{"id":93,"date":"2010-09-09T20:39:37","date_gmt":"2010-09-09T20:39:37","guid":{"rendered":"http:\/\/www.yourhealthyrelationship.com\/home\/?p=93"},"modified":"2010-09-09T20:41:21","modified_gmt":"2010-09-09T20:41:21","slug":"new-client-questionnaire","status":"publish","type":"post","link":"http:\/\/www.yourhealthyrelationship.com\/home\/new-client-questionnaire\/","title":{"rendered":"New Client Questionnaire"},"content":{"rendered":"<div style=\"float: right; margin-left: 10px;\"><a href=\"https:\/\/twitter.com\/share\" class=\"twitter-share-button\" data-count=\"horizontal\" data-url=\"http:\/\/www.yourhealthyrelationship.com\/home\/new-client-questionnaire\/\">Tweet<\/a><\/div>\n<p><span style=\"color: #ffffff;\">.<\/span><\/p>\n<p>In order to make the most of our time together, it is important for me to understand some basics about you, your spouse and your relationship.\u00a0 Please complete the form below and submit to me before your first session.<\/p>\n<p><em>Please Note:\u00a0 Amy and Your Healthy Relationship understand the sensitive nature of your responses and are committed to keeping your information confidential.\u00a0 Please view our confidentiality policy here:\u00a0 <a href=\"http:\/\/www.yourhealthyrelationship.com\/home\/confidentiality-and-cancellation-policy\/\" target=\"_blank\">CLICK HERE TO DOWNLOAD<\/a><\/em><\/p>\n\n                <div class='gf_browser_gecko gform_wrapper' id='gform_wrapper_1' ><form method='post' enctype='multipart\/form-data'  id='gform_1'  action='\/home\/wp-json\/wp\/v2\/posts\/93'>\n                        <div class='gform_heading'>\n                            <h3 class='gform_title'>New Client Questionnaire<\/h3>\n                        <\/div>\n                        <div class='gform_body'><ul id='gform_fields_1' class='gform_fields top_label form_sublabel_below description_below'><li id='field_1_32'  class='gfield field_sublabel_below field_description_below gfield_visibility_visible' ><label class='gfield_label' for='input_1_32' >Today&#039;s Date<\/label><div class='ginput_container ginput_container_date'>\n                            <input name='input_32' id='input_1_32' type='text' value='' class='datepicker medium mdy datepicker_no_icon'   \/>\n                        <\/div>\n                        <input type='hidden' id='gforms_calendar_icon_input_1_32' class='gform_hidden' value='http:\/\/www.yourhealthyrelationship.com\/home\/wp-content\/plugins\/gravityforms\/images\/calendar.png'\/><\/li><li id='field_1_1'  class='gfield gsection field_sublabel_below field_description_below gfield_visibility_visible' ><h2 class='gsection_title'>YOUR INFORMATION:<\/h2><\/li><li id='field_1_2'  class='gfield gfield_contains_required field_sublabel_below field_description_below gfield_visibility_visible' ><label class='gfield_label gfield_label_before_complex'  >Name<span class='gfield_required'>*<\/span><\/label><div class='ginput_complex ginput_container no_prefix has_first_name no_middle_name has_last_name no_suffix gf_name_has_2 ginput_container_name' id='input_1_2'>\n                            <span id='input_1_2_3_container' class='name_first' >\n                                                    <input type='text' name='input_2.3' id='input_1_2_3' value='' aria-label='First name'   aria-required=\"true\" aria-invalid=\"false\" \/>\n                                                    <label for='input_1_2_3' >First<\/label>\n                                               <\/span>\n                            <span id='input_1_2_6_container' class='name_last' >\n                                                    <input type='text' name='input_2.6' id='input_1_2_6' value='' aria-label='Last name'   aria-required=\"true\" aria-invalid=\"false\" \/>\n                                                    <label for='input_1_2_6' >Last<\/label>\n                                                <\/span>\n                            <div class='gf_clear gf_clear_complex'><\/div>\n                        <\/div><\/li><li id='field_1_33'  class='gfield gfield_contains_required field_sublabel_below field_description_below gfield_visibility_visible' ><label class='gfield_label' for='input_1_33' >Your Primary Email<span class='gfield_required'>*<\/span><\/label><div class='ginput_container ginput_container_email'>\n                            <input name='input_33' id='input_1_33' type='text' value='' class='medium'    aria-required=\"true\" aria-invalid=\"false\" \/>\n                        <\/div><\/li><li id='field_1_5'  class='gfield gfield_contains_required field_sublabel_below field_description_below gfield_visibility_visible' ><label class='gfield_label' for='input_1_5' >Birthdate<span class='gfield_required'>*<\/span><\/label><div class='ginput_container ginput_container_date'>\n                            <input name='input_5' id='input_1_5' type='text' value='' class='datepicker medium mdy datepicker_no_icon'   \/>\n                        <\/div>\n                        <input type='hidden' id='gforms_calendar_icon_input_1_5' class='gform_hidden' value='http:\/\/www.yourhealthyrelationship.com\/home\/wp-content\/plugins\/gravityforms\/images\/calendar.png'\/><\/li><li id='field_1_3'  class='gfield gfield_contains_required field_sublabel_below field_description_below gfield_visibility_visible' ><label class='gfield_label gfield_label_before_complex'  >Address<span class='gfield_required'>*<\/span><\/label>    \n                    <div class='ginput_complex ginput_container has_street has_street2 has_city has_state has_zip has_country ginput_container_address' id='input_1_3' >\n                         <span class='ginput_full address_line_1' id='input_1_3_1_container' >\n                                        <input type='text' name='input_3.1' id='input_1_3_1' value=''    aria-required=\"true\"\/>\n                                        <label for='input_1_3_1' id='input_1_3_1_label' >Street Address<\/label>\n                                    <\/span><span class='ginput_full address_line_2' id='input_1_3_2_container' >\n                                        <input type='text' name='input_3.2' id='input_1_3_2' value=''   \/>\n                                        <label for='input_1_3_2' id='input_1_3_2_label' >Address Line 2<\/label>\n                                    <\/span><span class='ginput_left address_city' id='input_1_3_3_container' >\n                                    <input type='text' name='input_3.3' id='input_1_3_3' value=''   \/>\n                                    <label for='input_1_3_3' id='input_1_3_3_label' >City<\/label>\n                                 <\/span><span class='ginput_right address_state' id='input_1_3_4_container' >\n                                        <input type='text' name='input_3.4' id='input_1_3_4' value=''      aria-required=\"true\"\/>\n                                        <label for='input_1_3_4' id='input_1_3_4_label' >State \/ Province \/ Region<\/label>\n                                      <\/span><span class='ginput_left address_zip' id='input_1_3_5_container' >\n                                    <input type='text' name='input_3.5' id='input_1_3_5' value=''    aria-required=\"true\"\/>\n                                    <label for='input_1_3_5' id='input_1_3_5_label' >ZIP \/ Postal Code<\/label>\n                                <\/span><span class='ginput_right address_country' id='input_1_3_6_container' >\n                                        <select name='input_3.6' id='input_1_3_6'   aria-required=\"true\"><option value='' selected='selected'><\/option><option value='Afghanistan' >Afghanistan<\/option><option value='\u00c5land Islands' >\u00c5land Islands<\/option><option value='Albania' >Albania<\/option><option value='Algeria' >Algeria<\/option><option value='American Samoa' >American Samoa<\/option><option value='Andorra' >Andorra<\/option><option value='Angola' >Angola<\/option><option value='Anguilla' >Anguilla<\/option><option value='Antarctica' >Antarctica<\/option><option value='Antigua and Barbuda' >Antigua and Barbuda<\/option><option value='Argentina' >Argentina<\/option><option value='Armenia' >Armenia<\/option><option value='Aruba' >Aruba<\/option><option value='Australia' >Australia<\/option><option value='Austria' >Austria<\/option><option value='Azerbaijan' >Azerbaijan<\/option><option value='Bahamas' >Bahamas<\/option><option value='Bahrain' >Bahrain<\/option><option value='Bangladesh' >Bangladesh<\/option><option value='Barbados' >Barbados<\/option><option value='Belarus' >Belarus<\/option><option value='Belgium' >Belgium<\/option><option value='Belize' >Belize<\/option><option value='Benin' >Benin<\/option><option value='Bermuda' >Bermuda<\/option><option value='Bhutan' >Bhutan<\/option><option value='Bolivia' >Bolivia<\/option><option value='Bonaire, Sint Eustatius and Saba' >Bonaire, Sint Eustatius and Saba<\/option><option value='Bosnia and Herzegovina' >Bosnia and Herzegovina<\/option><option value='Botswana' >Botswana<\/option><option value='Bouvet Island' >Bouvet Island<\/option><option value='Brazil' >Brazil<\/option><option value='British Indian Ocean Territory' >British Indian Ocean Territory<\/option><option value='Brunei Darrussalam' >Brunei Darrussalam<\/option><option value='Bulgaria' >Bulgaria<\/option><option value='Burkina Faso' >Burkina Faso<\/option><option value='Burundi' >Burundi<\/option><option value='Cambodia' >Cambodia<\/option><option value='Cameroon' >Cameroon<\/option><option value='Canada' >Canada<\/option><option value='Cape Verde' >Cape Verde<\/option><option value='Cayman Islands' >Cayman Islands<\/option><option value='Central African Republic' >Central African Republic<\/option><option value='Chad' >Chad<\/option><option value='Chile' >Chile<\/option><option value='China' >China<\/option><option value='Christmas Island' >Christmas Island<\/option><option value='Cocos Islands' >Cocos Islands<\/option><option value='Colombia' >Colombia<\/option><option value='Comoros' >Comoros<\/option><option value='Congo, Democratic Republic of the' >Congo, Democratic Republic of the<\/option><option value='Congo, Republic of the' >Congo, Republic of the<\/option><option value='Cook Islands' >Cook Islands<\/option><option value='Costa Rica' >Costa Rica<\/option><option value='C\u00f4te d&#039;Ivoire' >C\u00f4te d&#039;Ivoire<\/option><option value='Croatia' >Croatia<\/option><option value='Cuba' >Cuba<\/option><option value='Cura\u00e7ao' >Cura\u00e7ao<\/option><option value='Cyprus' >Cyprus<\/option><option value='Czech Republic' >Czech Republic<\/option><option value='Denmark' >Denmark<\/option><option value='Djibouti' >Djibouti<\/option><option value='Dominica' >Dominica<\/option><option value='Dominican Republic' >Dominican Republic<\/option><option value='Ecuador' >Ecuador<\/option><option value='Egypt' >Egypt<\/option><option value='El Salvador' >El Salvador<\/option><option value='Equatorial Guinea' >Equatorial Guinea<\/option><option value='Eritrea' >Eritrea<\/option><option value='Estonia' >Estonia<\/option><option value='Eswatini (Swaziland)' >Eswatini (Swaziland)<\/option><option value='Ethiopia' >Ethiopia<\/option><option value='Falkland Islands' >Falkland Islands<\/option><option value='Faroe Islands' >Faroe Islands<\/option><option value='Fiji' >Fiji<\/option><option value='Finland' >Finland<\/option><option value='France' >France<\/option><option value='French Guiana' >French Guiana<\/option><option value='French Polynesia' >French Polynesia<\/option><option value='French Southern Territories' >French Southern Territories<\/option><option value='Gabon' >Gabon<\/option><option value='Gambia' >Gambia<\/option><option value='Georgia' >Georgia<\/option><option value='Germany' >Germany<\/option><option value='Ghana' >Ghana<\/option><option value='Gibraltar' >Gibraltar<\/option><option value='Greece' >Greece<\/option><option value='Greenland' >Greenland<\/option><option value='Grenada' >Grenada<\/option><option value='Guadeloupe' >Guadeloupe<\/option><option value='Guam' >Guam<\/option><option value='Guatemala' >Guatemala<\/option><option value='Guernsey' >Guernsey<\/option><option value='Guinea' >Guinea<\/option><option value='Guinea-Bissau' >Guinea-Bissau<\/option><option value='Guyana' >Guyana<\/option><option value='Haiti' >Haiti<\/option><option value='Heard and McDonald Islands' >Heard and McDonald Islands<\/option><option value='Holy See' >Holy See<\/option><option value='Honduras' >Honduras<\/option><option value='Hong Kong' >Hong Kong<\/option><option value='Hungary' >Hungary<\/option><option value='Iceland' >Iceland<\/option><option value='India' >India<\/option><option value='Indonesia' >Indonesia<\/option><option value='Iran' >Iran<\/option><option value='Iraq' >Iraq<\/option><option value='Ireland' >Ireland<\/option><option value='Isle of Man' >Isle of Man<\/option><option value='Israel' >Israel<\/option><option value='Italy' >Italy<\/option><option value='Jamaica' >Jamaica<\/option><option value='Japan' >Japan<\/option><option value='Jersey' >Jersey<\/option><option value='Jordan' >Jordan<\/option><option value='Kazakhstan' >Kazakhstan<\/option><option value='Kenya' >Kenya<\/option><option value='Kiribati' >Kiribati<\/option><option value='Kuwait' >Kuwait<\/option><option value='Kyrgyzstan' >Kyrgyzstan<\/option><option value='Lao People&#039;s Democratic Republic' >Lao People&#039;s Democratic Republic<\/option><option value='Latvia' >Latvia<\/option><option