{"id":431,"date":"2024-06-21T11:26:37","date_gmt":"2024-06-21T11:26:37","guid":{"rendered":"https:\/\/demolinks2.com\/baffour-agyeman\/?page_id=431"},"modified":"2024-06-21T11:28:51","modified_gmt":"2024-06-21T11:28:51","slug":"substance-abuse-intake-form","status":"publish","type":"page","link":"https:\/\/demolinks2.com\/baffour-agyeman\/substance-abuse-intake-form\/","title":{"rendered":"Substance Abuse Intake Form"},"content":{"rendered":"<div class=\"wpb-content-wrapper\"><p>[vc_row][vc_column]\t\t<div id=\"wd-6675637b02abb\" class=\"wd-image wd-wpb wd-rs-6675637b02abb text-center  refrl-frm-img\">\n\t\t\t\n\t\t\t<img loading=\"lazy\" decoding=\"async\" width=\"1239\" height=\"938\" src=\"https:\/\/demolinks2.com\/baffour-agyeman\/wp-content\/uploads\/2024\/04\/WDD-US-21032024-56483221334-Resilience-Psychiatry-01.png\" class=\"attachment-full size-full\" alt=\"\" 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d=gform.hooks[o][r];null==n&&(n=r+\"_\"+d.length),gform.hooks[o][r].push({tag:n,callable:e,priority:t=null==t?10:t})},doHook:function(r,o,e){var t;if(e=Array.prototype.slice.call(e,1),null!=gform.hooks[r][o]&&((o=gform.hooks[r][o]).sort(function(o,r){return o.priority-r.priority}),o.forEach(function(o){\"function\"!=typeof(t=o.callable)&&(t=window[t]),\"action\"==r?t.apply(null,e):e[0]=t.apply(null,e)})),\"filter\"==r)return e[0]},removeHook:function(o,r,t,n){var e;null!=gform.hooks[o][r]&&(e=(e=gform.hooks[o][r]).filter(function(o,r,e){return!!(null!=n&&n!=o.tag||null!=t&&t!=o.priority)}),gform.hooks[o][r]=e)}});\n\/* ]]> *\/\n<\/script>\n\n                <div class='gf_browser_gecko gform_wrapper gravity-theme gform-theme--no-framework' data-form-theme='gravity-theme' data-form-index='0' id='gform_wrapper_9' ><div id='gf_9' class='gform_anchor' tabindex='-1'><\/div><form method='post' enctype='multipart\/form-data' target='gform_ajax_frame_9' id='gform_9'  action='\/baffour-agyeman\/wp-json\/wp\/v2\/pages\/431#gf_9' data-formid='9' novalidate>\n                        <div class='gform-body gform_body'><div id='gform_fields_9' class='gform_fields top_label form_sublabel_below description_below validation_below'><div id=\"field_9_1\" class=\"gfield gfield--type-html gfield--input-type-html gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><h2>Substance Abuse Intake Form<\/h2><\/div><fieldset id=\"field_9_5\" 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' >Do you have any history of treatment from mental health professionals due to emotional or behavior problems?<\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_9_5'>\n\t\t\t<div class='gchoice gchoice_9_5_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_5' type='radio' value='Yes'  id='choice_9_5_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_9_5_0' id='label_9_5_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_9_5_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_5' type='radio' value='No'  id='choice_9_5_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_9_5_1' id='label_9_5_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_9_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' >If yes, are you currently seeing a mental health professional?<\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_9_4'>\n\t\t\t<div class='gchoice gchoice_9_4_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_4' type='radio' value='Yes'  id='choice_9_4_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_9_4_0' id='label_9_4_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_9_4_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_4' type='radio' value='No'  id='choice_9_4_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_9_4_1' id='label_9_4_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_9_6\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-half Witness field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_9_6'>If yes, how many years total have you received mental health services?<\/label><div class='ginput_container ginput_container_text'><input name='input_6' id='input_9_6' type='text' value='' class='large'    placeholder='Years:'  aria-invalid=\"false\"   \/><\/div><\/div><fieldset id=\"field_9_7\" 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' >Have you ever been hospitalized for mental health reasons?<\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_9_7'>\n\t\t\t<div class='gchoice gchoice_9_7_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_7' type='radio' value='Yes'  id='choice_9_7_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_9_7_0' id='label_9_7_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_9_7_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_7' type='radio' value='No'  id='choice_9_7_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_9_7_1' id='label_9_7_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_9_8\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-full Witness field_sublabel_below gfield--has-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_9_8'>Treatment history<\/label><div class='ginput_container ginput_container_text'><input name='input_8' id='input_9_8' type='text' value='' class='large'  aria-describedby=\"gfield_description_9_8\"    aria-invalid=\"false\"   \/><\/div><div class='gfield_description' id='gfield_description_9_8'>Month, Year, Agency name \/ Location # days Reason for service (Include DWI classes, detox, CD treatment, psychological\/medical hospitalization in the last 6 months counseling\/illness\/accidents.)