{"id":1706,"date":"2021-02-01T11:48:36","date_gmt":"2021-02-01T17:48:36","guid":{"rendered":"https:\/\/tamarackrehab.org\/?page_id=1706"},"modified":"2021-02-01T11:48:39","modified_gmt":"2021-02-01T17:48:39","slug":"intake-online-form","status":"publish","type":"page","link":"https:\/\/old.tamarackrecovery.org\/intake-online-form\/","title":{"rendered":"Intake Online Form"},"content":{"rendered":"<script type=\"text\/javascript\">var gform;gform||(document.addEventListener(\"gform_main_scripts_loaded\",function(){gform.scriptsLoaded=!0}),window.addEventListener(\"DOMContentLoaded\",function(){gform.domLoaded=!0}),gform={domLoaded:!1,scriptsLoaded:!1,initializeOnLoaded:function(o){gform.domLoaded&&gform.scriptsLoaded?o():!gform.domLoaded&&gform.scriptsLoaded?window.addEventListener(\"DOMContentLoaded\",o):document.addEventListener(\"gform_main_scripts_loaded\",o)},hooks:{action:{},filter:{}},addAction:function(o,n,r,t){gform.addHook(\"action\",o,n,r,t)},addFilter:function(o,n,r,t){gform.addHook(\"filter\",o,n,r,t)},doAction:function(o){gform.doHook(\"action\",o,arguments)},applyFilters:function(o){return gform.doHook(\"filter\",o,arguments)},removeAction:function(o,n){gform.removeHook(\"action\",o,n)},removeFilter:function(o,n,r){gform.removeHook(\"filter\",o,n,r)},addHook:function(o,n,r,t,i){null==gform.hooks[o][n]&&(gform.hooks[o][n]=[]);var e=gform.hooks[o][n];null==i&&(i=n+\"_\"+e.length),gform.hooks[o][n].push({tag:i,callable:r,priority:t=null==t?10:t})},doHook:function(n,o,r){var t;if(r=Array.prototype.slice.call(r,1),null!=gform.hooks[n][o]&&((o=gform.hooks[n][o]).sort(function(o,n){return o.priority-n.priority}),o.forEach(function(o){\"function\"!=typeof(t=o.callable)&&(t=window[t]),\"action\"==n?t.apply(null,r):r[0]=t.apply(null,r)})),\"filter\"==n)return r[0]},removeHook:function(o,n,t,i){var r;null!=gform.hooks[o][n]&&(r=(r=gform.hooks[o][n]).filter(function(o,n,r){return!!(null!=i&&i!=o.tag||null!=t&&t!=o.priority)}),gform.hooks[o][n]=r)}});<\/script>\n                <div class='gf_browser_gecko gform_wrapper gform_legacy_markup_wrapper gform-theme--no-framework' data-form-theme='legacy' data-form-index='0' id='gform_wrapper_5' style='display:none'><div id='gf_5' class='gform_anchor' tabindex='-1'><\/div>\n                        <div class='gform_heading'>\n                            <h3 class=\"gform_title\">Intake Form<\/h3>\n                        <\/div><form method='post' enctype='multipart\/form-data'  id='gform_5'  action='\/wp-json\/wp\/v2\/pages\/1706#gf_5' data-formid='5' novalidate>\n                        <div class='gform-body gform_body'><ul id='gform_fields_5' class='gform_fields top_label form_sublabel_below description_below'><li id=\"field_5_1\"  class=\"gfield gfield--type-date gfield--input-type-datepicker gfield--datepicker-no-icon field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_5_1\"><label class='gfield_label gform-field-label' for='input_5_1' >Date<\/label><div class='ginput_container ginput_container_date'>\n                            <input name='input_1' id='input_5_1' type='text' value='09\/19\/2024' class='datepicker gform-datepicker mdy datepicker_no_icon gdatepicker-no-icon'   placeholder='mm\/dd\/yyyy' aria-describedby=\"input_5_1_date_format\" aria-invalid=\"false\" \/>\n                            <span id='input_5_1_date_format' class='screen-reader-text'>MM slash DD slash YYYY<\/span>\n                        <\/div>\n                        <input type='hidden' id='gforms_calendar_icon_input_5_1' class='gform_hidden' value='https:\/\/old.tamarackrecovery.org\/wp-content\/plugins\/gravityforms\/images\/datepicker\/datepicker.svg'\/><\/li><li id=\"field_5_2\"  class=\"gfield gfield--type-name gfield_contains_required field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_5_2\"><label class='gfield_label gform-field-label gfield_label_before_complex'  >Name of Applicant<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_complex ginput_container ginput_container--name no_prefix has_first_name no_middle_name has_last_name no_suffix gf_name_has_2 ginput_container_name gform-grid-row' id='input_5_2'>\n                            \n                            <span id='input_5_2_3_container' class='name_first gform-grid-col gform-grid-col--size-auto' >\n                                                    <input type='text' name='input_2.3' id='input_5_2_3' value=''   aria-required='true'     \/>\n                                                    <label for='input_5_2_3' class='gform-field-label gform-field-label--type-sub '>First<\/label>\n                                                <\/span>\n                            \n                            <span id='input_5_2_6_container' class='name_last gform-grid-col gform-grid-col--size-auto' >\n                                                    <input type='text' name='input_2.6' id='input_5_2_6' value=''   aria-required='true'     \/>\n                                                    <label for='input_5_2_6' class='gform-field-label gform-field-label--type-sub '>Last<\/label>\n                                                <\/span>\n                            \n                        <\/div><\/li><li id=\"field_5_3\"  class=\"gfield gfield--type-name gfield_contains_required field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_5_3\"><label class='gfield_label gform-field-label gfield_label_before_complex'  >Name of person completing this form<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_complex ginput_container ginput_container--name no_prefix has_first_name no_middle_name has_last_name no_suffix gf_name_has_2 ginput_container_name gform-grid-row' id='input_5_3'>\n                            \n                            <span id='input_5_3_3_container' class='name_first gform-grid-col gform-grid-col--size-auto' >\n                                                    <input type='text' name='input_3.3' id='input_5_3_3' value=''   aria-required='true'     \/>\n                                                    <label for='input_5_3_3' class='gform-field-label gform-field-label--type-sub '>First<\/label>\n                                                <\/span>\n                            \n                            <span id='input_5_3_6_container' class='name_last gform-grid-col gform-grid-col--size-auto' >\n                                                    <input type='text' name='input_3.6' id='input_5_3_6' value=''   aria-required='true'     \/>\n                                                    <label for='input_5_3_6' class='gform-field-label gform-field-label--type-sub '>Last<\/label>\n                                                <\/span>\n                            \n                        <\/div><\/li><li id=\"field_5_5\"  class=\"gfield gfield--type-text gfield_contains_required field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_5_5\"><label class='gfield_label gform-field-label' for='input_5_5' >Relationship to Applicant<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_5' id='input_5_5' type='text' value='' class='medium'     aria-required=\"true\" aria-invalid=\"false\"   \/> <\/div><\/li><li id=\"field_5_6\"  class=\"gfield gfield--type-html gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_5_6\"><h3>Applicant Information<\/h3><\/li><li id=\"field_5_7\"  class=\"gfield gfield--type-address gfield_contains_required field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_5_7\"><label class='gfield_label gform-field-label gfield_label_before_complex'  >Home Address<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label>    \n                    <div class='ginput_complex ginput_container has_street has_street2 has_city has_state has_zip ginput_container_address gform-grid-row' id='input_5_7' >\n                         <span class='ginput_full address_line_1 ginput_address_line_1 gform-grid-col' id='input_5_7_1_container' >\n                                        <input type='text' name='input_7.1' id='input_5_7_1' value=''    aria-required='true'    \/>\n                                        <label for='input_5_7_1' id='input_5_7_1_label' class='gform-field-label gform-field-label--type-sub '>Street Address<\/label>\n                                    <\/span><span class='ginput_full address_line_2 ginput_address_line_2 gform-grid-col' id='input_5_7_2_container' >\n                                        <input type='text' name='input_7.2' id='input_5_7_2' value=''     aria-required='false'   \/>\n                                        <label for='input_5_7_2' id='input_5_7_2_label' class='gform-field-label gform-field-label--type-sub '>Address Line 2<\/label>\n                                    <\/span><span class='ginput_left address_city ginput_address_city gform-grid-col' id='input_5_7_3_container' >\n                                    <input type='text' name='input_7.3' id='input_5_7_3' value=''    aria-required='true'    \/>\n                                    <label for='input_5_7_3' id='input_5_7_3_label' class='gform-field-label gform-field-label--type-sub '>City<\/label>\n                                 <\/span><span class='ginput_right address_state ginput_address_state gform-grid-col' id='input_5_7_4_container' >\n                                        <select name='input_7.4' id='input_5_7_4'     aria-required='true'    ><option value='' ><\/option><option value='Alberta' >Alberta<\/option><option value='British Columbia' >British Columbia<\/option><option value='Manitoba' selected='selected'>Manitoba<\/option><option value='New Brunswick' >New Brunswick<\/option><option value='Newfoundland and Labrador' >Newfoundland and Labrador<\/option><option value='Northwest Territories' >Northwest Territories<\/option><option value='Nova Scotia' >Nova Scotia<\/option><option value='Nunavut' >Nunavut<\/option><option value='Ontario' >Ontario<\/option><option value='Prince Edward Island' >Prince Edward Island<\/option><option value='Quebec' >Quebec<\/option><option value='Saskatchewan' >Saskatchewan<\/option><option value='Yukon' >Yukon<\/option><\/select>\n                                        <label for='input_5_7_4' id='input_5_7_4_label' class='gform-field-label gform-field-label--type-sub '>Province<\/label>\n                                      <\/span><span class='ginput_left address_zip ginput_address_zip gform-grid-col' id='input_5_7_5_container' >\n                                    <input type='text' name='input_7.5' id='input_5_7_5' value=''    aria-required='true'    \/>\n                                    <label for='input_5_7_5' id='input_5_7_5_label' class='gform-field-label gform-field-label--type-sub '>Postal Code<\/label>\n                                <\/span><input type='hidden' class='gform_hidden' name='input_7.6' id='input_5_7_6' value='Canada' \/>\n                    <div class='gf_clear gf_clear_complex'><\/div>\n                <\/div><\/li><li id=\"field_5_8\"  class=\"gfield gfield--type-phone gfield_contains_required field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_5_8\"><label class='gfield_label gform-field-label' for='input_5_8' >Home Phone<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_phone'><input name='input_8' id='input_5_8' type='tel' value='' class='medium'   aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_5_10\"  class=\"gfield gfield--type-radio gfield--type-choice gfield_contains_required field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_5_10\"><label class='gfield_label gform-field-label'  >Home Phone Messages OK?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_5_10'>\n\t\t\t<li class='gchoice gchoice_5_10_0'>\n\t\t\t\t<input name='input_10' type='radio' value='Yes'  id='choice_5_10_0'    \/>\n\t\t\t\t<label for='choice_5_10_0' id='label_5_10_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_5_10_1'>\n\t\t\t\t<input name='input_10' type='radio' value='No'  id='choice_5_10_1'    \/>\n\t\t\t\t<label for='choice_5_10_1' id='label_5_10_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_5_11\"  class=\"gfield gfield--type-phone field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_5_11\"><label class='gfield_label gform-field-label' for='input_5_11' >Cell Phone<\/label><div class='ginput_container ginput_container_phone'><input name='input_11' id='input_5_11' type='tel' value='' class='medium'    aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_5_12\"  class=\"gfield gfield--type-radio gfield--type-choice gfield_contains_required field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_5_12\"><label class='gfield_label gform-field-label'  >Cell Phone Messages OK?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_5_12'>\n\t\t\t<li class='gchoice gchoice_5_12_0'>\n\t\t\t\t<input name='input_12' type='radio' value='Yes'  id='choice_5_12_0'    \/>\n\t\t\t\t<label for='choice_5_12_0' id='label_5_12_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_5_12_1'>\n\t\t\t\t<input name='input_12' type='radio' value='No'  id='choice_5_12_1'    \/>\n\t\t\t\t<label for='choice_5_12_1' id='label_5_12_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_5_13\"  class=\"gfield gfield--type-phone field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_5_13\"><label class='gfield_label gform-field-label' for='input_5_13' >Other Phone<\/label><div class='ginput_container ginput_container_phone'><input name='input_13' id='input_5_13' type='tel' value='' class='medium'    aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_5_14\"  class=\"gfield gfield--type-radio gfield--type-choice gfield_contains_required field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_5_14\"><label class='gfield_label gform-field-label'  >Other Phone Messages OK?