{"id":1590,"date":"2024-08-16T07:14:07","date_gmt":"2024-08-16T07:14:07","guid":{"rendered":"https:\/\/vmtc.us\/?page_id=1590"},"modified":"2025-02-06T22:18:25","modified_gmt":"2025-02-06T22:18:25","slug":"session_intake_form","status":"publish","type":"page","link":"https:\/\/www.vmtc.net\/en\/session_intake_form\/","title":{"rendered":"Session Intake"},"content":{"rendered":"<section class=\"l-section wpb_row height_custom\"><div class=\"l-section-h i-cf\"><div class=\"g-cols vc_row via_grid cols_2 laptops-cols_inherit tablets-cols_1 mobiles-cols_1 valign_middle type_default stacking_default\" style=\"--columns-gap:4vw;\"><div class=\"wpb_column vc_column_container us_custom_bdbb4a49\"><div class=\"vc_column-inner\"><div class=\"wpb_text_column us_custom_933613eb\"><div class=\"wpb_wrapper\"><h3 style=\"text-align: center;\">Greater Healing and Freedom in your life!<\/h3>\n<h4 style=\"text-align: center;\" data-pm-slice=\"1 1 &#091;&#093;\">How to Receive a VMTC Prayer Ministry Session<\/h4>\n<p style=\"text-align: left;\">If you are interested in receiving a prayer ministry Session:<\/p>\n<ul style=\"text-align: left;\" data-spread=\"false\">\n<li>Complete the pre-ministry intake form.\u00a0<\/li>\n<li>\n<p>Interview with a released VMTC-trained Prayer Minister.<\/p>\n<\/li>\n<li>\n<p>Schedule the location, date, and time of your ministry session.\u00a0<\/p>\n<\/li>\n<\/ul>\n<p style=\"text-align: left;\">Due to the limited number of trained Prayer Ministers, there may be a waiting period.\u00a0\u00a0<\/p>\n<p style=\"text-align: left;\">Sessions require significant time commitments and must be scheduled in advance. Next-day appointments are not possible.<\/p>\n<p style=\"text-align: left;\">There is no charge for VMTC Prayer Ministry! All trained prayer ministers serve voluntarily.<\/p>\n<\/div><\/div><div class=\"w-separator size_small\"><\/div><\/div><\/div><div class=\"wpb_column vc_column_container\"><div class=\"vc_column-inner\"><div class=\"w-image us_custom_f7999c5b has_ratio align_center\"><div class=\"w-image-h\"><div style=\"padding-bottom:100%\"><\/div><img decoding=\"async\" width=\"1\" height=\"1\" src=\"https:\/\/www.vmtc.net\/wp-content\/uploads\/2024\/08\/small-group-network-_VEYEAxV__0-unsplash.jpg\" class=\"attachment-large size-large\" alt=\"Deliverance ministry, deliverance, prayer, prayer session, spiritual warfare\" loading=\"lazy\" \/><\/div><\/div><\/div><\/div><\/div><\/div><\/section><section class=\"l-section wpb_row height_custom\"><div class=\"l-section-h i-cf\"><div class=\"g-cols vc_row via_grid cols_1 laptops-cols_inherit tablets-cols_inherit mobiles-cols_1 valign_top type_default stacking_default\"><div class=\"wpb_column vc_column_container\"><div class=\"vc_column-inner\"><div class=\"g-cols wpb_row via_grid cols_1 laptops-cols_inherit tablets-cols_inherit mobiles-cols_1 valign_top type_default stacking_default\" style=\"--columns-gap:3rem;\"><div class=\"wpb_column vc_column_container\"><div class=\"vc_column-inner\"><div class=\"wpb_text_column\"><div class=\"wpb_wrapper\"><h2 class=\"fl-heading\" style=\"text-align: center;\"><span class=\"fl-heading-text\">Confidential Prayer Ministry Intake Form<\/span><\/h2>\n<\/div><\/div><\/div><\/div><\/div><style id=\"wpforms-css-vars-1555\">\n\t\t\t\t#wpforms-1555 {\n\t\t\t\t\n\t\t\t}\n\t\t\t<\/style><div class=\"wpforms-container wpforms-container-full wpforms-render-modern\" id=\"wpforms-1555\"><form id=\"wpforms-form-1555\" class=\"wpforms-validate wpforms-form wpforms-ajax-form\" data-formid=\"1555\" method=\"post\" enctype=\"multipart\/form-data\" action=\"\/en\/wp-json\/wp\/v2\/pages\/1590\" data-token=\"93e5902df92c126b7360a6861f008c71\" data-token-time=\"1776199013\"><noscript class=\"wpforms-error-noscript\">Please enable JavaScript in your browser to complete this form.<\/noscript><div id=\"wpforms-error-noscript\" style=\"display: none;\">Please enable JavaScript in your browser to complete this form.<\/div><div class=\"wpforms-page-indicator progress\" data-indicator=\"progress\" data-indicator-color=\"#72b239\" data-scroll=\"1\" role=\"progressbar\" aria-valuenow=\"1\" aria-valuemin=\"1\" aria-valuemax=\"13\" tabindex=\"-1\"><span class=\"wpforms-page-indicator-page-title\" ><\/span><span class=\"wpforms-page-indicator-page-title-sep\" style=\"display:none;\"> - <\/span><span class=\"wpforms-page-indicator-steps\">Step <span class=\"wpforms-page-indicator-steps-current\">1<\/span> of 13<\/span><div class=\"wpforms-page-indicator-page-progress-wrap\"><div class=\"wpforms-page-indicator-page-progress\" style=\"width:7.6923076923077%;background-color:#72b239\"><\/div><\/div><\/div><div class=\"wpforms-field-container\"><div class=\"wpforms-page wpforms-page-1 \" data-page=\"1\"><div id=\"wpforms-1555-field_3-container\" class=\"wpforms-field wpforms-field-pagebreak\" data-field-id=\"3\"><\/div><div id=\"wpforms-1555-field_139-container\" class=\"wpforms-field wpforms-field-content\" data-field-id=\"139\"><div id=\"wpforms-1555-field_139\" class=\"wpforms-field-medium wpforms-field-row\" aria-errormessage=\"wpforms-1555-field_139-error\"><h2>Personal Information<\/h2>\n<p>&nbsp;<\/p>\n<div class=\"wpforms-field-content-display-frontend-clear\"><\/div><\/div><\/div><div id=\"wpforms-1555-field_11-container\" class=\"wpforms-field wpforms-field-date-time\" data-field-id=\"11\"><fieldset><legend class=\"wpforms-field-label\">Date \/ Time<\/legend><div class=\"wpforms-field-row wpforms-field-medium\"><div class=\"wpforms-field-row-block wpforms-date-type-datepicker\"><div class=\"wpforms-datepicker-wrap\"><input type=\"text\" id=\"wpforms-1555-field_11\" class=\"wpforms-field-date-time-date wpforms-datepicker\" data-date-format=\"m\/d\/Y\" data-disable-past-dates=\"0\" data-input=\"true\" name=\"wpforms[fields][11][date]\" aria-errormessage=\"wpforms-1555-field_11-error\" ><a title=\"Clear Date\" data-clear role=\"button\" tabindex=\"0\" class=\"wpforms-datepicker-clear\" aria-label=\"Clear Date\" style=\"display:none;\"><\/a><\/div><label for=\"wpforms-1555-field_11\" class=\"wpforms-field-sublabel after\">Date<\/label><\/div><div class=\"wpforms-field-row-block\"><input type=\"text\" id=\"wpforms-1555-field_11-time\" class=\"wpforms-field-date-time-time wpforms-timepicker\" data-time-format=\"g:i A\" data-step=\"30\" data-rule-time12h=\"true\" name=\"wpforms[fields][11][time]\" aria-errormessage=\"wpforms-1555-field_11-time-error\" ><label for=\"wpforms-1555-field_11-time\" class=\"wpforms-field-sublabel after\">Time<\/label><\/div><\/div><\/fieldset><\/div><div id=\"wpforms-1555-field_0-container\" class=\"wpforms-field wpforms-field-name\" data-field-id=\"0\"><fieldset><legend class=\"wpforms-field-label\">Name <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/legend><div class=\"wpforms-field-row wpforms-field-medium\"><div class=\"wpforms-field-row-block wpforms-first wpforms-one-half\"><input type=\"text\" id=\"wpforms-1555-field_0\" class=\"wpforms-field-name-first wpforms-field-required\" name=\"wpforms[fields][0][first]\" aria-errormessage=\"wpforms-1555-field_0-error\" required><label for=\"wpforms-1555-field_0\" class=\"wpforms-field-sublabel after\">First<\/label><\/div><div class=\"wpforms-field-row-block wpforms-one-half\"><input type=\"text\" id=\"wpforms-1555-field_0-last\" class=\"wpforms-field-name-last wpforms-field-required\" name=\"wpforms[fields][0][last]\" aria-errormessage=\"wpforms-1555-field_0-last-error\" required><label for=\"wpforms-1555-field_0-last\" class=\"wpforms-field-sublabel after\">Last<\/label><\/div><\/div><\/fieldset><\/div><div id=\"wpforms-1555-field_10-container\" class=\"wpforms-field wpforms-field-address\" data-field-id=\"10\"><fieldset><legend class=\"wpforms-field-label\">Address<\/legend><div class=\"wpforms-field-row wpforms-field-medium\"><div ><input type=\"text\" id=\"wpforms-1555-field_10\" class=\"wpforms-field-address-address1\" name=\"wpforms[fields][10][address1]\" aria-errormessage=\"wpforms-1555-field_10-error\" ><label for=\"wpforms-1555-field_10\" class=\"wpforms-field-sublabel after\">Address Line 1<\/label><\/div><\/div><div class=\"wpforms-field-row wpforms-field-medium\"><div ><input type=\"text\" id=\"wpforms-1555-field_10-address2\" class=\"wpforms-field-address-address2\" name=\"wpforms[fields][10][address2]\" aria-errormessage=\"wpforms-1555-field_10-address2-error\" ><label for=\"wpforms-1555-field_10-address2\" class=\"wpforms-field-sublabel after\">Address Line 2<\/label><\/div><\/div><div class=\"wpforms-field-row wpforms-field-medium\"><div class=\"wpforms-field-row-block wpforms-one-half wpforms-first\"><input type=\"text\" id=\"wpforms-1555-field_10-city\" class=\"wpforms-field-address-city\" name=\"wpforms[fields][10][city]\" aria-errormessage=\"wpforms-1555-field_10-city-error\" ><label for=\"wpforms-1555-field_10-city\" class=\"wpforms-field-sublabel after\">City<\/label><\/div><div class=\"wpforms-field-row-block wpforms-one-half\"><select id=\"wpforms-1555-field_10-state\" class=\"wpforms-field-address-state\" name=\"wpforms[fields][10][state]\" aria-errormessage=\"wpforms-1555-field_10-state-error\" ><option class=\"placeholder\" value=\"\" selected disabled>--- Select state ---<\/option><option value=\"AL\" >Alabama<\/option><option value=\"AK\" >Alaska<\/option><option value=\"AZ\" >Arizona<\/option><option value=\"AR\" >Arkansas<\/option><option value=\"CA\" >California<\/option><option value=\"CO\" >Colorado<\/option><option value=\"CT\" >Connecticut<\/option><option value=\"DE\" >Delaware<\/option><option value=\"DC\" >District of Columbia<\/option><option value=\"FL\" >Florida<\/option><option value=\"GA\" >Georgia<\/option><option value=\"HI\" >Hawaii<\/option><option value=\"ID\" >Idaho<\/option><option value=\"IL\" >Illinois<\/option><option value=\"IN\" >Indiana<\/option><option value=\"IA\" >Iowa<\/option><option value=\"KS\" >Kansas<\/option><option value=\"KY\" >Kentucky<\/option><option value=\"LA\" >Louisiana<\/option><option value=\"ME\" >Maine<\/option><option value=\"MD\" >Maryland<\/option><option value=\"MA\" >Massachusetts<\/option><option value=\"MI\" >Michigan<\/option><option value=\"MN\" >Minnesota<\/option><option value=\"MS\" >Mississippi<\/option><option value=\"MO\" >Missouri<\/option><option value=\"MT\" >Montana<\/option><option value=\"NE\" >Nebraska<\/option><option value=\"NV\" >Nevada<\/option><option value=\"NH\" >New Hampshire<\/option><option value=\"NJ\" >New Jersey<\/option><option value=\"NM\" >New Mexico<\/option><option value=\"NY\" >New York<\/option><option value=\"NC\" >North Carolina<\/option><option value=\"ND\" >North Dakota<\/option><option value=\"OH\" >Ohio<\/option><option value=\"OK\" >Oklahoma<\/option><option value=\"OR\" >Oregon<\/option><option value=\"PA\" >Pennsylvania<\/option><option value=\"RI\" >Rhode Island<\/option><option value=\"SC\" >South Carolina<\/option><option value=\"SD\" >South Dakota<\/option><option value=\"TN\" >Tennessee<\/option><option value=\"TX\" >Texas<\/option><option value=\"UT\" >Utah<\/option><option value=\"VT\" >Vermont<\/option><option value=\"VA\" >Virginia<\/option><option value=\"WA\" >Washington<\/option><option value=\"WV\" >West Virginia<\/option><option value=\"WI\" >Wisconsin<\/option><option value=\"WY\" >Wyoming<\/option><\/select><label for=\"wpforms-1555-field_10-state\" class=\"wpforms-field-sublabel after\">State<\/label><\/div><\/div><div class=\"wpforms-field-row wpforms-field-medium\"><div class=\"wpforms-field-row-block wpforms-one-half wpforms-first\"><input type=\"text\" id=\"wpforms-1555-field_10-postal\" class=\"wpforms-field-address-postal wpforms-masked-input\" data-inputmask-mask=\"(99999)|(99999-9999)\" data-inputmask-keepstatic=\"true\" data-rule-inputmask-incomplete=\"1\" name=\"wpforms[fields][10][postal]\" aria-errormessage=\"wpforms-1555-field_10-postal-error\" ><label for=\"wpforms-1555-field_10-postal\" class=\"wpforms-field-sublabel after\">Zip Code<\/label><\/div><\/div><\/fieldset><\/div><div id=\"wpforms-1555-field_1-container\" class=\"wpforms-field wpforms-field-email\" data-field-id=\"1\"><label class=\"wpforms-field-label\" for=\"wpforms-1555-field_1\">Email <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/label><input type=\"email\" id=\"wpforms-1555-field_1\" class=\"wpforms-field-medium wpforms-field-required\" name=\"wpforms[fields][1]\" spellcheck=\"false\" aria-errormessage=\"wpforms-1555-field_1-error\" required><\/div><div id=\"wpforms-1555-field_12-container\" class=\"wpforms-field wpforms-field-phone\" data-field-id=\"12\"><label class=\"wpforms-field-label\" for=\"wpforms-1555-field_12\">Phone<\/label><input type=\"tel\" id=\"wpforms-1555-field_12\" class=\"wpforms-field-medium wpforms-smart-phone-field\" data-rule-smart-phone-field=\"true\" name=\"wpforms[fields][12]\" aria-label=\"Phone\" aria-errormessage=\"wpforms-1555-field_12-error\" ><\/div><div id=\"wpforms-1555-field_14-container\" class=\"wpforms-field wpforms-field-checkbox\" data-field-id=\"14\"><fieldset><legend class=\"wpforms-field-label\">Biological Gender<\/legend><ul id=\"wpforms-1555-field_14\"><li class=\"choice-1 depth-1\"><input type=\"checkbox\" id=\"wpforms-1555-field_14_1\" name=\"wpforms[fields][14][]\" value=\"Male\" aria-errormessage=\"wpforms-1555-field_14_1-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-1555-field_14_1\">Male<\/label><\/li><li class=\"choice-2 depth-1\"><input type=\"checkbox\" id=\"wpforms-1555-field_14_2\" name=\"wpforms[fields][14][]\" value=\"Female\" aria-errormessage=\"wpforms-1555-field_14_2-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-1555-field_14_2\">Female<\/label><\/li><\/ul><\/fieldset><\/div><div id=\"wpforms-1555-field_15-container\" class=\"wpforms-field wpforms-field-checkbox\" data-field-id=\"15\"><fieldset><legend class=\"wpforms-field-label\">Do you attend Church?<\/legend><ul id=\"wpforms-1555-field_15\"><li class=\"choice-1 depth-1\"><input type=\"checkbox\" id=\"wpforms-1555-field_15_1\" name=\"wpforms[fields][15][]\" value=\"Yes\" aria-errormessage=\"wpforms-1555-field_15_1-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-1555-field_15_1\">Yes<\/label><\/li><li class=\"choice-2 depth-1\"><input type=\"checkbox\" id=\"wpforms-1555-field_15_2\" name=\"wpforms[fields][15][]\" value=\"No\" aria-errormessage=\"wpforms-1555-field_15_2-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-1555-field_15_2\">No<\/label><\/li><\/ul><\/fieldset><\/div><div id=\"wpforms-1555-field_17-container\" class=\"wpforms-field wpforms-field-text\" data-field-id=\"17\"><label class=\"wpforms-field-label\" for=\"wpforms-1555-field_17\">If &quot;YES&quot; which church<\/label><input type=\"text\" id=\"wpforms-1555-field_17\" class=\"wpforms-field-medium\" name=\"wpforms[fields][17]\" aria-errormessage=\"wpforms-1555-field_17-error\" ><\/div><div id=\"wpforms-1555-field_140-container\" class=\"wpforms-field wpforms-field-pagebreak\" data-field-id=\"140\"><div class=\"wpforms-clear wpforms-pagebreak-left\"><button class=\"wpforms-page-button wpforms-page-next wpforms-disabled\"\n\t\t\t\t\tdata-action=\"next\" data-page=\"1\" data-formid=\"1555\" aria-disabled=\"true\" aria-describedby=\"wpforms-error-noscript\">Next<\/button><\/div><\/div><\/div><div class=\"wpforms-page wpforms-page-2  \" data-page=\"2\" style=\"display:none;\"><div id=\"wpforms-1555-field_141-container\" class=\"wpforms-field wpforms-field-content\" data-field-id=\"141\"><div id=\"wpforms-1555-field_141\" class=\"wpforms-field-medium wpforms-field-row\" aria-errormessage=\"wpforms-1555-field_141-error\"><h2 class=\"gsection_title\">Ministry Expectations<\/h2>\n<p>&nbsp;<\/p>\n<div class=\"wpforms-field-content-display-frontend-clear\"><\/div><\/div><\/div><div id=\"wpforms-1555-field_19-container\" class=\"wpforms-field wpforms-field-checkbox\" data-field-id=\"19\"><fieldset><legend class=\"wpforms-field-label\">Which of the following best describes the sense of urgency you feel?<\/legend><ul id=\"wpforms-1555-field_19\"><li class=\"choice-1 depth-1\"><input type=\"checkbox\" id=\"wpforms-1555-field_19_1\" name=\"wpforms[fields][19][]\" value=\"Regularly fear what I may do to myself or others\" aria-errormessage=\"wpforms-1555-field_19_1-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-1555-field_19_1\">Regularly fear what I may do to myself or others<\/label><\/li><li class=\"choice-2 depth-1\"><input type=\"checkbox\" id=\"wpforms-1555-field_19_2\" name=\"wpforms[fields][19][]\" value=\"Sometimes fear what I may do to myself or others\" aria-errormessage=\"wpforms-1555-field_19_2-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-1555-field_19_2\">Sometimes fear what I may do to myself or others<\/label><\/li><li class=\"choice-3 depth-1\"><input type=\"checkbox\" id=\"wpforms-1555-field_19_3\" name=\"wpforms[fields][19][]\" value=\"Struggling a great deal, please help soon\" aria-errormessage=\"wpforms-1555-field_19_3-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-1555-field_19_3\">Struggling a great deal, please help soon<\/label><\/li><li class=\"choice-4 depth-1\"><input type=\"checkbox\" id=\"wpforms-1555-field_19_4\" name=\"wpforms[fields][19][]\" value=\"Interested in help whenever it is available\" aria-errormessage=\"wpforms-1555-field_19_4-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-1555-field_19_4\">Interested in help whenever it is available<\/label><\/li><li class=\"choice-5 depth-1\"><input type=\"checkbox\" id=\"wpforms-1555-field_19_5\" name=\"wpforms[fields][19][]\" value=\"Interested in going through Spiritual Warfare Bootcamp for my own growth, but am in no hurry\" aria-errormessage=\"wpforms-1555-field_19_5-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-1555-field_19_5\">Interested in going through Spiritual Warfare Bootcamp for my own growth, but am in no hurry<\/label><\/li><\/ul><\/fieldset><\/div><div id=\"wpforms-1555-field_6-container\" class=\"wpforms-field wpforms-field-text\" data-field-id=\"6\"><label class=\"wpforms-field-label\" for=\"wpforms-1555-field_6\">Why are you seeking ministry for yourself? <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/label><input type=\"text\" id=\"wpforms-1555-field_6\" class=\"wpforms-field-medium wpforms-field-required\" name=\"wpforms[fields][6]\" aria-errormessage=\"wpforms-1555-field_6-error\" required><\/div><div id=\"wpforms-1555-field_20-container\" class=\"wpforms-field wpforms-field-text\" data-field-id=\"20\"><label class=\"wpforms-field-label\" for=\"wpforms-1555-field_20\">What are your expectations and desires for receiving deliverance ministry? <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/label><input type=\"text\" id=\"wpforms-1555-field_20\" class=\"wpforms-field-medium wpforms-field-required\" name=\"wpforms[fields][20]\" aria-errormessage=\"wpforms-1555-field_20-error\" required><\/div><div id=\"wpforms-1555-field_21-container\" class=\"wpforms-field wpforms-field-text\" data-field-id=\"21\"><label class=\"wpforms-field-label\" for=\"wpforms-1555-field_21\">Describe any past issues that you have overcome. If this does not apply to you, please write &quot;not applicable.&quot; <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/label><input type=\"text\" id=\"wpforms-1555-field_21\" class=\"wpforms-field-medium wpforms-field-required\" name=\"wpforms[fields][21]\" aria-errormessage=\"wpforms-1555-field_21-error\" required><\/div><div id=\"wpforms-1555-field_22-container\" class=\"wpforms-field wpforms-field-text\" data-field-id=\"22\"><label class=\"wpforms-field-label\" for=\"wpforms-1555-field_22\">How did you hear about Spiritual Warfare Academy? <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/label><input type=\"text\" id=\"wpforms-1555-field_22\" class=\"wpforms-field-medium wpforms-field-required\" name=\"wpforms[fields][22]\" aria-errormessage=\"wpforms-1555-field_22-error\" required><\/div><div id=\"wpforms-1555-field_24-container\" class=\"wpforms-field wpforms-field-checkbox\" data-field-id=\"24\"><fieldset><legend class=\"wpforms-field-label\">Have you ever received professional counseling in the past?