value='Lebanon' >Lebanon<\/option><option value='Lesotho' >Lesotho<\/option><option value='Liberia' >Liberia<\/option><option value='Libya' >Libya<\/option><option value='Liechtenstein' >Liechtenstein<\/option><option value='Lithuania' >Lithuania<\/option><option value='Luxembourg' >Luxembourg<\/option><option value='Macau' >Macau<\/option><option value='Macedonia' >Macedonia<\/option><option value='Madagascar' >Madagascar<\/option><option value='Malawi' >Malawi<\/option><option value='Malaysia' >Malaysia<\/option><option value='Maldives' >Maldives<\/option><option value='Mali' >Mali<\/option><option value='Malta' >Malta<\/option><option value='Marshall Islands' >Marshall Islands<\/option><option value='Martinique' >Martinique<\/option><option value='Mauritania' >Mauritania<\/option><option value='Mauritius' >Mauritius<\/option><option value='Mayotte' >Mayotte<\/option><option value='Mexico' >Mexico<\/option><option value='Micronesia' >Micronesia<\/option><option value='Moldova' >Moldova<\/option><option value='Monaco' >Monaco<\/option><option value='Mongolia' >Mongolia<\/option><option value='Montenegro' >Montenegro<\/option><option value='Montserrat' >Montserrat<\/option><option value='Morocco' >Morocco<\/option><option value='Mozambique' >Mozambique<\/option><option value='Myanmar' >Myanmar<\/option><option value='Namibia' >Namibia<\/option><option value='Nauru' >Nauru<\/option><option value='Nepal' >Nepal<\/option><option value='Netherlands' >Netherlands<\/option><option value='New Caledonia' >New Caledonia<\/option><option value='New Zealand' >New Zealand<\/option><option value='Nicaragua' >Nicaragua<\/option><option value='Niger' >Niger<\/option><option value='Nigeria' >Nigeria<\/option><option value='Niue' >Niue<\/option><option value='Norfolk Island' >Norfolk Island<\/option><option value='North Korea' >North Korea<\/option><option value='Northern Mariana Islands' >Northern Mariana Islands<\/option><option value='Norway' >Norway<\/option><option value='Oman' >Oman<\/option><option value='Pakistan' >Pakistan<\/option><option value='Palau' >Palau<\/option><option value='Palestine, State of' >Palestine, State of<\/option><option value='Panama' >Panama<\/option><option value='Papua New Guinea' >Papua New Guinea<\/option><option value='Paraguay' >Paraguay<\/option><option value='Peru' >Peru<\/option><option value='Philippines' >Philippines<\/option><option value='Pitcairn' >Pitcairn<\/option><option value='Poland' >Poland<\/option><option value='Portugal' >Portugal<\/option><option value='Puerto Rico' >Puerto Rico<\/option><option value='Qatar' >Qatar<\/option><option value='R\u00e9union' >R\u00e9union<\/option><option value='Romania' >Romania<\/option><option value='Russia' >Russia<\/option><option value='Rwanda' >Rwanda<\/option><option value='Saint Barth\u00e9lemy' >Saint Barth\u00e9lemy<\/option><option value='Saint Helena' >Saint Helena<\/option><option value='Saint Kitts and Nevis' >Saint Kitts and Nevis<\/option><option value='Saint Lucia' >Saint Lucia<\/option><option value='Saint Martin' >Saint Martin<\/option><option value='Saint Pierre and Miquelon' >Saint Pierre and Miquelon<\/option><option value='Saint Vincent and the Grenadines' >Saint Vincent and the Grenadines<\/option><option value='Samoa' >Samoa<\/option><option value='San Marino' >San Marino<\/option><option value='Sao Tome and Principe' >Sao Tome and Principe<\/option><option value='Saudi Arabia' >Saudi Arabia<\/option><option value='Senegal' >Senegal<\/option><option value='Serbia' >Serbia<\/option><option value='Seychelles' >Seychelles<\/option><option value='Sierra Leone' >Sierra Leone<\/option><option value='Singapore' >Singapore<\/option><option value='Sint Maarten' >Sint Maarten<\/option><option value='Slovakia' >Slovakia<\/option><option value='Slovenia' >Slovenia<\/option><option value='Solomon Islands' >Solomon Islands<\/option><option value='Somalia' >Somalia<\/option><option value='South Africa' >South Africa<\/option><option value='South Georgia' >South Georgia<\/option><option value='South Korea' >South Korea<\/option><option value='South Sudan' >South Sudan<\/option><option value='Spain' >Spain<\/option><option value='Sri Lanka' >Sri Lanka<\/option><option value='Sudan' >Sudan<\/option><option value='Suriname' >Suriname<\/option><option value='Svalbard and Jan Mayen Islands' >Svalbard and Jan Mayen Islands<\/option><option value='Sweden' >Sweden<\/option><option value='Switzerland' >Switzerland<\/option><option value='Syria' >Syria<\/option><option value='Taiwan' >Taiwan<\/option><option value='Tajikistan' >Tajikistan<\/option><option value='Tanzania' >Tanzania<\/option><option value='Thailand' >Thailand<\/option><option value='Timor-Leste' >Timor-Leste<\/option><option value='Togo' >Togo<\/option><option value='Tokelau' >Tokelau<\/option><option value='Tonga' >Tonga<\/option><option value='Trinidad and Tobago' >Trinidad and Tobago<\/option><option value='Tunisia' >Tunisia<\/option><option value='Turkey' >Turkey<\/option><option value='Turkmenistan' >Turkmenistan<\/option><option value='Turks and Caicos Islands' >Turks and Caicos Islands<\/option><option value='Tuvalu' >Tuvalu<\/option><option value='Uganda' >Uganda<\/option><option value='Ukraine' >Ukraine<\/option><option value='United Arab Emirates' >United Arab Emirates<\/option><option value='United Kingdom' >United Kingdom<\/option><option value='United States' >United States<\/option><option value='Uruguay' >Uruguay<\/option><option value='US Minor Outlying Islands' >US Minor Outlying Islands<\/option><option value='Uzbekistan' >Uzbekistan<\/option><option value='Vanuatu' >Vanuatu<\/option><option value='Venezuela' >Venezuela<\/option><option value='Vietnam' >Vietnam<\/option><option value='Virgin Islands, British' >Virgin Islands, British<\/option><option value='Virgin Islands, U.S.' >Virgin Islands, U.S.