\"><\/h2><\/li><li id=\"field_3_22\"  class=\"gfield gfield--type-name gfield_contains_required field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_3_22\"><label class='gfield_label gform-field-label gfield_label_before_complex'  >Parent \/ Guardian<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><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_3_22'>\n                            <span id='input_3_22_3_container' class='name_first gform-grid-col' >\n                                                    <input type='text' name='input_22.3' id='input_3_22_3' value=''   aria-required='true'    \/>\n                                                    <label for='input_3_22_3' class='gform-field-label gform-field-label--type-sub '>First<\/label>\n                                               <\/span>\n                            <span id='input_3_22_6_container' class='name_last gform-grid-col' >\n                                                    <input type='text' name='input_22.6' id='input_3_22_6' value=''   aria-required='true'    \/>\n                                                    <label for='input_3_22_6' class='gform-field-label gform-field-label--type-sub '>Last<\/label>\n                                                <\/span>\n                            <div class='gf_clear gf_clear_complex'><\/div>\n                        <\/div><\/li><li id=\"field_3_9\"  class=\"gfield gfield--type-address gfield_contains_required field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_3_9\"><label class='gfield_label gform-field-label gfield_label_before_complex'  >Address<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label>    \n                    <div class='ginput_complex ginput_container has_street has_street2 has_city has_state has_zip has_country ginput_container_address gform-grid-row' id='input_3_9' >\n                         <span class='ginput_full address_line_1 ginput_address_line_1 gform-grid-col' id='input_3_9_1_container' >\n                                        <input type='text' name='input_9.1' id='input_3_9_1' value=''    aria-required='true'    \/>\n                                        <label for='input_3_9_1' id='input_3_9_1_label' class='gform-field-label gform-field-label--type-sub '>Street Address<\/label>\n                                    <\/span><span class='ginput_left address_city ginput_address_city gform-grid-col' id='input_3_9_3_container' >\n                                    <input type='text' name='input_9.3' id='input_3_9_3' value=''    aria-required='true'    \/>\n                                    <label for='input_3_9_3' id='input_3_9_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_3_9_4_container' >\n                                        <select name='input_9.4' id='input_3_9_4'     aria-required='true'    ><option value='' selected='selected'><\/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' >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_3_9_4' id='input_3_9_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_3_9_5_container' >\n                                    <input type='text' name='input_9.5' id='input_3_9_5' value=''    aria-required='true'    \/>\n                                    <label for='input_3_9_5' id='input_3_9_5_label' class='gform-field-label gform-field-label--type-sub '>ZIP Code<\/label>\n                                <\/span><input type='hidden' class='gform_hidden' name='input_9.6' id='input_3_9_6' value='United States' \/>\n                    <div class='gf_clear gf_clear_complex'><\/div>\n                <\/div><\/li><li id=\"field_3_3\"  class=\"gfield gfield--type-phone gfield_contains_required field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_3_3\"><label class='gfield_label gform-field-label' for='input_3_3' >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_3' id='input_3_3' type='text' value='' class='medium'   aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_3_4\"  class=\"gfield gfield--type-email gfield_contains_required field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_3_4\"><label class='gfield_label gform-field-label' for='input_3_4' >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_4' id='input_3_4' type='text' value='' class='medium'    aria-required=\"true\" aria-invalid=\"false\"  \/>\n                        <\/div><\/li><li id=\"field_3_10\"  class=\"gfield gfield--type-section gsection field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_3_10\"><h2 class=\"gsection_title\">Referral Information<\/h2><\/li><li id=\"field_3_24\"  class=\"gfield gfield--type-select gfield_contains_required field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_3_24\"><label class='gfield_label gform-field-label' for='input_3_24' >Therapy or Program Referring To<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_select'><select name='input_24' id='input_3_24' class='medium gfield_select'    aria-required=\"true\" aria-invalid=\"false\" ><option value='Individual Therapy' >Individual Therapy<\/option><option value='Couples Therapy' >Couples Therapy<\/option><option value='Family Therapy' >Family Therapy<\/option><option value='Group Therapy' >Group Therapy<\/option><option value='Therapeutic Day Treatment' >Therapeutic Day Treatment<\/option><option value='Intensive In-Home Services' >Intensive In-Home Services<\/option><option value='Mental Health Support' >Mental Health Support<\/option><option value='Behavorial Aide' >Behavorial Aide<\/option><option value='Crisis Intervention' >Crisis Intervention<\/option><option value='Crisis Stabilization' >Crisis Stabilization<\/option><option value='Mentoring' >Mentoring<\/option><\/select><\/div><\/li><li id=\"field_3_25\"  class=\"gfield gfield--type-text field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_3_25\"><label class='gfield_label gform-field-label' for='input_3_25' >How did you hear about our office (or from whom)?