<\/legend><ul id=\"wpforms-1555-field_24\"><li class=\"choice-1 depth-1\"><input type=\"checkbox\" id=\"wpforms-1555-field_24_1\" name=\"wpforms[fields][24][]\" value=\"yes\" aria-errormessage=\"wpforms-1555-field_24_1-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-1555-field_24_1\">yes<\/label><\/li><li class=\"choice-2 depth-1\"><input type=\"checkbox\" id=\"wpforms-1555-field_24_2\" name=\"wpforms[fields][24][]\" value=\"no\" aria-errormessage=\"wpforms-1555-field_24_2-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-1555-field_24_2\">no<\/label><\/li><\/ul><\/fieldset><\/div><div id=\"wpforms-1555-field_29-container\" class=\"wpforms-field wpforms-field-text\" data-field-id=\"29\"><label class=\"wpforms-field-label\" for=\"wpforms-1555-field_29\">If yes when, where, and for how long? <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/label><input type=\"text\" id=\"wpforms-1555-field_29\" class=\"wpforms-field-medium wpforms-field-required\" name=\"wpforms[fields][29]\" aria-errormessage=\"wpforms-1555-field_29-error\" required><\/div><div id=\"wpforms-1555-field_30-container\" class=\"wpforms-field wpforms-field-checkbox\" data-field-id=\"30\"><fieldset><legend class=\"wpforms-field-label\">Are you currently receiving professional counseling?<\/legend><ul id=\"wpforms-1555-field_30\"><li class=\"choice-1 depth-1\"><input type=\"checkbox\" id=\"wpforms-1555-field_30_1\" name=\"wpforms[fields][30][]\" value=\"yes\" aria-errormessage=\"wpforms-1555-field_30_1-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-1555-field_30_1\">yes<\/label><\/li><li class=\"choice-2 depth-1\"><input type=\"checkbox\" id=\"wpforms-1555-field_30_2\" name=\"wpforms[fields][30][]\" value=\"no\" aria-errormessage=\"wpforms-1555-field_30_2-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-1555-field_30_2\">no<\/label><\/li><\/ul><\/fieldset><\/div><div id=\"wpforms-1555-field_26-container\" class=\"wpforms-field wpforms-field-checkbox\" data-field-id=\"26\"><fieldset><legend class=\"wpforms-field-label\">Have you ever received deliverance ministry?<\/legend><ul id=\"wpforms-1555-field_26\"><li class=\"choice-1 depth-1\"><input type=\"checkbox\" id=\"wpforms-1555-field_26_1\" name=\"wpforms[fields][26][]\" value=\"yes\" aria-errormessage=\"wpforms-1555-field_26_1-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-1555-field_26_1\">yes<\/label><\/li><li class=\"choice-2 depth-1\"><input type=\"checkbox\" id=\"wpforms-1555-field_26_2\" name=\"wpforms[fields][26][]\" value=\"no\" aria-errormessage=\"wpforms-1555-field_26_2-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-1555-field_26_2\">no<\/label><\/li><\/ul><\/fieldset><\/div><div id=\"wpforms-1555-field_32-container\" class=\"wpforms-field wpforms-field-text\" data-field-id=\"32\"><label class=\"wpforms-field-label\" for=\"wpforms-1555-field_32\">If  yes, with whom and when<\/label><input type=\"text\" id=\"wpforms-1555-field_32\" class=\"wpforms-field-medium\" name=\"wpforms[fields][32]\" aria-errormessage=\"wpforms-1555-field_32-error\" ><\/div><div id=\"wpforms-1555-field_27-container\" class=\"wpforms-field wpforms-field-checkbox\" data-field-id=\"27\"><fieldset><legend class=\"wpforms-field-label\">Have you ever received prayer ministry the Spiritual Warfare Academy?<\/legend><ul id=\"wpforms-1555-field_27\"><li class=\"choice-1 depth-1\"><input type=\"checkbox\" id=\"wpforms-1555-field_27_1\" name=\"wpforms[fields][27][]\" value=\"yes\" aria-errormessage=\"wpforms-1555-field_27_1-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-1555-field_27_1\">yes<\/label><\/li><li class=\"choice-2 depth-1\"><input type=\"checkbox\" id=\"wpforms-1555-field_27_2\" name=\"wpforms[fields][27][]\" value=\"no\" aria-errormessage=\"wpforms-1555-field_27_2-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-1555-field_27_2\">no<\/label><\/li><\/ul><\/fieldset><\/div><div id=\"wpforms-1555-field_33-container\" class=\"wpforms-field wpforms-field-text\" data-field-id=\"33\"><label class=\"wpforms-field-label\" for=\"wpforms-1555-field_33\">If yes, what was it for and what was the outcome?<\/label><input type=\"text\" id=\"wpforms-1555-field_33\" class=\"wpforms-field-medium\" name=\"wpforms[fields][33]\" aria-errormessage=\"wpforms-1555-field_33-error\" ><\/div><div id=\"wpforms-1555-field_28-container\" class=\"wpforms-field wpforms-field-text\" data-field-id=\"28\"><label class=\"wpforms-field-label\" for=\"wpforms-1555-field_28\">Briefly describe any other previous personal ministry that you have received including when, for what, with whom and the outcome. <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/label><input type=\"text\" id=\"wpforms-1555-field_28\" class=\"wpforms-field-medium wpforms-field-required\" name=\"wpforms[fields][28]\" aria-errormessage=\"wpforms-1555-field_28-error\" required><\/div><div id=\"wpforms-1555-field_142-container\" class=\"wpforms-field wpforms-field-pagebreak\" data-field-id=\"142\"><div class=\"wpforms-clear wpforms-pagebreak-left\"><button class=\"wpforms-page-button wpforms-page-next wpforms-disabled\"\n\t\t\t\t\tdata-action=\"next\" data-page=\"2\" data-formid=\"1555\" aria-disabled=\"true\" aria-describedby=\"wpforms-error-noscript\">Next<\/button><\/div><\/div><\/div><div class=\"wpforms-page wpforms-page-3  \" data-page=\"3\" style=\"display:none;\"><div id=\"wpforms-1555-field_143-container\" class=\"wpforms-field wpforms-field-content\" data-field-id=\"143\"><div id=\"wpforms-1555-field_143\" class=\"wpforms-field-medium wpforms-field-row\" aria-errormessage=\"wpforms-1555-field_143-error\"><h2>Spiritual Information<\/h2>\n<p>&nbsp;<\/p>\n<div class=\"wpforms-field-content-display-frontend-clear\"><\/div><\/div><\/div><div id=\"wpforms-1555-field_35-container\" class=\"wpforms-field wpforms-field-checkbox\" data-field-id=\"35\"><fieldset><legend class=\"wpforms-field-label\">Do you have a personal relationship with Jesus Christ?<\/legend><ul id=\"wpforms-1555-field_35\"><li class=\"choice-1 depth-1\"><input type=\"checkbox\" id=\"wpforms-1555-field_35_1\" name=\"wpforms[fields][35][]\" value=\"yes\" aria-errormessage=\"wpforms-1555-field_35_1-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-1555-field_35_1\">yes<\/label><\/li><li class=\"choice-2 depth-1\"><input type=\"checkbox\" id=\"wpforms-1555-field_35_2\" name=\"wpforms[fields][35][]\" value=\"no\" aria-errormessage=\"wpforms-1555-field_35_2-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-1555-field_35_2\">no<\/label><\/li><\/ul><\/fieldset><\/div><div id=\"wpforms-1555-field_49-container\" class=\"wpforms-field wpforms-field-text\" data-field-id=\"49\"><label class=\"wpforms-field-label\" for=\"wpforms-1555-field_49\">If yes, how long?<\/label><input type=\"text\" id=\"wpforms-1555-field_49\" class=\"wpforms-field-medium\" name=\"wpforms[fields][49]\" aria-errormessage=\"wpforms-1555-field_49-error\" ><\/div><div id=\"wpforms-1555-field_50-container\" class=\"wpforms-field wpforms-field-text\" data-field-id=\"50\"><label class=\"wpforms-field-label\" for=\"wpforms-1555-field_50\">Briefly describe your conversion experience.<\/label><input type=\"text\" id=\"wpforms-1555-field_50\" class=\"wpforms-field-medium\" name=\"wpforms[fields][50]\" aria-errormessage=\"wpforms-1555-field_50-error\" ><\/div><div id=\"wpforms-1555-field_36-container\" class=\"wpforms-field wpforms-field-checkbox\" data-field-id=\"36\"><fieldset><legend class=\"wpforms-field-label\">Have you ever been water baptized?<\/legend><ul id=\"wpforms-1555-field_36\"><li class=\"choice-1 depth-1\"><input type=\"checkbox\" id=\"wpforms-1555-field_36_1\" name=\"wpforms[fields][36][]\" value=\"yes\" aria-errormessage=\"wpforms-1555-field_36_1-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-1555-field_36_1\">yes<\/label><\/li><li class=\"choice-2 depth-1\"><input type=\"checkbox\" id=\"wpforms-1555-field_36_2\" name=\"wpforms[fields][36][]\" value=\"no\" aria-errormessage=\"wpforms-1555-field_36_2-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-1555-field_36_2\">no<\/label><\/li><\/ul><\/fieldset><\/div><div id=\"wpforms-1555-field_37-container\" class=\"wpforms-field wpforms-field-checkbox\" data-field-id=\"37\"><fieldset><legend class=\"wpforms-field-label\">Do you have assurance of your salvation?<\/legend><ul id=\"wpforms-1555-field_37\"><li class=\"choice-1 depth-1\"><input type=\"checkbox\" id=\"wpforms-1555-field_37_1\" name=\"wpforms[fields][37][]\" value=\"yes\" aria-errormessage=\"wpforms-1555-field_37_1-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-1555-field_37_1\">yes<\/label><\/li><li class=\"choice-2 depth-1\"><input type=\"checkbox\" id=\"wpforms-1555-field_37_2\" name=\"wpforms[fields][37][]\" value=\"no\" aria-errormessage=\"wpforms-1555-field_37_2-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-1555-field_37_2\">no<\/label><\/li><\/ul><\/fieldset><\/div><div id=\"wpforms-1555-field_51-container\" class=\"wpforms-field wpforms-field-text\" data-field-id=\"51\"><label class=\"wpforms-field-label\" for=\"wpforms-1555-field_51\">If no, briefly explain<\/label><input type=\"text\" id=\"wpforms-1555-field_51\" class=\"wpforms-field-medium\" name=\"wpforms[fields][51]\" aria-errormessage=\"wpforms-1555-field_51-error\" ><\/div><div id=\"wpforms-1555-field_38-container\" class=\"wpforms-field wpforms-field-text\" data-field-id=\"38\"><label class=\"wpforms-field-label\" for=\"wpforms-1555-field_38\">Describe spiritual disciplines in your life (quiet time, prayer, the Word, fellowship).<\/label><input type=\"text\" id=\"wpforms-1555-field_38\" class=\"wpforms-field-medium\" name=\"wpforms[fields][38]\" aria-errormessage=\"wpforms-1555-field_38-error\" ><\/div><div id=\"wpforms-1555-field_39-container\" class=\"wpforms-field wpforms-field-text\" data-field-id=\"39\"><label class=\"wpforms-field-label\" for=\"wpforms-1555-field_39\">What is your church background? Include denominations and\/or church experience.<\/label><input type=\"text\" id=\"wpforms-1555-field_39\" class=\"wpforms-field-medium\" name=\"wpforms[fields][39]\" aria-errormessage=\"wpforms-1555-field_39-error\" ><\/div><div id=\"wpforms-1555-field_40-container\" class=\"wpforms-field wpforms-field-checkbox\" data-field-id=\"40\"><fieldset><legend class=\"wpforms-field-label\">Are you currently involved in a church?<\/legend><ul id=\"wpforms-1555-field_40\"><li class=\"choice-1 depth-1\"><input type=\"checkbox\" id=\"wpforms-1555-field_40_1\" name=\"wpforms[fields][40][]\" value=\"yes\" aria-errormessage=\"wpforms-1555-field_40_1-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-1555-field_40_1\">yes<\/label><\/li><li class=\"choice-2 depth-1\"><input type=\"checkbox\" id=\"wpforms-1555-field_40_2\" name=\"wpforms[fields][40][]\" value=\"no\" aria-errormessage=\"wpforms-1555-field_40_2-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-1555-field_40_2\">no<\/label><\/li><\/ul><\/fieldset><\/div><div id=\"wpforms-1555-field_41-container\" class=\"wpforms-field wpforms-field-text\" data-field-id=\"41\"><label class=\"wpforms-field-label\" for=\"wpforms-1555-field_41\">Please describe your involvement (leadership, volunteering, attendance, small groups, etc.).<\/label><input type=\"text\" id=\"wpforms-1555-field_41\" class=\"wpforms-field-medium\" name=\"wpforms[fields][41]\" aria-errormessage=\"wpforms-1555-field_41-error\" ><\/div><div id=\"wpforms-1555-field_42-container\" class=\"wpforms-field wpforms-field-checkbox\" data-field-id=\"42\"><fieldset><legend class=\"wpforms-field-label\">Do you find prayer difficult?<\/legend><ul id=\"wpforms-1555-field_42\"><li class=\"choice-1 depth-1\"><input type=\"checkbox\" id=\"wpforms-1555-field_42_1\" name=\"wpforms[fields][42][]\" value=\"yes\" aria-errormessage=\"wpforms-1555-field_42_1-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-1555-field_42_1\">yes<\/label><\/li><li class=\"choice-2 depth-1\"><input type=\"checkbox\" id=\"wpforms-1555-field_42_2\" name=\"wpforms[fields][42][]\" value=\"no\" aria-errormessage=\"wpforms-1555-field_42_2-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-1555-field_42_2\">no<\/label><\/li><\/ul><\/fieldset><\/div><div id=\"wpforms-1555-field_44-container\" class=\"wpforms-field wpforms-field-text\" data-field-id=\"44\"><label class=\"wpforms-field-label\" for=\"wpforms-1555-field_44\">IF yes, please explain.<\/label><input type=\"text\" id=\"wpforms-1555-field_44\" class=\"wpforms-field-medium\" name=\"wpforms[fields][44]\" aria-errormessage=\"wpforms-1555-field_44-error\" ><\/div><div id=\"wpforms-1555-field_46-container\" class=\"wpforms-field wpforms-field-checkbox\" data-field-id=\"46\"><fieldset><legend class=\"wpforms-field-label\">Are you plagued with envy, jealousies, and other mental harassments when attending church or Christian gatherings?<\/legend><ul id=\"wpforms-1555-field_46\"><li class=\"choice-1 depth-1\"><input type=\"checkbox\" id=\"wpforms-1555-field_46_1\" name=\"wpforms[fields][46][]\" value=\"yes\" aria-errormessage=\"wpforms-1555-field_46_1-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-1555-field_46_1\">yes<\/label><\/li><li class=\"choice-2 depth-1\"><input type=\"checkbox\" id=\"wpforms-1555-field_46_2\" name=\"wpforms[fields][46][]\" value=\"no\" aria-errormessage=\"wpforms-1555-field_46_2-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-1555-field_46_2\">no<\/label><\/li><\/ul><\/fieldset><\/div><div id=\"wpforms-1555-field_144-container\" class=\"wpforms-field wpforms-field-textarea\" data-field-id=\"144\"><label class=\"wpforms-field-label\" for=\"wpforms-1555-field_144\">If yes, please explain.<\/label><textarea id=\"wpforms-1555-field_144\" class=\"wpforms-field-medium\" name=\"wpforms[fields][144]\" aria-errormessage=\"wpforms-1555-field_144-error\" ><\/textarea><\/div><div id=\"wpforms-1555-field_2-container\" class=\"wpforms-field wpforms-field-pagebreak\" data-field-id=\"2\"><div class=\"wpforms-clear wpforms-pagebreak-left\"><button class=\"wpforms-page-button wpforms-page-next wpforms-disabled\"\n\t\t\t\t\tdata-action=\"next\" data-page=\"3\" data-formid=\"1555\" aria-disabled=\"true\" aria-describedby=\"wpforms-error-noscript\">Next<\/button><\/div><\/div><\/div><div class=\"wpforms-page wpforms-page-4  \" data-page=\"4\" style=\"display:none;\"><div id=\"wpforms-1555-field_145-container\" class=\"wpforms-field wpforms-field-content\" data-field-id=\"145\"><div id=\"wpforms-1555-field_145\" class=\"wpforms-field-medium wpforms-field-row\" aria-errormessage=\"wpforms-1555-field_145-error\"><h2 class=\"gsection_title\">Health Information<\/h2>\n<p>&nbsp;<\/p>\n<div class=\"wpforms-field-content-display-frontend-clear\"><\/div><\/div><\/div><div id=\"wpforms-1555-field_52-container\" class=\"wpforms-field wpforms-field-text\" data-field-id=\"52\"><label class=\"wpforms-field-label\" for=\"wpforms-1555-field_52\">Please list any medication that you are currently taking If this does not apply to you, please write &quot;none.&quot;. <\/label><input type=\"text\" id=\"wpforms-1555-field_52\" class=\"wpforms-field-medium\" name=\"wpforms[fields][52]\" aria-errormessage=\"wpforms-1555-field_52-error\" ><\/div><div id=\"wpforms-1555-field_53-container\" class=\"wpforms-field wpforms-field-text\" data-field-id=\"53\"><label class=\"wpforms-field-label\" for=\"wpforms-1555-field_53\">Describe your eating habits. Do you eat regularly or sporadically? Do you have a balanced diet?<\/label><input type=\"text\" id=\"wpforms-1555-field_53\" class=\"wpforms-field-medium\" name=\"wpforms[fields][53]\" aria-errormessage=\"wpforms-1555-field_53-error\" ><\/div><div id=\"wpforms-1555-field_54-container\" class=\"wpforms-field wpforms-field-checkbox\" data-field-id=\"54\"><fieldset><legend class=\"wpforms-field-label\">Do you exercise?<\/legend><ul id=\"wpforms-1555-field_54\"><li class=\"choice-1 depth-1\"><input type=\"checkbox\" id=\"wpforms-1555-field_54_1\" name=\"wpforms[fields][54][]\" value=\"yes\" aria-errormessage=\"wpforms-1555-field_54_1-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-1555-field_54_1\">yes<\/label><\/li><li class=\"choice-2 depth-1\"><input type=\"checkbox\" id=\"wpforms-1555-field_54_2\" name=\"wpforms[fields][54][]\" value=\"no\" aria-errormessage=\"wpforms-1555-field_54_2-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-1555-field_54_2\">no<\/label><\/li><\/ul><\/fieldset><\/div><div id=\"wpforms-1555-field_55-container\" class=\"wpforms-field wpforms-field-text\" data-field-id=\"55\"><label class=\"wpforms-field-label\" for=\"wpforms-1555-field_55\">If yes, how often and what type?<\/label><input type=\"text\" id=\"wpforms-1555-field_55\" class=\"wpforms-field-medium\" name=\"wpforms[fields][55]\" aria-errormessage=\"wpforms-1555-field_55-error\" ><\/div><div id=\"wpforms-1555-field_56-container\" class=\"wpforms-field wpforms-field-checkbox\" data-field-id=\"56\"><fieldset><legend class=\"wpforms-field-label\">Do you get regular rest and sleep?<\/legend><ul id=\"wpforms-1555-field_56\"><li class=\"choice-1 depth-1\"><input type=\"checkbox\" id=\"wpforms-1555-field_56_1\" name=\"wpforms[fields][56][]\" value=\"yes\" aria-errormessage=\"wpforms-1555-field_56_1-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-1555-field_56_1\">yes<\/label><\/li><li class=\"choice-2 depth-1\"><input type=\"checkbox\" id=\"wpforms-1555-field_56_2\" name=\"wpforms[fields][56][]\" value=\"no\" aria-errormessage=\"wpforms-1555-field_56_2-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-1555-field_56_2\">no<\/label><\/li><\/ul><\/fieldset><\/div><div id=\"wpforms-1555-field_57-container\" class=\"wpforms-field wpforms-field-checkbox\" data-field-id=\"57\"><fieldset><legend class=\"wpforms-field-label\">Do you experience regular nightmares?<\/legend><ul id=\"wpforms-1555-field_57\"><li class=\"choice-1 depth-1\"><input type=\"checkbox\" id=\"wpforms-1555-field_57_1\" name=\"wpforms[fields][57][]\" value=\"yes\" aria-errormessage=\"wpforms-1555-field_57_1-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-1555-field_57_1\">yes<\/label><\/li><li class=\"choice-2 depth-1\"><input type=\"checkbox\" id=\"wpforms-1555-field_57_2\" name=\"wpforms[fields][57][]\" value=\"no\" aria-errormessage=\"wpforms-1555-field_57_2-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-1555-field_57_2\">no<\/label><\/li><\/ul><\/fieldset><\/div><div id=\"wpforms-1555-field_58-container\" class=\"wpforms-field wpforms-field-checkbox\" data-field-id=\"58\"><fieldset><legend class=\"wpforms-field-label\">Please identify what physical health symptoms you have experienced from the list below.