<\/option><option value='Wallis and Futuna' >Wallis and Futuna<\/option><option value='Western Sahara' >Western Sahara<\/option><option value='Yemen' >Yemen<\/option><option value='Zambia' >Zambia<\/option><option value='Zimbabwe' >Zimbabwe<\/option><\/select>\n                                        <label for='input_1_3_6' id='input_1_3_6_label' >Country<\/label>\n                                    <\/span>\n                    <div class='gf_clear gf_clear_complex'><\/div>\n                <\/div><\/li><li id='field_1_4'  class='gfield gfield_contains_required field_sublabel_below field_description_below gfield_visibility_visible' ><label class='gfield_label' for='input_1_4' >Home Phone<span class='gfield_required'>*<\/span><\/label><div class='ginput_container ginput_container_phone'><input name='input_4' id='input_1_4' type='text' value='' class='medium'   aria-required=\"true\" aria-invalid=\"false\"  \/><\/div><\/li><li id='field_1_6'  class='gfield field_sublabel_below field_description_below gfield_visibility_visible' ><label class='gfield_label' for='input_1_6' >Cell Phone<\/label><div class='ginput_container ginput_container_phone'><input name='input_6' id='input_1_6' type='text' value='' class='medium'    aria-invalid=\"false\"  \/><\/div><\/li><li id='field_1_7'  class='gfield gfield_contains_required field_sublabel_below field_description_below gfield_visibility_visible' ><label class='gfield_label' for='input_1_7' >Profession<span class='gfield_required'>*<\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_7' id='input_1_7' type='text' value='' class='medium'     aria-required=\"true\" aria-invalid=\"false\" \/><\/div><\/li><li id='field_1_8'  class='gfield gfield_contains_required field_sublabel_below field_description_below gfield_visibility_visible' ><label class='gfield_label' for='input_1_8' >Number of Years Married to Current Spouse<span class='gfield_required'>*<\/span><\/label><div class='ginput_container ginput_container_number'><input name='input_8' id='input_1_8' type='text'    value='' class='medium'     aria-required=\"true\" aria-invalid=\"false\" \/><\/div><\/li><li id='field_1_9'  class='gfield field_sublabel_below field_description_below gfield_visibility_visible' ><label class='gfield_label' for='input_1_9' >If you have Children, please enter names and ages:<\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_9' id='input_1_9' class='textarea medium'      aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/li><li id='field_1_10'  class='gfield field_sublabel_below field_description_below gfield_visibility_visible' ><label class='gfield_label' for='input_1_10' >If you&#039;ve been married before, please list length of each marriage<\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_10' id='input_1_10' class='textarea medium'      aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/li><li id='field_1_11'  class='gfield gsection field_sublabel_below field_description_below gfield_visibility_visible' ><h2 class='gsection_title'>SPOUSE&#039;S INFORMATION<\/h2><\/li><li id='field_1_12'  class='gfield gfield_contains_required field_sublabel_below field_description_below gfield_visibility_visible' ><label class='gfield_label gfield_label_before_complex'  >Spouse&#039;s Name<span class='gfield_required'>*<\/span><\/label><div class='ginput_complex ginput_container no_prefix has_first_name no_middle_name has_last_name no_suffix gf_name_has_2 ginput_container_name' id='input_1_12'>\n                            <span id='input_1_12_3_container' class='name_first' >\n                                                    <input type='text' name='input_12.3' id='input_1_12_3' value='' aria-label='First name'   aria-required=\"true\" aria-invalid=\"false\" \/>\n                                                    <label for='input_1_12_3' >First<\/label>\n                                               <\/span>\n                            <span id='input_1_12_6_container' class='name_last' >\n                                                    <input type='text' name='input_12.6' id='input_1_12_6' value='' aria-label='Last name'   aria-required=\"true\" aria-invalid=\"false\" \/>\n                                                    <label for='input_1_12_6' >Last<\/label>\n                                                <\/span>\n                            <div class='gf_clear gf_clear_complex'><\/div>\n                        <\/div><\/li><li id='field_1_13'  class='gfield gfield_contains_required field_sublabel_below field_description_below gfield_visibility_visible' ><label class='gfield_label gfield_label_before_complex'  >Spouse&#039;s Address<span class='gfield_required'>*<\/span><\/label>    \n                    <div class='ginput_complex ginput_container has_street has_street2 has_city has_state has_zip has_country ginput_container_address' id='input_1_13' >\n                         <span class='ginput_full address_line_1' id='input_1_13_1_container' >\n                                        <input type='text' name='input_13.1' id='input_1_13_1' value=''    aria-required=\"true\"\/>\n                                        <label for='input_1_13_1' id='input_1_13_1_label' >Street Address<\/label>\n                                    <\/span><span class='ginput_full address_line_2' id='input_1_13_2_container' >\n                                        <input type='text' name='input_13.2' id='input_1_13_2' value=''   \/>\n                                        <label for='input_1_13_2' id='input_1_13_2_label' >Address Line 2<\/label>\n                                    <\/span><span class='ginput_left address_city' id='input_1_13_3_container' >\n                                    <input type='text' name='input_13.3' id='input_1_13_3' value=''   \/>\n                                    <label for='input_1_13_3' id='input_1_13_3_label' >City<\/label>\n                                 <\/span><span class='ginput_right address_state' id='input_1_13_4_container' >\n                                        <input type='text' name='input_13.4' id='input_1_13_4' value=''      aria-required=\"true\"\/>\n                                        <label for='input_1_13_4' id='input_1_13_4_label' >State \/ Province \/ Region<\/label>\n                                      <\/span><span class='ginput_left address_zip' id='input_1_13_5_container' >\n                                    <input type='text' name='input_13.5' id='input_1_13_5' value=''    aria-required=\"true\"\/>\n                                    <label for='input_1_13_5' id='input_1_13_5_label' >ZIP \/ Postal Code<\/label>\n                                <\/span><span class='ginput_right address_country' id='input_1_13_6_container' >\n                                        <select name='input_13.6' id='input_1_13_6'   aria-required=\"true\"><option value='' selected='selected'><\/option><option value='Afghanistan' >Afghanistan<\/option><option value='\u00c5land Islands' >\u00c5land Islands<\/option><option value='Albania' >Albania<\/option><option value='Algeria' >Algeria<\/option><option value='American Samoa' >American Samoa<\/option><option value='Andorra' >Andorra<\/option><option value='Angola' >Angola<\/option><option value='Anguilla' >Anguilla<\/option><option value='Antarctica' >Antarctica<\/option><option value='Antigua and Barbuda' >Antigua and Barbuda<\/option><option value='Argentina' >Argentina<\/option><option value='Armenia' >Armenia<\/option><option value='Aruba' >Aruba<\/option><option value='Australia' >Australia<\/option><option value='Austria' >Austria<\/option><option value='Azerbaijan' >Azerbaijan<\/option><option