<\/div><\/div><fieldset id=\"field_9_9\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield--input-type-checkbox gfield--width-full field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' >In your LIFETIME, which of the following substances have you ever used?<\/legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox ' id='input_9_9'><div class='gchoice gchoice_9_9_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_9.1' type='checkbox'  value='Cocaine (coke, crack, etc.)'  id='choice_9_9_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_9_9_1' id='label_9_9_1' class='gform-field-label gform-field-label--type-inline'>Cocaine (coke, crack, etc.)<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_9_9_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_9.2' type='checkbox'  value='Prescription stimulants (Ritalin, Adderall, etc.)'  id='choice_9_9_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_9_9_2' id='label_9_9_2' class='gform-field-label gform-field-label--type-inline'>Prescription stimulants (Ritalin, Adderall, etc.)<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_9_9_3'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_9.3' type='checkbox'  value='Methamphetamine (speed, crystal, etc.)'  id='choice_9_9_3'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_9_9_3' id='label_9_9_3' class='gform-field-label gform-field-label--type-inline'>Methamphetamine (speed, crystal, etc.)<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_9_9_4'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_9.4' type='checkbox'  value='Inhalants (nitrous oxide, glue, etc.)'  id='choice_9_9_4'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_9_9_4' id='label_9_9_4' class='gform-field-label gform-field-label--type-inline'>Inhalants (nitrous oxide, glue, etc.)<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_9_9_5'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_9.5' type='checkbox'  value='Sedatives (Valium, sleeping pills, etc.)'  id='choice_9_9_5'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_9_9_5' id='label_9_9_5' class='gform-field-label gform-field-label--type-inline'>Sedatives (Valium, sleeping pills, etc.)<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_9_9_6'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_9.6' type='checkbox'  value='Hallucinogens (LSD, acid, etc.)'  id='choice_9_9_6'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_9_9_6' id='label_9_9_6' class='gform-field-label gform-field-label--type-inline'>Hallucinogens (LSD, acid, etc.)<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_9_9_7'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_9.7' type='checkbox'  value='Street opioids (heroin, opium, etc.)'  id='choice_9_9_7'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_9_9_7' id='label_9_9_7' class='gform-field-label gform-field-label--type-inline'>Street opioids (heroin, opium, etc.)<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_9_9_8'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_9.8' type='checkbox'  value='Prescription opioids (oxycodone, etc.)'  id='choice_9_9_8'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_9_9_8' id='label_9_9_8' class='gform-field-label gform-field-label--type-inline'>Prescription opioids (oxycodone, etc.)<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_9_10\" 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\"  ><h2>In the past year, how often have you used the following: <\/h2><\/div><div id=\"field_9_15\" class=\"gfield gfield--type-select gfield--input-type-select gfield--width-half Witness field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_9_15'>Cocaine<\/label><div class='ginput_container ginput_container_select'><select name='input_15' id='input_9_15' class='large gfield_select'     aria-invalid=\"false\" ><option value='Never' >Never<\/option><option value='Once or Twice' >Once or Twice<\/option><option value='Monthly' >Monthly<\/option><option value='Weekly' >Weekly<\/option><option value='Daily or Almost Daily' >Daily or Almost Daily<\/option><\/select><\/div><\/div><div id=\"field_9_18\" class=\"gfield gfield--type-select gfield--input-type-select gfield--width-half Witness field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_9_18'>RX amphetamines<\/label><div class='ginput_container