<\/legend><ul id=\"wpforms-1555-field_58\"><li class=\"choice-1 depth-1\"><input type=\"checkbox\" id=\"wpforms-1555-field_58_1\" name=\"wpforms[fields][58][]\" value=\"Depression\" aria-errormessage=\"wpforms-1555-field_58_1-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-1555-field_58_1\">Depression<\/label><\/li><li class=\"choice-2 depth-1\"><input type=\"checkbox\" id=\"wpforms-1555-field_58_2\" name=\"wpforms[fields][58][]\" value=\"Ulcers\" aria-errormessage=\"wpforms-1555-field_58_2-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-1555-field_58_2\">Ulcers<\/label><\/li><li class=\"choice-5 depth-1\"><input type=\"checkbox\" id=\"wpforms-1555-field_58_5\" name=\"wpforms[fields][58][]\" value=\"Heart Disease or Hypertension\" aria-errormessage=\"wpforms-1555-field_58_5-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-1555-field_58_5\">Heart Disease or Hypertension<\/label><\/li><li class=\"choice-4 depth-1\"><input type=\"checkbox\" id=\"wpforms-1555-field_58_4\" name=\"wpforms[fields][58][]\" value=\"Diabetes\" aria-errormessage=\"wpforms-1555-field_58_4-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-1555-field_58_4\">Diabetes<\/label><\/li><li class=\"choice-20 depth-1\"><input type=\"checkbox\" id=\"wpforms-1555-field_58_20\" name=\"wpforms[fields][58][]\" value=\"Cancer\" aria-errormessage=\"wpforms-1555-field_58_20-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-1555-field_58_20\">Cancer<\/label><\/li><li class=\"choice-19 depth-1\"><input type=\"checkbox\" id=\"wpforms-1555-field_58_19\" name=\"wpforms[fields][58][]\" value=\"Mental Illness, DID, MPD\" aria-errormessage=\"wpforms-1555-field_58_19-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-1555-field_58_19\">Mental Illness, DID, MPD<\/label><\/li><li class=\"choice-18 depth-1\"><input type=\"checkbox\" id=\"wpforms-1555-field_58_18\" name=\"wpforms[fields][58][]\" value=\"Gambling Addiction\" aria-errormessage=\"wpforms-1555-field_58_18-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-1555-field_58_18\">Gambling Addiction<\/label><\/li><li class=\"choice-17 depth-1\"><input type=\"checkbox\" id=\"wpforms-1555-field_58_17\" name=\"wpforms[fields][58][]\" value=\"Alcoholism\" aria-errormessage=\"wpforms-1555-field_58_17-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-1555-field_58_17\">Alcoholism<\/label><\/li><li class=\"choice-16 depth-1\"><input type=\"checkbox\" id=\"wpforms-1555-field_58_16\" name=\"wpforms[fields][58][]\" value=\"Drug Addiction\" aria-errormessage=\"wpforms-1555-field_58_16-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-1555-field_58_16\">Drug Addiction<\/label><\/li><li class=\"choice-15 depth-1\"><input type=\"checkbox\" id=\"wpforms-1555-field_58_15\" name=\"wpforms[fields][58][]\" value=\"Food\/Eating Disorders\" aria-errormessage=\"wpforms-1555-field_58_15-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-1555-field_58_15\">Food\/Eating Disorders<\/label><\/li><li class=\"choice-14 depth-1\"><input type=\"checkbox\" id=\"wpforms-1555-field_58_14\" name=\"wpforms[fields][58][]\" value=\"Sleeping Disorders\" aria-errormessage=\"wpforms-1555-field_58_14-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-1555-field_58_14\">Sleeping Disorders<\/label><\/li><li class=\"choice-13 depth-1\"><input type=\"checkbox\" id=\"wpforms-1555-field_58_13\" name=\"wpforms[fields][58][]\" value=\"ADHD\" aria-errormessage=\"wpforms-1555-field_58_13-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-1555-field_58_13\">ADHD<\/label><\/li><li class=\"choice-12 depth-1\"><input type=\"checkbox\" id=\"wpforms-1555-field_58_12\" name=\"wpforms[fields][58][]\" value=\"Asthma\" aria-errormessage=\"wpforms-1555-field_58_12-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-1555-field_58_12\">Asthma<\/label><\/li><li class=\"choice-11 depth-1\"><input type=\"checkbox\" id=\"wpforms-1555-field_58_11\" name=\"wpforms[fields][58][]\" value=\"Migraine Headaches\" aria-errormessage=\"wpforms-1555-field_58_11-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-1555-field_58_11\">Migraine Headaches<\/label><\/li><li class=\"choice-10 depth-1\"><input type=\"checkbox\" id=\"wpforms-1555-field_58_10\" name=\"wpforms[fields][58][]\" value=\"Glandular Problems\" aria-errormessage=\"wpforms-1555-field_58_10-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-1555-field_58_10\">Glandular Problems<\/label><\/li><li class=\"choice-9 depth-1\"><input type=\"checkbox\" id=\"wpforms-1555-field_58_9\" name=\"wpforms[fields][58][]\" value=\"Anxiety\" aria-errormessage=\"wpforms-1555-field_58_9-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-1555-field_58_9\">Anxiety<\/label><\/li><li class=\"choice-8 depth-1\"><input type=\"checkbox\" id=\"wpforms-1555-field_58_8\" name=\"wpforms[fields][58][]\" value=\"Sex addiction\" aria-errormessage=\"wpforms-1555-field_58_8-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-1555-field_58_8\">Sex addiction<\/label><\/li><li class=\"choice-7 depth-1\"><input type=\"checkbox\" id=\"wpforms-1555-field_58_7\" name=\"wpforms[fields][58][]\" value=\"Other\" aria-errormessage=\"wpforms-1555-field_58_7-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-1555-field_58_7\">Other<\/label><\/li><li class=\"choice-6 depth-1\"><input type=\"checkbox\" id=\"wpforms-1555-field_58_6\" name=\"wpforms[fields][58][]\" value=\"None\" aria-errormessage=\"wpforms-1555-field_58_6-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-1555-field_58_6\">None<\/label><\/li><\/ul><\/fieldset><\/div><div id=\"wpforms-1555-field_146-container\" class=\"wpforms-field wpforms-field-pagebreak\" data-field-id=\"146\"><div class=\"wpforms-clear wpforms-pagebreak-left\"><button class=\"wpforms-page-button wpforms-page-next wpforms-disabled\"\n\t\t\t\t\tdata-action=\"next\" data-page=\"4\" data-formid=\"1555\" aria-disabled=\"true\" aria-describedby=\"wpforms-error-noscript\">Next<\/button><\/div><\/div><\/div><div class=\"wpforms-page wpforms-page-5  \" data-page=\"5\" style=\"display:none;\"><div id=\"wpforms-1555-field_147-container\" class=\"wpforms-field wpforms-field-content\" data-field-id=\"147\"><div id=\"wpforms-1555-field_147\" class=\"wpforms-field-medium wpforms-field-row\" aria-errormessage=\"wpforms-1555-field_147-error\"><h2 class=\"gsection_title\">Unforgiveness<\/h2>\n<p>&nbsp;<\/p>\n<div class=\"wpforms-field-content-display-frontend-clear\"><\/div><\/div><\/div><div id=\"wpforms-1555-field_65-container\" class=\"wpforms-field wpforms-field-checkbox\" data-field-id=\"65\"><fieldset><legend class=\"wpforms-field-label\">Do you have unforgiveness (unresolved offenses, bitterness, resentment, unresolved anger, etc.) towards any of the following? Check all that apply and explain each below.<\/legend><ul id=\"wpforms-1555-field_65\"><li class=\"choice-1 depth-1\"><input type=\"checkbox\" id=\"wpforms-1555-field_65_1\" name=\"wpforms[fields][65][]\" value=\"God\" aria-errormessage=\"wpforms-1555-field_65_1-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-1555-field_65_1\">God<\/label><\/li><li class=\"choice-9 depth-1\"><input type=\"checkbox\" id=\"wpforms-1555-field_65_9\" name=\"wpforms[fields][65][]\" value=\"Self\" aria-errormessage=\"wpforms-1555-field_65_9-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-1555-field_65_9\">Self<\/label><\/li><li class=\"choice-8 depth-1\"><input type=\"checkbox\" id=\"wpforms-1555-field_65_8\" name=\"wpforms[fields][65][]\" value=\"Spouse\" aria-errormessage=\"wpforms-1555-field_65_8-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-1555-field_65_8\">Spouse<\/label><\/li><li class=\"choice-7 depth-1\"><input type=\"checkbox\" id=\"wpforms-1555-field_65_7\" name=\"wpforms[fields][65][]\" value=\"Parents\" aria-errormessage=\"wpforms-1555-field_65_7-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-1555-field_65_7\">Parents<\/label><\/li><li class=\"choice-6 depth-1\"><input type=\"checkbox\" id=\"wpforms-1555-field_65_6\" name=\"wpforms[fields][65][]\" value=\"Children\" aria-errormessage=\"wpforms-1555-field_65_6-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-1555-field_65_6\">Children<\/label><\/li><li class=\"choice-5 depth-1\"><input type=\"checkbox\" id=\"wpforms-1555-field_65_5\" name=\"wpforms[fields][65][]\" value=\"Brothers or Sisters\" aria-errormessage=\"wpforms-1555-field_65_5-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-1555-field_65_5\">Brothers or Sisters<\/label><\/li><li class=\"choice-4 depth-1\"><input type=\"checkbox\" id=\"wpforms-1555-field_65_4\" name=\"wpforms[fields][65][]\" value=\"Others\" aria-errormessage=\"wpforms-1555-field_65_4-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-1555-field_65_4\">Others<\/label><\/li><li class=\"choice-2 depth-1\"><input type=\"checkbox\" id=\"wpforms-1555-field_65_2\" name=\"wpforms[fields][65][]\" value=\"I do not have unforgiveness toward anyone\" aria-errormessage=\"wpforms-1555-field_65_2-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-1555-field_65_2\">I do not have unforgiveness toward anyone<\/label><\/li><\/ul><\/fieldset><\/div><div id=\"wpforms-1555-field_148-container\" class=\"wpforms-field wpforms-field-textarea\" data-field-id=\"148\"><label class=\"wpforms-field-label\" for=\"wpforms-1555-field_148\">If yes, Please explain your unforgiveness towards those checked above. <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/label><textarea id=\"wpforms-1555-field_148\" class=\"wpforms-field-medium wpforms-field-required\" name=\"wpforms[fields][148]\" aria-errormessage=\"wpforms-1555-field_148-error\" required><\/textarea><\/div><div id=\"wpforms-1555-field_199-container\" class=\"wpforms-field wpforms-field-content\" data-field-id=\"199\"><div id=\"wpforms-1555-field_199\" class=\"wpforms-field-medium wpforms-field-row\" aria-errormessage=\"wpforms-1555-field_199-error\"><h2 class=\"gsection_title\">Permissions to Spiritual Oppression<\/h2>\n<p>&nbsp;<\/p>\n<div class=\"wpforms-field-content-display-frontend-clear\"><\/div><\/div><\/div><div id=\"wpforms-1555-field_64-container\" class=\"wpforms-field wpforms-field-checkbox\" data-field-id=\"64\"><fieldset><legend class=\"wpforms-field-label\">Have you ever had any experience with the following:<\/legend><ul id=\"wpforms-1555-field_64\"><li class=\"choice-1 depth-1\"><input type=\"checkbox\" id=\"wpforms-1555-field_64_1\" name=\"wpforms[fields][64][]\" value=\"Astral Projection\" aria-errormessage=\"wpforms-1555-field_64_1-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-1555-field_64_1\">Astral Projection<\/label><\/li><li class=\"choice-2 depth-1\"><input type=\"checkbox\" id=\"wpforms-1555-field_64_2\" name=\"wpforms[fields][64][]\" value=\"Ouija Board\" aria-errormessage=\"wpforms-1555-field_64_2-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-1555-field_64_2\">Ouija Board<\/label><\/li><li class=\"choice-27 depth-1\"><input type=\"checkbox\" id=\"wpforms-1555-field_64_27\" name=\"wpforms[fields][64][]\" value=\"Going to Psychics\" aria-errormessage=\"wpforms-1555-field_64_27-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-1555-field_64_27\">Going to Psychics<\/label><\/li><li class=\"choice-26 depth-1\"><input type=\"checkbox\" id=\"wpforms-1555-field_64_26\" name=\"wpforms[fields][64][]\" value=\"Palmistry\" aria-errormessage=\"wpforms-1555-field_64_26-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-1555-field_64_26\">Palmistry<\/label><\/li><li class=\"choice-25 depth-1\"><input type=\"checkbox\" id=\"wpforms-1555-field_64_25\" name=\"wpforms[fields][64][]\" value=\"Crystals\" aria-errormessage=\"wpforms-1555-field_64_25-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-1555-field_64_25\">Crystals<\/label><\/li><li class=\"choice-24 depth-1\"><input type=\"checkbox\" id=\"wpforms-1555-field_64_24\" name=\"wpforms[fields][64][]\" value=\"Fortune Telling\" aria-errormessage=\"wpforms-1555-field_64_24-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-1555-field_64_24\">Fortune Telling<\/label><\/li><li class=\"choice-23 depth-1\"><input type=\"checkbox\" id=\"wpforms-1555-field_64_23\" name=\"wpforms[fields][64][]\" value=\"Tarot Cards\" aria-errormessage=\"wpforms-1555-field_64_23-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-1555-field_64_23\">Tarot Cards<\/label><\/li><li class=\"choice-22 depth-1\"><input type=\"checkbox\" id=\"wpforms-1555-field_64_22\" name=\"wpforms[fields][64][]\" value=\"Good Luck Charms\" aria-errormessage=\"wpforms-1555-field_64_22-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-1555-field_64_22\">Good Luck Charms<\/label><\/li><li class=\"choice-21 depth-1\"><input type=\"checkbox\" id=\"wpforms-1555-field_64_21\" name=\"wpforms[fields][64][]\" value=\"Voodoo\" aria-errormessage=\"wpforms-1555-field_64_21-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-1555-field_64_21\">Voodoo<\/label><\/li><li class=\"choice-20 depth-1\"><input type=\"checkbox\" id=\"wpforms-1555-field_64_20\" name=\"wpforms[fields][64][]\" value=\"Hypnosis\" aria-errormessage=\"wpforms-1555-field_64_20-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-1555-field_64_20\">Hypnosis<\/label><\/li><li class=\"choice-19 depth-1\"><input type=\"checkbox\" id=\"wpforms-1555-field_64_19\" name=\"wpforms[fields][64][]\" value=\"Witch Doctors\" aria-errormessage=\"wpforms-1555-field_64_19-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-1555-field_64_19\">Witch Doctors<\/label><\/li><li class=\"choice-18 depth-1\"><input type=\"checkbox\" id=\"wpforms-1555-field_64_18\" name=\"wpforms[fields][64][]\" value=\"Magic (Black or White)\" aria-errormessage=\"wpforms-1555-field_64_18-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-1555-field_64_18\">Magic (Black or White)<\/label><\/li><li class=\"choice-17 depth-1\"><input type=\"checkbox\" id=\"wpforms-1555-field_64_17\" name=\"wpforms[fields][64][]\" value=\"Seances\" aria-errormessage=\"wpforms-1555-field_64_17-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-1555-field_64_17\">Seances<\/label><\/li><li class=\"choice-16 depth-1\"><input type=\"checkbox\" id=\"wpforms-1555-field_64_16\" name=\"wpforms[fields][64][]\" value=\"Mediums\" aria-errormessage=\"wpforms-1555-field_64_16-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-1555-field_64_16\">Mediums<\/label><\/li><li class=\"choice-15 depth-1\"><input type=\"checkbox\" id=\"wpforms-1555-field_64_15\" name=\"wpforms[fields][64][]\" value=\"Table Tilting\" aria-errormessage=\"wpforms-1555-field_64_15-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-1555-field_64_15\">Table Tilting<\/label><\/li><li class=\"choice-14 depth-1\"><input type=\"checkbox\" id=\"wpforms-1555-field_64_14\" name=\"wpforms[fields][64][]\" value=\"Speaking in Trance\" aria-errormessage=\"wpforms-1555-field_64_14-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-1555-field_64_14\">Speaking in Trance<\/label><\/li><li class=\"choice-13 depth-1\"><input type=\"checkbox\" id=\"wpforms-1555-field_64_13\" name=\"wpforms[fields][64][]\" value=\"Automatic Writing\" aria-errormessage=\"wpforms-1555-field_64_13-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-1555-field_64_13\">Automatic Writing<\/label><\/li><li class=\"choice-12 depth-1\"><input type=\"checkbox\" id=\"wpforms-1555-field_64_12\" name=\"wpforms[fields][64][]\" value=\"Demonic Dreams\" aria-errormessage=\"wpforms-1555-field_64_12-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-1555-field_64_12\">Demonic Dreams<\/label><\/li><li class=\"choice-11 depth-1\"><input type=\"checkbox\" id=\"wpforms-1555-field_64_11\" name=\"wpforms[fields][64][]\" value=\"Telepathy\" aria-errormessage=\"wpforms-1555-field_64_11-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-1555-field_64_11\">Telepathy<\/label><\/li><li class=\"choice-10 depth-1\"><input type=\"checkbox\" id=\"wpforms-1555-field_64_10\" name=\"wpforms[fields][64][]\" value=\"Clairvoyance\" aria-errormessage=\"wpforms-1555-field_64_10-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-1555-field_64_10\">Clairvoyance<\/label><\/li><li class=\"choice-9 depth-1\"><input type=\"checkbox\" id=\"wpforms-1555-field_64_9\" name=\"wpforms[fields][64][]\" value=\"Healing Magnetism\" aria-errormessage=\"wpforms-1555-field_64_9-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-1555-field_64_9\">Healing Magnetism<\/label><\/li><li class=\"choice-8 depth-1\"><input type=\"checkbox\" id=\"wpforms-1555-field_64_8\" name=\"wpforms[fields][64][]\" value=\"Palm Reading\" aria-errormessage=\"wpforms-1555-field_64_8-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-1555-field_64_8\">Palm Reading<\/label><\/li><li class=\"choice-7 depth-1\"><input type=\"checkbox\" id=\"wpforms-1555-field_64_7\" name=\"wpforms[fields][64][]\" value=\"Blood Pacts\" aria-errormessage=\"wpforms-1555-field_64_7-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-1555-field_64_7\">Blood Pacts<\/label><\/li><li class=\"choice-6 depth-1\"><input type=\"checkbox\" id=\"wpforms-1555-field_64_6\" name=\"wpforms[fields][64][]\" value=\"Astrology\" aria-errormessage=\"wpforms-1555-field_64_6-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-1555-field_64_6\">Astrology<\/label><\/li><li class=\"choice-5 depth-1\"><input type=\"checkbox\" id=\"wpforms-1555-field_64_5\" name=\"wpforms[fields][64][]\" value=\"Dowsing (Rod or Pendulum)\" aria-errormessage=\"wpforms-1555-field_64_5-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-1555-field_64_5\">Dowsing (Rod or Pendulum)<\/label><\/li><li class=\"choice-4 depth-1\"><input type=\"checkbox\" id=\"wpforms-1555-field_64_4\" name=\"wpforms[fields][64][]\" value=\"None\" aria-errormessage=\"wpforms-1555-field_64_4-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-1555-field_64_4\">None<\/label><\/li><\/ul><\/fieldset><\/div><div id=\"wpforms-1555-field_68-container\" class=\"wpforms-field wpforms-field-checkbox\" data-field-id=\"68\"><fieldset><legend class=\"wpforms-field-label\">Have you ever read books on occultism or witchcraft?<\/legend><ul id=\"wpforms-1555-field_68\"><li class=\"choice-1 depth-1\"><input type=\"checkbox\" id=\"wpforms-1555-field_68_1\" name=\"wpforms[fields][68][]\" value=\"yes\" aria-errormessage=\"wpforms-1555-field_68_1-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-1555-field_68_1\">yes<\/label><\/li><li class=\"choice-2 depth-1\"><input type=\"checkbox\" id=\"wpforms-1555-field_68_2\" name=\"wpforms[fields][68][]\" value=\"no\" aria-errormessage=\"wpforms-1555-field_68_2-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-1555-field_68_2\">no<\/label><\/li><\/ul><\/fieldset><\/div><div id=\"wpforms-1555-field_150-container\" class=\"wpforms-field wpforms-field-textarea\" data-field-id=\"150\"><label class=\"wpforms-field-label\" for=\"wpforms-1555-field_150\">If yes, what and why?<\/label><textarea id=\"wpforms-1555-field_150\" class=\"wpforms-field-medium\" name=\"wpforms[fields][150]\" aria-errormessage=\"wpforms-1555-field_150-error\" ><\/textarea><\/div><div id=\"wpforms-1555-field_69-container\" class=\"wpforms-field wpforms-field-checkbox\" data-field-id=\"69\"><fieldset><legend class=\"wpforms-field-label\">Have you ever made agreements with Satan?<\/legend><ul id=\"wpforms-1555-field_69\"><li class=\"choice-1 depth-1\"><input type=\"checkbox\" id=\"wpforms-1555-field_69_1\" name=\"wpforms[fields][69][]\" value=\"yes\" aria-errormessage=\"wpforms-1555-field_69_1-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-1555-field_69_1\">yes<\/label><\/li><li class=\"choice-2 depth-1\"><input type=\"checkbox\" id=\"wpforms-1555-field_69_2\" name=\"wpforms[fields][69][]\" value=\"no\" aria-errormessage=\"wpforms-1555-field_69_2-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-1555-field_69_2\">no<\/label><\/li><\/ul><\/fieldset><\/div><div id=\"wpforms-1555-field_151-container\" class=\"wpforms-field wpforms-field-textarea\" data-field-id=\"151\"><label class=\"wpforms-field-label\" for=\"wpforms-1555-field_151\">If yes, what?<\/label><textarea id=\"wpforms-1555-field_151\" class=\"wpforms-field-medium\" name=\"wpforms[fields][151]\" aria-errormessage=\"wpforms-1555-field_151-error\" ><\/textarea><\/div><div id=\"wpforms-1555-field_71-container\" class=\"wpforms-field wpforms-field-checkbox\" data-field-id=\"71\"><fieldset><legend class=\"wpforms-field-label\">Have you ever been tempted to commit suicide?<\/legend><ul id=\"wpforms-1555-field_71\"><li class=\"choice-1 depth-1\"><input type=\"checkbox\" id=\"wpforms-1555-field_71_1\" name=\"wpforms[fields][71][]\" value=\"yes\" aria-errormessage=\"wpforms-1555-field_71_1-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-1555-field_71_1\">yes<\/label><\/li><li class=\"choice-2 depth-1\"><input type=\"checkbox\" id=\"wpforms-1555-field_71_2\" name=\"wpforms[fields][71][]\" value=\"no\" aria-errormessage=\"wpforms-1555-field_71_2-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-1555-field_71_2\">no<\/label><\/li><\/ul><\/fieldset><\/div><div id=\"wpforms-1555-field_152-container\" class=\"wpforms-field wpforms-field-textarea\" data-field-id=\"152\"><label class=\"wpforms-field-label\" for=\"wpforms-1555-field_152\">If yes, when and why?<\/label><textarea id=\"wpforms-1555-field_152\" class=\"wpforms-field-medium\" name=\"wpforms[fields][152]\" aria-errormessage=\"wpforms-1555-field_152-error\" ><\/textarea><\/div><div id=\"wpforms-1555-field_73-container\" class=\"wpforms-field wpforms-field-checkbox\" data-field-id=\"73\"><fieldset><legend class=\"wpforms-field-label\">Have you ever tried to commit suicide?<\/legend><ul id=\"wpforms-1555-field_73\"><li class=\"choice-1 depth-1\"><input type=\"checkbox\" id=\"wpforms-1555-field_73_1\" name=\"wpforms[fields][73][]\" value=\"yes\" aria-errormessage=\"wpforms-1555-field_73_1-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-1555-field_73_1\">yes<\/label><\/li><li class=\"choice-2 depth-1\"><input type=\"checkbox\" id=\"wpforms-1555-field_73_2\" name=\"wpforms[fields][73][]\" value=\"no\" aria-errormessage=\"wpforms-1555-field_73_2-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-1555-field_73_2\">no<\/label><\/li><\/ul><\/fieldset><\/div><div id=\"wpforms-1555-field_153-container\" class=\"wpforms-field wpforms-field-textarea\" data-field-id=\"153\"><label class=\"wpforms-field-label\" for=\"wpforms-1555-field_153\">If yes, how, when, and why?