<\/label><div class='ginput_container ginput_container_text'><input name='input_25' id='input_3_25' type='text' value='' class='medium'      aria-invalid=\"false\"   \/> <\/div><\/li><li id=\"field_3_26\"  class=\"gfield gfield--type-section gsection field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_3_26\"><h2 class=\"gsection_title\"><\/h2><\/li><li id=\"field_3_11\"  class=\"gfield gfield--type-name gfield_contains_required field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_3_11\"><label class='gfield_label gform-field-label gfield_label_before_complex'  >Person Making Referral<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><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_3_11'>\n                            <span id='input_3_11_3_container' class='name_first gform-grid-col' >\n                                                    <input type='text' name='input_11.3' id='input_3_11_3' value=''   aria-required='true'    \/>\n                                                    <label for='input_3_11_3' class='gform-field-label gform-field-label--type-sub '>First<\/label>\n                                               <\/span>\n                            <span id='input_3_11_6_container' class='name_last gform-grid-col' >\n                                                    <input type='text' name='input_11.6' id='input_3_11_6' value=''   aria-required='true'    \/>\n                                                    <label for='input_3_11_6' class='gform-field-label gform-field-label--type-sub '>Last<\/label>\n                                                <\/span>\n                            <div class='gf_clear gf_clear_complex'><\/div>\n                        <\/div><\/li><li id=\"field_3_27\"  class=\"gfield gfield--type-text gfield_contains_required field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_3_27\"><label class='gfield_label gform-field-label' for='input_3_27' >Agency<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_27' id='input_3_27' type='text' value='' class='medium'     aria-required=\"true\" aria-invalid=\"false\"   \/> <\/div><\/li><li id=\"field_3_28\"  class=\"gfield gfield--type-address gfield_contains_required field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_3_28\"><label class='gfield_label gform-field-label gfield_label_before_complex'  >Address<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label>    \n                    <div class='ginput_complex ginput_container has_street has_street2 has_city has_state has_zip has_country ginput_container_address gform-grid-row' id='input_3_28' >\n                         <span class='ginput_full address_line_1 ginput_address_line_1 gform-grid-col' id='input_3_28_1_container' >\n                                        <input type='text' name='input_28.1' id='input_3_28_1' value=''    aria-required='true'    \/>\n                                        <label for='input_3_28_1' id='input_3_28_1_label' class='gform-field-label gform-field-label--type-sub '>Street Address<\/label>\n                                    <\/span><span class='ginput_left address_city ginput_address_city gform-grid-col' id='input_3_28_3_container' >\n                                    <input type='text' name='input_28.3' id='input_3_28_3' value=''    aria-required='true'    \/>\n                                    <label for='input_3_28_3' id='input_3_28_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_3_28_4_container' >\n                                        <select name='input_28.4' id='input_3_28_4'     aria-required='true'    ><option value='' selected='selected'><\/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' >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_3_28_4' id='input_3_28_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_3_28_5_container' >\n                                    <input type='text' name='input_28.5' id='input_3_28_5' value=''    aria-required='true'    \/>\n                                    <label for='input_3_28_5' id='input_3_28_5_label' class='gform-field-label gform-field-label--type-sub '>ZIP Code<\/label>\n                                <\/span><input type='hidden' class='gform_hidden' name='input_28.6' id='input_3_28_6' value='United States' \/>\n                    <div class='gf_clear gf_clear_complex'><\/div>\n                <\/div><\/li><li id=\"field_3_15\"  class=\"gfield gfield--type-phone gfield_contains_required field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_3_15\"><label class='gfield_label gform-field-label' for='input_3_15' >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_15' id='input_3_15' type='text' value='' class='medium'   aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_3_14\"  class=\"gfield gfield--type-email field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_3_14\"><label class='gfield_label gform-field-label' for='input_3_14' >Email<\/label><div class='ginput_container ginput_container_email'>\n                            <input name='input_14' id='input_3_14' type='text' value='' class='medium'     aria-invalid=\"false\"  \/>\n                        <\/div><\/li><li id=\"field_3_29\"  class=\"gfield gfield--type-text field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_3_29\"><label class='gfield_label gform-field-label' for='input_3_29' >Referral Source Relationship to Client<\/label><div class='ginput_container ginput_container_text'><input name='input_29' id='input_3_29' type='text' value='' class='medium'      aria-invalid=\"false\"   \/> <\/div><\/li><li id=\"field_3_6\"  class=\"gfield gfield--type-section gsection field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_3_6\"><h2 class=\"gsection_title\">Feedback<\/h2><\/li><li id=\"field_3_30\"  class=\"gfield gfield--type-checkbox gfield--type-choice field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_3_30\"><label class='gfield_label gform-field-label gfield_label_before_complex'  >Current \/ Presenting Problems<\/label><div