ginput_container_select'><select name='input_18' id='input_9_18' class='large gfield_select'     aria-invalid=\"false\" ><option value='Never' >Never<\/option><option value='Once or Twice' >Once or Twice<\/option><option value='Monthly' >Monthly<\/option><option value='Weekly' >Weekly<\/option><option value='Daily or Almost Daily' >Daily or Almost Daily<\/option><\/select><\/div><\/div><div id=\"field_9_19\" class=\"gfield gfield--type-select gfield--input-type-select gfield--width-half Witness field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_9_19'>Street opioids<\/label><div class='ginput_container ginput_container_select'><select name='input_19' id='input_9_19' class='large gfield_select'     aria-invalid=\"false\" ><option value='Never' >Never<\/option><option value='Once or Twice' >Once or Twice<\/option><option value='Monthly' >Monthly<\/option><option value='Weekly' >Weekly<\/option><option value='Daily or Almost Daily' >Daily or Almost Daily<\/option><\/select><\/div><\/div><div id=\"field_9_20\" class=\"gfield gfield--type-select gfield--input-type-select gfield--width-half Witness field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_9_20'>Methamphetamine<\/label><div class='ginput_container ginput_container_select'><select name='input_20' id='input_9_20' class='large gfield_select'     aria-invalid=\"false\" ><option value='Never' >Never<\/option><option value='Once or Twice' >Once or Twice<\/option><option value='Monthly' >Monthly<\/option><option value='Weekly' >Weekly<\/option><option value='Daily or Almost Daily' >Daily or Almost Daily<\/option><\/select><\/div><\/div><div id=\"field_9_21\" class=\"gfield gfield--type-select gfield--input-type-select gfield--width-half Witness field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_9_21'>Inhalants<\/label><div class='ginput_container ginput_container_select'><select name='input_21' id='input_9_21' class='large gfield_select'     aria-invalid=\"false\" ><option value='Never' >Never<\/option><option value='Once or Twice' >Once or Twice<\/option><option value='Monthly' >Monthly<\/option><option value='Weekly' >Weekly<\/option><option value='Daily or Almost Daily' >Daily or Almost Daily<\/option><\/select><\/div><\/div><div id=\"field_9_22\" class=\"gfield gfield--type-select gfield--input-type-select gfield--width-half Witness field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_9_22'>Sedatives<\/label><div class='ginput_container ginput_container_select'><select name='input_22' id='input_9_22' class='large gfield_select'     aria-invalid=\"false\" ><option value='Never' >Never<\/option><option value='Once or Twice' >Once or Twice<\/option><option value='Monthly' >Monthly<\/option><option value='Weekly' >Weekly<\/option><option value='Daily or Almost Daily' >Daily or Almost Daily<\/option><\/select><\/div><\/div><div id=\"field_9_23\" class=\"gfield gfield--type-select gfield--input-type-select gfield--width-half Witness field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_9_23'>Prescription opioids<\/label><div class='ginput_container ginput_container_select'><select name='input_23' id='input_9_23' class='large gfield_select'     aria-invalid=\"false\" ><option value='Never' >Never<\/option><option value='Once or Twice' >Once or Twice<\/option><option value='Monthly' >Monthly<\/option><option value='Weekly' >Weekly<\/option><option value='Daily or Almost Daily' >Daily or Almost Daily<\/option><\/select><\/div><\/div><div id=\"field_9_24\" class=\"gfield gfield--type-select gfield--input-type-select gfield--width-half Witness field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_9_24'>Hallucinogens<\/label><div class='ginput_container ginput_container_select'><select name='input_24' id='input_9_24' class='large gfield_select'     aria-invalid=\"false\" ><option value='Never' >Never<\/option><option value='Once or Twice' >Once or Twice<\/option><option value='Monthly' >Monthly<\/option><option value='Weekly' >Weekly<\/option><option value='Daily or Almost Daily' >Daily or Almost Daily<\/option><\/select><\/div><\/div><div id=\"field_9_26\" class=\"gfield gfield--type-select gfield--input-type-select gfield--width-half Witness field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_9_26'>Alcohol (For men, 5 or more drinks a day. For women, 4 or more drinks a day)<\/label><div class='ginput_container ginput_container_select'><select name='input_26' id='input_9_26' class='large gfield_select'     aria-invalid=\"false\" ><option value='Never' >Never<\/option><option value='Once or Twice' >Once or Twice<\/option><option value='Monthly' >Monthly<\/option><option value='Weekly' >Weekly<\/option><option value='Daily or Almost Daily' >Daily or Almost Daily<\/option><\/select><\/div><\/div><div id=\"field_9_25\" class=\"gfield gfield--type-select gfield--input-type-select gfield--width-half Witness field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_9_25'>Tobacco