<\/label><textarea id=\"wpforms-1555-field_153\" class=\"wpforms-field-medium\" name=\"wpforms[fields][153]\" aria-errormessage=\"wpforms-1555-field_153-error\" ><\/textarea><\/div><div id=\"wpforms-1555-field_72-container\" class=\"wpforms-field wpforms-field-checkbox\" data-field-id=\"72\"><fieldset><legend class=\"wpforms-field-label\">Have you ever wished to die?<\/legend><ul id=\"wpforms-1555-field_72\"><li class=\"choice-1 depth-1\"><input type=\"checkbox\" id=\"wpforms-1555-field_72_1\" name=\"wpforms[fields][72][]\" value=\"yes\" aria-errormessage=\"wpforms-1555-field_72_1-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-1555-field_72_1\">yes<\/label><\/li><li class=\"choice-2 depth-1\"><input type=\"checkbox\" id=\"wpforms-1555-field_72_2\" name=\"wpforms[fields][72][]\" value=\"no\" aria-errormessage=\"wpforms-1555-field_72_2-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-1555-field_72_2\">no<\/label><\/li><\/ul><\/fieldset><\/div><div id=\"wpforms-1555-field_155-container\" class=\"wpforms-field wpforms-field-textarea\" data-field-id=\"155\"><label class=\"wpforms-field-label\" for=\"wpforms-1555-field_155\">If yes, when and why?<\/label><textarea id=\"wpforms-1555-field_155\" class=\"wpforms-field-medium\" name=\"wpforms[fields][155]\" aria-errormessage=\"wpforms-1555-field_155-error\" ><\/textarea><\/div><div id=\"wpforms-1555-field_67-container\" class=\"wpforms-field wpforms-field-checkbox\" data-field-id=\"67\"><fieldset><legend class=\"wpforms-field-label\">Are you emotionally honest with God?<\/legend><ul id=\"wpforms-1555-field_67\"><li class=\"choice-1 depth-1\"><input type=\"checkbox\" id=\"wpforms-1555-field_67_1\" name=\"wpforms[fields][67][]\" value=\"yes\" aria-errormessage=\"wpforms-1555-field_67_1-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-1555-field_67_1\">yes<\/label><\/li><li class=\"choice-2 depth-1\"><input type=\"checkbox\" id=\"wpforms-1555-field_67_2\" name=\"wpforms[fields][67][]\" value=\"no\" aria-errormessage=\"wpforms-1555-field_67_2-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-1555-field_67_2\">no<\/label><\/li><\/ul><\/fieldset><\/div><div id=\"wpforms-1555-field_156-container\" class=\"wpforms-field wpforms-field-textarea\" data-field-id=\"156\"><label class=\"wpforms-field-label\" for=\"wpforms-1555-field_156\">Explain why or why not.<\/label><textarea id=\"wpforms-1555-field_156\" class=\"wpforms-field-medium\" name=\"wpforms[fields][156]\" aria-errormessage=\"wpforms-1555-field_156-error\" ><\/textarea><\/div><div id=\"wpforms-1555-field_157-container\" class=\"wpforms-field wpforms-field-pagebreak\" data-field-id=\"157\"><div class=\"wpforms-clear wpforms-pagebreak-left\"><button class=\"wpforms-page-button wpforms-page-next wpforms-disabled\"\n\t\t\t\t\tdata-action=\"next\" data-page=\"5\" data-formid=\"1555\" aria-disabled=\"true\" aria-describedby=\"wpforms-error-noscript\">Next<\/button><\/div><\/div><\/div><div class=\"wpforms-page wpforms-page-6  \" data-page=\"6\" style=\"display:none;\"><div id=\"wpforms-1555-field_158-container\" class=\"wpforms-field wpforms-field-content\" data-field-id=\"158\"><div id=\"wpforms-1555-field_158\" class=\"wpforms-field-medium wpforms-field-row\" aria-errormessage=\"wpforms-1555-field_158-error\"><h2 class=\"gsection_title\">Behavioral Issues<\/h2>\n<p>&nbsp;<\/p>\n<div class=\"wpforms-field-content-display-frontend-clear\"><\/div><\/div><\/div><div id=\"wpforms-1555-field_78-container\" class=\"wpforms-field wpforms-field-checkbox\" data-field-id=\"78\"><fieldset><legend class=\"wpforms-field-label\">Do you habitually practice or struggle in any of the following areas? Check all that apply and explain each below.<\/legend><ul id=\"wpforms-1555-field_78\"><li class=\"choice-1 depth-1\"><input type=\"checkbox\" id=\"wpforms-1555-field_78_1\" name=\"wpforms[fields][78][]\" value=\"Addictions (alcohol or drug use, pornography, sex, food)\" aria-errormessage=\"wpforms-1555-field_78_1-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-1555-field_78_1\">Addictions (alcohol or drug use, pornography, sex, food)<\/label><\/li><li class=\"choice-2 depth-1\"><input type=\"checkbox\" id=\"wpforms-1555-field_78_2\" name=\"wpforms[fields][78][]\" value=\"Idolatries (excesses; i.e. exercise, entertainment)\" aria-errormessage=\"wpforms-1555-field_78_2-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-1555-field_78_2\">Idolatries (excesses; i.e. exercise, entertainment)<\/label><\/li><li class=\"choice-27 depth-1\"><input type=\"checkbox\" id=\"wpforms-1555-field_78_27\" name=\"wpforms[fields][78][]\" value=\"Relationship (control, manipulation, abuse, etc.)\" aria-errormessage=\"wpforms-1555-field_78_27-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-1555-field_78_27\">Relationship (control, manipulation, abuse, etc.)<\/label><\/li><li class=\"choice-26 depth-1\"><input type=\"checkbox\" id=\"wpforms-1555-field_78_26\" name=\"wpforms[fields][78][]\" value=\"Emotional (excessive anger, pride, jealousy, envy, fear, etc.)\" aria-errormessage=\"wpforms-1555-field_78_26-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-1555-field_78_26\">Emotional (excessive anger, pride, jealousy, envy, fear, etc.)<\/label><\/li><li class=\"choice-25 depth-1\"><input type=\"checkbox\" id=\"wpforms-1555-field_78_25\" name=\"wpforms[fields][78][]\" value=\"Spiritual (unbelief, anxiety, idolatry, etc.)\" aria-errormessage=\"wpforms-1555-field_78_25-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-1555-field_78_25\">Spiritual (unbelief, anxiety, idolatry, etc.)<\/label><\/li><li class=\"choice-24 depth-1\"><input type=\"checkbox\" id=\"wpforms-1555-field_78_24\" name=\"wpforms[fields][78][]\" value=\"Sexual (Past? Present?) Provide a brief description\" aria-errormessage=\"wpforms-1555-field_78_24-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-1555-field_78_24\">Sexual (Past? Present?) Provide a brief description<\/label><\/li><li class=\"choice-23 depth-1\"><input type=\"checkbox\" id=\"wpforms-1555-field_78_23\" name=\"wpforms[fields][78][]\" value=\"Rape (who, when, where)\" aria-errormessage=\"wpforms-1555-field_78_23-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-1555-field_78_23\">Rape (who, when, where)<\/label><\/li><li class=\"choice-22 depth-1\"><input type=\"checkbox\" id=\"wpforms-1555-field_78_22\" name=\"wpforms[fields][78][]\" value=\"Molestation (who, when, where)\" aria-errormessage=\"wpforms-1555-field_78_22-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-1555-field_78_22\">Molestation (who, when, where)<\/label><\/li><li class=\"choice-21 depth-1\"><input type=\"checkbox\" id=\"wpforms-1555-field_78_21\" name=\"wpforms[fields][78][]\" value=\"Adultery (sex with a married person)\" aria-errormessage=\"wpforms-1555-field_78_21-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-1555-field_78_21\">Adultery (sex with a married person)<\/label><\/li><li class=\"choice-20 depth-1\"><input type=\"checkbox\" id=\"wpforms-1555-field_78_20\" name=\"wpforms[fields][78][]\" value=\"Incest (sex between family members)\" aria-errormessage=\"wpforms-1555-field_78_20-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-1555-field_78_20\">Incest (sex between family members)<\/label><\/li><li class=\"choice-19 depth-1\"><input type=\"checkbox\" id=\"wpforms-1555-field_78_19\" name=\"wpforms[fields][78][]\" value=\"Fornication (sex before or outside of marriage)\" aria-errormessage=\"wpforms-1555-field_78_19-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-1555-field_78_19\">Fornication (sex before or outside of marriage)<\/label><\/li><li class=\"choice-18 depth-1\"><input type=\"checkbox\" id=\"wpforms-1555-field_78_18\" name=\"wpforms[fields][78][]\" value=\"Magic (Black or White)\" aria-errormessage=\"wpforms-1555-field_78_18-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-1555-field_78_18\">Magic (Black or White)<\/label><\/li><li class=\"choice-17 depth-1\"><input type=\"checkbox\" id=\"wpforms-1555-field_78_17\" name=\"wpforms[fields][78][]\" value=\"Homosexual or lesbian lifestyle\" aria-errormessage=\"wpforms-1555-field_78_17-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-1555-field_78_17\">Homosexual or lesbian lifestyle<\/label><\/li><li class=\"choice-16 depth-1\"><input type=\"checkbox\" id=\"wpforms-1555-field_78_16\" name=\"wpforms[fields][78][]\" value=\"Abortion (had one or pressured someone to get one)s\" aria-errormessage=\"wpforms-1555-field_78_16-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-1555-field_78_16\">Abortion (had one or pressured someone to get one)s<\/label><\/li><li class=\"choice-15 depth-1\"><input type=\"checkbox\" id=\"wpforms-1555-field_78_15\" name=\"wpforms[fields][78][]\" value=\"Any oaths that put anything before God (fraternities, sororities, clubs, etc.)\" aria-errormessage=\"wpforms-1555-field_78_15-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-1555-field_78_15\">Any oaths that put anything before God (fraternities, sororities, clubs, etc.)<\/label><\/li><li class=\"choice-14 depth-1\"><input type=\"checkbox\" id=\"wpforms-1555-field_78_14\" name=\"wpforms[fields][78][]\" value=\"Others\" aria-errormessage=\"wpforms-1555-field_78_14-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-1555-field_78_14\">Others<\/label><\/li><li class=\"choice-13 depth-1\"><input type=\"checkbox\" id=\"wpforms-1555-field_78_13\" name=\"wpforms[fields][78][]\" value=\"I do not struggle with any of these\" aria-errormessage=\"wpforms-1555-field_78_13-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-1555-field_78_13\">I do not struggle with any of these<\/label><\/li><\/ul><\/fieldset><\/div><div id=\"wpforms-1555-field_159-container\" class=\"wpforms-field wpforms-field-textarea\" data-field-id=\"159\"><label class=\"wpforms-field-label\" for=\"wpforms-1555-field_159\">Please provide as much information as possible regarding each area you checked above (I.E. when you&#039;ve experienced them and to what extent).<\/label><textarea id=\"wpforms-1555-field_159\" class=\"wpforms-field-medium\" name=\"wpforms[fields][159]\" aria-errormessage=\"wpforms-1555-field_159-error\" ><\/textarea><\/div><div id=\"wpforms-1555-field_80-container\" class=\"wpforms-field wpforms-field-checkbox\" data-field-id=\"80\"><fieldset><legend class=\"wpforms-field-label\">Have you ever utilized any of the following drugs:<\/legend><ul id=\"wpforms-1555-field_80\"><li class=\"choice-1 depth-1\"><input type=\"checkbox\" id=\"wpforms-1555-field_80_1\" name=\"wpforms[fields][80][]\" value=\"LSD\" aria-errormessage=\"wpforms-1555-field_80_1-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-1555-field_80_1\">LSD<\/label><\/li><li class=\"choice-2 depth-1\"><input type=\"checkbox\" id=\"wpforms-1555-field_80_2\" name=\"wpforms[fields][80][]\" value=\"Cocaine\" aria-errormessage=\"wpforms-1555-field_80_2-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-1555-field_80_2\">Cocaine<\/label><\/li><li class=\"choice-3 depth-1\"><input type=\"checkbox\" id=\"wpforms-1555-field_80_3\" name=\"wpforms[fields][80][]\" value=\"Marijuana\" aria-errormessage=\"wpforms-1555-field_80_3-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-1555-field_80_3\">Marijuana<\/label><\/li><li class=\"choice-9 depth-1\"><input type=\"checkbox\" id=\"wpforms-1555-field_80_9\" name=\"wpforms[fields][80][]\" value=\"Speed\" aria-errormessage=\"wpforms-1555-field_80_9-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-1555-field_80_9\">Speed<\/label><\/li><li class=\"choice-8 depth-1\"><input type=\"checkbox\" id=\"wpforms-1555-field_80_8\" name=\"wpforms[fields][80][]\" value=\"Crack\" aria-errormessage=\"wpforms-1555-field_80_8-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-1555-field_80_8\">Crack<\/label><\/li><li class=\"choice-7 depth-1\"><input type=\"checkbox\" id=\"wpforms-1555-field_80_7\" name=\"wpforms[fields][80][]\" value=\"Downers\" aria-errormessage=\"wpforms-1555-field_80_7-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-1555-field_80_7\">Downers<\/label><\/li><li class=\"choice-6 depth-1\"><input type=\"checkbox\" id=\"wpforms-1555-field_80_6\" name=\"wpforms[fields][80][]\" value=\"Uppers\" aria-errormessage=\"wpforms-1555-field_80_6-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-1555-field_80_6\">Uppers<\/label><\/li><li class=\"choice-5 depth-1\"><input type=\"checkbox\" id=\"wpforms-1555-field_80_5\" name=\"wpforms[fields][80][]\" value=\"Others that are not listed\" aria-errormessage=\"wpforms-1555-field_80_5-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-1555-field_80_5\">Others that are not listed<\/label><\/li><li class=\"choice-4 depth-1\"><input type=\"checkbox\" id=\"wpforms-1555-field_80_4\" name=\"wpforms[fields][80][]\" value=\"None\" aria-errormessage=\"wpforms-1555-field_80_4-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-1555-field_80_4\">None<\/label><\/li><\/ul><\/fieldset><\/div><div id=\"wpforms-1555-field_81-container\" class=\"wpforms-field wpforms-field-checkbox\" data-field-id=\"81\"><fieldset><legend class=\"wpforms-field-label\">Have you ever been arrested?<\/legend><ul id=\"wpforms-1555-field_81\"><li class=\"choice-1 depth-1\"><input type=\"checkbox\" id=\"wpforms-1555-field_81_1\" name=\"wpforms[fields][81][]\" value=\"yes\" aria-errormessage=\"wpforms-1555-field_81_1-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-1555-field_81_1\">yes<\/label><\/li><li class=\"choice-2 depth-1\"><input type=\"checkbox\" id=\"wpforms-1555-field_81_2\" name=\"wpforms[fields][81][]\" value=\"no\" aria-errormessage=\"wpforms-1555-field_81_2-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-1555-field_81_2\">no<\/label><\/li><\/ul><\/fieldset><\/div><div id=\"wpforms-1555-field_160-container\" class=\"wpforms-field wpforms-field-textarea\" data-field-id=\"160\"><label class=\"wpforms-field-label\" for=\"wpforms-1555-field_160\">If so, why?<\/label><textarea id=\"wpforms-1555-field_160\" class=\"wpforms-field-medium\" name=\"wpforms[fields][160]\" aria-errormessage=\"wpforms-1555-field_160-error\" ><\/textarea><\/div><div id=\"wpforms-1555-field_161-container\" class=\"wpforms-field wpforms-field-textarea\" data-field-id=\"161\"><label class=\"wpforms-field-label\" for=\"wpforms-1555-field_161\">About how much time do you spend per week watching media? What are you watching?<\/label><textarea id=\"wpforms-1555-field_161\" class=\"wpforms-field-medium\" name=\"wpforms[fields][161]\" aria-errormessage=\"wpforms-1555-field_161-error\" ><\/textarea><\/div><div id=\"wpforms-1555-field_162-container\" class=\"wpforms-field wpforms-field-textarea\" data-field-id=\"162\"><label class=\"wpforms-field-label\" for=\"wpforms-1555-field_162\">How much time do you spend per week reading? What do you read?<\/label><textarea id=\"wpforms-1555-field_162\" class=\"wpforms-field-medium\" name=\"wpforms[fields][162]\" aria-errormessage=\"wpforms-1555-field_162-error\" ><\/textarea><\/div><div id=\"wpforms-1555-field_163-container\" class=\"wpforms-field wpforms-field-textarea\" data-field-id=\"163\"><label class=\"wpforms-field-label\" for=\"wpforms-1555-field_163\">How much do you listen to music? What kind(s)?<\/label><textarea id=\"wpforms-1555-field_163\" class=\"wpforms-field-medium\" name=\"wpforms[fields][163]\" aria-errormessage=\"wpforms-1555-field_163-error\" ><\/textarea><\/div><div id=\"wpforms-1555-field_83-container\" class=\"wpforms-field wpforms-field-checkbox\" data-field-id=\"83\"><fieldset><legend class=\"wpforms-field-label\">Which of the following best describes how you handle positive and negative emotions? <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/legend><ul id=\"wpforms-1555-field_83\" class=\"wpforms-field-required\"><li class=\"choice-1 depth-1\"><input type=\"checkbox\" id=\"wpforms-1555-field_83_1\" name=\"wpforms[fields][83][]\" value=\"Readily express all emotions\" aria-errormessage=\"wpforms-1555-field_83_1-error\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-1555-field_83_1\">Readily express all emotions<\/label><\/li><li class=\"choice-2 depth-1\"><input type=\"checkbox\" id=\"wpforms-1555-field_83_2\" name=\"wpforms[fields][83][]\" value=\"Acknowledge their presence, but reserved\" aria-errormessage=\"wpforms-1555-field_83_2-error\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-1555-field_83_2\">Acknowledge their presence, but reserved<\/label><\/li><li class=\"choice-3 depth-1\"><input type=\"checkbox\" id=\"wpforms-1555-field_83_3\" name=\"wpforms[fields][83][]\" value=\"Find it safest not to express how I feel\" aria-errormessage=\"wpforms-1555-field_83_3-error\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-1555-field_83_3\">Find it safest not to express how I feel<\/label><\/li><li class=\"choice-9 depth-1\"><input type=\"checkbox\" id=\"wpforms-1555-field_83_9\" name=\"wpforms[fields][83][]\" value=\"Express some of my emotions, but not all\" aria-errormessage=\"wpforms-1555-field_83_9-error\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-1555-field_83_9\">Express some of my emotions, but not all<\/label><\/li><li class=\"choice-8 depth-1\"><input type=\"checkbox\" id=\"wpforms-1555-field_83_8\" name=\"wpforms[fields][83][]\" value=\"Tend to suppress my emotions\" aria-errormessage=\"wpforms-1555-field_83_8-error\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-1555-field_83_8\">Tend to suppress my emotions<\/label><\/li><li class=\"choice-7 depth-1\"><input type=\"checkbox\" id=\"wpforms-1555-field_83_7\" name=\"wpforms[fields][83][]\" value=\"Tend to disregard how I feel since I can&#039;t trust my feelings\" aria-errormessage=\"wpforms-1555-field_83_7-error\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-1555-field_83_7\">Tend to disregard how I feel since I can't trust my feelings<\/label><\/li><li class=\"choice-6 depth-1\"><input type=\"checkbox\" id=\"wpforms-1555-field_83_6\" name=\"wpforms[fields][83][]\" value=\"Deny them since it is too painful to deal with them\" aria-errormessage=\"wpforms-1555-field_83_6-error\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-1555-field_83_6\">Deny them since it is too painful to deal with them<\/label><\/li><\/ul><\/fieldset><\/div><div id=\"wpforms-1555-field_165-container\" class=\"wpforms-field wpforms-field-pagebreak\" data-field-id=\"165\"><div class=\"wpforms-clear wpforms-pagebreak-left\"><button class=\"wpforms-page-button wpforms-page-next wpforms-disabled\"\n\t\t\t\t\tdata-action=\"next\" data-page=\"6\" data-formid=\"1555\" aria-disabled=\"true\" aria-describedby=\"wpforms-error-noscript\">Next<\/button><\/div><\/div><\/div><div class=\"wpforms-page wpforms-page-7  \" data-page=\"7\" style=\"display:none;\"><div id=\"wpforms-1555-field_164-container\" class=\"wpforms-field wpforms-field-content\" data-field-id=\"164\"><div id=\"wpforms-1555-field_164\" class=\"wpforms-field-medium wpforms-field-row\" aria-errormessage=\"wpforms-1555-field_164-error\"><h2 class=\"gsection_title\">Hurts and Traumas<\/h2>\n<p>&nbsp;<\/p>\n<div class=\"wpforms-field-content-display-frontend-clear\"><\/div><\/div><\/div><div id=\"wpforms-1555-field_88-container\" class=\"wpforms-field wpforms-field-checkbox\" data-field-id=\"88\"><fieldset><legend class=\"wpforms-field-label\">Have you ever been a victim of or witnessed traumatic incidents that frightened you\u2014especially (but not exclusively) in childhood? Check all that apply.