{"id":1530,"date":"2023-09-06T23:37:33","date_gmt":"2023-09-06T23:37:33","guid":{"rendered":"https:\/\/ct-prod-wp.taftcollege.edu\/forms\/?page_id=1530"},"modified":"2023-09-06T23:44:01","modified_gmt":"2023-09-06T23:44:01","slug":"confidential-counseling-self-referral-form","status":"publish","type":"page","link":"https:\/\/ct-prod-wp.taftcollege.edu\/forms\/admissions\/confidential-counseling-self-referral-form\/","title":{"rendered":"Confidential Counseling Self-Referral Form"},"content":{"rendered":"<div class=\"wpb-content-wrapper\" id=\"wpb-content-root\"><p>[vc_row][vc_column]<div id=\"ultimate-heading-1576aa67ce41a108\" class=\"uvc-heading ult-adjust-bottom-margin ultimate-heading-1576aa67ce41a108 uvc-8895 \" data-hspacer=\"no_spacer\"  data-halign=\"left\" style=\"text-align:left\"><div class=\"uvc-heading-spacer no_spacer\" style=\"top\"><\/div><div class=\"uvc-main-heading ult-responsive\"  data-ultimate-target='.uvc-heading.ultimate-heading-1576aa67ce41a108 h1'  data-responsive-json-new='{\"font-size\":\"\",\"line-height\":\"\"}' ><h1 style=\"font-weight:normal;\">Confidential Counseling Self-Referral Form<\/h1><\/div><div class=\"uvc-sub-heading ult-responsive\"  data-ultimate-target='.uvc-heading.ultimate-heading-1576aa67ce41a108 .uvc-sub-heading '  data-responsive-json-new='{\"font-size\":\"\",\"line-height\":\"\"}'  style=\"font-weight:normal;\">Refer yourself for counseling services at Taft College by completing the form below.<\/div><\/div><script>\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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var(--gf-field-img-choice-check-ind-icon-size-md);--gf-field-pg-steps-number-color: rgba(17, 35, 55, 0.8);}<\/style>\n                        <div class='gform_heading'>\n\t\t\t\t\t\t\t<p class='gform_required_legend'>&quot;<span class=\"gfield_required gfield_required_asterisk\">*<\/span>&quot; indicates required fields<\/p>\n                        <\/div><form method='post' enctype='multipart\/form-data'  id='gform_58'  action='\/forms\/wp-json\/wp\/v2\/pages\/1530' data-formid='58' novalidate>\n                        <div class='gform-body gform_body'><div id='gform_fields_58' class='gform_fields top_label form_sublabel_below description_below validation_below'><div id=\"field_58_26\" 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\">Student Information<\/h3><\/div><fieldset id=\"field_58_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' ><span class='gform-field-label__text'>Name<\/span><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 has_suffix gf_name_has_3 ginput_container_name gform-grid-row' id='input_58_1'>\n                            \n                            <span id='input_58_1_3_container' class='name_first gform-grid-col gform-grid-col--size-auto' >\n                                                    <input type='text' name='input_1.3' id='input_58_1_3' value=''   aria-required='true'     \/>\n                                                    <label for='input_58_1_3' class='gform-field-label gform-field-label--type-sub '>First<\/label>\n                                                <\/span>\n                            \n                            <span id='input_58_1_6_container' class='name_last gform-grid-col gform-grid-col--size-auto' >\n                                                    <input type='text' name='input_1.6' id='input_58_1_6' value=''   aria-required='true'     \/>\n                                                    <label for='input_58_1_6' class='gform-field-label gform-field-label--type-sub '>Last<\/label>\n                                                <\/span>\n                            <span id='input_58_1_8_container' class='name_suffix  gform-grid-col gform-grid-col--size-auto' >\n                                                    <input type='text' name='input_1.8' id='input_58_1_8' value=''   aria-required='false'     \/>\n                                                    <label for='input_58_1_8' class='gform-field-label gform-field-label--type-sub '>Student ID<\/label>\n                                                <\/span>\n                        <\/div><\/fieldset><div id=\"field_58_6\" class=\"gfield gfield--type-email 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_58_6'><span class='gform-field-label__text'>Email<\/span><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_6' id='input_58_6' type='email' value='' class='medium'    aria-required=\"true\" aria-invalid=\"false\"  \/>\n                        <\/div><\/div><div id=\"field_58_29\" class=\"gfield gfield--type-phone gfield--phone-format-standard gfield--width-full gfield_contains_required field_sublabel_below gfield--has-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_58_29'><span class='gform-field-label__text'>Phone<\/span><span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_phone'><input name='input_29' id='input_58_29' type='tel' value='' class='large'  placeholder='(999) 999-9999' aria-required=\"true\" aria-invalid=\"false\" aria-describedby=\"gfield_description_58_29\"  data-mask=\"(999) 999-9999\" \/><\/div><div class='gfield_description' id='gfield_description_58_29'>Please tell us how to contact you.