value='Bahamas' >Bahamas<\/option><option value='Bahrain' >Bahrain<\/option><option value='Bangladesh' >Bangladesh<\/option><option value='Barbados' >Barbados<\/option><option value='Belarus' >Belarus<\/option><option value='Belgium' >Belgium<\/option><option value='Belize' >Belize<\/option><option value='Benin' >Benin<\/option><option value='Bermuda' >Bermuda<\/option><option value='Bhutan' >Bhutan<\/option><option value='Bolivia' >Bolivia<\/option><option value='Bonaire, Sint Eustatius and Saba' >Bonaire, Sint Eustatius and Saba<\/option><option value='Bosnia and Herzegovina' >Bosnia and Herzegovina<\/option><option value='Botswana' >Botswana<\/option><option value='Bouvet Island' >Bouvet Island<\/option><option value='Brazil' >Brazil<\/option><option value='British Indian Ocean Territory' >British Indian Ocean Territory<\/option><option value='Brunei Darrussalam' >Brunei Darrussalam<\/option><option value='Bulgaria' >Bulgaria<\/option><option value='Burkina Faso' >Burkina Faso<\/option><option value='Burundi' >Burundi<\/option><option value='Cambodia' >Cambodia<\/option><option value='Cameroon' >Cameroon<\/option><option value='Canada' >Canada<\/option><option value='Cape Verde' >Cape Verde<\/option><option value='Cayman Islands' >Cayman Islands<\/option><option value='Central African Republic' >Central African Republic<\/option><option value='Chad' >Chad<\/option><option value='Chile' >Chile<\/option><option value='China' >China<\/option><option value='Christmas Island' >Christmas Island<\/option><option value='Cocos Islands' >Cocos Islands<\/option><option value='Colombia' >Colombia<\/option><option value='Comoros' >Comoros<\/option><option value='Congo, Democratic Republic of the' >Congo, Democratic Republic of the<\/option><option value='Congo, Republic of the' >Congo, Republic of the<\/option><option value='Cook Islands' >Cook Islands<\/option><option value='Costa Rica' >Costa Rica<\/option><option value='C\u00f4te d&#039;Ivoire' >C\u00f4te d&#039;Ivoire<\/option><option value='Croatia' >Croatia<\/option><option value='Cuba' >Cuba<\/option><option value='Cura\u00e7ao' >Cura\u00e7ao<\/option><option value='Cyprus' >Cyprus<\/option><option value='Czech Republic' >Czech Republic<\/option><option value='Denmark' >Denmark<\/option><option value='Djibouti' >Djibouti<\/option><option value='Dominica' >Dominica<\/option><option value='Dominican Republic' >Dominican Republic<\/option><option value='Ecuador' >Ecuador<\/option><option value='Egypt' >Egypt<\/option><option value='El Salvador' >El Salvador<\/option><option value='Equatorial Guinea' >Equatorial Guinea<\/option><option value='Eritrea' >Eritrea<\/option><option value='Estonia' >Estonia<\/option><option value='Eswatini (Swaziland)' >Eswatini (Swaziland)<\/option><option value='Ethiopia' >Ethiopia<\/option><option value='Falkland Islands' >Falkland Islands<\/option><option value='Faroe Islands' >Faroe Islands<\/option><option value='Fiji' >Fiji<\/option><option value='Finland' >Finland<\/option><option value='France' >France<\/option><option value='French Guiana' >French Guiana<\/option><option value='French Polynesia' >French Polynesia<\/option><option value='French Southern Territories' >French Southern Territories<\/option><option value='Gabon' >Gabon<\/option><option value='Gambia' >Gambia<\/option><option value='Georgia' >Georgia<\/option><option value='Germany' >Germany<\/option><option value='Ghana' >Ghana<\/option><option value='Gibraltar' >Gibraltar<\/option><option value='Greece' >Greece<\/option><option value='Greenland' >Greenland<\/option><option value='Grenada' >Grenada<\/option><option value='Guadeloupe' >Guadeloupe<\/option><option value='Guam' >Guam<\/option><option value='Guatemala' >Guatemala<\/option><option value='Guernsey' >Guernsey<\/option><option value='Guinea' >Guinea<\/option><option value='Guinea-Bissau' >Guinea-Bissau<\/option><option value='Guyana' >Guyana<\/option><option value='Haiti' >Haiti<\/option><option value='Heard and McDonald Islands' >Heard and McDonald Islands<\/option><option value='Holy See' >Holy See<\/option><option value='Honduras' >Honduras<\/option><option value='Hong Kong' >Hong Kong<\/option><option value='Hungary' >Hungary<\/option><option value='Iceland' >Iceland<\/option><option value='India' >India<\/option><option value='Indonesia' >Indonesia<\/option><option value='Iran' >Iran<\/option><option value='Iraq' >Iraq<\/option><option value='Ireland' >Ireland<\/option><option value='Isle of Man' >Isle of Man<\/option><option value='Israel' >Israel<\/option><option value='Italy' >Italy<\/option><option value='Jamaica' >Jamaica<\/option><option value='Japan' >Japan<\/option><option value='Jersey' >Jersey<\/option><option value='Jordan' >Jordan<\/option><option value='Kazakhstan' >Kazakhstan<\/option><option value='Kenya' >Kenya<\/option><option value='Kiribati' >Kiribati<\/option><option value='Kuwait' >Kuwait<\/option><option value='Kyrgyzstan' >Kyrgyzstan<\/option><option value='Lao People&#039;s Democratic Republic' >Lao People&#039;s Democratic Republic<\/option><option value='Latvia' >Latvia<\/option><option value='Lebanon' >Lebanon<\/option><option value='Lesotho' >Lesotho<\/option><option value='Liberia' >Liberia<\/option><option value='Libya' >Libya<\/option><option value='Liechtenstein' >Liechtenstein<\/option><option value='Lithuania' >Lithuania<\/option><option value='Luxembourg' >Luxembourg<\/option><option value='Macau' >Macau<\/option><option value='Macedonia' >Macedonia<\/option><option value='Madagascar' >Madagascar<\/option><option value='Malawi' >Malawi<\/option><option value='Malaysia' >Malaysia<\/option><option value='Maldives' >Maldives<\/option><option value='Mali' >Mali<\/option><option value='Malta' >Malta<\/option><option value='Marshall Islands' >Marshall Islands<\/option><option value='Martinique' >Martinique<\/option><option value='Mauritania' >Mauritania<\/option><option value='Mauritius' >Mauritius<\/option><option value='Mayotte' >Mayotte<\/option><option value='Mexico' >Mexico<\/option><option value='Micronesia' >Micronesia<\/option><option value='Moldova' >Moldova<\/option><option value='Monaco' >Monaco<\/option><option value='Mongolia' >Mongolia<\/option><option value='Montenegro' >Montenegro<\/option><option value='Montserrat' >Montserrat<\/option><option value='Morocco' >Morocco<\/option><option value='Mozambique' >Mozambique<\/option><option value='Myanmar' >Myanmar<\/option><option value='Namibia' >Namibia<\/option><option value='Nauru' >Nauru<\/option><option value='Nepal' >Nepal<\/option><option value='Netherlands' >Netherlands<\/option><option value='New Caledonia' >New Caledonia<\/option><option value='New Zealand' >New Zealand<\/option><option value='Nicaragua' >Nicaragua<\/option><option