<\/legend><ul id=\"wpforms-1555-field_88\"><li class=\"choice-1 depth-1\"><input type=\"checkbox\" id=\"wpforms-1555-field_88_1\" name=\"wpforms[fields][88][]\" value=\"Abuse (physical, sexual, or emotional)\" aria-errormessage=\"wpforms-1555-field_88_1-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-1555-field_88_1\">Abuse (physical, sexual, or emotional)<\/label><\/li><li class=\"choice-2 depth-1\"><input type=\"checkbox\" id=\"wpforms-1555-field_88_2\" name=\"wpforms[fields][88][]\" value=\"Rejection\" aria-errormessage=\"wpforms-1555-field_88_2-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-1555-field_88_2\">Rejection<\/label><\/li><li class=\"choice-3 depth-1\"><input type=\"checkbox\" id=\"wpforms-1555-field_88_3\" name=\"wpforms[fields][88][]\" value=\"Abandonment\" aria-errormessage=\"wpforms-1555-field_88_3-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-1555-field_88_3\">Abandonment<\/label><\/li><li class=\"choice-9 depth-1\"><input type=\"checkbox\" id=\"wpforms-1555-field_88_9\" name=\"wpforms[fields][88][]\" value=\"Betrayal\" aria-errormessage=\"wpforms-1555-field_88_9-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-1555-field_88_9\">Betrayal<\/label><\/li><li class=\"choice-8 depth-1\"><input type=\"checkbox\" id=\"wpforms-1555-field_88_8\" name=\"wpforms[fields][88][]\" value=\"Neglect\" aria-errormessage=\"wpforms-1555-field_88_8-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-1555-field_88_8\">Neglect<\/label><\/li><li class=\"choice-7 depth-1\"><input type=\"checkbox\" id=\"wpforms-1555-field_88_7\" name=\"wpforms[fields][88][]\" value=\"Accidents or near-death experiences\" aria-errormessage=\"wpforms-1555-field_88_7-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-1555-field_88_7\">Accidents or near-death experiences<\/label><\/li><li class=\"choice-6 depth-1\"><input type=\"checkbox\" id=\"wpforms-1555-field_88_6\" name=\"wpforms[fields][88][]\" value=\"Death of a loved one\" aria-errormessage=\"wpforms-1555-field_88_6-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-1555-field_88_6\">Death of a loved one<\/label><\/li><li class=\"choice-18 depth-1\"><input type=\"checkbox\" id=\"wpforms-1555-field_88_18\" name=\"wpforms[fields][88][]\" value=\"Serious Illnesses\" aria-errormessage=\"wpforms-1555-field_88_18-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-1555-field_88_18\">Serious Illnesses<\/label><\/li><li class=\"choice-17 depth-1\"><input type=\"checkbox\" id=\"wpforms-1555-field_88_17\" name=\"wpforms[fields][88][]\" value=\"Personal failures (i.e. bankruptcy)\" aria-errormessage=\"wpforms-1555-field_88_17-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-1555-field_88_17\">Personal failures (i.e. bankruptcy)<\/label><\/li><li class=\"choice-16 depth-1\"><input type=\"checkbox\" id=\"wpforms-1555-field_88_16\" name=\"wpforms[fields][88][]\" value=\"Nightmares\" aria-errormessage=\"wpforms-1555-field_88_16-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-1555-field_88_16\">Nightmares<\/label><\/li><li class=\"choice-15 depth-1\"><input type=\"checkbox\" id=\"wpforms-1555-field_88_15\" name=\"wpforms[fields][88][]\" value=\"Injustices\" aria-errormessage=\"wpforms-1555-field_88_15-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-1555-field_88_15\">Injustices<\/label><\/li><li class=\"choice-14 depth-1\"><input type=\"checkbox\" id=\"wpforms-1555-field_88_14\" name=\"wpforms[fields][88][]\" value=\"Prejudice\" aria-errormessage=\"wpforms-1555-field_88_14-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-1555-field_88_14\">Prejudice<\/label><\/li><li class=\"choice-13 depth-1\"><input type=\"checkbox\" id=\"wpforms-1555-field_88_13\" name=\"wpforms[fields][88][]\" value=\"Satanic worship rituals\" aria-errormessage=\"wpforms-1555-field_88_13-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-1555-field_88_13\">Satanic worship rituals<\/label><\/li><li class=\"choice-12 depth-1\"><input type=\"checkbox\" id=\"wpforms-1555-field_88_12\" name=\"wpforms[fields][88][]\" value=\"Abortion\" aria-errormessage=\"wpforms-1555-field_88_12-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-1555-field_88_12\">Abortion<\/label><\/li><li class=\"choice-11 depth-1\"><input type=\"checkbox\" id=\"wpforms-1555-field_88_11\" name=\"wpforms[fields][88][]\" value=\"Miscarriage\" aria-errormessage=\"wpforms-1555-field_88_11-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-1555-field_88_11\">Miscarriage<\/label><\/li><li class=\"choice-10 depth-1\"><input type=\"checkbox\" id=\"wpforms-1555-field_88_10\" name=\"wpforms[fields][88][]\" value=\"Incest\" aria-errormessage=\"wpforms-1555-field_88_10-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-1555-field_88_10\">Incest<\/label><\/li><li class=\"choice-20 depth-1\"><input type=\"checkbox\" id=\"wpforms-1555-field_88_20\" name=\"wpforms[fields][88][]\" value=\"Other\" aria-errormessage=\"wpforms-1555-field_88_20-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-1555-field_88_20\">Other<\/label><\/li><li class=\"choice-19 depth-1\"><input type=\"checkbox\" id=\"wpforms-1555-field_88_19\" name=\"wpforms[fields][88][]\" value=\"I have not been a victim of any of these\" aria-errormessage=\"wpforms-1555-field_88_19-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-1555-field_88_19\">I have not been a victim of any of these<\/label><\/li><\/ul><\/fieldset><\/div><div id=\"wpforms-1555-field_166-container\" class=\"wpforms-field wpforms-field-textarea\" data-field-id=\"166\"><label class=\"wpforms-field-label\" for=\"wpforms-1555-field_166\">Please provide details of the hurts and traumas you checked above.<\/label><textarea id=\"wpforms-1555-field_166\" class=\"wpforms-field-medium\" name=\"wpforms[fields][166]\" aria-errormessage=\"wpforms-1555-field_166-error\" ><\/textarea><\/div><div id=\"wpforms-1555-field_168-container\" class=\"wpforms-field wpforms-field-content\" data-field-id=\"168\"><div id=\"wpforms-1555-field_168\" class=\"wpforms-field-medium wpforms-field-row\" aria-errormessage=\"wpforms-1555-field_168-error\"><h2 class=\"gsection_title\">Generational Issues<\/h2>\n<p>&nbsp;<\/p>\n<div class=\"wpforms-field-content-display-frontend-clear\"><\/div><\/div><\/div><div id=\"wpforms-1555-field_92-container\" class=\"wpforms-field wpforms-field-checkbox\" data-field-id=\"92\"><fieldset><legend class=\"wpforms-field-label\">Have you, your spouse, your parents, or your grandparents been involved in any of the following religions? Check all that apply. (copy)<\/legend><ul id=\"wpforms-1555-field_92\"><li class=\"choice-1 depth-1\"><input type=\"checkbox\" id=\"wpforms-1555-field_92_1\" name=\"wpforms[fields][92][]\" value=\"Buddhism\" aria-errormessage=\"wpforms-1555-field_92_1-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-1555-field_92_1\">Buddhism<\/label><\/li><li class=\"choice-2 depth-1\"><input type=\"checkbox\" id=\"wpforms-1555-field_92_2\" name=\"wpforms[fields][92][]\" value=\"Hinduism\" aria-errormessage=\"wpforms-1555-field_92_2-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-1555-field_92_2\">Hinduism<\/label><\/li><li class=\"choice-3 depth-1\"><input type=\"checkbox\" id=\"wpforms-1555-field_92_3\" name=\"wpforms[fields][92][]\" value=\"Islam\" aria-errormessage=\"wpforms-1555-field_92_3-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-1555-field_92_3\">Islam<\/label><\/li><li class=\"choice-9 depth-1\"><input type=\"checkbox\" id=\"wpforms-1555-field_92_9\" name=\"wpforms[fields][92][]\" value=\"Baha&#039;i\" aria-errormessage=\"wpforms-1555-field_92_9-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-1555-field_92_9\">Baha'i<\/label><\/li><li class=\"choice-8 depth-1\"><input type=\"checkbox\" id=\"wpforms-1555-field_92_8\" name=\"wpforms[fields][92][]\" value=\"Neglect\" aria-errormessage=\"wpforms-1555-field_92_8-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-1555-field_92_8\">Neglect<\/label><\/li><li class=\"choice-7 depth-1\"><input type=\"checkbox\" id=\"wpforms-1555-field_92_7\" name=\"wpforms[fields][92][]\" value=\"Hare Krishna\" aria-errormessage=\"wpforms-1555-field_92_7-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-1555-field_92_7\">Hare Krishna<\/label><\/li><li class=\"choice-6 depth-1\"><input type=\"checkbox\" id=\"wpforms-1555-field_92_6\" name=\"wpforms[fields][92][]\" value=\"Transcendental Meditation\" aria-errormessage=\"wpforms-1555-field_92_6-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-1555-field_92_6\">Transcendental Meditation<\/label><\/li><li class=\"choice-18 depth-1\"><input type=\"checkbox\" id=\"wpforms-1555-field_92_18\" name=\"wpforms[fields][92][]\" value=\"Native Religion\" aria-errormessage=\"wpforms-1555-field_92_18-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-1555-field_92_18\">Native Religion<\/label><\/li><li class=\"choice-17 depth-1\"><input type=\"checkbox\" id=\"wpforms-1555-field_92_17\" name=\"wpforms[fields][92][]\" value=\"Science of Mind\" aria-errormessage=\"wpforms-1555-field_92_17-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-1555-field_92_17\">Science of Mind<\/label><\/li><li class=\"choice-16 depth-1\"><input type=\"checkbox\" id=\"wpforms-1555-field_92_16\" name=\"wpforms[fields][92][]\" value=\"Silva Mind Control\" aria-errormessage=\"wpforms-1555-field_92_16-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-1555-field_92_16\">Silva Mind Control<\/label><\/li><li class=\"choice-15 depth-1\"><input type=\"checkbox\" id=\"wpforms-1555-field_92_15\" name=\"wpforms[fields][92][]\" value=\"Eckankar\" aria-errormessage=\"wpforms-1555-field_92_15-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-1555-field_92_15\">Eckankar<\/label><\/li><li class=\"choice-14 depth-1\"><input type=\"checkbox\" id=\"wpforms-1555-field_92_14\" name=\"wpforms[fields][92][]\" value=\"Erhard Seminars\" aria-errormessage=\"wpforms-1555-field_92_14-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-1555-field_92_14\">Erhard Seminars<\/label><\/li><li class=\"choice-13 depth-1\"><input type=\"checkbox\" id=\"wpforms-1555-field_92_13\" name=\"wpforms[fields][92][]\" value=\"Satanic worship rituals\" aria-errormessage=\"wpforms-1555-field_92_13-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-1555-field_92_13\">Satanic worship rituals<\/label><\/li><li class=\"choice-12 depth-1\"><input type=\"checkbox\" id=\"wpforms-1555-field_92_12\" name=\"wpforms[fields][92][]\" value=\"Religious Communes\" aria-errormessage=\"wpforms-1555-field_92_12-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-1555-field_92_12\">Religious Communes<\/label><\/li><li class=\"choice-11 depth-1\"><input type=\"checkbox\" id=\"wpforms-1555-field_92_11\" name=\"wpforms[fields][92][]\" value=\"Others, Please List\" aria-errormessage=\"wpforms-1555-field_92_11-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-1555-field_92_11\">Others, Please List<\/label><\/li><li class=\"choice-10 depth-1\"><input type=\"checkbox\" id=\"wpforms-1555-field_92_10\" name=\"wpforms[fields][92][]\" value=\"None\" aria-errormessage=\"wpforms-1555-field_92_10-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-1555-field_92_10\">None<\/label><\/li><\/ul><\/fieldset><\/div><div id=\"wpforms-1555-field_167-container\" class=\"wpforms-field wpforms-field-textarea\" data-field-id=\"167\"><label class=\"wpforms-field-label\" for=\"wpforms-1555-field_167\">Please provide details of the hurts and traumas you checked above.<\/label><textarea id=\"wpforms-1555-field_167\" class=\"wpforms-field-medium\" name=\"wpforms[fields][167]\" aria-errormessage=\"wpforms-1555-field_167-error\" ><\/textarea><\/div><div id=\"wpforms-1555-field_90-container\" class=\"wpforms-field wpforms-field-checkbox\" data-field-id=\"90\"><fieldset><legend class=\"wpforms-field-label\">Have you, your spouse, your parents, or your grandparents been a member of any of the following cults? Check all that apply.<\/legend><ul id=\"wpforms-1555-field_90\"><li class=\"choice-1 depth-1\"><input type=\"checkbox\" id=\"wpforms-1555-field_90_1\" name=\"wpforms[fields][90][]\" value=\"New Age\" aria-errormessage=\"wpforms-1555-field_90_1-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-1555-field_90_1\">New Age<\/label><\/li><li class=\"choice-2 depth-1\"><input type=\"checkbox\" id=\"wpforms-1555-field_90_2\" name=\"wpforms[fields][90][]\" value=\"Freemasons\/Masons\" aria-errormessage=\"wpforms-1555-field_90_2-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-1555-field_90_2\">Freemasons\/Masons<\/label><\/li><li class=\"choice-3 depth-1\"><input type=\"checkbox\" id=\"wpforms-1555-field_90_3\" name=\"wpforms[fields][90][]\" value=\"Shiners\" aria-errormessage=\"wpforms-1555-field_90_3-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-1555-field_90_3\">Shiners<\/label><\/li><li class=\"choice-9 depth-1\"><input type=\"checkbox\" id=\"wpforms-1555-field_90_9\" name=\"wpforms[fields][90][]\" value=\"Jehovah&#039;s Witnesses\" aria-errormessage=\"wpforms-1555-field_90_9-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-1555-field_90_9\">Jehovah's Witnesses<\/label><\/li><li class=\"choice-8 depth-1\"><input type=\"checkbox\" id=\"wpforms-1555-field_90_8\" name=\"wpforms[fields][90][]\" value=\"Scientology\" aria-errormessage=\"wpforms-1555-field_90_8-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-1555-field_90_8\">Scientology<\/label><\/li><li class=\"choice-7 depth-1\"><input type=\"checkbox\" id=\"wpforms-1555-field_90_7\" name=\"wpforms[fields][90][]\" value=\"Mormonism\" aria-errormessage=\"wpforms-1555-field_90_7-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-1555-field_90_7\">Mormonism<\/label><\/li><li class=\"choice-6 depth-1\"><input type=\"checkbox\" id=\"wpforms-1555-field_90_6\" name=\"wpforms[fields][90][]\" value=\"Unitarianism\" aria-errormessage=\"wpforms-1555-field_90_6-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-1555-field_90_6\">Unitarianism<\/label><\/li><li class=\"choice-18 depth-1\"><input type=\"checkbox\" id=\"wpforms-1555-field_90_18\" name=\"wpforms[fields][90][]\" value=\"Unification Church\" aria-errormessage=\"wpforms-1555-field_90_18-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-1555-field_90_18\">Unification Church<\/label><\/li><li class=\"choice-17 depth-1\"><input type=\"checkbox\" id=\"wpforms-1555-field_90_17\" name=\"wpforms[fields][90][]\" value=\"Children of Love\" aria-errormessage=\"wpforms-1555-field_90_17-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-1555-field_90_17\">Children of Love<\/label><\/li><li class=\"choice-16 depth-1\"><input type=\"checkbox\" id=\"wpforms-1555-field_90_16\" name=\"wpforms[fields][90][]\" value=\"Theosophy\" aria-errormessage=\"wpforms-1555-field_90_16-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-1555-field_90_16\">Theosophy<\/label><\/li><li class=\"choice-15 depth-1\"><input type=\"checkbox\" id=\"wpforms-1555-field_90_15\" name=\"wpforms[fields][90][]\" value=\"Rainbow Girls\" aria-errormessage=\"wpforms-1555-field_90_15-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-1555-field_90_15\">Rainbow Girls<\/label><\/li><li class=\"choice-14 depth-1\"><input type=\"checkbox\" id=\"wpforms-1555-field_90_14\" name=\"wpforms[fields][90][]\" value=\"Erhard Seminars\" aria-errormessage=\"wpforms-1555-field_90_14-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-1555-field_90_14\">Erhard Seminars<\/label><\/li><li class=\"choice-13 depth-1\"><input type=\"checkbox\" id=\"wpforms-1555-field_90_13\" name=\"wpforms[fields][90][]\" value=\"Rainbow Girls\" aria-errormessage=\"wpforms-1555-field_90_13-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-1555-field_90_13\">Rainbow Girls<\/label><\/li><li class=\"choice-12 depth-1\"><input type=\"checkbox\" id=\"wpforms-1555-field_90_12\" name=\"wpforms[fields][90][]\" value=\"Eastern Star\" aria-errormessage=\"wpforms-1555-field_90_12-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-1555-field_90_12\">Eastern Star<\/label><\/li><li class=\"choice-11 depth-1\"><input type=\"checkbox\" id=\"wpforms-1555-field_90_11\" name=\"wpforms[fields][90][]\" value=\"Elks Club\/Lodge\" aria-errormessage=\"wpforms-1555-field_90_11-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-1555-field_90_11\">Elks Club\/Lodge<\/label><\/li><li class=\"choice-10 depth-1\"><input type=\"checkbox\" id=\"wpforms-1555-field_90_10\" name=\"wpforms[fields][90][]\" value=\"Job&#039;s Daughters\" aria-errormessage=\"wpforms-1555-field_90_10-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-1555-field_90_10\">Job's Daughters<\/label><\/li><li class=\"choice-38 depth-1\"><input type=\"checkbox\" id=\"wpforms-1555-field_90_38\" name=\"wpforms[fields][90][]\" value=\"Oddfellows\" aria-errormessage=\"wpforms-1555-field_90_38-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-1555-field_90_38\">Oddfellows<\/label><\/li><li class=\"choice-37 depth-1\"><input type=\"checkbox\" id=\"wpforms-1555-field_90_37\" name=\"wpforms[fields][90][]\" value=\"DeMolay\" aria-errormessage=\"wpforms-1555-field_90_37-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-1555-field_90_37\">DeMolay<\/label><\/li><li class=\"choice-36 depth-1\"><input type=\"checkbox\" id=\"wpforms-1555-field_90_36\" name=\"wpforms[fields][90][]\" value=\"Daughters of the Nile\" aria-errormessage=\"wpforms-1555-field_90_36-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-1555-field_90_36\">Daughters of the Nile<\/label><\/li><li class=\"choice-35 depth-1\"><input type=\"checkbox\" id=\"wpforms-1555-field_90_35\" name=\"wpforms[fields][90][]\" value=\"Rosicrucianism\" aria-errormessage=\"wpforms-1555-field_90_35-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-1555-field_90_35\">Rosicrucianism<\/label><\/li><li class=\"choice-34 depth-1\"><input type=\"checkbox\" id=\"wpforms-1555-field_90_34\" name=\"wpforms[fields][90][]\" value=\"Gurus\" aria-errormessage=\"wpforms-1555-field_90_34-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-1555-field_90_34\">Gurus<\/label><\/li><li class=\"choice-33 depth-1\"><input type=\"checkbox\" id=\"wpforms-1555-field_90_33\" name=\"wpforms[fields][90][]\" value=\"Spiritism\/Spiritualist Churches\" aria-errormessage=\"wpforms-1555-field_90_33-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-1555-field_90_33\">Spiritism\/Spiritualist Churches<\/label><\/li><li class=\"choice-32 depth-1\"><input type=\"checkbox\" id=\"wpforms-1555-field_90_32\" name=\"wpforms[fields][90][]\" value=\"Christadelphians\" aria-errormessage=\"wpforms-1555-field_90_32-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-1555-field_90_32\">Christadelphians<\/label><\/li><li class=\"choice-31 depth-1\"><input type=\"checkbox\" id=\"wpforms-1555-field_90_31\" name=\"wpforms[fields][90][]\" value=\"Christian Science\" aria-errormessage=\"wpforms-1555-field_90_31-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-1555-field_90_31\">Christian Science<\/label><\/li><li class=\"choice-30 depth-1\"><input type=\"checkbox\" id=\"wpforms-1555-field_90_30\" name=\"wpforms[fields][90][]\" value=\"Children of God\" aria-errormessage=\"wpforms-1555-field_90_30-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-1555-field_90_30\">Children of God<\/label><\/li><li class=\"choice-29 depth-1\"><input type=\"checkbox\" id=\"wpforms-1555-field_90_29\" name=\"wpforms[fields][90][]\" value=\"The Way International\" aria-errormessage=\"wpforms-1555-field_90_29-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-1555-field_90_29\">The Way International<\/label><\/li><li class=\"choice-28 depth-1\"><input type=\"checkbox\" id=\"wpforms-1555-field_90_28\" name=\"wpforms[fields][90][]\" value=\"Worldwide Church of God (Armstrong)\" aria-errormessage=\"wpforms-1555-field_90_28-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-1555-field_90_28\">Worldwide Church of God (Armstrong)<\/label><\/li><li class=\"choice-27 depth-1\"><input type=\"checkbox\" id=\"wpforms-1555-field_90_27\" name=\"wpforms[fields][90][]\" value=\"Other, Please List\" aria-errormessage=\"wpforms-1555-field_90_27-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-1555-field_90_27\">Other, Please List<\/label><\/li><li class=\"choice-26 depth-1\"><input type=\"checkbox\" id=\"wpforms-1555-field_90_26\" name=\"wpforms[fields][90][]\" value=\"None\" aria-errormessage=\"wpforms-1555-field_90_26-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-1555-field_90_26\">None<\/label><\/li><\/ul><\/fieldset><\/div><div id=\"wpforms-1555-field_169-container\" class=\"wpforms-field wpforms-field-textarea\" data-field-id=\"169\"><label class=\"wpforms-field-label\" for=\"wpforms-1555-field_169\">If you have checked any of the above, state who was involved, when, and to what extent.<\/label><textarea id=\"wpforms-1555-field_169\" class=\"wpforms-field-medium\" name=\"wpforms[fields][169]\" aria-errormessage=\"wpforms-1555-field_169-error\" ><\/textarea><\/div><div id=\"wpforms-1555-field_96-container\" class=\"wpforms-field wpforms-field-textarea\" data-field-id=\"96\"><label class=\"wpforms-field-label\" for=\"wpforms-1555-field_96\">Describe any family history of addictive behaviors, physical illness patterns, or major willful sins. If this does not apply to you, please write &quot;not applicable.