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_5_14'>\n\t\t\t<li class='gchoice gchoice_5_14_0'>\n\t\t\t\t<input name='input_14' type='radio' value='Yes'  id='choice_5_14_0'    \/>\n\t\t\t\t<label for='choice_5_14_0' id='label_5_14_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_5_14_1'>\n\t\t\t\t<input name='input_14' type='radio' value='No'  id='choice_5_14_1'    \/>\n\t\t\t\t<label for='choice_5_14_1' id='label_5_14_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_5_15\"  class=\"gfield gfield--type-date gfield--input-type-datepicker gfield--datepicker-no-icon gfield_contains_required field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_5_15\"><label class='gfield_label gform-field-label' for='input_5_15' >Date of Birth<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_date'>\n                            <input name='input_15' id='input_5_15' type='text' value='' class='datepicker gform-datepicker mdy datepicker_no_icon gdatepicker-no-icon'   placeholder='mm\/dd\/yyyy' aria-describedby=\"input_5_15_date_format\" aria-invalid=\"false\" aria-required=\"true\"\/>\n                            <span id='input_5_15_date_format' class='screen-reader-text'>MM slash DD slash YYYY<\/span>\n                        <\/div>\n                        <input type='hidden' id='gforms_calendar_icon_input_5_15' class='gform_hidden' value='https:\/\/old.tamarackrecovery.org\/wp-content\/plugins\/gravityforms\/images\/datepicker\/datepicker.svg'\/><\/li><li id=\"field_5_16\"  class=\"gfield gfield--type-select gfield_contains_required field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_5_16\"><label class='gfield_label gform-field-label' for='input_5_16' >Sex Assigned at birth<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_select'><select name='input_16' id='input_5_16' class='medium gfield_select'    aria-required=\"true\" aria-invalid=\"false\" ><option value='Female' >Female<\/option><option value='Male' >Male<\/option><option value='Intersex' >Intersex<\/option><option value='Prefer not to say' >Prefer not to say<\/option><\/select><\/div><\/li><li id=\"field_5_17\"  class=\"gfield gfield--type-select gfield_contains_required field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_5_17\"><label class='gfield_label gform-field-label' for='input_5_17' >What gender do you identify as?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_select'><select name='input_17' id='input_5_17' class='medium gfield_select'    aria-required=\"true\" aria-invalid=\"false\" ><option value='Woman' >Woman<\/option><option value='Man' >Man<\/option><option value='Non-binary\/third gender' >Non-binary\/third gender<\/option><option value='Prefer to self-describe' >Prefer to self-describe<\/option><option value='Prefer not to say' >Prefer not to say<\/option><\/select><\/div><\/li><li id=\"field_5_18\"  class=\"gfield gfield--type-text field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_5_18\"><label class='gfield_label gform-field-label' for='input_5_18' >Prefer to self-describe<\/label><div class='ginput_container ginput_container_text'><input name='input_18' id='input_5_18' type='text' value='' class='medium'      aria-invalid=\"false\"   \/> <\/div><\/li><li id=\"field_5_19\"  class=\"gfield gfield--type-select gfield_contains_required field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_5_19\"><label class='gfield_label gform-field-label' for='input_5_19' >Preferred Pronoun<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_select'><select name='input_19' id='input_5_19' class='medium gfield_select'    aria-required=\"true\" aria-invalid=\"false\" ><option value='He' >He<\/option><option value='She' >She<\/option><option value='They' >They<\/option><option value='Ze' >Ze<\/option><option value='A pronoun not listed' >A pronoun not listed<\/option><option value='No pronoun preference' >No pronoun preference<\/option><\/select><\/div><\/li><li id=\"field_5_20\"  class=\"gfield gfield--type-html gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_5_20\"><h3>Referral Source<\/h3><\/li><li id=\"field_5_21\"  class=\"gfield gfield--type-select field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_5_21\"><label class='gfield_label gform-field-label' for='input_5_21' >Referral Source<\/label><div class='ginput_container ginput_container_select'><select name='input_21' id='input_5_21' class='medium gfield_select'     aria-invalid=\"false\" ><option value='Self' >Self<\/option><option value='Other' >Other<\/option><\/select><\/div><\/li><li id=\"field_5_22\"  class=\"gfield gfield--type-text field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_5_22\"><label class='gfield_label gform-field-label' for='input_5_22' >Referral source other (Name and Organization)<\/label><div class='ginput_container ginput_container_text'><input name='input_22' id='input_5_22' type='text' value='' class='medium'      aria-invalid=\"false\"   \/> <\/div><\/li><li id=\"field_5_23\"  class=\"gfield gfield--type-text field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_5_23\"><label class='gfield_label gform-field-label' for='input_5_23' >How did you\/they hear about Tamarack? (website; radio; newspaper; organization; family member)<\/label><div class='ginput_container ginput_container_text'><input name='input_23' id='input_5_23' type='text' value='' class='medium'      aria-invalid=\"false\"   \/> <\/div><\/li><li id=\"field_5_24\"  class=\"gfield gfield--type-html gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_5_24\"><h3>Employment Status \/ Income Source<\/h3><\/li><li id=\"field_5_25\"  class=\"gfield gfield--type-checkbox gfield--type-choice field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_5_25\"><label class='gfield_label gform-field-label gfield_label_before_complex'  >Employment<\/label><div class='ginput_container ginput_container_checkbox'><ul class='gfield_checkbox' id='input_5_25'><li class='gchoice gchoice_5_25_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_25.1' type='checkbox'  value='Full-Time'  id='choice_5_25_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_5_25_1' id='label_5_25_1' class='gform-field-label gform-field-label--type-inline'>Full-Time<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_5_25_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_25.2' type='checkbox'  value='Part-Time'  id='choice_5_25_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_5_25_2' id='label_5_25_2' class='gform-field-label gform-field-label--type-inline'>Part-Time<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_5_25_3'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_25.3' type='checkbox'  value='Correctional Facility'  id='choice_5_25_3'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_5_25_3' id='label_5_25_3' class='gform-field-label gform-field-label--type-inline'>Correctional Facility<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_5_25_4'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_25.4' type='checkbox'  value='EIA'  id='choice_5_25_4'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_5_25_4' id='label_5_25_4' class='gform-field-label gform-field-label--type-inline'>EIA<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_5_25_5'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_25.5' type='checkbox'  value='Retired'  id='choice_5_25_5'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_5_25_5' id='label_5_25_5' class='gform-field-label gform-field-label--type-inline'>Retired<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_5_25_6'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_25.6' type='checkbox'  value='Short-Term Disability'  