<\/div><\/div><fieldset id=\"field_58_7\" class=\"gfield gfield--type-checkbox gfield--type-choice gf_list_3col field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible gfield--choice-align-vertical\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' ><span class='gform-field-label__text'>Check box(es) where messages may be left:<\/span><\/legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox ' id='input_58_7'><div class='gchoice gchoice_58_7_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_7.1' type='checkbox'  value='Home'  id='choice_58_7_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_58_7_1' id='label_58_7_1' class='gform-field-label gform-field-label--type-inline'>Home<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_58_7_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_7.2' type='checkbox'  value='Cell'  id='choice_58_7_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_58_7_2' id='label_58_7_2' class='gform-field-label gform-field-label--type-inline'>Cell<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_58_7_3'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_7.3' type='checkbox'  value='Email'  id='choice_58_7_3'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_58_7_3' id='label_58_7_3' class='gform-field-label gform-field-label--type-inline'>Email<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_58_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\">Emergency Contact<\/h3><\/div><div id=\"field_58_8\" class=\"gfield gfield--type-text gf_left_half gfield--width-half field_sublabel_below gfield--has-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_58_8'><span class='gform-field-label__text'>Emergency Contact<\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_8' id='input_58_8' type='text' value='' class='medium'  aria-describedby=\"gfield_description_58_8\"    aria-invalid=\"false\"   \/><\/div><div class='gfield_description' id='gfield_description_58_8'>Name of Emergency Contact<\/div><\/div><div id=\"field_58_9\" class=\"gfield gfield--type-text gf_right_half gfield--width-half field_sublabel_below gfield--has-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_58_9'><span class='gform-field-label__text'>Relationship<\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_9' id='input_58_9' type='text' value='' class='medium'  aria-describedby=\"gfield_description_58_9\"    aria-invalid=\"false\"   \/><\/div><div class='gfield_description' id='gfield_description_58_9'>Relationship to Emergency Contact.<\/div><\/div><div id=\"field_58_10\" class=\"gfield gfield--type-phone gfield--phone-format-standard gf_left_half gfield--width-half field_sublabel_below gfield--has-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_58_10'><span class='gform-field-label__text'>Emergency Contact Phone<\/span><\/label><div class='ginput_container ginput_container_phone'><input name='input_10' id='input_58_10' type='tel' value='' class='medium'  placeholder='(999) 999-9999'  aria-invalid=\"false\" aria-describedby=\"gfield_description_58_10\"  data-mask=\"(999) 999-9999\" \/><\/div><div class='gfield_description' id='gfield_description_58_10'>Phone Number of Emergency Contact.<\/div><\/div><fieldset id=\"field_58_11\" class=\"gfield gfield--type-checkbox gfield--type-choice gf_right_half gfield--width-half field_sublabel_below gfield--has-description field_description_below field_validation_below gfield_visibility_visible gfield--choice-align-vertical\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' ><span class='gform-field-label__text'>Check Here to give permission to contact<\/span><\/legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox ' id='input_58_11'><div class='gchoice gchoice_58_11_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_11.1' type='checkbox'  value='I permit contact.'  id='choice_58_11_1'   aria-describedby=\"gfield_description_58_11\"\/>\n\t\t\t\t\t\t\t\t<label for='choice_58_11_1' id='label_58_11_1' class='gform-field-label gform-field-label--type-inline'>I permit contact.<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><div class='gfield_description' id='gfield_description_58_11'>Check this box if you give permission to contact this individual<\/div><\/fieldset><div id=\"field_58_12\" class=\"gfield gfield--type-textarea cucomment field_sublabel_below gfield--has-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_58_12'><span class='gform-field-label__text'>Current Concerns<\/span><\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_12' id='input_58_12' class='textarea medium'  aria-describedby=\"gfield_description_58_12\"    aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><div class='gfield_description' id='gfield_description_58_12'>Please explain your reason for requesting services.<\/div><\/div><fieldset id=\"field_58_13\" class=\"gfield gfield--type-radio gfield--type-choice gf_left_third gfield--width-third field_sublabel_below gfield--has-description field_description_below field_validation_below gfield_visibility_visible gfield--choice-align-vertical\"  ><legend class='gfield_label gform-field-label' ><span class='gform-field-label__text'>Are you thinking of killing yourself?