class='ginput_container ginput_container_checkbox'><ul class='gfield_checkbox' id='input_3_30'><li class='gchoice gchoice_3_30_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_30.1' type='checkbox'  value='Unhappy'  id='choice_3_30_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_3_30_1' id='label_3_30_1' class='gform-field-label gform-field-label--type-inline'>Unhappy<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_3_30_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_30.2' type='checkbox'  value='Irritable'  id='choice_3_30_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_3_30_2' id='label_3_30_2' class='gform-field-label gform-field-label--type-inline'>Irritable<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_3_30_3'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_30.3' type='checkbox'  value='Easily Agitated'  id='choice_3_30_3'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_3_30_3' id='label_3_30_3' class='gform-field-label gform-field-label--type-inline'>Easily Agitated<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_3_30_4'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_30.4' type='checkbox'  value='Easily Distracted'  id='choice_3_30_4'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_3_30_4' id='label_3_30_4' class='gform-field-label gform-field-label--type-inline'>Easily Distracted<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_3_30_5'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_30.5' type='checkbox'  value='Shyness'  id='choice_3_30_5'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_3_30_5' id='label_3_30_5' class='gform-field-label gform-field-label--type-inline'>Shyness<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_3_30_6'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_30.6' type='checkbox'  value='Stubborn'  id='choice_3_30_6'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_3_30_6' id='label_3_30_6' class='gform-field-label gform-field-label--type-inline'>Stubborn<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_3_30_7'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_30.7' type='checkbox'  value='Disobedient'  id='choice_3_30_7'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_3_30_7' id='label_3_30_7' class='gform-field-label gform-field-label--type-inline'>Disobedient<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_3_30_8'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_30.8' type='checkbox'  value='Aggression'  id='choice_3_30_8'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_3_30_8' id='label_3_30_8' class='gform-field-label gform-field-label--type-inline'>Aggression<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_3_30_9'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_30.9' type='checkbox'  value='Daydreams'  id='choice_3_30_9'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_3_30_9' id='label_3_30_9' class='gform-field-label gform-field-label--type-inline'>Daydreams<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_3_30_11'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_30.11' type='checkbox'  value='Nightmares'  id='choice_3_30_11'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_3_30_11' id='label_3_30_11' class='gform-field-label gform-field-label--type-inline'>Nightmares<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_3_30_12'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_30.12' type='checkbox'  value='Panic Attacks'  id='choice_3_30_12'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_3_30_12' id='label_3_30_12' class='gform-field-label gform-field-label--type-inline'>Panic Attacks<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_3_30_13'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_30.13' type='checkbox'  value='Separation \/ Divorce'  id='choice_3_30_13'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_3_30_13' id='label_3_30_13' class='gform-field-label gform-field-label--type-inline'>Separation \/ Divorce<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_3_30_14'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_30.14' type='checkbox'  value='Low Self-Esteem'  id='choice_3_30_14'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_3_30_14' id='label_3_30_14' class='gform-field-label gform-field-label--type-inline'>Low Self-Esteem<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_3_30_15'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_30.15' type='checkbox'  value='Depression'  id='choice_3_30_15'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_3_30_15' id='label_3_30_15' class='gform-field-label gform-field-label--type-inline'>Depression<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_3_30_16'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_30.16' type='checkbox'  value='Withdrawn'  id='choice_3_30_16'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_3_30_16' id='label_3_30_16' class='gform-field-label gform-field-label--type-inline'>Withdrawn<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_3_30_17'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_30.17' type='checkbox'  value='Thoughts of Suicide'  id='choice_3_30_17'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_3_30_17' id='label_3_30_17' class='gform-field-label gform-field-label--type-inline'>Thoughts of Suicide<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_3_30_18'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_30.18' type='checkbox'  value='Short Attention Span'  id='choice_3_30_18'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_3_30_18' id='label_3_30_18' class='gform-field-label gform-field-label--type-inline'>Short Attention Span<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_3_30_19'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_30.19' type='checkbox'  value='Destructive'  id='choice_3_30_19'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_3_30_19' id='label_3_30_19' class='gform-field-label