value='Niger' >Niger<\/option><option value='Nigeria' >Nigeria<\/option><option value='Niue' >Niue<\/option><option value='Norfolk Island' >Norfolk Island<\/option><option value='North Korea' >North Korea<\/option><option value='Northern Mariana Islands' >Northern Mariana Islands<\/option><option value='Norway' >Norway<\/option><option value='Oman' >Oman<\/option><option value='Pakistan' >Pakistan<\/option><option value='Palau' >Palau<\/option><option value='Palestine, State of' >Palestine, State of<\/option><option value='Panama' >Panama<\/option><option value='Papua New Guinea' >Papua New Guinea<\/option><option value='Paraguay' >Paraguay<\/option><option value='Peru' >Peru<\/option><option value='Philippines' >Philippines<\/option><option value='Pitcairn' >Pitcairn<\/option><option value='Poland' >Poland<\/option><option value='Portugal' >Portugal<\/option><option value='Puerto Rico' >Puerto Rico<\/option><option value='Qatar' >Qatar<\/option><option value='R\u00e9union' >R\u00e9union<\/option><option value='Romania' >Romania<\/option><option value='Russia' >Russia<\/option><option value='Rwanda' >Rwanda<\/option><option value='Saint Barth\u00e9lemy' >Saint Barth\u00e9lemy<\/option><option value='Saint Helena' >Saint Helena<\/option><option value='Saint Kitts and Nevis' >Saint Kitts and Nevis<\/option><option value='Saint Lucia' >Saint Lucia<\/option><option value='Saint Martin' >Saint Martin<\/option><option value='Saint Pierre and Miquelon' >Saint Pierre and Miquelon<\/option><option value='Saint Vincent and the Grenadines' >Saint Vincent and the Grenadines<\/option><option value='Samoa' >Samoa<\/option><option value='San Marino' >San Marino<\/option><option value='Sao Tome and Principe' >Sao Tome and Principe<\/option><option value='Saudi Arabia' >Saudi Arabia<\/option><option value='Senegal' >Senegal<\/option><option value='Serbia' >Serbia<\/option><option value='Seychelles' >Seychelles<\/option><option value='Sierra Leone' >Sierra Leone<\/option><option value='Singapore' >Singapore<\/option><option value='Sint Maarten' >Sint Maarten<\/option><option value='Slovakia' >Slovakia<\/option><option value='Slovenia' >Slovenia<\/option><option value='Solomon Islands' >Solomon Islands<\/option><option value='Somalia' >Somalia<\/option><option value='South Africa' >South Africa<\/option><option value='South Georgia' >South Georgia<\/option><option value='South Korea' >South Korea<\/option><option value='South Sudan' >South Sudan<\/option><option value='Spain' >Spain<\/option><option value='Sri Lanka' >Sri Lanka<\/option><option value='Sudan' >Sudan<\/option><option value='Suriname' >Suriname<\/option><option value='Svalbard and Jan Mayen Islands' >Svalbard and Jan Mayen Islands<\/option><option value='Sweden' >Sweden<\/option><option value='Switzerland' >Switzerland<\/option><option value='Syria' >Syria<\/option><option value='Taiwan' >Taiwan<\/option><option value='Tajikistan' >Tajikistan<\/option><option value='Tanzania' >Tanzania<\/option><option value='Thailand' >Thailand<\/option><option value='Timor-Leste' >Timor-Leste<\/option><option value='Togo' >Togo<\/option><option value='Tokelau' >Tokelau<\/option><option value='Tonga' >Tonga<\/option><option value='Trinidad and Tobago' >Trinidad and Tobago<\/option><option value='Tunisia' >Tunisia<\/option><option value='Turkey' >Turkey<\/option><option value='Turkmenistan' >Turkmenistan<\/option><option value='Turks and Caicos Islands' >Turks and Caicos Islands<\/option><option value='Tuvalu' >Tuvalu<\/option><option value='Uganda' >Uganda<\/option><option value='Ukraine' >Ukraine<\/option><option value='United Arab Emirates' >United Arab Emirates<\/option><option value='United Kingdom' >United Kingdom<\/option><option value='United States' >United States<\/option><option value='Uruguay' >Uruguay<\/option><option value='US Minor Outlying Islands' >US Minor Outlying Islands<\/option><option value='Uzbekistan' >Uzbekistan<\/option><option value='Vanuatu' >Vanuatu<\/option><option value='Venezuela' >Venezuela<\/option><option value='Vietnam' >Vietnam<\/option><option value='Virgin Islands, British' >Virgin Islands, British<\/option><option value='Virgin Islands, U.S.' >Virgin Islands, U.S.<\/option><option value='Wallis and Futuna' >Wallis and Futuna<\/option><option value='Western Sahara' >Western Sahara<\/option><option value='Yemen' >Yemen<\/option><option value='Zambia' >Zambia<\/option><option value='Zimbabwe' >Zimbabwe<\/option><\/select>\n                                        <label for='input_1_13_6' id='input_1_13_6_label' >Country<\/label>\n                                    <\/span>\n                    <div class='gf_clear gf_clear_complex'><\/div>\n                <\/div><\/li><li id='field_1_14'  class='gfield gfield_contains_required field_sublabel_below field_description_below gfield_visibility_visible' ><label class='gfield_label' for='input_1_14' >Spouse&#039;s Birth Date<span class='gfield_required'>*<\/span><\/label><div class='ginput_container ginput_container_date'>\n                            <input name='input_14' id='input_1_14' type='text' value='' class='datepicker medium mdy datepicker_no_icon'   \/>\n                        <\/div>\n                        <input type='hidden' id='gforms_calendar_icon_input_1_14' class='gform_hidden' value='http:\/\/www.yourhealthyrelationship.com\/home\/wp-content\/plugins\/gravityforms\/images\/calendar.png'\/><\/li><li id='field_1_15'  class='gfield gfield_contains_required field_sublabel_below field_description_below gfield_visibility_visible' ><label class='gfield_label' for='input_1_15' >Spouse&#039;s Profession<span class='gfield_required'>*<\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_15' id='input_1_15' type='text' value='' class='medium'     aria-required=\"true\" aria-invalid=\"false\" \/><\/div><\/li><li id='field_1_16'  class='gfield field_sublabel_below field_description_below gfield_visibility_visible' ><label class='gfield_label' for='input_1_16' >If your spouse has been married before, please list length of previous marriage(s)<\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_16' id='input_1_16' class='textarea medium'      aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/li><li id='field_1_17'  class='gfield gsection field_sublabel_below field_description_below gfield_visibility_visible' ><h2 class='gsection_title'>RELATIONSHIP INFORMATION<\/h2><\/li><li id='field_1_18'  class='gfield gfield_contains_required field_sublabel_below field_description_below gfield_visibility_visible' ><label class='gfield_label'  >Have you ever sought professional counselling or relationship coaching before?