<\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_58_13'>\n\t\t\t<div class='gchoice gchoice_58_13_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_13' type='radio' value='Yes'  id='choice_58_13_0' onchange='gformToggleRadioOther( this )' aria-describedby=\"gfield_description_58_13\"   \/>\n\t\t\t\t\t<label for='choice_58_13_0' id='label_58_13_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_58_13_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_13' type='radio' value='No'  id='choice_58_13_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_58_13_1' id='label_58_13_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/div><div class='gfield_description' id='gfield_description_58_13'>Please choose Yes or No.<\/div><\/fieldset><fieldset id=\"field_58_14\" class=\"gfield gfield--type-radio gfield--type-choice gf_middle_third gfield--width-third field_sublabel_below gfield--has-description field_description_below field_validation_below gfield_visibility_visible gfield--choice-align-vertical\"  ><legend class='gfield_label gform-field-label' ><span class='gform-field-label__text'>Are you thinking of harming or killing another person?<\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_58_14'>\n\t\t\t<div class='gchoice gchoice_58_14_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_14' type='radio' value='Yes'  id='choice_58_14_0' onchange='gformToggleRadioOther( this )' aria-describedby=\"gfield_description_58_14\"   \/>\n\t\t\t\t\t<label for='choice_58_14_0' id='label_58_14_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_58_14_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_14' type='radio' value='No'  id='choice_58_14_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_58_14_1' id='label_58_14_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/div><div class='gfield_description' id='gfield_description_58_14'>Please choose Yes or No.<\/div><\/fieldset><fieldset id=\"field_58_15\" class=\"gfield gfield--type-radio gfield--type-choice gf_right_third gfield--width-third field_sublabel_below gfield--has-description field_description_below field_validation_below gfield_visibility_visible gfield--choice-align-vertical\"  ><legend class='gfield_label gform-field-label' ><span class='gform-field-label__text'>Are you having suicidal thoughts?<\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_58_15'>\n\t\t\t<div class='gchoice gchoice_58_15_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_15' type='radio' value='Yes'  id='choice_58_15_0' onchange='gformToggleRadioOther( this )' aria-describedby=\"gfield_description_58_15\"   \/>\n\t\t\t\t\t<label for='choice_58_15_0' id='label_58_15_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_58_15_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_15' type='radio' value='No'  id='choice_58_15_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_58_15_1' id='label_58_15_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/div><div class='gfield_description' id='gfield_description_58_15'>Please choose Yes or No.<\/div><\/fieldset><fieldset id=\"field_58_16\" class=\"gfield gfield--type-checkbox gfield--type-choice gf_list_5col field_sublabel_below gfield--has-description field_description_below field_validation_below gfield_visibility_visible gfield--choice-align-vertical\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' ><span class='gform-field-label__text'>Please check any Stressful Events That May Apply to You.<\/span><\/legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox ' id='input_58_16'><div class='gchoice gchoice_58_16_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_16.1' type='checkbox'  value='Depression'  id='choice_58_16_1'   aria-describedby=\"gfield_description_58_16\"\/>\n\t\t\t\t\t\t\t\t<label for='choice_58_16_1' id='label_58_16_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_58_16_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_16.2' type='checkbox'  value='Grief and loss'  id='choice_58_16_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_58_16_2' id='label_58_16_2' class='gform-field-label gform-field-label--type-inline'>Grief and loss<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_58_16_3'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_16.3' type='checkbox'  value='Addiction or recovery issues'  id='choice_58_16_3'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_58_16_3' id='label_58_16_3' class='gform-field-label gform-field-label--type-inline'>Addiction or recovery issues<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_58_16_4'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_16.4' type='checkbox'  value='Difficulty adjusting to life changes'  id='choice_58_16_4'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_58_16_4' id='label_58_16_4' class='gform-field-label gform-field-label--type-inline'>Difficulty adjusting to life changes<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_58_16_5'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_16.5' type='checkbox'  value='Parenting issues'  id='choice_58_16_5'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_58_16_5' id='label_58_16_5' class='gform-field-label gform-field-label--type-inline'>Parenting issues<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_58_16_6'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_16.6' type='checkbox'  