id='choice_5_25_6'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_5_25_6' id='label_5_25_6' class='gform-field-label gform-field-label--type-inline'>Short-Term Disability<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_5_25_7'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_25.7' type='checkbox'  value='Long-Term Disability'  id='choice_5_25_7'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_5_25_7' id='label_5_25_7' class='gform-field-label gform-field-label--type-inline'>Long-Term Disability<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_5_25_8'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_25.8' type='checkbox'  value='Employment Insurance-EI'  id='choice_5_25_8'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_5_25_8' id='label_5_25_8' class='gform-field-label gform-field-label--type-inline'>Employment Insurance-EI<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_5_25_9'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_25.9' type='checkbox'  value='Volunteer\/Service Work'  id='choice_5_25_9'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_5_25_9' id='label_5_25_9' class='gform-field-label gform-field-label--type-inline'>Volunteer\/Service Work<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_5_25_11'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_25.11' type='checkbox'  value='Student'  id='choice_5_25_11'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_5_25_11' id='label_5_25_11' class='gform-field-label gform-field-label--type-inline'>Student<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_5_25_12'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_25.12' type='checkbox'  value='Work at Home'  id='choice_5_25_12'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_5_25_12' id='label_5_25_12' class='gform-field-label gform-field-label--type-inline'>Work at Home<\/label>\n\t\t\t\t\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_5_26\"  class=\"gfield gfield--type-text field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_5_26\"><label class='gfield_label gform-field-label' for='input_5_26' >Employed Full-Time: Employer<\/label><div class='ginput_container ginput_container_text'><input name='input_26' id='input_5_26' type='text' value='' class='medium'      aria-invalid=\"false\"   \/> <\/div><\/li><li id=\"field_5_27\"  class=\"gfield gfield--type-text field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_5_27\"><label class='gfield_label gform-field-label' for='input_5_27' >Employed Part-Time: Employer<\/label><div class='ginput_container ginput_container_text'><input name='input_27' id='input_5_27' type='text' value='' class='medium'      aria-invalid=\"false\"   \/> <\/div><\/li><li id=\"field_5_28\"  class=\"gfield gfield--type-text field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_5_28\"><label class='gfield_label gform-field-label' for='input_5_28' >Correctional Facility<\/label><div class='ginput_container ginput_container_text'><input name='input_28' id='input_5_28' type='text' value='' class='medium'      aria-invalid=\"false\"   \/> <\/div><\/li><li id=\"field_5_29\"  class=\"gfield gfield--type-text field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_5_29\"><label class='gfield_label gform-field-label' for='input_5_29' >Work at Home<\/label><div class='ginput_container ginput_container_text'><input name='input_29' id='input_5_29' type='text' value='' class='medium'      aria-invalid=\"false\"   \/> <\/div><\/li><li id=\"field_5_30\"  class=\"gfield gfield--type-text field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_5_30\"><label class='gfield_label gform-field-label' for='input_5_30' >Student at (program)<\/label><div class='ginput_container ginput_container_text'><input name='input_30' id='input_5_30' type='text' value='' class='medium'      aria-invalid=\"false\"   \/> <\/div><\/li><li id=\"field_5_31\"  class=\"gfield gfield--type-text field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_5_31\"><label class='gfield_label gform-field-label' for='input_5_31' >Volunteer\/Service Work at:<\/label><div class='ginput_container ginput_container_text'><input name='input_31' id='input_5_31' type='text' value='' class='medium'      aria-invalid=\"false\"   \/> <\/div><\/li><li id=\"field_5_32\"  class=\"gfield gfield--type-html gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_5_32\"><h3>Medication<\/h3><\/li><li id=\"field_5_33\"  class=\"gfield gfield--type-radio gfield--type-choice gfield_contains_required field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_5_33\"><label class='gfield_label gform-field-label'  >Are you currently taking prescription medication for physical or mental health reasons?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_5_33'>\n\t\t\t<li class='gchoice gchoice_5_33_0'>\n\t\t\t\t<input name='input_33' type='radio' value='Yes'  id='choice_5_33_0'    \/>\n\t\t\t\t<label for='choice_5_33_0' id='label_5_33_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_5_33_1'>\n\t\t\t\t<input name='input_33' type='radio' value='No'  id='choice_5_33_1'    \/>\n\t\t\t\t<label for='choice_5_33_1' id='label_5_33_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_5_34\"  class=\"gfield gfield--type-text field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_5_34\"><label class='gfield_label gform-field-label' for='input_5_34' >Medication Name 1<\/label><div class='ginput_container ginput_container_text'><input name='input_34' id='input_5_34' type='text' value='' class='medium'      aria-invalid=\"false\"   \/> <\/div><\/li><li id=\"field_5_35\"  class=\"gfield gfield--type-text field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_5_35\"><label class='gfield_label gform-field-label' for='input_5_35' >Medication Purpose 1<\/label><div class='ginput_container ginput_container_text'><input name='input_35' id='input_5_35' type='text' value='' class='medium'      aria-invalid=\"false\"   \/> <\/div><\/li><li id=\"field_5_36\"  class=\"gfield gfield--type-text field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_5_36\"><label class='gfield_label gform-field-label' for='input_5_36' >Medication Name 2<\/label><div class='ginput_container ginput_container_text'><input name='input_36' id='input_5_36' type='text' value='' class='medium'      aria-invalid=\"false\"   \/> <\/div><\/li><li id=\"field_5_37\"  class=\"gfield gfield--type-text field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_5_37\"><label class='gfield_label gform-field-label' for='input_5_37' >Medication Purpose 2<\/label><div class='ginput_container ginput_container_text'><input name='input_37' id='input_5_37' type='text' value='' class='medium'      aria-invalid=\"false\"   \/> <\/div><\/li><li id=\"field_5_38\"  class=\"gfield gfield--type-text field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_5_38\"><label class='gfield_label gform-field-label' for='input_5_38' >Medication Name 3<\/label><div class='ginput_container ginput_container_text'><input name='input_38' id='input_5_38' type='text' value='' class='medium'      aria-invalid=\"false\"   \/> <\/div><\/li><li id=\"field_5_39\"  