&quot;<\/label><textarea id=\"wpforms-1555-field_96\" class=\"wpforms-field-medium\" name=\"wpforms[fields][96]\" aria-errormessage=\"wpforms-1555-field_96-error\" ><\/textarea><\/div><div id=\"wpforms-1555-field_98-container\" class=\"wpforms-field wpforms-field-checkbox\" data-field-id=\"98\"><fieldset><legend class=\"wpforms-field-label\">Have you ever had someone of influence speak cruel or negative words over you or to you? <\/legend><ul id=\"wpforms-1555-field_98\"><li class=\"choice-1 depth-1\"><input type=\"checkbox\" id=\"wpforms-1555-field_98_1\" name=\"wpforms[fields][98][]\" value=\"yes\" aria-errormessage=\"wpforms-1555-field_98_1-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-1555-field_98_1\">yes<\/label><\/li><li class=\"choice-2 depth-1\"><input type=\"checkbox\" id=\"wpforms-1555-field_98_2\" name=\"wpforms[fields][98][]\" value=\"no\" aria-errormessage=\"wpforms-1555-field_98_2-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-1555-field_98_2\">no<\/label><\/li><\/ul><\/fieldset><\/div><div id=\"wpforms-1555-field_170-container\" class=\"wpforms-field wpforms-field-textarea\" data-field-id=\"170\"><label class=\"wpforms-field-label\" for=\"wpforms-1555-field_170\">If so, explain below.<\/label><textarea id=\"wpforms-1555-field_170\" class=\"wpforms-field-medium\" name=\"wpforms[fields][170]\" aria-errormessage=\"wpforms-1555-field_170-error\" ><\/textarea><\/div><div id=\"wpforms-1555-field_171-container\" class=\"wpforms-field wpforms-field-pagebreak\" data-field-id=\"171\"><div class=\"wpforms-clear wpforms-pagebreak-left\"><button class=\"wpforms-page-button wpforms-page-next wpforms-disabled\"\n\t\t\t\t\tdata-action=\"next\" data-page=\"7\" data-formid=\"1555\" aria-disabled=\"true\" aria-describedby=\"wpforms-error-noscript\">Next<\/button><\/div><\/div><\/div><div class=\"wpforms-page wpforms-page-8  \" data-page=\"8\" style=\"display:none;\"><div id=\"wpforms-1555-field_172-container\" class=\"wpforms-field wpforms-field-content\" data-field-id=\"172\"><div id=\"wpforms-1555-field_172\" class=\"wpforms-field-medium wpforms-field-row\" aria-errormessage=\"wpforms-1555-field_172-error\"><h2 class=\"gsection_title\">Mental Strongholds<\/h2>\n<p>&nbsp;<\/p>\n<div class=\"wpforms-field-content-display-frontend-clear\"><\/div><\/div><\/div><div id=\"wpforms-1555-field_99-container\" class=\"wpforms-field wpforms-field-textarea\" data-field-id=\"99\"><label class=\"wpforms-field-label\" for=\"wpforms-1555-field_99\">Are there areas of emotional immaturity that you are aware of (fear of commitment, unable to resolve relational conflict)? Please explain. If this does not apply to you, please write &quot;not applicable.&quot;<\/label><textarea id=\"wpforms-1555-field_99\" class=\"wpforms-field-medium\" name=\"wpforms[fields][99]\" aria-errormessage=\"wpforms-1555-field_99-error\" ><\/textarea><\/div><div id=\"wpforms-1555-field_102-container\" class=\"wpforms-field wpforms-field-textarea\" data-field-id=\"102\"><label class=\"wpforms-field-label\" for=\"wpforms-1555-field_102\">Can you identify any destructive or negative patterns of thinking? Please explain.  If this does not apply to you, please write &quot;not applicable.&quot;<\/label><textarea id=\"wpforms-1555-field_102\" class=\"wpforms-field-medium\" name=\"wpforms[fields][102]\" aria-errormessage=\"wpforms-1555-field_102-error\" ><\/textarea><\/div><div id=\"wpforms-1555-field_103-container\" class=\"wpforms-field wpforms-field-textarea\" data-field-id=\"103\"><label class=\"wpforms-field-label\" for=\"wpforms-1555-field_103\">Are there any patterns of thinking that often lead to negative behavior? Please explain. If this does not apply to you, please write &quot;not applicable.&quot;<\/label><textarea id=\"wpforms-1555-field_103\" class=\"wpforms-field-medium\" name=\"wpforms[fields][103]\" aria-errormessage=\"wpforms-1555-field_103-error\" ><\/textarea><\/div><div id=\"wpforms-1555-field_100-container\" class=\"wpforms-field wpforms-field-textarea\" data-field-id=\"100\"><label class=\"wpforms-field-label\" for=\"wpforms-1555-field_100\">Are you affected by any cultural or geographical strongholds (patterns of thinking), such as racial prejudice, victim of poverty, religion, pride, intellectualism, etc.? Please explain. If this does not apply to you, please write &quot;not applicable.&quot;<\/label><textarea id=\"wpforms-1555-field_100\" class=\"wpforms-field-medium\" name=\"wpforms[fields][100]\" aria-errormessage=\"wpforms-1555-field_100-error\" ><\/textarea><\/div><div id=\"wpforms-1555-field_101-container\" class=\"wpforms-field wpforms-field-textarea\" data-field-id=\"101\"><label class=\"wpforms-field-label\" for=\"wpforms-1555-field_101\">Are you given to uncontrollable fantasizing, daydreaming, or losing track of time? Please explain. If this does not apply to you, please write &quot;not applicable.&quot;<\/label><textarea id=\"wpforms-1555-field_101\" class=\"wpforms-field-medium\" name=\"wpforms[fields][101]\" aria-errormessage=\"wpforms-1555-field_101-error\" ><\/textarea><\/div><div id=\"wpforms-1555-field_7-container\" class=\"wpforms-field wpforms-field-pagebreak\" data-field-id=\"7\"><div class=\"wpforms-clear wpforms-pagebreak-left\"><button class=\"wpforms-page-button wpforms-page-next wpforms-disabled\"\n\t\t\t\t\tdata-action=\"next\" data-page=\"8\" data-formid=\"1555\" aria-disabled=\"true\" aria-describedby=\"wpforms-error-noscript\">Next<\/button><\/div><\/div><\/div><div class=\"wpforms-page wpforms-page-9  \" data-page=\"9\" style=\"display:none;\"><div id=\"wpforms-1555-field_173-container\" class=\"wpforms-field wpforms-field-content\" data-field-id=\"173\"><div id=\"wpforms-1555-field_173\" class=\"wpforms-field-medium wpforms-field-row\" aria-errormessage=\"wpforms-1555-field_173-error\"><h2 class=\"gsection_title\">Family History<\/h2>\n<p>&nbsp;<\/p>\n<div class=\"wpforms-field-content-display-frontend-clear\"><\/div><\/div><\/div><div id=\"wpforms-1555-field_104-container\" class=\"wpforms-field wpforms-field-textarea\" data-field-id=\"104\"><label class=\"wpforms-field-label\" for=\"wpforms-1555-field_104\">Describe your relationship with the following people. Spouse, Children, Father, Mother, Siblings, Grandparents, Step-Parent, Step-Siblings, Others<\/label><textarea id=\"wpforms-1555-field_104\" class=\"wpforms-field-medium\" name=\"wpforms[fields][104]\" aria-errormessage=\"wpforms-1555-field_104-error\" ><\/textarea><\/div><div id=\"wpforms-1555-field_174-container\" class=\"wpforms-field wpforms-field-content\" data-field-id=\"174\"><div id=\"wpforms-1555-field_174\" class=\"wpforms-field-medium wpforms-field-row\" aria-errormessage=\"wpforms-1555-field_174-error\"><h2 class=\"gsection_title\">Parents<\/h2>\n<p>&nbsp;<\/p>\n<div class=\"wpforms-field-content-display-frontend-clear\"><\/div><\/div><\/div><div id=\"wpforms-1555-field_18-container\" class=\"wpforms-field wpforms-field-checkbox\" data-field-id=\"18\"><fieldset><legend class=\"wpforms-field-label\">Were you a planned pregnancy?<\/legend><ul id=\"wpforms-1555-field_18\"><li class=\"choice-1 depth-1\"><input type=\"checkbox\" id=\"wpforms-1555-field_18_1\" name=\"wpforms[fields][18][]\" value=\"yes\" aria-errormessage=\"wpforms-1555-field_18_1-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-1555-field_18_1\">yes<\/label><\/li><li class=\"choice-2 depth-1\"><input type=\"checkbox\" id=\"wpforms-1555-field_18_2\" name=\"wpforms[fields][18][]\" value=\"no\" aria-errormessage=\"wpforms-1555-field_18_2-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-1555-field_18_2\">no<\/label><\/li><li class=\"choice-3 depth-1\"><input type=\"checkbox\" id=\"wpforms-1555-field_18_3\" name=\"wpforms[fields][18][]\" value=\"I don&#039;t know\" aria-errormessage=\"wpforms-1555-field_18_3-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-1555-field_18_3\">I don't know<\/label><\/li><\/ul><\/fieldset><\/div><div id=\"wpforms-1555-field_106-container\" class=\"wpforms-field wpforms-field-checkbox\" data-field-id=\"106\"><fieldset><legend class=\"wpforms-field-label\">Were you conceived out of wedlock?<\/legend><ul id=\"wpforms-1555-field_106\"><li class=\"choice-1 depth-1\"><input type=\"checkbox\" id=\"wpforms-1555-field_106_1\" name=\"wpforms[fields][106][]\" value=\"yes\" aria-errormessage=\"wpforms-1555-field_106_1-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-1555-field_106_1\">yes<\/label><\/li><li class=\"choice-2 depth-1\"><input type=\"checkbox\" id=\"wpforms-1555-field_106_2\" name=\"wpforms[fields][106][]\" value=\"no\" aria-errormessage=\"wpforms-1555-field_106_2-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-1555-field_106_2\">no<\/label><\/li><li class=\"choice-3 depth-1\"><input type=\"checkbox\" id=\"wpforms-1555-field_106_3\" name=\"wpforms[fields][106][]\" value=\"I don&#039;t know\" aria-errormessage=\"wpforms-1555-field_106_3-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-1555-field_106_3\">I don't know<\/label><\/li><\/ul><\/fieldset><\/div><div id=\"wpforms-1555-field_107-container\" class=\"wpforms-field wpforms-field-checkbox\" data-field-id=\"107\"><fieldset><legend class=\"wpforms-field-label\">Were you conceived as a result of a rape?<\/legend><ul id=\"wpforms-1555-field_107\"><li class=\"choice-1 depth-1\"><input type=\"checkbox\" id=\"wpforms-1555-field_107_1\" name=\"wpforms[fields][107][]\" value=\"yes\" aria-errormessage=\"wpforms-1555-field_107_1-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-1555-field_107_1\">yes<\/label><\/li><li class=\"choice-2 depth-1\"><input type=\"checkbox\" id=\"wpforms-1555-field_107_2\" name=\"wpforms[fields][107][]\" value=\"no\" aria-errormessage=\"wpforms-1555-field_107_2-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-1555-field_107_2\">no<\/label><\/li><li class=\"choice-3 depth-1\"><input type=\"checkbox\" id=\"wpforms-1555-field_107_3\" name=\"wpforms[fields][107][]\" value=\"I don&#039;t know\" aria-errormessage=\"wpforms-1555-field_107_3-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-1555-field_107_3\">I don't know<\/label><\/li><\/ul><\/fieldset><\/div><div id=\"wpforms-1555-field_108-container\" class=\"wpforms-field wpforms-field-checkbox\" data-field-id=\"108\"><fieldset><legend class=\"wpforms-field-label\">Were you born after a traumatic pregnancy? (I.E. &quot;We shouldn&#039;t be having this child.&quot;)<\/legend><ul id=\"wpforms-1555-field_108\"><li class=\"choice-1 depth-1\"><input type=\"checkbox\" id=\"wpforms-1555-field_108_1\" name=\"wpforms[fields][108][]\" value=\"yes\" aria-errormessage=\"wpforms-1555-field_108_1-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-1555-field_108_1\">yes<\/label><\/li><li class=\"choice-2 depth-1\"><input type=\"checkbox\" id=\"wpforms-1555-field_108_2\" name=\"wpforms[fields][108][]\" value=\"no\" aria-errormessage=\"wpforms-1555-field_108_2-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-1555-field_108_2\">no<\/label><\/li><li class=\"choice-3 depth-1\"><input type=\"checkbox\" id=\"wpforms-1555-field_108_3\" name=\"wpforms[fields][108][]\" value=\"I don&#039;t know\" aria-errormessage=\"wpforms-1555-field_108_3-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-1555-field_108_3\">I don't know<\/label><\/li><\/ul><\/fieldset><\/div><div id=\"wpforms-1555-field_110-container\" class=\"wpforms-field wpforms-field-checkbox\" data-field-id=\"110\"><fieldset><legend class=\"wpforms-field-label\">Were you adopted?<\/legend><ul id=\"wpforms-1555-field_110\"><li class=\"choice-1 depth-1\"><input type=\"checkbox\" id=\"wpforms-1555-field_110_1\" name=\"wpforms[fields][110][]\" value=\"yes\" aria-errormessage=\"wpforms-1555-field_110_1-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-1555-field_110_1\">yes<\/label><\/li><li class=\"choice-2 depth-1\"><input type=\"checkbox\" id=\"wpforms-1555-field_110_2\" name=\"wpforms[fields][110][]\" value=\"no\" aria-errormessage=\"wpforms-1555-field_110_2-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-1555-field_110_2\">no<\/label><\/li><li class=\"choice-3 depth-1\"><input type=\"checkbox\" id=\"wpforms-1555-field_110_3\" name=\"wpforms[fields][110][]\" value=\"I don&#039;t know\" aria-errormessage=\"wpforms-1555-field_110_3-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-1555-field_110_3\">I don't know<\/label><\/li><\/ul><\/fieldset><\/div><div id=\"wpforms-1555-field_111-container\" class=\"wpforms-field wpforms-field-checkbox\" data-field-id=\"111\"><fieldset><legend class=\"wpforms-field-label\">Are your parents still living?<\/legend><ul id=\"wpforms-1555-field_111\"><li class=\"choice-1 depth-1\"><input type=\"checkbox\" id=\"wpforms-1555-field_111_1\" name=\"wpforms[fields][111][]\" value=\"yes\" aria-errormessage=\"wpforms-1555-field_111_1-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-1555-field_111_1\">yes<\/label><\/li><li class=\"choice-2 depth-1\"><input type=\"checkbox\" id=\"wpforms-1555-field_111_2\" name=\"wpforms[fields][111][]\" value=\"no\" aria-errormessage=\"wpforms-1555-field_111_2-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-1555-field_111_2\">no<\/label><\/li><li class=\"choice-3 depth-1\"><input type=\"checkbox\" id=\"wpforms-1555-field_111_3\" name=\"wpforms[fields][111][]\" value=\"I don&#039;t know\" aria-errormessage=\"wpforms-1555-field_111_3-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-1555-field_111_3\">I don't know<\/label><\/li><\/ul><\/fieldset><\/div><div id=\"wpforms-1555-field_112-container\" class=\"wpforms-field wpforms-field-checkbox\" data-field-id=\"112\"><fieldset><legend class=\"wpforms-field-label\">Are your parents Christians?<\/legend><ul id=\"wpforms-1555-field_112\"><li class=\"choice-1 depth-1\"><input type=\"checkbox\" id=\"wpforms-1555-field_112_1\" name=\"wpforms[fields][112][]\" value=\"yes\" aria-errormessage=\"wpforms-1555-field_112_1-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-1555-field_112_1\">yes<\/label><\/li><li class=\"choice-2 depth-1\"><input type=\"checkbox\" id=\"wpforms-1555-field_112_2\" name=\"wpforms[fields][112][]\" value=\"no\" aria-errormessage=\"wpforms-1555-field_112_2-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-1555-field_112_2\">no<\/label><\/li><li class=\"choice-3 depth-1\"><input type=\"checkbox\" id=\"wpforms-1555-field_112_3\" name=\"wpforms[fields][112][]\" value=\"I don&#039;t know\" aria-errormessage=\"wpforms-1555-field_112_3-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-1555-field_112_3\">I don't know<\/label><\/li><\/ul><\/fieldset><\/div><div id=\"wpforms-1555-field_113-container\" class=\"wpforms-field wpforms-field-checkbox\" data-field-id=\"113\"><fieldset><legend class=\"wpforms-field-label\">Are your parents presently married or divorced?<\/legend><ul id=\"wpforms-1555-field_113\"><li class=\"choice-1 depth-1\"><input type=\"checkbox\" id=\"wpforms-1555-field_113_1\" name=\"wpforms[fields][113][]\" value=\"yes\" aria-errormessage=\"wpforms-1555-field_113_1-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-1555-field_113_1\">yes<\/label><\/li><li class=\"choice-2 depth-1\"><input type=\"checkbox\" id=\"wpforms-1555-field_113_2\" name=\"wpforms[fields][113][]\" value=\"no\" aria-errormessage=\"wpforms-1555-field_113_2-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-1555-field_113_2\">no<\/label><\/li><li class=\"choice-3 depth-1\"><input type=\"checkbox\" id=\"wpforms-1555-field_113_3\" name=\"wpforms[fields][113][]\" value=\"I don&#039;t know\" aria-errormessage=\"wpforms-1555-field_113_3-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-1555-field_113_3\">I don't know<\/label><\/li><\/ul><\/fieldset><\/div><div id=\"wpforms-1555-field_114-container\" class=\"wpforms-field wpforms-field-textarea\" data-field-id=\"114\"><label class=\"wpforms-field-label\" for=\"wpforms-1555-field_114\">Who provided discipline in your home, and how was it handled?<\/label><textarea id=\"wpforms-1555-field_114\" class=\"wpforms-field-medium\" name=\"wpforms[fields][114]\" aria-errormessage=\"wpforms-1555-field_114-error\" ><\/textarea><\/div><div id=\"wpforms-1555-field_115-container\" class=\"wpforms-field wpforms-field-textarea\" data-field-id=\"115\"><label class=\"wpforms-field-label\" for=\"wpforms-1555-field_115\">How was affection demonstrated by different members in your home?<\/label><textarea id=\"wpforms-1555-field_115\" class=\"wpforms-field-medium\" name=\"wpforms[fields][115]\" aria-errormessage=\"wpforms-1555-field_115-error\" ><\/textarea><\/div><div id=\"wpforms-1555-field_116-container\" class=\"wpforms-field wpforms-field-textarea\" data-field-id=\"116\"><label class=\"wpforms-field-label\" for=\"wpforms-1555-field_116\">How would you describe your family&#039;s financial situation when you were a child?<\/label><textarea id=\"wpforms-1555-field_116\" class=\"wpforms-field-medium\" name=\"wpforms[fields][116]\" aria-errormessage=\"wpforms-1555-field_116-error\" ><\/textarea><\/div><div id=\"wpforms-1555-field_118-container\" class=\"wpforms-field wpforms-field-checkbox\" data-field-id=\"118\"><fieldset><legend class=\"wpforms-field-label\">Please check which description most accurately describes your father.<\/legend><ul id=\"wpforms-1555-field_118\"><li class=\"choice-1 depth-1\"><input type=\"checkbox\" id=\"wpforms-1555-field_118_1\" name=\"wpforms[fields][118][]\" value=\"Passive\" aria-errormessage=\"wpforms-1555-field_118_1-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-1555-field_118_1\">Passive<\/label><\/li><li class=\"choice-2 depth-1\"><input type=\"checkbox\" id=\"wpforms-1555-field_118_2\" name=\"wpforms[fields][118][]\" value=\"Strong\" aria-errormessage=\"wpforms-1555-field_118_2-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-1555-field_118_2\">Strong<\/label><\/li><li class=\"choice-3 depth-1\"><input type=\"checkbox\" id=\"wpforms-1555-field_118_3\" name=\"wpforms[fields][118][]\" value=\"Provider\" aria-errormessage=\"wpforms-1555-field_118_3-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-1555-field_118_3\">Provider<\/label><\/li><li class=\"choice-8 depth-1\"><input type=\"checkbox\" id=\"wpforms-1555-field_118_8\" name=\"wpforms[fields][118][]\" value=\"Dominant\" aria-errormessage=\"wpforms-1555-field_118_8-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-1555-field_118_8\">Dominant<\/label><\/li><li class=\"choice-7 depth-1\"><input type=\"checkbox\" id=\"wpforms-1555-field_118_7\" name=\"wpforms[fields][118][]\" value=\"Absent\" aria-errormessage=\"wpforms-1555-field_118_7-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-1555-field_118_7\">Absent<\/label><\/li><li class=\"choice-6 depth-1\"><input type=\"checkbox\" id=\"wpforms-1555-field_118_6\" name=\"wpforms[fields][118][]\" value=\"Manipulative\" aria-errormessage=\"wpforms-1555-field_118_6-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-1555-field_118_6\">Manipulative<\/label><\/li><li class=\"choice-5 depth-1\"><input type=\"checkbox\" id=\"wpforms-1555-field_118_5\" name=\"wpforms[fields][118][]\" value=\"Other\" aria-errormessage=\"wpforms-1555-field_118_5-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-1555-field_118_5\">Other<\/label><\/li><\/ul><\/fieldset><\/div><div id=\"wpforms-1555-field_119-container\" class=\"wpforms-field wpforms-field-textarea\" data-field-id=\"119\"><label class=\"wpforms-field-label\" for=\"wpforms-1555-field_119\">Provide any additional explanation.<\/label><textarea id=\"wpforms-1555-field_119\" class=\"wpforms-field-medium\" name=\"wpforms[fields][119]\" aria-errormessage=\"wpforms-1555-field_119-error\" ><\/textarea><\/div><div id=\"wpforms-1555-field_121-container\" class=\"wpforms-field wpforms-field-checkbox\" data-field-id=\"121\"><fieldset><legend class=\"wpforms-field-label\">Please check which description most accurately describes your mother.