value='Anxiety'  id='choice_58_16_6'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_58_16_6' id='label_58_16_6' class='gform-field-label gform-field-label--type-inline'>Anxiety<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_58_16_7'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_16.7' type='checkbox'  value='Victim of abuse'  id='choice_58_16_7'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_58_16_7' id='label_58_16_7' class='gform-field-label gform-field-label--type-inline'>Victim of abuse<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_58_16_8'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_16.8' type='checkbox'  value='Relationship issues'  id='choice_58_16_8'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_58_16_8' id='label_58_16_8' class='gform-field-label gform-field-label--type-inline'>Relationship issues<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_58_16_9'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_16.9' type='checkbox'  value='LGBT issues'  id='choice_58_16_9'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_58_16_9' id='label_58_16_9' class='gform-field-label gform-field-label--type-inline'>LGBT issues<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_58_16_11'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_16.11' type='checkbox'  value='Other'  id='choice_58_16_11'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_58_16_11' id='label_58_16_11' class='gform-field-label gform-field-label--type-inline'>Other<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><div class='gfield_description' id='gfield_description_58_16'>Please check all that apply.<\/div><\/fieldset><div id=\"field_58_17\" class=\"gfield gfield--type-textarea cucomment field_sublabel_below gfield--has-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_58_17'><span class='gform-field-label__text'>Other<\/span><\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_17' id='input_58_17' class='textarea medium'  aria-describedby=\"gfield_description_58_17\"    aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><div class='gfield_description' id='gfield_description_58_17'>Please tell us about the Stressful Event.<\/div><\/div><fieldset id=\"field_58_18\" class=\"gfield gfield--type-radio gfield--type-choice gf_list_3col field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible gfield--choice-align-vertical\"  ><legend class='gfield_label gform-field-label' ><span class='gform-field-label__text'>Rate your current level of distress<\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_58_18'>\n\t\t\t<div class='gchoice gchoice_58_18_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_18' type='radio' value='MINAMAL'  id='choice_58_18_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_58_18_0' id='label_58_18_0' class='gform-field-label gform-field-label--type-inline'>MINAMAL<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_58_18_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_18' type='radio' value='MILD'  id='choice_58_18_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_58_18_1' id='label_58_18_1' class='gform-field-label gform-field-label--type-inline'>MILD<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_58_18_2'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_18' type='radio' value='MODERATE SEVERE'  id='choice_58_18_2' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_58_18_2' id='label_58_18_2' class='gform-field-label gform-field-label--type-inline'>MODERATE SEVERE<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_58_19\" class=\"gfield gfield--type-radio gfield--type-choice gf_list_inline field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible gfield--choice-align-vertical\"  ><legend class='gfield_label gform-field-label' ><span class='gform-field-label__text'>Have you ever received mental health counseling before?<\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_58_19'>\n\t\t\t<div class='gchoice gchoice_58_19_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_19' type='radio' value='Yes'  id='choice_58_19_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_58_19_0' id='label_58_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_58_19_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_19' type='radio' value='No'  id='choice_58_19_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_58_19_1' id='label_58_19_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_58_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_58_20'><span class='gform-field-label__text'>If \u201cYes,\u201d please give the name of previous counselor, or agency<\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_20' id='input_58_20' type='text' value='' class='medium'      aria-invalid=\"false\"   \/><\/div><\/div><fieldset id=\"field_58_21\" class=\"gfield gfield--type-radio gfield--type-choice gf_list_inline field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible gfield--choice-align-vertical\"  ><legend class='gfield_label gform-field-label' ><span class='gform-field-label__text'>Do you have a primary care physician (PCP)?