class=\"gfield gfield--type-text field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_5_39\"><label class='gfield_label gform-field-label' for='input_5_39' >Medication Purpose 3<\/label><div class='ginput_container ginput_container_text'><input name='input_39' id='input_5_39' type='text' value='' class='medium'      aria-invalid=\"false\"   \/> <\/div><\/li><li id=\"field_5_40\"  class=\"gfield gfield--type-text field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_5_40\"><label class='gfield_label gform-field-label' for='input_5_40' >Medication Name 4<\/label><div class='ginput_container ginput_container_text'><input name='input_40' id='input_5_40' type='text' value='' class='medium'      aria-invalid=\"false\"   \/> <\/div><\/li><li id=\"field_5_41\"  class=\"gfield gfield--type-text field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_5_41\"><label class='gfield_label gform-field-label' for='input_5_41' >Medication Purpose 4<\/label><div class='ginput_container ginput_container_text'><input name='input_41' id='input_5_41' type='text' value='' class='medium'      aria-invalid=\"false\"   \/> <\/div><\/li><li id=\"field_5_42\"  class=\"gfield gfield--type-text field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_5_42\"><label class='gfield_label gform-field-label' for='input_5_42' >Medication Name 5<\/label><div class='ginput_container ginput_container_text'><input name='input_42' id='input_5_42' type='text' value='' class='medium'      aria-invalid=\"false\"   \/> <\/div><\/li><li id=\"field_5_43\"  class=\"gfield gfield--type-text field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_5_43\"><label class='gfield_label gform-field-label' for='input_5_43' >Medication Purpose 5<\/label><div class='ginput_container ginput_container_text'><input name='input_43' id='input_5_43' type='text' value='' class='medium'      aria-invalid=\"false\"   \/> <\/div><\/li><li id=\"field_5_45\"  class=\"gfield gfield--type-text field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_5_45\"><label class='gfield_label gform-field-label' for='input_5_45' >Medication Name 6<\/label><div class='ginput_container ginput_container_text'><input name='input_45' id='input_5_45' type='text' value='' class='medium'      aria-invalid=\"false\"   \/> <\/div><\/li><li id=\"field_5_44\"  class=\"gfield gfield--type-text field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_5_44\"><label class='gfield_label gform-field-label' for='input_5_44' >Medication Purpose 6<\/label><div class='ginput_container ginput_container_text'><input name='input_44' id='input_5_44' type='text' value='' class='medium'      aria-invalid=\"false\"   \/> <\/div><\/li><li id=\"field_5_47\"  class=\"gfield gfield--type-text field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_5_47\"><label class='gfield_label gform-field-label' for='input_5_47' >Medication Name 7<\/label><div class='ginput_container ginput_container_text'><input name='input_47' id='input_5_47' type='text' value='' class='medium'      aria-invalid=\"false\"   \/> <\/div><\/li><li id=\"field_5_46\"  class=\"gfield gfield--type-text field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_5_46\"><label class='gfield_label gform-field-label' for='input_5_46' >Medication Purpose 7<\/label><div class='ginput_container ginput_container_text'><input name='input_46' id='input_5_46' type='text' value='' class='medium'      aria-invalid=\"false\"   \/> <\/div><\/li><li id=\"field_5_48\"  class=\"gfield gfield--type-text field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_5_48\"><label class='gfield_label gform-field-label' for='input_5_48' >Medication Name 8<\/label><div class='ginput_container ginput_container_text'><input name='input_48' id='input_5_48' type='text' value='' class='medium'      aria-invalid=\"false\"   \/> <\/div><\/li><li id=\"field_5_49\"  class=\"gfield gfield--type-text field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_5_49\"><label class='gfield_label gform-field-label' for='input_5_49' >Medication Purpose 8<\/label><div class='ginput_container ginput_container_text'><input name='input_49' id='input_5_49' type='text' value='' class='medium'      aria-invalid=\"false\"   \/> <\/div><\/li><li id=\"field_5_50\"  class=\"gfield gfield--type-html gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_5_50\"><h3>Addiction\/Treatment History<\/h3><\/li><li id=\"field_5_51\"  class=\"gfield gfield--type-textarea gfield_contains_required field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_5_51\"><label class='gfield_label gform-field-label' for='input_5_51' >What are the current circumstances that have motivated you to apply to Tamarack Recovery Centre?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_51' id='input_5_51' class='textarea medium'     aria-required=\"true\" aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/li><li id=\"field_5_52\"  class=\"gfield gfield--type-text gfield_contains_required field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_5_52\"><label class='gfield_label gform-field-label' for='input_5_52' >What is your drug of choice?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_52' id='input_5_52' type='text' value='' class='medium'     aria-required=\"true\" aria-invalid=\"false\"   \/> <\/div><\/li><li id=\"field_5_53\"  class=\"gfield gfield--type-date gfield--input-type-datepicker gfield--datepicker-no-icon gfield_contains_required field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_5_53\"><label class='gfield_label gform-field-label' for='input_5_53' >Date last used?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_date'>\n                            <input name='input_53' id='input_5_53' type='text' value='' class='datepicker gform-datepicker mdy datepicker_no_icon gdatepicker-no-icon'   placeholder='mm\/dd\/yyyy' aria-describedby=\"input_5_53_date_format\" aria-invalid=\"false\" aria-required=\"true\"\/>\n                            <span id='input_5_53_date_format' class='screen-reader-text'>MM slash DD slash YYYY<\/span>\n                        <\/div>\n                        <input type='hidden' id='gforms_calendar_icon_input_5_53' class='gform_hidden' value='https:\/\/old.tamarackrecovery.org\/wp-content\/plugins\/gravityforms\/images\/datepicker\/datepicker.svg'\/><\/li><li id=\"field_5_55\"  class=\"gfield gfield--type-textarea field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_5_55\"><label class='gfield_label gform-field-label' for='input_5_55' >Please list other drugs used:<\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_55' id='input_5_55' class='textarea medium'      aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/li><li id=\"field_5_56\"  class=\"gfield gfield--type-text gfield_contains_required field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_5_56\"><label class='gfield_label gform-field-label' for='input_5_56' >How frequently do you typically use substances?