gform-field-label--type-inline'>Destructive<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_3_30_21'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_30.21' type='checkbox'  value='School Suspensions'  id='choice_3_30_21'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_3_30_21' id='label_3_30_21' class='gform-field-label gform-field-label--type-inline'>School Suspensions<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_3_30_22'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_30.22' type='checkbox'  value='Defies Rules'  id='choice_3_30_22'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_3_30_22' id='label_3_30_22' class='gform-field-label gform-field-label--type-inline'>Defies Rules<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_3_30_23'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_30.23' type='checkbox'  value='Lacks Initiative'  id='choice_3_30_23'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_3_30_23' id='label_3_30_23' class='gform-field-label gform-field-label--type-inline'>Lacks Initiative<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_3_30_24'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_30.24' type='checkbox'  value='Fears \/ Anxiety \/ Phobias'  id='choice_3_30_24'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_3_30_24' id='label_3_30_24' class='gform-field-label gform-field-label--type-inline'>Fears \/ Anxiety \/ Phobias<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_3_30_25'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_30.25' type='checkbox'  value='Social Problems'  id='choice_3_30_25'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_3_30_25' id='label_3_30_25' class='gform-field-label gform-field-label--type-inline'>Social Problems<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_3_30_26'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_30.26' type='checkbox'  value='Death In Family'  id='choice_3_30_26'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_3_30_26' id='label_3_30_26' class='gform-field-label gform-field-label--type-inline'>Death In Family<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_3_30_27'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_30.27' type='checkbox'  value='Sleeping Problems'  id='choice_3_30_27'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_3_30_27' id='label_3_30_27' class='gform-field-label gform-field-label--type-inline'>Sleeping Problems<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_3_30_28'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_30.28' type='checkbox'  value='Sexual Abuse Issues'  id='choice_3_30_28'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_3_30_28' id='label_3_30_28' class='gform-field-label gform-field-label--type-inline'>Sexual Abuse Issues<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_3_30_29'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_30.29' type='checkbox'  value='Physical Abuse Issues'  id='choice_3_30_29'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_3_30_29' id='label_3_30_29' class='gform-field-label gform-field-label--type-inline'>Physical Abuse Issues<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_3_30_31'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_30.31' type='checkbox'  value='Stealing \/ Lying'  id='choice_3_30_31'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_3_30_31' id='label_3_30_31' class='gform-field-label gform-field-label--type-inline'>Stealing \/ Lying<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_3_30_32'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_30.32' type='checkbox'  value='Peer Conflict'  id='choice_3_30_32'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_3_30_32' id='label_3_30_32' class='gform-field-label gform-field-label--type-inline'>Peer Conflict<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_3_30_33'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_30.33' type='checkbox'  value='Fire Setting'  id='choice_3_30_33'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_3_30_33' id='label_3_30_33' class='gform-field-label gform-field-label--type-inline'>Fire Setting<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_3_30_34'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_30.34' type='checkbox'  value='Eating Problems'  id='choice_3_30_34'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_3_30_34' id='label_3_30_34' class='gform-field-label gform-field-label--type-inline'>Eating Problems<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_3_30_35'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_30.35' type='checkbox'  value='Blames Others'  id='choice_3_30_35'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_3_30_35' id='label_3_30_35' class='gform-field-label gform-field-label--type-inline'>Blames Others<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_3_30_36'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_30.36' type='checkbox'  value='Excess Worries \/ Nervousness'  id='choice_3_30_36'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_3_30_36' id='label_3_30_36' class='gform-field-label gform-field-label--type-inline'>Excess Worries \/ Nervousness<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_3_30_37'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_30.37' type='checkbox'  value='Work \/ Career Problems'  id='choice_3_30_37'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_3_30_37' id='label_3_30_37' class='gform-field-label gform-field-label--type-inline'>Work \/ Career Problems<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_3_30_38'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_30.38' type='checkbox'  value='Memory Problems'  id='choice_3_30_38'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_3_30_38' id='label_3_30_38' class='gform-field-label gform-field-label--type-inline'>Memory Problems<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_3_30_39'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_30.39' type='checkbox'  value='Anger