<\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_58_21'>\n\t\t\t<div class='gchoice gchoice_58_21_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_21' type='radio' value='Yes'  id='choice_58_21_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_58_21_0' id='label_58_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_58_21_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_21' type='radio' value='No'  id='choice_58_21_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_58_21_1' id='label_58_21_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_58_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_58_22'><span class='gform-field-label__text'>If \u201cYes,\u201d please give the name of your PCP and their clinic<\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_22' id='input_58_22' type='text' value='' class='medium'      aria-invalid=\"false\"   \/><\/div><\/div><fieldset id=\"field_58_23\" class=\"gfield gfield--type-radio gfield--type-choice gf_list_inline field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible gfield--choice-align-vertical\"  ><legend class='gfield_label gform-field-label' ><span class='gform-field-label__text'>Do you have insurance?<\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_58_23'>\n\t\t\t<div class='gchoice gchoice_58_23_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_23' type='radio' value='Yes'  id='choice_58_23_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_58_23_0' id='label_58_23_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_58_23_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_23' type='radio' value='No'  id='choice_58_23_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_58_23_1' id='label_58_23_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_58_24\" 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_58_24'><span class='gform-field-label__text'>If so, what type<\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_24' id='input_58_24' type='text' value='' class='medium'      aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_58_28\" class=\"gfield gfield--type-captcha field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_58_28'><span class='gform-field-label__text'>CAPTCHA<\/span><\/label><div id='input_58_28' class='ginput_container ginput_recaptcha' data-sitekey='6LdnShATAAAAAFLb7O2paFy9ZtLWttHkcZtCLSzc'  data-theme='light' data-tabindex='0'  data-badge=''><\/div><\/div><\/div><\/div>\n        <div class='gform-footer gform_footer top_label'> <button type='submit' id='gform_submit_button_58' class='gform_button button' onclick='gform.submission.handleButtonClick(this);' data-submission-type='submit' >Submit<\/button> \n            <input type='hidden' class='gform_hidden' name='gform_submission_method' data-js='gform_submission_method_58' value='postback' \/>\n            <input type='hidden' class='gform_hidden' name='gform_theme' data-js='gform_theme_58' id='gform_theme_58' value='orbital' \/>\n            <input type='hidden' class='gform_hidden' name='gform_style_settings' data-js='gform_style_settings_58' id='gform_style_settings_58' value='[]' \/>\n            <input type='hidden' class='gform_hidden' name='is_submit_58' value='1' \/>\n            <input type='hidden' class='gform_hidden' name='gform_submit' value='58' \/>\n            \n            <input type='hidden' class='gform_hidden' name='gform_currency' data-currency='USD' value='cNiVqmXMHVYKzskJ4D1uk+qm8YuMkOVpkFTG7k9kyIvzrQ1oEjBzBRItbiLwOljYV971Q9fnJGkhPQwyXdyQEa23wA4qQOOpKyqfGzNP\/jE6ypc=' \/>\n            <input type='hidden' 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id='gform_source_page_number_58' value='1' \/>\n            <input type='hidden' name='gform_field_values' value='' \/>\n            \n        <\/div>\n                        <\/form>\n                        <\/div>[\/vc_column][\/vc_row]<\/p>\n<\/div>","protected":false},"excerpt":{"rendered":"<p>[vc_row][vc_column][\/vc_column][\/vc_row]<\/p>\n","protected":false},"author":1,"featured_media":0,"parent":89,"menu_order":0,"comment_status":"closed","ping_status":"closed","template":"full-width-page.php","meta":{"footnotes":""},"class_list":["post-1530","page","type-page","status-publish","hentry"],"_links":{"self":[{"href":"https:\/\/ct-prod-wp.taftcollege.edu\/forms\/wp-json\/wp\/v2\/pages\/1530","targetHints":{"allow":["GET"]}}],"collection":[{"href":"https:\/\/ct-prod-wp.taftcollege.edu\/forms\/wp-json\/wp\/v2\/pages"}],"about":[{"href":"https:\/\/ct-prod-wp.taftcollege.edu\/forms\/wp-json\/wp\/v2\/types\/page"}],"author":[{"embeddable":true,"href":"https:\/\/ct-prod-wp.taftcollege.edu\/forms\/wp-json\/wp\/v2\/users\/1"}],"replies":[{"embeddable":true,"href":"https:\/\/ct-prod-wp.taftcollege.edu\/forms\/wp-json\/wp\/v2\/comments?post=1530"}],"version-history":[{"count":2,"href":"https:\/\/ct-prod-wp.taftcollege.edu\/forms\/wp-json\/wp\/v2\/pages\/1530\/revisions"}],"predecessor-version":[{"id":1532,"href":"https:\/\/ct-prod-wp.taftcollege.edu\/forms\/wp-json\/wp\/v2\/pages\/1530\/revisions\/1532"}],"up":[{"embeddable":true,"href":"https:\/\/ct-prod-wp.taftcollege.edu\/forms\/wp-json\/wp\/v2\/pages\/89"}],"wp:attachment":[{"href":"https:\/\/ct-prod-wp.taftcollege.edu\/forms\/wp-json\/wp\/v2\/media?parent=1530"}],"curies":[{"name":"wp","href":"https:\/\/api.w.org\/{rel}","templated":true}]}}