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_56' id='input_5_56' type='text' value='' class='medium'     aria-required=\"true\" aria-invalid=\"false\"   \/> <\/div><\/li><li id=\"field_5_57\"  class=\"gfield gfield--type-textarea gfield_contains_required field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_5_57\"><label class='gfield_label gform-field-label' for='input_5_57' >What withdrawal symptoms have you experienced when you have tried to stop using?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_57' id='input_5_57' class='textarea medium'     aria-required=\"true\" aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/li><li id=\"field_5_58\"  class=\"gfield gfield--type-radio gfield--type-choice gfield_contains_required field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_5_58\"><label class='gfield_label gform-field-label'  >Have you ever overdosed (accidentally or otherwise)?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_5_58'>\n\t\t\t<li class='gchoice gchoice_5_58_0'>\n\t\t\t\t<input name='input_58' type='radio' value='Yes'  id='choice_5_58_0'    \/>\n\t\t\t\t<label for='choice_5_58_0' id='label_5_58_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_5_58_1'>\n\t\t\t\t<input name='input_58' type='radio' value='No'  id='choice_5_58_1'    \/>\n\t\t\t\t<label for='choice_5_58_1' id='label_5_58_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_5_59\"  class=\"gfield gfield--type-text field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_5_59\"><label class='gfield_label gform-field-label' for='input_5_59' >On which substance did you overdose?<\/label><div class='ginput_container ginput_container_text'><input name='input_59' id='input_5_59' type='text' value='' class='medium'      aria-invalid=\"false\"   \/> <\/div><\/li><li id=\"field_5_60\"  class=\"gfield gfield--type-text field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_5_60\"><label class='gfield_label gform-field-label' for='input_5_60' >When did you overdoes?<\/label><div class='ginput_container ginput_container_text'><input name='input_60' id='input_5_60' type='text' value='' class='medium'      aria-invalid=\"false\"   \/> <\/div><\/li><li id=\"field_5_61\"  class=\"gfield gfield--type-checkbox gfield--type-choice field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_5_61\"><label class='gfield_label gform-field-label gfield_label_before_complex'  >What other addictive behaviours do you currently struggle or have you struggled with?<\/label><div class='ginput_container ginput_container_checkbox'><ul class='gfield_checkbox' id='input_5_61'><li class='gchoice gchoice_5_61_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_61.1' type='checkbox'  value='Gambling\/Gaming'  id='choice_5_61_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_5_61_1' id='label_5_61_1' class='gform-field-label gform-field-label--type-inline'>Gambling\/Gaming<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_5_61_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_61.2' type='checkbox'  value='Spending'  id='choice_5_61_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_5_61_2' id='label_5_61_2' class='gform-field-label gform-field-label--type-inline'>Spending<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_5_61_3'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_61.3' type='checkbox'  value='Internet'  id='choice_5_61_3'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_5_61_3' id='label_5_61_3' class='gform-field-label gform-field-label--type-inline'>Internet<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_5_61_4'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_61.4' type='checkbox'  value='Food'  id='choice_5_61_4'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_5_61_4' id='label_5_61_4' class='gform-field-label gform-field-label--type-inline'>Food<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_5_61_5'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_61.5' type='checkbox'  value='Sex'  id='choice_5_61_5'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_5_61_5' id='label_5_61_5' class='gform-field-label gform-field-label--type-inline'>Sex<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_5_61_6'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_61.6' type='checkbox'  value='Relationships'  id='choice_5_61_6'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_5_61_6' id='label_5_61_6' class='gform-field-label gform-field-label--type-inline'>Relationships<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_5_61_7'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_61.7' type='checkbox'  value='Other'  id='choice_5_61_7'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_5_61_7' id='label_5_61_7' class='gform-field-label gform-field-label--type-inline'>Other<\/label>\n\t\t\t\t\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_5_62\"  class=\"gfield gfield--type-text field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_5_62\"><label class='gfield_label gform-field-label' for='input_5_62' >other addictive behaviour:<\/label><div class='ginput_container ginput_container_text'><input name='input_62' id='input_5_62' type='text' value='' class='medium'      aria-invalid=\"false\"   \/> <\/div><\/li><li id=\"field_5_63\"  class=\"gfield gfield--type-html gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_5_63\"><h3>Previous Treatment Programs Attended<\/h3><\/li><li id=\"field_5_64\"  class=\"gfield gfield--type-text field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_5_64\"><label class='gfield_label gform-field-label' for='input_5_64' >Previous Treatment Program Name 1<\/label><div class='ginput_container ginput_container_text'><input name='input_64' id='input_5_64' type='text' value='' class='medium'      aria-invalid=\"false\"   \/> <\/div><\/li><li id=\"field_5_65\"  class=\"gfield gfield--type-date gfield--input-type-datepicker gfield--datepicker-no-icon field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_5_65\"><label class='gfield_label gform-field-label' for='input_5_65' >Previous Treatment Program Date 1<\/label><div class='ginput_container ginput_container_date'>\n                            <input name='input_65' id='input_5_65' type='text' value='' class='datepicker gform-datepicker mdy datepicker_no_icon gdatepicker-no-icon'   placeholder='mm\/dd\/yyyy' aria-describedby=\"input_5_65_date_format\" aria-invalid=\"false\" \/>\n                            <span id='input_5_65_date_format' class='screen-reader-text'>MM slash DD slash YYYY<\/span>\n                        <\/div>\n                        <input type='hidden' id='gforms_calendar_icon_input_5_65' class='gform_hidden' value='https:\/\/old.tamarackrecovery.org\/wp-content\/plugins\/gravityforms\/images\/datepicker\/datepicker.svg'\/><\/li><li id=\"field_5_67\"  class=\"gfield gfield--type-checkbox gfield--type-choice field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_5_67\"><label class='gfield_label gform-field-label gfield_label_before_complex'  >Previous Treatment Program 1 &#8211; Complete Program?