Outbursts'  id='choice_3_30_39'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_3_30_39' id='label_3_30_39' class='gform-field-label gform-field-label--type-inline'>Anger Outbursts<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_3_30_41'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_30.41' type='checkbox'  value='Head Banging'  id='choice_3_30_41'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_3_30_41' id='label_3_30_41' class='gform-field-label gform-field-label--type-inline'>Head Banging<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_3_30_42'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_30.42' type='checkbox'  value='Excessive Rocking'  id='choice_3_30_42'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_3_30_42' id='label_3_30_42' class='gform-field-label gform-field-label--type-inline'>Excessive Rocking<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_3_30_43'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_30.43' type='checkbox'  value='Impulsive'  id='choice_3_30_43'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_3_30_43' id='label_3_30_43' class='gform-field-label gform-field-label--type-inline'>Impulsive<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_3_30_44'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_30.44' type='checkbox'  value='Trouble With Law'  id='choice_3_30_44'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_3_30_44' id='label_3_30_44' class='gform-field-label gform-field-label--type-inline'>Trouble With Law<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_3_30_45'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_30.45' type='checkbox'  value='Alcohol \/ Drug Abuse'  id='choice_3_30_45'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_3_30_45' id='label_3_30_45' class='gform-field-label gform-field-label--type-inline'>Alcohol \/ Drug Abuse<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_3_30_46'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_30.46' type='checkbox'  value='Runaway'  id='choice_3_30_46'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_3_30_46' id='label_3_30_46' class='gform-field-label gform-field-label--type-inline'>Runaway<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_3_30_47'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_30.47' type='checkbox'  value='Self-Mutilation'  id='choice_3_30_47'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_3_30_47' id='label_3_30_47' class='gform-field-label gform-field-label--type-inline'>Self-Mutilation<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_3_30_48'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_30.48' type='checkbox'  value='Academic Issues'  id='choice_3_30_48'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_3_30_48' id='label_3_30_48' class='gform-field-label gform-field-label--type-inline'>Academic Issues<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_3_30_49'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_30.49' type='checkbox'  value='Marital Problems'  id='choice_3_30_49'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_3_30_49' id='label_3_30_49' class='gform-field-label gform-field-label--type-inline'>Marital Problems<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_3_30_51'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_30.51' type='checkbox'  value='Low Motivation'  id='choice_3_30_51'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_3_30_51' id='label_3_30_51' class='gform-field-label gform-field-label--type-inline'>Low Motivation<\/label>\n\t\t\t\t\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_3_31\"  class=\"gfield gfield--type-select gfield_contains_required field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_3_31\"><label class='gfield_label gform-field-label' for='input_3_31' >Has client received counseling, psychological or psychiatric treatment in the past?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_select'><select name='input_31' id='input_3_31' class='medium gfield_select'    aria-required=\"true\" aria-invalid=\"false\" ><option value='Yes' >Yes<\/option><option value='No' >No<\/option><\/select><\/div><\/li><li id=\"field_3_32\"  class=\"gfield gfield--type-name field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_3_32\"><label class='gfield_label gform-field-label gfield_label_before_complex'  >Professional Name<\/label><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_3_32'>\n                            <span id='input_3_32_3_container' class='name_first gform-grid-col' >\n                                                    <input type='text' name='input_32.3' id='input_3_32_3' value=''   aria-required='false'    \/>\n                                                    <label for='input_3_32_3' class='gform-field-label gform-field-label--type-sub '>First<\/label>\n                                      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 <\/div>\n                        <p style=\"display: none !important;\"><label>&#916;<textarea name=\"ak_hp_textarea\" cols=\"45\" rows=\"8\" maxlength=\"100\"><\/textarea><\/label><input type=\"hidden\" id=\"ak_js_1\" name=\"ak_js\" value=\"40\"\/><script>document.getElementById( \"ak_js_1\" ).setAttribute( \"value\", ( new Date() ).getTime() );<\/script><\/p><\/form>\n                        <\/div><script type=\"text\/javascript\">\n\/* <![CDATA[ *\/\n gform.initializeOnLoaded( function() {gformInitSpinner( 3, 'https:\/\/www.ndutime.org\/wp-content\/plugins\/gravityforms\/images\/spinner.svg', true );jQuery('#gform_ajax_frame_3').on('load',function(){var contents = jQuery(this).contents().find('*').html();var is_postback = contents.indexOf('GF_AJAX_POSTBACK') >= 0;if(!is_postback){return;}var form_content = jQuery(this).contents().find('#gform_wrapper_3');var is_confirmation = jQuery(this).contents().find('#gform_confirmation_wrapper_3').length > 0;var is_redirect = 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