products<\/label><div class='ginput_container ginput_container_select'><select name='input_25' id='input_9_25' class='large gfield_select'     aria-invalid=\"false\" ><option value='Never' >Never<\/option><option value='Once or Twice' >Once or Twice<\/option><option value='Monthly' >Monthly<\/option><option value='Weekly' >Weekly<\/option><option value='Daily or Almost Daily' >Daily or Almost Daily<\/option><\/select><\/div><\/div><div id=\"field_9_27\" class=\"gfield gfield--type-textarea gfield--input-type-textarea gfield--width-half Witness field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_9_27'>Drug of choice<\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_27' id='input_9_27' class='textarea small'      aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/div><div id=\"field_9_28\" class=\"gfield gfield--type-textarea gfield--input-type-textarea gfield--width-half Witness field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_9_28'>Date of last use<\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_28' id='input_9_28' class='textarea small'      aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/div><fieldset id=\"field_9_29\" 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' >Have you tried to quit before?<\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_9_29'>\n\t\t\t<div class='gchoice gchoice_9_29_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_29' type='radio' value='Yes'  id='choice_9_29_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_9_29_0' id='label_9_29_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_9_29_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_29' type='radio' value='No'  id='choice_9_29_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_9_29_1' id='label_9_29_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_9_30\" class=\"gfield gfield--type-textarea gfield--input-type-textarea gfield--width-half Witness field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_9_30'>Longest period of abstinence?<\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_30' id='input_9_30' class='textarea small'      aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/div><fieldset id=\"field_9_31\" 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' >How many children do you have?<\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_9_31'>\n\t\t\t<div class='gchoice gchoice_9_31_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_31' type='radio' value='0'  id='choice_9_31_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_9_31_0' id='label_9_31_0' class='gform-field-label gform-field-label--type-inline'>0<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_9_31_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_31' type='radio' value='1'  id='choice_9_31_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_9_31_1' id='label_9_31_1' class='gform-field-label gform-field-label--type-inline'>1<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_9_31_2'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_31' type='radio' value='2'  id='choice_9_31_2' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_9_31_2' id='label_9_31_2' class='gform-field-label gform-field-label--type-inline'>2<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_9_31_3'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_31' type='radio' value='3 or more'  id='choice_9_31_3' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_9_31_3' id='label_9_31_3' class='gform-field-label gform-field-label--type-inline'>3 or more<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_9_32\" class=\"gfield gfield--type-textarea gfield--input-type-textarea gfield--width-half Witness field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_9_32'>How has your chemical use affected the relationship with your children?<\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_32' id='input_9_32' class='textarea small'      aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/div><div id=\"field_9_33\" class=\"gfield gfield--type-textarea gfield--input-type-textarea gfield--width-half Witness field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_9_33'>How has your relationship with family\/significant other been affected by your chemical use?<\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_33' id='input_9_33' class='textarea small'      aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/div><fieldset id=\"field_9_34\" 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' >Have you ever been physically or sexually abused?