<span class='gfield_required'>*<\/span><\/label><div class='ginput_container ginput_container_checkbox'><ul class='gfield_checkbox' id='input_1_18'><li class='gchoice_1_18_1'>\n\t\t\t\t\t\t\t\t<input name='input_18.1' type='checkbox'  value='Yes'  id='choice_1_18_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_1_18_1' id='label_1_18_1'>Yes<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice_1_18_2'>\n\t\t\t\t\t\t\t\t<input name='input_18.2' type='checkbox'  value='No'  id='choice_1_18_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_1_18_2' id='label_1_18_2'>No<\/label>\n\t\t\t\t\t\t\t<\/li><\/ul><\/div><\/li><li id='field_1_21'  class='gfield gfield_contains_required field_sublabel_below field_description_below gfield_visibility_visible' ><label class='gfield_label' for='input_1_21' >What is your primary reason for seeking relationship coaching?<span class='gfield_required'>*<\/span><\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_21' id='input_1_21' class='textarea medium'     aria-required=\"true\" aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/li><li id='field_1_19'  class='gfield gfield_contains_required field_sublabel_below field_description_below gfield_visibility_visible' ><label class='gfield_label' for='input_1_19' >Please describe the primary challenge in your relationship:<span class='gfield_required'>*<\/span><\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_19' id='input_1_19' class='textarea medium'     aria-required=\"true\" aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/li><li id='field_1_20'  class='gfield gfield_contains_required field_sublabel_below field_description_below gfield_visibility_visible' ><label class='gfield_label' for='input_1_20' >Please share 3 adjectives to describe you mother and 3 adjectives to describe your father.<span class='gfield_required'>*<\/span><\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_20' id='input_1_20' class='textarea medium'     aria-required=\"true\" aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/li><li id='field_1_22'  class='gfield gsection field_sublabel_below field_description_below gfield_visibility_visible' ><h2 class='gsection_title'>Health Checklist<\/h2><div class='gsection_description' id='gfield_description_1_22'>Please check all that apply.<\/div><\/li><li id='field_1_23'  class='gfield field_sublabel_below field_description_below gfield_visibility_visible' ><label class='gfield_label'  >Anxiety<\/label><div class='ginput_container ginput_container_checkbox'><ul class='gfield_checkbox' id='input_1_23'><li class='gchoice_1_23_1'>\n\t\t\t\t\t\t\t\t<input name='input_23.1' type='checkbox'  value='You'  id='choice_1_23_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_1_23_1' id='label_1_23_1'>You<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice_1_23_2'>\n\t\t\t\t\t\t\t\t<input name='input_23.2' type='checkbox'  value='Your Spouse'  id='choice_1_23_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_1_23_2' id='label_1_23_2'>Your Spouse<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice_1_23_3'>\n\t\t\t\t\t\t\t\t<input name='input_23.3' type='checkbox'  value='Child\/Children'  id='choice_1_23_3'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_1_23_3' id='label_1_23_3'>Child\/Children<\/label>\n\t\t\t\t\t\t\t<\/li><\/ul><\/div><\/li><li id='field_1_24'  class='gfield field_sublabel_below field_description_below gfield_visibility_visible' ><label class='gfield_label'  >Depression<\/label><div class='ginput_container ginput_container_checkbox'><ul class='gfield_checkbox' id='input_1_24'><li class='gchoice_1_24_1'>\n\t\t\t\t\t\t\t\t<input name='input_24.1' type='checkbox'  value='You'  id='choice_1_24_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_1_24_1' id='label_1_24_1'>You<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice_1_24_2'>\n\t\t\t\t\t\t\t\t<input name='input_24.2' type='checkbox'  value='Your Spouse'  id='choice_1_24_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_1_24_2' id='label_1_24_2'>Your Spouse<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice_1_24_3'>\n\t\t\t\t\t\t\t\t<input name='input_24.3' type='checkbox'  value='Child\/Children'  id='choice_1_24_3'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_1_24_3' id='label_1_24_3'>Child\/Children<\/label>\n\t\t\t\t\t\t\t<\/li><\/ul><\/div><\/li><li id='field_1_25'  class='gfield field_sublabel_below field_description_below gfield_visibility_visible' ><label class='gfield_label'  >Alcohol\/Substance Abuse<\/label><div class='ginput_container ginput_container_checkbox'><ul class='gfield_checkbox' id='input_1_25'><li class='gchoice_1_25_1'>\n\t\t\t\t\t\t\t\t<input name='input_25.1' type='checkbox'  value='You'  id='choice_1_25_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_1_25_1' id='label_1_25_1'>You<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice_1_25_2'>\n\t\t\t\t\t\t\t\t<input name='input_25.2' type='checkbox'  value='Your Spouse'  id='choice_1_25_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_1_25_2' id='label_1_25_2'>Your Spouse<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice_1_25_3'>\n\t\t\t\t\t\t\t\t<input name='input_25.3' type='checkbox'  value='Child\/Children'  id='choice_1_25_3'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_1_25_3' id='label_1_25_3'>Child\/Children<\/label>\n\t\t\t\t\t\t\t<\/li><\/ul><\/div><\/li><li id='field_1_26'  class='gfield field_sublabel_below field_description_below gfield_visibility_visible' ><label class='gfield_label'  >Extreme Stress or Anger<\/label><div class='ginput_container ginput_container_checkbox'><ul class='gfield_checkbox' id='input_1_26'><li class='gchoice_1_26_1'>\n\t\t\t\t\t\t\t\t<input name='input_26.1' type='checkbox'  value='You'  id='choice_1_26_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_1_26_1' id='label_1_26_1'>You<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice_1_26_2'>\n\t\t\t\t\t\t\t\t<input name='input_26.2' type='checkbox'  value='Your Spouse'  id='choice_1_26_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_1_26_2' id='label_1_26_2'>Your Spouse<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice_1_26_3'>\n\t\t\t\t\t\t\t\t<input name='input_26.3' type='checkbox'  value='Child\/Children'  id='choice_1_26_3'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_1_26_3' id='label_1_26_3'>Child\/Children<\/label>\n\t\t\t\t\t\t\t<\/li><\/ul><\/div><\/li><li id='field_1_27'  class='gfield field_sublabel_below field_description_below gfield_visibility_visible' ><label class='gfield_label'  >Workaholic<\/label><div class='ginput_container ginput_container_checkbox'><ul class='gfield_checkbox' id='input_1_27'><li class='gchoice_1_27_1'>\n\t\t\t\t\t\t\t\t<input name='input_27.1' type='checkbox'  value='You'  