<\/legend><ul id=\"wpforms-1555-field_121\"><li class=\"choice-1 depth-1\"><input type=\"checkbox\" id=\"wpforms-1555-field_121_1\" name=\"wpforms[fields][121][]\" value=\"Passive\" aria-errormessage=\"wpforms-1555-field_121_1-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-1555-field_121_1\">Passive<\/label><\/li><li class=\"choice-2 depth-1\"><input type=\"checkbox\" id=\"wpforms-1555-field_121_2\" name=\"wpforms[fields][121][]\" value=\"Strong\" aria-errormessage=\"wpforms-1555-field_121_2-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-1555-field_121_2\">Strong<\/label><\/li><li class=\"choice-3 depth-1\"><input type=\"checkbox\" id=\"wpforms-1555-field_121_3\" name=\"wpforms[fields][121][]\" value=\"Provider\" aria-errormessage=\"wpforms-1555-field_121_3-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-1555-field_121_3\">Provider<\/label><\/li><li class=\"choice-8 depth-1\"><input type=\"checkbox\" id=\"wpforms-1555-field_121_8\" name=\"wpforms[fields][121][]\" value=\"Dominant\" aria-errormessage=\"wpforms-1555-field_121_8-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-1555-field_121_8\">Dominant<\/label><\/li><li class=\"choice-7 depth-1\"><input type=\"checkbox\" id=\"wpforms-1555-field_121_7\" name=\"wpforms[fields][121][]\" value=\"Absent\" aria-errormessage=\"wpforms-1555-field_121_7-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-1555-field_121_7\">Absent<\/label><\/li><li class=\"choice-6 depth-1\"><input type=\"checkbox\" id=\"wpforms-1555-field_121_6\" name=\"wpforms[fields][121][]\" value=\"Manipulative\" aria-errormessage=\"wpforms-1555-field_121_6-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-1555-field_121_6\">Manipulative<\/label><\/li><li class=\"choice-5 depth-1\"><input type=\"checkbox\" id=\"wpforms-1555-field_121_5\" name=\"wpforms[fields][121][]\" value=\"Other\" aria-errormessage=\"wpforms-1555-field_121_5-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-1555-field_121_5\">Other<\/label><\/li><\/ul><\/fieldset><\/div><div id=\"wpforms-1555-field_120-container\" class=\"wpforms-field wpforms-field-textarea\" data-field-id=\"120\"><label class=\"wpforms-field-label\" for=\"wpforms-1555-field_120\">Provide any additional explanation. <\/label><textarea id=\"wpforms-1555-field_120\" class=\"wpforms-field-medium\" name=\"wpforms[fields][120]\" aria-errormessage=\"wpforms-1555-field_120-error\" ><\/textarea><\/div><div id=\"wpforms-1555-field_122-container\" class=\"wpforms-field wpforms-field-checkbox\" data-field-id=\"122\"><fieldset><legend class=\"wpforms-field-label\">In whose homes were you raised? (Check all that apply)<\/legend><ul id=\"wpforms-1555-field_122\"><li class=\"choice-1 depth-1\"><input type=\"checkbox\" id=\"wpforms-1555-field_122_1\" name=\"wpforms[fields][122][]\" value=\"Both biological parent&#039;s home\" aria-errormessage=\"wpforms-1555-field_122_1-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-1555-field_122_1\">Both biological parent's home<\/label><\/li><li class=\"choice-2 depth-1\"><input type=\"checkbox\" id=\"wpforms-1555-field_122_2\" name=\"wpforms[fields][122][]\" value=\"Father&#039;s home\" aria-errormessage=\"wpforms-1555-field_122_2-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-1555-field_122_2\">Father's home<\/label><\/li><li class=\"choice-3 depth-1\"><input type=\"checkbox\" id=\"wpforms-1555-field_122_3\" name=\"wpforms[fields][122][]\" value=\"Mother&#039;s home\" aria-errormessage=\"wpforms-1555-field_122_3-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-1555-field_122_3\">Mother's home<\/label><\/li><li class=\"choice-8 depth-1\"><input type=\"checkbox\" id=\"wpforms-1555-field_122_8\" name=\"wpforms[fields][122][]\" value=\"Grandparent&#039;s home\" aria-errormessage=\"wpforms-1555-field_122_8-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-1555-field_122_8\">Grandparent's home<\/label><\/li><li class=\"choice-7 depth-1\"><input type=\"checkbox\" id=\"wpforms-1555-field_122_7\" name=\"wpforms[fields][122][]\" value=\"Other relative&#039;s home\" aria-errormessage=\"wpforms-1555-field_122_7-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-1555-field_122_7\">Other relative's home<\/label><\/li><li class=\"choice-6 depth-1\"><input type=\"checkbox\" id=\"wpforms-1555-field_122_6\" name=\"wpforms[fields][122][]\" value=\"Orphanage\" aria-errormessage=\"wpforms-1555-field_122_6-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-1555-field_122_6\">Orphanage<\/label><\/li><li class=\"choice-5 depth-1\"><input type=\"checkbox\" id=\"wpforms-1555-field_122_5\" name=\"wpforms[fields][122][]\" value=\"Foster home(s)\" aria-errormessage=\"wpforms-1555-field_122_5-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-1555-field_122_5\">Foster home(s)<\/label><\/li><li class=\"choice-10 depth-1\"><input type=\"checkbox\" id=\"wpforms-1555-field_122_10\" name=\"wpforms[fields][122][]\" value=\"Adoptive parent&#039;s home\" aria-errormessage=\"wpforms-1555-field_122_10-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-1555-field_122_10\">Adoptive parent's home<\/label><\/li><li class=\"choice-9 depth-1\"><input type=\"checkbox\" id=\"wpforms-1555-field_122_9\" name=\"wpforms[fields][122][]\" value=\"Friend&#039;s home\" aria-errormessage=\"wpforms-1555-field_122_9-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-1555-field_122_9\">Friend's home<\/label><\/li><\/ul><\/fieldset><\/div><div id=\"wpforms-1555-field_123-container\" class=\"wpforms-field wpforms-field-checkbox\" data-field-id=\"123\"><fieldset><legend class=\"wpforms-field-label\">Was there a sense of security in your home during the first five years?<\/legend><ul id=\"wpforms-1555-field_123\"><li class=\"choice-1 depth-1\"><input type=\"checkbox\" id=\"wpforms-1555-field_123_1\" name=\"wpforms[fields][123][]\" value=\"yes\" aria-errormessage=\"wpforms-1555-field_123_1-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-1555-field_123_1\">yes<\/label><\/li><li class=\"choice-2 depth-1\"><input type=\"checkbox\" id=\"wpforms-1555-field_123_2\" name=\"wpforms[fields][123][]\" value=\"no\" aria-errormessage=\"wpforms-1555-field_123_2-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-1555-field_123_2\">no<\/label><\/li><\/ul><\/fieldset><\/div><div id=\"wpforms-1555-field_175-container\" class=\"wpforms-field wpforms-field-textarea\" data-field-id=\"175\"><label class=\"wpforms-field-label\" for=\"wpforms-1555-field_175\">If no, please explain.<\/label><textarea id=\"wpforms-1555-field_175\" class=\"wpforms-field-medium\" name=\"wpforms[fields][175]\" aria-errormessage=\"wpforms-1555-field_175-error\" ><\/textarea><\/div><div id=\"wpforms-1555-field_124-container\" class=\"wpforms-field wpforms-field-checkbox\" data-field-id=\"124\"><fieldset><legend class=\"wpforms-field-label\">Was there a sense of security in your home from age 6\u201312?<\/legend><ul id=\"wpforms-1555-field_124\"><li class=\"choice-1 depth-1\"><input type=\"checkbox\" id=\"wpforms-1555-field_124_1\" name=\"wpforms[fields][124][]\" value=\"yes\" aria-errormessage=\"wpforms-1555-field_124_1-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-1555-field_124_1\">yes<\/label><\/li><li class=\"choice-2 depth-1\"><input type=\"checkbox\" id=\"wpforms-1555-field_124_2\" name=\"wpforms[fields][124][]\" value=\"no\" aria-errormessage=\"wpforms-1555-field_124_2-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-1555-field_124_2\">no<\/label><\/li><\/ul><\/fieldset><\/div><div id=\"wpforms-1555-field_176-container\" class=\"wpforms-field wpforms-field-textarea\" data-field-id=\"176\"><label class=\"wpforms-field-label\" for=\"wpforms-1555-field_176\">If no, please explain.<\/label><textarea id=\"wpforms-1555-field_176\" class=\"wpforms-field-medium\" name=\"wpforms[fields][176]\" aria-errormessage=\"wpforms-1555-field_176-error\" ><\/textarea><\/div><div id=\"wpforms-1555-field_125-container\" class=\"wpforms-field wpforms-field-checkbox\" data-field-id=\"125\"><fieldset><legend class=\"wpforms-field-label\">Were you raised in a Christian home?<\/legend><ul id=\"wpforms-1555-field_125\"><li class=\"choice-1 depth-1\"><input type=\"checkbox\" id=\"wpforms-1555-field_125_1\" name=\"wpforms[fields][125][]\" value=\"yes\" aria-errormessage=\"wpforms-1555-field_125_1-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-1555-field_125_1\">yes<\/label><\/li><li class=\"choice-2 depth-1\"><input type=\"checkbox\" id=\"wpforms-1555-field_125_2\" name=\"wpforms[fields][125][]\" value=\"no\" aria-errormessage=\"wpforms-1555-field_125_2-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-1555-field_125_2\">no<\/label><\/li><\/ul><\/fieldset><\/div><div id=\"wpforms-1555-field_126-container\" class=\"wpforms-field wpforms-field-checkbox\" data-field-id=\"126\"><fieldset><legend class=\"wpforms-field-label\">Was your upbringing in an alcoholic or drug-dominated home<\/legend><ul id=\"wpforms-1555-field_126\"><li class=\"choice-1 depth-1\"><input type=\"checkbox\" id=\"wpforms-1555-field_126_1\" name=\"wpforms[fields][126][]\" value=\"yes\" aria-errormessage=\"wpforms-1555-field_126_1-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-1555-field_126_1\">yes<\/label><\/li><li class=\"choice-2 depth-1\"><input type=\"checkbox\" id=\"wpforms-1555-field_126_2\" name=\"wpforms[fields][126][]\" value=\"no\" aria-errormessage=\"wpforms-1555-field_126_2-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-1555-field_126_2\">no<\/label><\/li><\/ul><\/fieldset><\/div><div id=\"wpforms-1555-field_127-container\" class=\"wpforms-field wpforms-field-checkbox\" data-field-id=\"127\"><fieldset><legend class=\"wpforms-field-label\">Do you have brothers or sisters?<\/legend><ul id=\"wpforms-1555-field_127\"><li class=\"choice-1 depth-1\"><input type=\"checkbox\" id=\"wpforms-1555-field_127_1\" name=\"wpforms[fields][127][]\" value=\"yes\" aria-errormessage=\"wpforms-1555-field_127_1-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-1555-field_127_1\">yes<\/label><\/li><li class=\"choice-2 depth-1\"><input type=\"checkbox\" id=\"wpforms-1555-field_127_2\" name=\"wpforms[fields][127][]\" value=\"no\" aria-errormessage=\"wpforms-1555-field_127_2-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-1555-field_127_2\">no<\/label><\/li><\/ul><\/fieldset><\/div><div id=\"wpforms-1555-field_200-container\" class=\"wpforms-field wpforms-field-textarea\" data-field-id=\"200\"><label class=\"wpforms-field-label\" for=\"wpforms-1555-field_200\">If yes, please list their name, age, and relationship to you (brother\/ sister\/ full\/ half\/ step) <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/label><textarea id=\"wpforms-1555-field_200\" class=\"wpforms-field-medium wpforms-field-required\" name=\"wpforms[fields][200]\" aria-errormessage=\"wpforms-1555-field_200-error\" required><\/textarea><\/div><div id=\"wpforms-1555-field_182-container\" class=\"wpforms-field wpforms-field-pagebreak\" data-field-id=\"182\"><div class=\"wpforms-clear wpforms-pagebreak-left\"><button class=\"wpforms-page-button wpforms-page-prev wpforms-disabled\"\n\t\t\t\t\tdata-action=\"prev\" data-page=\"9\" data-formid=\"1555\" aria-disabled=\"true\" aria-describedby=\"wpforms-error-noscript\">Previous<\/button><button class=\"wpforms-page-button wpforms-page-next wpforms-disabled\"\n\t\t\t\t\tdata-action=\"next\" data-page=\"9\" data-formid=\"1555\" aria-disabled=\"true\" aria-describedby=\"wpforms-error-noscript\">Next<\/button><\/div><\/div><\/div><div class=\"wpforms-page wpforms-page-10  \" data-page=\"10\" style=\"display:none;\"><div id=\"wpforms-1555-field_201-container\" class=\"wpforms-field wpforms-field-content\" data-field-id=\"201\"><div id=\"wpforms-1555-field_201\" class=\"wpforms-field-medium wpforms-field-row\" aria-errormessage=\"wpforms-1555-field_201-error\"><h2 class=\"gsection_title\">Immediate Family<\/h2>\n<p>&nbsp;<\/p>\n<div class=\"wpforms-field-content-display-frontend-clear\"><\/div><\/div><\/div><div id=\"wpforms-1555-field_128-container\" class=\"wpforms-field wpforms-field-checkbox\" data-field-id=\"128\"><fieldset><legend class=\"wpforms-field-label\">What is your current marital status?<\/legend><ul id=\"wpforms-1555-field_128\"><li class=\"choice-1 depth-1\"><input type=\"checkbox\" id=\"wpforms-1555-field_128_1\" name=\"wpforms[fields][128][]\" value=\"Single\" aria-errormessage=\"wpforms-1555-field_128_1-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-1555-field_128_1\">Single<\/label><\/li><li class=\"choice-2 depth-1\"><input type=\"checkbox\" id=\"wpforms-1555-field_128_2\" name=\"wpforms[fields][128][]\" value=\"Married\" aria-errormessage=\"wpforms-1555-field_128_2-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-1555-field_128_2\">Married<\/label><\/li><li class=\"choice-3 depth-1\"><input type=\"checkbox\" id=\"wpforms-1555-field_128_3\" name=\"wpforms[fields][128][]\" value=\"Divorced\" aria-errormessage=\"wpforms-1555-field_128_3-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-1555-field_128_3\">Divorced<\/label><\/li><li class=\"choice-4 depth-1\"><input type=\"checkbox\" id=\"wpforms-1555-field_128_4\" name=\"wpforms[fields][128][]\" value=\"Separated\" aria-errormessage=\"wpforms-1555-field_128_4-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-1555-field_128_4\">Separated<\/label><\/li><li class=\"choice-5 depth-1\"><input type=\"checkbox\" id=\"wpforms-1555-field_128_5\" name=\"wpforms[fields][128][]\" value=\"Widowed\" aria-errormessage=\"wpforms-1555-field_128_5-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-1555-field_128_5\">Widowed<\/label><\/li><\/ul><\/fieldset><\/div><div id=\"wpforms-1555-field_129-container\" class=\"wpforms-field wpforms-field-checkbox\" data-field-id=\"129\"><fieldset><legend class=\"wpforms-field-label\">Do you have children?<\/legend><ul id=\"wpforms-1555-field_129\"><li class=\"choice-1 depth-1\"><input type=\"checkbox\" id=\"wpforms-1555-field_129_1\" name=\"wpforms[fields][129][]\" value=\"yes\" aria-errormessage=\"wpforms-1555-field_129_1-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-1555-field_129_1\">yes<\/label><\/li><li class=\"choice-2 depth-1\"><input type=\"checkbox\" id=\"wpforms-1555-field_129_2\" name=\"wpforms[fields][129][]\" value=\"no\" aria-errormessage=\"wpforms-1555-field_129_2-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-1555-field_129_2\">no<\/label><\/li><\/ul><\/fieldset><\/div><div id=\"wpforms-1555-field_202-container\" class=\"wpforms-field wpforms-field-textarea\" data-field-id=\"202\"><label class=\"wpforms-field-label\" for=\"wpforms-1555-field_202\">Please list names and ages list them in birth order <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/label><textarea id=\"wpforms-1555-field_202\" class=\"wpforms-field-medium wpforms-field-required\" name=\"wpforms[fields][202]\" aria-errormessage=\"wpforms-1555-field_202-error\" required><\/textarea><\/div><div id=\"wpforms-1555-field_130-container\" class=\"wpforms-field wpforms-field-text\" data-field-id=\"130\"><label class=\"wpforms-field-label\" for=\"wpforms-1555-field_130\">How many times have you been married?<\/label><input type=\"text\" id=\"wpforms-1555-field_130\" class=\"wpforms-field-medium\" name=\"wpforms[fields][130]\" aria-errormessage=\"wpforms-1555-field_130-error\" ><\/div><div id=\"wpforms-1555-field_131-container\" class=\"wpforms-field wpforms-field-checkbox\" data-field-id=\"131\"><fieldset><legend class=\"wpforms-field-label\">Have you ever been divorced?<\/legend><ul id=\"wpforms-1555-field_131\"><li class=\"choice-1 depth-1\"><input type=\"checkbox\" id=\"wpforms-1555-field_131_1\" name=\"wpforms[fields][131][]\" value=\"yes\" aria-errormessage=\"wpforms-1555-field_131_1-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-1555-field_131_1\">yes<\/label><\/li><li class=\"choice-2 depth-1\"><input type=\"checkbox\" id=\"wpforms-1555-field_131_2\" name=\"wpforms[fields][131][]\" value=\"no\" aria-errormessage=\"wpforms-1555-field_131_2-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-1555-field_131_2\">no<\/label><\/li><\/ul><\/fieldset><\/div><div id=\"wpforms-1555-field_132-container\" class=\"wpforms-field wpforms-field-text\" data-field-id=\"132\"><label class=\"wpforms-field-label\" for=\"wpforms-1555-field_132\">If yes, how many times<\/label><input type=\"text\" id=\"wpforms-1555-field_132\" class=\"wpforms-field-medium\" name=\"wpforms[fields][132]\" aria-errormessage=\"wpforms-1555-field_132-error\" ><\/div><div id=\"wpforms-1555-field_203-container\" class=\"wpforms-field wpforms-field-textarea\" data-field-id=\"203\"><label class=\"wpforms-field-label\" for=\"wpforms-1555-field_203\">Explain why you divorced.<\/label><textarea id=\"wpforms-1555-field_203\" class=\"wpforms-field-medium\" name=\"wpforms[fields][203]\" aria-errormessage=\"wpforms-1555-field_203-error\" aria-describedby=\"wpforms-1555-field_203-description\" ><\/textarea><div id=\"wpforms-1555-field_203-description\" class=\"wpforms-field-description\"> <\/div><\/div><div id=\"wpforms-1555-field_204-container\" class=\"wpforms-field wpforms-field-text\" data-field-id=\"204\"><label class=\"wpforms-field-label\" for=\"wpforms-1555-field_204\">How many times has your spouse been married?<\/label><input type=\"text\" id=\"wpforms-1555-field_204\" class=\"wpforms-field-medium\" name=\"wpforms[fields][204]\" aria-errormessage=\"wpforms-1555-field_204-error\" ><\/div><div id=\"wpforms-1555-field_183-container\" class=\"wpforms-field wpforms-field-pagebreak\" data-field-id=\"183\"><div class=\"wpforms-clear wpforms-pagebreak-left\"><button class=\"wpforms-page-button wpforms-page-next wpforms-disabled\"\n\t\t\t\t\tdata-action=\"next\" data-page=\"10\" data-formid=\"1555\" aria-disabled=\"true\" aria-describedby=\"wpforms-error-noscript\">Next<\/button><\/div><\/div><\/div><div class=\"wpforms-page wpforms-page-11  \" data-page=\"11\" style=\"display:none;\"><div id=\"wpforms-1555-field_184-container\" class=\"wpforms-field wpforms-field-content\" data-field-id=\"184\"><div id=\"wpforms-1555-field_184\" class=\"wpforms-field-medium wpforms-field-row\" aria-errormessage=\"wpforms-1555-field_184-error\"><h2 class=\"gsection_title\">Family Health History<\/h2>\n<p>&nbsp;<\/p>\n<div class=\"wpforms-field-content-display-frontend-clear\"><\/div><\/div><\/div><div id=\"wpforms-1555-field_133-container\" class=\"wpforms-field wpforms-field-checkbox\" data-field-id=\"133\"><fieldset><legend class=\"wpforms-field-label\">Please indicate below if you have any of the following in your family history.