<\/label><div class='ginput_container ginput_container_checkbox'><ul class='gfield_checkbox' id='input_5_67'><li class='gchoice gchoice_5_67_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_67.1' type='checkbox'  value='Yes'  id='choice_5_67_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_5_67_1' id='label_5_67_1' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_5_67_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_67.2' type='checkbox'  value='No'  id='choice_5_67_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_5_67_2' id='label_5_67_2' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t\t\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_5_66\"  class=\"gfield gfield--type-textarea field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_5_66\"><label class='gfield_label gform-field-label' for='input_5_66' >Previous Treatment Program 1 &#8211; What did you gain?<\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_66' id='input_5_66' class='textarea medium'      aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/li><li id=\"field_5_68\"  class=\"gfield gfield--type-text field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_5_68\"><label class='gfield_label gform-field-label' for='input_5_68' >Previous Treatment Program Name 2<\/label><div class='ginput_container ginput_container_text'><input name='input_68' id='input_5_68' type='text' value='' class='medium'      aria-invalid=\"false\"   \/> <\/div><\/li><li id=\"field_5_69\"  class=\"gfield gfield--type-date gfield--input-type-datepicker gfield--datepicker-no-icon field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_5_69\"><label class='gfield_label gform-field-label' for='input_5_69' >Previous Treatment Program Date 2<\/label><div class='ginput_container ginput_container_date'>\n                            <input name='input_69' id='input_5_69' type='text' value='' class='datepicker gform-datepicker mdy datepicker_no_icon gdatepicker-no-icon'   placeholder='mm\/dd\/yyyy' aria-describedby=\"input_5_69_date_format\" aria-invalid=\"false\" \/>\n                            <span id='input_5_69_date_format' class='screen-reader-text'>MM slash DD slash YYYY<\/span>\n                        <\/div>\n                        <input type='hidden' id='gforms_calendar_icon_input_5_69' class='gform_hidden' value='https:\/\/old.tamarackrecovery.org\/wp-content\/plugins\/gravityforms\/images\/datepicker\/datepicker.svg'\/><\/li><li id=\"field_5_70\"  class=\"gfield gfield--type-checkbox gfield--type-choice field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_5_70\"><label class='gfield_label gform-field-label gfield_label_before_complex'  >Previous Treatment Program 2 &#8211; Complete Program?<\/label><div class='ginput_container ginput_container_checkbox'><ul class='gfield_checkbox' id='input_5_70'><li class='gchoice gchoice_5_70_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_70.1' type='checkbox'  value='Yes'  id='choice_5_70_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_5_70_1' id='label_5_70_1' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_5_70_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_70.2' type='checkbox'  value='No'  id='choice_5_70_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_5_70_2' id='label_5_70_2' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t\t\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_5_71\"  class=\"gfield gfield--type-textarea field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_5_71\"><label class='gfield_label gform-field-label' for='input_5_71' >Previous Treatment Program 2 &#8211; What did you gain?<\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_71' id='input_5_71' class='textarea medium'      aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/li><li id=\"field_5_72\"  class=\"gfield gfield--type-text field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_5_72\"><label class='gfield_label gform-field-label' for='input_5_72' >Previous Treatment Program Name 3<\/label><div class='ginput_container ginput_container_text'><input name='input_72' id='input_5_72' type='text' value='' class='medium'      aria-invalid=\"false\"   \/> <\/div><\/li><li id=\"field_5_73\"  class=\"gfield gfield--type-date gfield--input-type-datepicker gfield--datepicker-no-icon field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_5_73\"><label class='gfield_label gform-field-label' for='input_5_73' >Previous Treatment Program Date 3<\/label><div class='ginput_container ginput_container_date'>\n                            <input name='input_73' id='input_5_73' type='text' value='' class='datepicker gform-datepicker mdy datepicker_no_icon gdatepicker-no-icon'   placeholder='mm\/dd\/yyyy' aria-describedby=\"input_5_73_date_format\" aria-invalid=\"false\" \/>\n                            <span id='input_5_73_date_format' class='screen-reader-text'>MM slash DD slash YYYY<\/span>\n                        <\/div>\n                        <input type='hidden' id='gforms_calendar_icon_input_5_73' class='gform_hidden' value='https:\/\/old.tamarackrecovery.org\/wp-content\/plugins\/gravityforms\/images\/datepicker\/datepicker.svg'\/><\/li><li id=\"field_5_74\"  class=\"gfield gfield--type-checkbox gfield--type-choice field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_5_74\"><label class='gfield_label gform-field-label gfield_label_before_complex'  >Previous Treatment Program 3 &#8211; Complete Program?<\/label><div class='ginput_container ginput_container_checkbox'><ul class='gfield_checkbox' id='input_5_74'><li class='gchoice gchoice_5_74_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_74.1' type='checkbox'  value='Yes'  id='choice_5_74_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_5_74_1' id='label_5_74_1' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_5_74_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_74.2' type='checkbox'  value='No'  id='choice_5_74_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_5_74_2' id='label_5_74_2' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t\t\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_5_75\"  class=\"gfield gfield--type-textarea field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_5_75\"><label class='gfield_label gform-field-label' for='input_5_75' >Previous Treatment Program 3 &#8211; What did you gain?<\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_75' id='input_5_75' class='textarea medium'      aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/li><li id=\"field_5_76\"  class=\"gfield gfield--type-checkbox gfield--type-choice field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_5_76\"><label class='gfield_label gform-field-label gfield_label_before_complex'  >Are Self-Help Groups (e.g. AA\/CA\/Refuge for Recovery\/SOS\/SMART) part of your Recovery Plan?