<\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_9_34'>\n\t\t\t<div class='gchoice gchoice_9_34_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_34' type='radio' value='Yes'  id='choice_9_34_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_9_34_0' id='label_9_34_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_9_34_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_34' type='radio' value='Second Choice'  id='choice_9_34_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_9_34_1' id='label_9_34_1' class='gform-field-label gform-field-label--type-inline'>Second Choice<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_9_35\" 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' >Does anyone in your immediate family have a problem with chemicals?<\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_9_35'>\n\t\t\t<div class='gchoice gchoice_9_35_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_35' type='radio' value='Yes'  id='choice_9_35_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_9_35_0' id='label_9_35_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_9_35_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_35' type='radio' value='No'  id='choice_9_35_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_9_35_1' id='label_9_35_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_9_36\" 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' >Have concerned person(s) complained about your use of chemicals?<\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_9_36'>\n\t\t\t<div class='gchoice gchoice_9_36_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_36' type='radio' value='Yes'  id='choice_9_36_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_9_36_0' id='label_9_36_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_9_36_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_36' type='radio' value='No'  id='choice_9_36_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_9_36_1' id='label_9_36_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_9_37\" class=\"gfield gfield--type-textarea gfield--input-type-textarea gfield--width-half Witness field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_9_37'>What do you normally do with your leisure time?<\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_37' id='input_9_37' class='textarea small'      aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/div><div id=\"field_9_38\" class=\"gfield gfield--type-textarea gfield--input-type-textarea gfield--width-half Witness field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_9_38'>How many close friends do you have?<\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_38' id='input_9_38' class='textarea small'      aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/div><div id=\"field_9_39\" class=\"gfield gfield--type-textarea gfield--input-type-textarea gfield--width-half Witness field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_9_39'>What are your interests\/hobbies?<\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_39' id='input_9_39' class='textarea small'      aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/div><fieldset id=\"field_9_40\" 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' >Do you socialize with people who use drugs and\/or alcohol?<\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_9_40'>\n\t\t\t<div class='gchoice gchoice_9_40_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_40' type='radio' value='Yes'  id='choice_9_40_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_9_40_0' id='label_9_40_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_9_40_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_40' type='radio' value='No'  id='choice_9_40_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_9_40_1' id='label_9_40_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_9_41\" class=\"gfield gfield--type-textarea gfield--input-type-textarea gfield--width-half Witness field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_9_41'>Percent of leisure time spent drinking\/using?<\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_41' id='input_9_41' class='textarea small'      aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/div><div id=\"field_9_42\" class=\"gfield gfield--type-textarea gfield--input-type-textarea gfield--width-half Witness field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_9_42'>Is there anything else about either your history or your current condition that you feel is important to mention?<\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_42' id='input_9_42' class='textarea small'      aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/div><\/div><\/div>\n        <div class='gform-footer gform_footer top_label'> <input type='submit' id='gform_submit_button_9' class='gform_button button' onclick='gform.submission.handleButtonClick(this);' data-submission-type='submit' value='Submit'  \/> <input type='hidden' name='gform_ajax' value='form_id=9&amp;title=&amp;description=&amp;tabindex=0&amp;theme=gravity-theme&amp;styles=[]&amp;hash=d7f2bc1209ea8bd6f1f7336f29552e47' \/>\n            <input type='hidden' 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