<\/legend><ul id=\"wpforms-1555-field_133\"><li class=\"choice-1 depth-1\"><input type=\"checkbox\" id=\"wpforms-1555-field_133_1\" name=\"wpforms[fields][133][]\" value=\"Depression\" aria-errormessage=\"wpforms-1555-field_133_1-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-1555-field_133_1\">Depression<\/label><\/li><li class=\"choice-20 depth-1\"><input type=\"checkbox\" id=\"wpforms-1555-field_133_20\" name=\"wpforms[fields][133][]\" value=\"Anxiety\" aria-errormessage=\"wpforms-1555-field_133_20-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-1555-field_133_20\">Anxiety<\/label><\/li><li class=\"choice-19 depth-1\"><input type=\"checkbox\" id=\"wpforms-1555-field_133_19\" name=\"wpforms[fields][133][]\" value=\"Ulcers\" aria-errormessage=\"wpforms-1555-field_133_19-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-1555-field_133_19\">Ulcers<\/label><\/li><li class=\"choice-18 depth-1\"><input type=\"checkbox\" id=\"wpforms-1555-field_133_18\" name=\"wpforms[fields][133][]\" value=\"Heart disease or hypertension\" aria-errormessage=\"wpforms-1555-field_133_18-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-1555-field_133_18\">Heart disease or hypertension<\/label><\/li><li class=\"choice-17 depth-1\"><input type=\"checkbox\" id=\"wpforms-1555-field_133_17\" name=\"wpforms[fields][133][]\" value=\"Diabetes\" aria-errormessage=\"wpforms-1555-field_133_17-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-1555-field_133_17\">Diabetes<\/label><\/li><li class=\"choice-16 depth-1\"><input type=\"checkbox\" id=\"wpforms-1555-field_133_16\" name=\"wpforms[fields][133][]\" value=\"Cancer\" aria-errormessage=\"wpforms-1555-field_133_16-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-1555-field_133_16\">Cancer<\/label><\/li><li class=\"choice-15 depth-1\"><input type=\"checkbox\" id=\"wpforms-1555-field_133_15\" name=\"wpforms[fields][133][]\" value=\"Mental Illness, DID, MPD\" aria-errormessage=\"wpforms-1555-field_133_15-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-1555-field_133_15\">Mental Illness, DID, MPD<\/label><\/li><li class=\"choice-14 depth-1\"><input type=\"checkbox\" id=\"wpforms-1555-field_133_14\" name=\"wpforms[fields][133][]\" value=\"Gambling addiction\" aria-errormessage=\"wpforms-1555-field_133_14-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-1555-field_133_14\">Gambling addiction<\/label><\/li><li class=\"choice-13 depth-1\"><input type=\"checkbox\" id=\"wpforms-1555-field_133_13\" name=\"wpforms[fields][133][]\" value=\"Alcoholism\" aria-errormessage=\"wpforms-1555-field_133_13-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-1555-field_133_13\">Alcoholism<\/label><\/li><li class=\"choice-12 depth-1\"><input type=\"checkbox\" id=\"wpforms-1555-field_133_12\" name=\"wpforms[fields][133][]\" value=\"Drug addiction\" aria-errormessage=\"wpforms-1555-field_133_12-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-1555-field_133_12\">Drug addiction<\/label><\/li><li class=\"choice-11 depth-1\"><input type=\"checkbox\" id=\"wpforms-1555-field_133_11\" name=\"wpforms[fields][133][]\" value=\"Food\/eating disorders\" aria-errormessage=\"wpforms-1555-field_133_11-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-1555-field_133_11\">Food\/eating disorders<\/label><\/li><li class=\"choice-10 depth-1\"><input type=\"checkbox\" id=\"wpforms-1555-field_133_10\" name=\"wpforms[fields][133][]\" value=\"Sleeping disorders\" aria-errormessage=\"wpforms-1555-field_133_10-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-1555-field_133_10\">Sleeping disorders<\/label><\/li><li class=\"choice-9 depth-1\"><input type=\"checkbox\" id=\"wpforms-1555-field_133_9\" name=\"wpforms[fields][133][]\" value=\"ADHD\" aria-errormessage=\"wpforms-1555-field_133_9-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-1555-field_133_9\">ADHD<\/label><\/li><li class=\"choice-8 depth-1\"><input type=\"checkbox\" id=\"wpforms-1555-field_133_8\" name=\"wpforms[fields][133][]\" value=\"Any medically defined disorder\" aria-errormessage=\"wpforms-1555-field_133_8-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-1555-field_133_8\">Any medically defined disorder<\/label><\/li><li class=\"choice-7 depth-1\"><input type=\"checkbox\" id=\"wpforms-1555-field_133_7\" name=\"wpforms[fields][133][]\" value=\"Asthma\" aria-errormessage=\"wpforms-1555-field_133_7-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-1555-field_133_7\">Asthma<\/label><\/li><li class=\"choice-6 depth-1\"><input type=\"checkbox\" id=\"wpforms-1555-field_133_6\" name=\"wpforms[fields][133][]\" value=\"Migraine Headaches\" aria-errormessage=\"wpforms-1555-field_133_6-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-1555-field_133_6\">Migraine Headaches<\/label><\/li><li class=\"choice-5 depth-1\"><input type=\"checkbox\" id=\"wpforms-1555-field_133_5\" name=\"wpforms[fields][133][]\" value=\"Glandular problems\" aria-errormessage=\"wpforms-1555-field_133_5-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-1555-field_133_5\">Glandular problems<\/label><\/li><li class=\"choice-4 depth-1\"><input type=\"checkbox\" id=\"wpforms-1555-field_133_4\" name=\"wpforms[fields][133][]\" value=\"Other (explain)\" aria-errormessage=\"wpforms-1555-field_133_4-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-1555-field_133_4\">Other (explain)<\/label><\/li><li class=\"choice-2 depth-1\"><input type=\"checkbox\" id=\"wpforms-1555-field_133_2\" name=\"wpforms[fields][133][]\" value=\"None\" aria-errormessage=\"wpforms-1555-field_133_2-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-1555-field_133_2\">None<\/label><\/li><\/ul><\/fieldset><\/div>\t\t<div id=\"wpforms-1555-field_5-container\"\n\t\t\tclass=\"wpforms-field wpforms-field-text\"\n\t\t\tdata-field-type=\"text\"\n\t\t\tdata-field-id=\"5\"\n\t\t\t>\n\t\t\t<label class=\"wpforms-field-label\" for=\"wpforms-1555-field_5\" >apply) does yes<\/label>\n\t\t\t<input type=\"text\" id=\"wpforms-1555-field_5\" class=\"wpforms-field-medium\" name=\"wpforms[fields][5]\" >\n\t\t<\/div>\n\t\t<div id=\"wpforms-1555-field_185-container\" class=\"wpforms-field wpforms-field-textarea\" data-field-id=\"185\"><label class=\"wpforms-field-label\" for=\"wpforms-1555-field_185\">If any please provide a brief explanation. Please state who was involved, when and to what extent.<\/label><textarea id=\"wpforms-1555-field_185\" class=\"wpforms-field-medium\" name=\"wpforms[fields][185]\" aria-errormessage=\"wpforms-1555-field_185-error\" ><\/textarea><\/div><div id=\"wpforms-1555-field_186-container\" class=\"wpforms-field wpforms-field-pagebreak\" data-field-id=\"186\"><div class=\"wpforms-clear wpforms-pagebreak-left\"><button class=\"wpforms-page-button wpforms-page-next wpforms-disabled\"\n\t\t\t\t\tdata-action=\"next\" data-page=\"11\" data-formid=\"1555\" aria-disabled=\"true\" aria-describedby=\"wpforms-error-noscript\">Next<\/button><\/div><\/div><\/div><div class=\"wpforms-page wpforms-page-12  \" data-page=\"12\" style=\"display:none;\"><div id=\"wpforms-1555-field_187-container\" class=\"wpforms-field wpforms-field-content\" data-field-id=\"187\"><div id=\"wpforms-1555-field_187\" class=\"wpforms-field-medium wpforms-field-row\" aria-errormessage=\"wpforms-1555-field_187-error\"><h2 class=\"gsection_title\">Additional Relevant Information<\/h2>\n<p>&nbsp;<\/p>\n<div class=\"wpforms-field-content-display-frontend-clear\"><\/div><\/div><\/div><div id=\"wpforms-1555-field_134-container\" class=\"wpforms-field wpforms-field-textarea\" data-field-id=\"134\"><label class=\"wpforms-field-label\" for=\"wpforms-1555-field_134\">Are there any other problems you feel this intake form has not addressed?<\/label><textarea id=\"wpforms-1555-field_134\" class=\"wpforms-field-medium\" name=\"wpforms[fields][134]\" aria-errormessage=\"wpforms-1555-field_134-error\" ><\/textarea><\/div><div id=\"wpforms-1555-field_135-container\" class=\"wpforms-field wpforms-field-textarea\" data-field-id=\"135\"><label class=\"wpforms-field-label\" for=\"wpforms-1555-field_135\">Is there any additional information that you feel our team needs to know?<\/label><textarea id=\"wpforms-1555-field_135\" class=\"wpforms-field-medium\" name=\"wpforms[fields][135]\" aria-errormessage=\"wpforms-1555-field_135-error\" aria-describedby=\"wpforms-1555-field_135-description\" ><\/textarea><div id=\"wpforms-1555-field_135-description\" class=\"wpforms-field-description\">If you have encountered difficulty or confusion in filling out this questionnaire, or in any way have concern about your experience, please contact Spiritual Warfare Academy Advisors and ask for the deliverance Help Department.<\/div><\/div><div id=\"wpforms-1555-field_188-container\" class=\"wpforms-field wpforms-field-pagebreak\" data-field-id=\"188\"><div class=\"wpforms-clear wpforms-pagebreak-left\"><button class=\"wpforms-page-button wpforms-page-next wpforms-disabled\"\n\t\t\t\t\tdata-action=\"next\" data-page=\"12\" data-formid=\"1555\" aria-disabled=\"true\" aria-describedby=\"wpforms-error-noscript\">Next<\/button><\/div><\/div><\/div><div class=\"wpforms-page wpforms-page-13 last \" data-page=\"13\" style=\"display:none;\"><div id=\"wpforms-1555-field_194-container\" class=\"wpforms-field wpforms-field-content\" data-field-id=\"194\"><div id=\"wpforms-1555-field_194\" class=\"wpforms-field-medium wpforms-field-row\" aria-errormessage=\"wpforms-1555-field_194-error\"><h5>Voluntary Release, Assumption of Risk, and Indemnity Agreement<\/h5>\n<p>In consideration for being permitted to participate in voluntary prayer ministry, herein referred to as the \u201cPrayer Ministry,\u201d the undersigned, herein referred to as the \u201cReleasor,\u201d agrees as follows:<\/p>\n<p><b>RELEASE, WAIVER, DISCHARGE AND COVENANT NOT TO SUE<\/b><\/p>\n<p>Releasor and releasor\u2019s personal representatives, assigns, insurer, heirs, executors, administrators, spouse and next of kin, hereby releases, waives, discharges and covenants not to sue Northwoods Community Church of Peoria, Illinois and its directors, officers, elders, pastors, deacons, ministry team members, employees, agents and volunteers, as well as its successors, affiliates, and subsidiaries, all herein referred to as the \u201cReleasees,\u201d from any and all liability to Releasor, and to<\/p>\n<p>Releasor\u2019s personal representatives, assigns, insurers, heirs, executors, administrators, spouses and next of kin for any and all loss, damage, or cost on account of injury to the person or property or resulting in the death of Releasor, whether caused by the negligence of Releasees or otherwise while Releasor is participating in the Prayer Ministry and any other activities in connection with the Prayer Ministry.<\/p>\n<p><b>ASSUMPTION OF RISK<\/b><\/p>\n<p>Releasor understands, is aware of, and assumes all risks inherent in participating in the prayer ministry. These risks include, but are not limited to, physical and emotional responses and reactions as a result of this Prayer Ministry.<\/p>\n<p><b>INDEMNITY<\/b><\/p>\n<p>Releasor agrees to indemnify Releasees from any liability, loss, damage or cost Releasees may incur due to the participation by Releasor in the prayer ministry whether caused by the negligence of Releasees or otherwise. Releasor assumes full responsibility for and risk of bodily injury, death or property damage due to negligence of Releasees or otherwise while participating in the Prayer Ministry.<\/p>\n<p>Releasor expressly agrees that this Voluntary Release, Assumption of Risk and Indemnity Agreement, herein referred to as \u201cAgreement,\u201d is intended to be as broad and inclusive as permitted by the laws of the State of Illinois and that, if any portion of this Agreement is held invalid, it is agreed that a balance, notwithstanding, continue in full legal force and effect. This Agreement, along with the Ministry Agreement contains the entire agreement between the parties in regard to the Prayer Ministry.<\/p>\n<div class=\"wpforms-field-content-display-frontend-clear\"><\/div><\/div><\/div><div id=\"wpforms-1555-field_195-container\" class=\"wpforms-field wpforms-field-checkbox\" data-field-id=\"195\"><fieldset><legend class=\"wpforms-field-label\">I have carefully read this agreement. I understand, and it is a release of all claims, including the negligence of Releases. I have been given an opportunity to review this agreement with an attorney of my choosing. I understand that I assume all risks inherent in the Prayer Ministry set forth in this Agreement. I understand that I am indemnifying the Releasees. I voluntarily sign my name evidencing my understanding and acceptance of the provisions of this Agreement. <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/legend><ul id=\"wpforms-1555-field_195\" class=\"wpforms-field-required\"><li class=\"choice-1 depth-1\"><input type=\"checkbox\" id=\"wpforms-1555-field_195_1\" name=\"wpforms[fields][195][]\" value=\"I agree to the agreement\" aria-errormessage=\"wpforms-1555-field_195_1-error\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-1555-field_195_1\">I agree to the agreement<\/label><\/li><\/ul><\/fieldset><\/div><div id=\"wpforms-1555-field_196-container\" class=\"wpforms-field wpforms-field-content\" data-field-id=\"196\"><div id=\"wpforms-1555-field_196\" class=\"wpforms-field-medium wpforms-field-row\" aria-errormessage=\"wpforms-1555-field_196-error\"><h4>Ministry Agreement<\/h4>\n<p>Consideration for being permitted to participate in voluntary pastoral and religious counseling, herein referred to as \u201cCounseling\u201d, and prayer ministry, herein referred to as \u201cPrayer Ministry\u201d, the undersigned, herein referred to as \u201cCounselee\u201d, agrees as follows:<\/p>\n<p><b>1.<\/b>&nbsp;This is a church-based ministry of Northwoods Community Church providing Counseling and Prayer Ministry in individual and group settings. Our Counseling is done by pastoral staff and lay-ministers, herein referred to as \u201cCounselors.\u201d These individuals are not acting as licensed professional counselors, social workers, or psychologists because they perform religious counseling and not secular or psychological counseling. If it becomes apparent that secular or psychological counseling may better address the Counselee\u2019s needs, the Counselor will immediately initiate a referral to a licensed professional counselor, social worker, or psychologist. If you believe that you have questions which would benefit from the assistance of a psychotherapist or other mental health professional, it is ultimately up to you to decide whether to pursue mental health services and, if so, to select the provider whom you wish to see.<\/p>\n<p><b>2.<\/b>&nbsp;Under all circumstances, sexual contact between a Counselor and Counselee is prohibited. If any Counselor suggests or attempts sexual advances, the Counselee shall terminate the session immediately and report the incident to the Executive Senior Pastor, or any other Elder not involved in the counseling.<\/p>\n<p><b>3.<\/b>&nbsp;Under normal circumstances, your Counselor will use their good faith efforts to keep your discussions in confidence. However, you should be aware there are some situations in which your Counselor may be required by law to report information to the proper authorities without your permission or knowledge. These situations include but may not be limited to: a Counselee\u2019s intent of harm to self or others, involvement in a felony, suicidal intentions, and\/or reasonable evidence of child or elder abuse or neglect. Your Counselor may also disclose information in response to a subpoena issued by a court of law. Additionally, if you occupy a leadership or ministry position, your Counselor may also disclose information to the person in authority over you, in the event he or she deems it relevant to your fitness or ability to fulfill your position.<\/p>\n<p><b>4.<\/b>&nbsp;Officially recognized church staff and lay-personnel may also have limited access to your pastoral file. Any other person seeking access to your pastoral file may do so only with your written permission. However, Northwoods Community Church cannot guarantee complete confidentiality with regard to the information received from you. Because our guidance is spiritual as opposed to mental health in nature, it is also important for you to understand that the law may place limits on the confidentiality of the information that you share with us. We do not have the broad confidentiality privileges of a psychotherapist or other licensed mental health professional, so it is entirely possible that our records could be subpoenaed and\/or that we could be required to testify in judicial proceedings involving you or your family members. If you have concerns about the confidentiality of any information you intend to share with Northwoods, you should consult an attorney before revealing the information to us. Please rest assured that we strongly prefer not to disclose your personal information and that, within the limits of the law, we will make every effort to protect your privacy.<\/p>\n<p><b>5.<\/b>&nbsp;Northwoods Community Church requires that parent(s) must be actively involved in any Counseling and\/or Prayer Ministry that is extended to a minor child as determined by the Counselor. At the discretion of the Counselor, parent(s) will be required to make themselves accountable for active participation in Counseling and\/or Prayer Ministry offered by Northwoods Community Church.<\/p>\n<p><b>6.<\/b>&nbsp;Counselees with any concerns or questions about this agreement agree to raise them with their Counselor at the earliest possible time.<\/p>\n<p><b>7.<\/b>&nbsp;This agreement, herein referred to as the \u201cMinistry Agreement\u201d, will govern all relations involved during the term of the counseling process. Should the Counselee participate in Prayer Ministry, the Voluntary Release, Assumption of Risk, and Indemnity Agreement will be incorporated as part of this Ministry Agreement. It is agreed that any disputed or modifications of this Ministry Agreement will be determined directly between the individuals involved. If this Ministry Agreement is not satisfactory, then it is further agreed that disputes and disagreements will be taken to the Northwoods Community Church Board of Elders for mediation. In the event that a satisfactory resolution is not achieved, then it is further agreed that a mutually acceptable third-party mediator will be utilized. All expenses incurred will be the responsibility of the party bringing the dispute.<\/p>\n<div class=\"wpforms-field-content-display-frontend-clear\"><\/div><\/div><\/div><div id=\"wpforms-1555-field_197-container\" class=\"wpforms-field wpforms-field-checkbox\" data-field-id=\"197\"><fieldset><legend class=\"wpforms-field-label\">Checkboxes <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/legend><ul id=\"wpforms-1555-field_197\" class=\"wpforms-field-required\"><li class=\"choice-1 depth-1\"><input type=\"checkbox\" id=\"wpforms-1555-field_197_1\" name=\"wpforms[fields][197][]\" value=\"I have read the above ministry agreement, understand it, and agree to the terms herein written.\" aria-errormessage=\"wpforms-1555-field_197_1-error\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-1555-field_197_1\">I have read the above ministry agreement, understand it, and agree to the terms herein written.<\/label><\/li><\/ul><\/fieldset><\/div><div id=\"wpforms-1555-field_198-container\" class=\"wpforms-field wpforms-field-content\" data-field-id=\"198\"><div id=\"wpforms-1555-field_198\" class=\"wpforms-field-medium wpforms-field-row\" aria-errormessage=\"wpforms-1555-field_198-error\"><h6>When you click SUBMIT, you will receive an email confirmation with the contents of this form. <strong>Please print the email, sign it, and bring it along to your appointment.<\/strong><\/h6>\n<p>Clicking SUBMIT does not guarantee your appointment. Someone from the Spiritual Warfare Academy Help team will contact you to schedule your appointment.<\/p>\n<div class=\"wpforms-field-content-display-frontend-clear\"><\/div><\/div><\/div><div id=\"wpforms-1555-field_189-container\" class=\"wpforms-field wpforms-field-entry-preview\" data-field-id=\"189\"><div class=\"wpforms-entry-preview-updating-message\">Updating preview\u2026<\/div><div class=\"wpforms-entry-preview-notice\" style=\"display: none;\"><strong>This is a preview of your submission. It has not been submitted yet!<\/strong><br \/>\r\nPlease take a moment to verify your information. You can also go back to make changes.<\/div><div class=\"wpforms-entry-preview-wrapper\" style=\"display: none;\"><\/div><\/div><div id=\"wpforms-1555-field_205-container\" class=\"wpforms-field wpforms-field-captcha\" data-field-id=\"205\"><label class=\"wpforms-field-label\" for=\"wpforms-1555-field_205\">Custom Captcha <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/label>\t\t\t<div class=\"wpforms-captcha-math\">\n\t\t\t\t<span id=\"wpforms-1555-field_205-question\" class=\"wpforms-captcha-equation\">\n\t\t\t\t\t<span class=\"n1\">14<\/span>\n\t\t\t\t\t\t\t<span class=\"cal\">+<\/span>\n\t\t\t\t\t\t\t<span class=\"n2\">5<\/span>\t\t\t\t\t<span class=\"e\">=<\/span>\n\t\t\t\t<\/span>\n\t\t\t\t<input type=\"text\" id=\"wpforms-1555-field_205\" class=\"wpforms-field-medium wpforms-field-required a\" data-rule-wpf-captcha=\"math\" data-is-wrapped-field=\"1\" name=\"wpforms[fields][205][a]\" aria-errormessage=\"wpforms-1555-field_205-error\" aria-describedby=\"wpforms-1555-field_205-question\" required>\t\t\t\t<input type=\"hidden\" name=\"wpforms[fields][205][cal]\" class=\"cal\">\n\t\t\t\t<input type=\"hidden\" name=\"wpforms[fields][205][n2]\" class=\"n2\">\n\t\t\t\t<input type=\"hidden\" name=\"wpforms[fields][205][n1]\" class=\"n1\">\n\t\t\t<\/div>\n\t\t\t<\/div><div id=\"wpforms-1555-field_4-container\" class=\"wpforms-field wpforms-field-pagebreak\" data-field-id=\"4\"><div class=\"wpforms-clear wpforms-pagebreak-left\"><button class=\"wpforms-page-button wpforms-page-prev wpforms-disabled\"\n\t\t\t\t\tdata-action=\"prev\" data-page=\"13\" data-formid=\"1555\" aria-disabled=\"true\" aria-describedby=\"wpforms-error-noscript\">Previous<\/button><\/div><\/div><\/div><script>\n\t\t\t\t( function() {\n\t\t\t\t\tconst style = document.createElement( 'style' );\n\t\t\t\t\tstyle.appendChild( document.createTextNode( '#wpforms-1555-field_5-container { position: absolute !important; 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