<\/label><div class='ginput_container ginput_container_checkbox'><ul class='gfield_checkbox' id='input_5_76'><li class='gchoice gchoice_5_76_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_76.1' type='checkbox'  value='Yes'  id='choice_5_76_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_5_76_1' id='label_5_76_1' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_5_76_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_76.2' type='checkbox'  value='No'  id='choice_5_76_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_5_76_2' id='label_5_76_2' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t\t\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_5_77\"  class=\"gfield gfield--type-html gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_5_77\"><h3>Legal<\/h3><\/li><li id=\"field_5_78\"  class=\"gfield gfield--type-radio gfield--type-choice gfield_contains_required field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_5_78\"><label class='gfield_label gform-field-label'  >Criminal\/ Civil Charges Pending<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_5_78'>\n\t\t\t<li class='gchoice gchoice_5_78_0'>\n\t\t\t\t<input name='input_78' type='radio' value='Yes'  id='choice_5_78_0'    \/>\n\t\t\t\t<label for='choice_5_78_0' id='label_5_78_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_5_78_1'>\n\t\t\t\t<input name='input_78' type='radio' value='No'  id='choice_5_78_1'    \/>\n\t\t\t\t<label for='choice_5_78_1' id='label_5_78_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_5_79\"  class=\"gfield gfield--type-radio gfield--type-choice gfield_contains_required field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_5_79\"><label class='gfield_label gform-field-label'  >Outstanding Warrants<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_5_79'>\n\t\t\t<li class='gchoice gchoice_5_79_0'>\n\t\t\t\t<input name='input_79' type='radio' value='Yes'  id='choice_5_79_0'    \/>\n\t\t\t\t<label for='choice_5_79_0' id='label_5_79_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_5_79_1'>\n\t\t\t\t<input name='input_79' type='radio' value='No'  id='choice_5_79_1'    \/>\n\t\t\t\t<label for='choice_5_79_1' id='label_5_79_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_5_80\"  class=\"gfield gfield--type-radio gfield--type-choice gfield_contains_required field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_5_80\"><label class='gfield_label gform-field-label'  >Restraining Orders<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_5_80'>\n\t\t\t<li class='gchoice gchoice_5_80_0'>\n\t\t\t\t<input name='input_80' type='radio' value='Yes'  id='choice_5_80_0'    \/>\n\t\t\t\t<label for='choice_5_80_0' id='label_5_80_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_5_80_1'>\n\t\t\t\t<input name='input_80' type='radio' value='No'  id='choice_5_80_1'    \/>\n\t\t\t\t<label for='choice_5_80_1' id='label_5_80_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_5_81\"  class=\"gfield gfield--type-radio gfield--type-choice gfield_contains_required field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_5_81\"><label class='gfield_label gform-field-label'  >Court Hearing Dates<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_5_81'>\n\t\t\t<li class='gchoice gchoice_5_81_0'>\n\t\t\t\t<input name='input_81' type='radio' value='Yes'  id='choice_5_81_0'    \/>\n\t\t\t\t<label for='choice_5_81_0' id='label_5_81_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_5_81_1'>\n\t\t\t\t<input name='input_81' type='radio' value='No'  id='choice_5_81_1'    \/>\n\t\t\t\t<label for='choice_5_81_1' id='label_5_81_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_5_82\"  class=\"gfield gfield--type-radio gfield--type-choice gfield_contains_required field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_5_82\"><label class='gfield_label gform-field-label'  >Bail (probations) Conditions<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_5_82'>\n\t\t\t<li class='gchoice gchoice_5_82_0'>\n\t\t\t\t<input name='input_82' type='radio' value='Yes'  id='choice_5_82_0'    \/>\n\t\t\t\t<label for='choice_5_82_0' id='label_5_82_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_5_82_1'>\n\t\t\t\t<input name='input_82' type='radio' value='No'  id='choice_5_82_1'    \/>\n\t\t\t\t<label for='choice_5_82_1' id='label_5_82_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_5_83\"  class=\"gfield gfield--type-textarea field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_5_83\"><label class='gfield_label gform-field-label' for='input_5_83' >Please provide details of current and past charges as referenced above.<\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_83' id='input_5_83' class='textarea medium'      aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/li><li id=\"field_5_84\"  class=\"gfield gfield--type-html gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_5_84\"><h3>Personal Goals<\/h3><\/li><li id=\"field_5_85\"  class=\"gfield gfield--type-radio gfield--type-choice gfield_contains_required field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_5_85\"><label class='gfield_label gform-field-label'  >At this point in time do you feel that there are any barriers or challenges to you being able to access residential treatment at Tamarack (financial, personal, motivational, mental or physical, for example)?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_5_85'>\n\t\t\t<li class='gchoice gchoice_5_85_0'>\n\t\t\t\t<input name='input_85' type='radio' value='Yes'  id='choice_5_85_0'    \/>\n\t\t\t\t<label for='choice_5_85_0' id='label_5_85_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_5_85_1'>\n\t\t\t\t<input name='input_85' type='radio' value='No'  id='choice_5_85_1'    \/>\n\t\t\t\t<label for='choice_5_85_1' id='label_5_85_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_5_86\"  class=\"gfield gfield--type-textarea field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_5_86\"><label class='gfield_label gform-field-label' for='input_5_86' >Please describe your barriers or challenges<\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_86' id='input_5_86' class='textarea medium'      aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/li><li id=\"field_5_87\"  class=\"gfield gfield--type-textarea field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_5_87\"><label class='gfield_label gform-field-label' for='input_5_87' >What goals would you like to achieve by coming to Tamarack?<\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_87' id='input_5_87' class='textarea medium'      aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/li><li id=\"field_5_88\"  class=\"gfield gfield--type-textarea field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_5_88\"><label class='gfield_label gform-field-label' for='input_5_88' >Is there any additional information you would like us to know?<\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_88' id='input_5_88' class='textarea medium'      aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/li><li id=\"field_5_89\"  class=\"gfield gfield--type-html gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_5_89\"><strong>Please note:<\/strong> We reserve the right to terminate a client\u2019s stay if the information on the application form is later found to be deliberately incorrect or new information emerges that has been deliberately withheld.<\/li><\/ul><\/div>\n        <div class='gform_footer top_label'> <input type='submit' id='gform_submit_button_5' class='gform_button button' value='Submit'  onclick='if(window[\"gf_submitting_5\"]){return false;}  if( 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