id='choice_1_27_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_1_27_1' id='label_1_27_1'>You<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice_1_27_2'>\n\t\t\t\t\t\t\t\t<input name='input_27.2' type='checkbox'  value='Your Spouse'  id='choice_1_27_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_1_27_2' id='label_1_27_2'>Your Spouse<\/label>\n\t\t\t\t\t\t\t<\/li><\/ul><\/div><\/li><li id='field_1_28'  class='gfield field_sublabel_below field_description_below gfield_visibility_visible' ><label class='gfield_label'  >Food Addiction<\/label><div class='ginput_container ginput_container_checkbox'><ul class='gfield_checkbox' id='input_1_28'><li class='gchoice_1_28_1'>\n\t\t\t\t\t\t\t\t<input name='input_28.1' type='checkbox'  value='You'  id='choice_1_28_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_1_28_1' id='label_1_28_1'>You<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice_1_28_2'>\n\t\t\t\t\t\t\t\t<input name='input_28.2' type='checkbox'  value='Your Spouse'  id='choice_1_28_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_1_28_2' id='label_1_28_2'>Your Spouse<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice_1_28_3'>\n\t\t\t\t\t\t\t\t<input name='input_28.3' type='checkbox'  value='Child\/Children'  id='choice_1_28_3'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_1_28_3' id='label_1_28_3'>Child\/Children<\/label>\n\t\t\t\t\t\t\t<\/li><\/ul><\/div><\/li><li id='field_1_29'  class='gfield field_sublabel_below field_description_below gfield_visibility_visible' ><label class='gfield_label'  >Excessive Spending\/Gambling or Money Challenges<\/label><div class='ginput_container ginput_container_checkbox'><ul class='gfield_checkbox' id='input_1_29'><li class='gchoice_1_29_1'>\n\t\t\t\t\t\t\t\t<input name='input_29.1' type='checkbox'  value='You'  id='choice_1_29_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_1_29_1' id='label_1_29_1'>You<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice_1_29_2'>\n\t\t\t\t\t\t\t\t<input name='input_29.2' type='checkbox'  value='Your Spouse'  id='choice_1_29_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_1_29_2' id='label_1_29_2'>Your Spouse<\/label>\n\t\t\t\t\t\t\t<\/li><\/ul><\/div><\/li><li id='field_1_30'  class='gfield field_sublabel_below field_description_below gfield_visibility_visible' ><label class='gfield_label'  >Sexual Addiction<\/label><div class='ginput_container ginput_container_checkbox'><ul class='gfield_checkbox' id='input_1_30'><li class='gchoice_1_30_1'>\n\t\t\t\t\t\t\t\t<input name='input_30.1' type='checkbox'  value='You'  id='choice_1_30_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_1_30_1' id='label_1_30_1'>You<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice_1_30_2'>\n\t\t\t\t\t\t\t\t<input name='input_30.2' type='checkbox'  value='Your Spouse'  id='choice_1_30_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_1_30_2' id='label_1_30_2'>Your Spouse<\/label>\n\t\t\t\t\t\t\t<\/li><\/ul><\/div><\/li><li id='field_1_31'  class='gfield field_sublabel_below field_description_below gfield_visibility_visible' ><label class='gfield_label'  >Poor Health or Health Challenges<\/label><div class='ginput_container ginput_container_checkbox'><ul class='gfield_checkbox' id='input_1_31'><li class='gchoice_1_31_1'>\n\t\t\t\t\t\t\t\t<input name='input_31.1' type='checkbox'  value='You'  id='choice_1_31_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_1_31_1' id='label_1_31_1'>You<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice_1_31_2'>\n\t\t\t\t\t\t\t\t<input name='input_31.2' type='checkbox'  value='Your Spouse'  id='choice_1_31_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_1_31_2' id='label_1_31_2'>Your Spouse<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice_1_31_3'>\n\t\t\t\t\t\t\t\t<input name='input_31.3' type='checkbox'  value='Child\/Children'  id='choice_1_31_3'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_1_31_3' id='label_1_31_3'>Child\/Children<\/label>\n\t\t\t\t\t\t\t<\/li><\/ul><\/div><\/li><li id='field_1_34'  class='gfield field_sublabel_below field_description_below gfield_visibility_visible' ><label class='gfield_label' for='input_1_34' >Please enter the two words 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13){jQuery(this).blur();} } );} } );jQuery(document).bind('gform_post_conditional_logic', function(event, formId, fields, isInit){} );<\/script><script type='text\/javascript'> jQuery(document).ready(function(){jQuery(document).trigger('gform_post_render', [1, 1]) } ); <\/script>\n<p><span style=\"color: #ffffff;\">.<\/span><\/p>\n<p><span style=\"color: #ffffff;\">.<\/span><\/p>\n","protected":false},"excerpt":{"rendered":"<p>Tweet . In order to make the most of our time together, it is important for me to understand some basics about you, your spouse and your relationship.\u00a0 Please complete the form below and submit to me before your first session. Please Note:\u00a0 Amy and Your Healthy Relationship understand the sensitive nature of your responses [&hellip;]<\/p>\n","protected":false},"author":1,"featured_media":0,"comment_status":"open","ping_status":"open","sticky":false,"template":"","format":"standard","meta":{"_monsterinsights_skip_tracking":false,"_monsterinsights_sitenote_active":false,"_monsterinsights_sitenote_note":"","_monsterinsights_sitenote_category":0,"footnotes":""},"categories":[7],"tags":[],"class_list":["post-93","post","type-post","status-publish","format-standard","hentry","category-client-resources","entry"],"_links":{"self":[{"href":"http:\/\/www.yourhealthyrelationship.com\/home\/wp-json\/wp\/v2\/posts\/93","targetHints":{"allow":["GET"]}}],"collection":[{"href":"http:\/\/www.yourhealthyrelationship.com\/home\/wp-json\/wp\/v2\/posts"}],"about":[{"href":"http:\/\/www.yourhealthyrelationship.com\/home\/wp-json\/wp\/v2\/types\/post"}],"author":[{"embeddable":true,"href":"http:\/\/www.yourhealthyrelationship.com\/home\/wp-json\/wp\/v2\/users\/1"}],"replies":[{"embeddable":true,"href":"http:\/\/www.yourhealthyrelationship.com\/home\/wp-json\/wp\/v2\/comments?post=93"}],"version-history":[{"count":3,"href":"http:\/\/www.yourhealthyrelationship.com\/home\/wp-json\/wp\/v2\/posts\/93\/revisions"}],"predecessor-version":[{"id":197,"href":"http:\/\/www.yourhealthyrelationship.com\/home\/wp-json\/wp\/v2\/posts\/93\/revisions\/197"}],"wp:attachment":[{"href":"http:\/\/www.yourhealthyrelationship.com\/home\/wp-json\/wp\/v2\/media?parent=93"}],"wp:term":[{"taxonomy":"category","embeddable":true,"href":"http:\/\/www.yourhealthyrelationship.com\/home\/wp-json\/wp\/v2\/categories?post=93"},{"taxonomy":"post_tag","embeddable":true,"href":"http:\/\/www.yourhealthyrelationship.com\/home\/wp-json\/wp\/v2\/tags?post=93"}],"curies":[{"name":"wp","href":"https:\/\/api.w.org\/{rel}","templated":true}]}}