{"id":1407,"date":"2025-02-13T08:10:51","date_gmt":"2025-02-13T08:10:51","guid":{"rendered":"https:\/\/www.capoecounselingllc.com\/demo\/?page_id=1407"},"modified":"2025-02-26T09:45:57","modified_gmt":"2025-02-26T09:45:57","slug":"premarital-counseling-form","status":"publish","type":"page","link":"https:\/\/www.capoecounselingllc.com\/demo\/premarital-counseling-form\/","title":{"rendered":"Premarital Counseling Form"},"content":{"rendered":"\t\t<div data-elementor-type=\"wp-page\" data-elementor-id=\"1407\" class=\"elementor elementor-1407\">\n\t\t\t\t<div class=\"elementor-element elementor-element-57bf89d e-flex e-con-boxed wpr-particle-no wpr-jarallax-no wpr-parallax-no wpr-sticky-section-no e-con e-parent\" data-id=\"57bf89d\" data-element_type=\"container\">\n\t\t\t\t\t<div class=\"e-con-inner\">\n\t\t<div class=\"elementor-element elementor-element-c36bd0f e-con-full e-flex wpr-particle-no wpr-jarallax-no wpr-parallax-no wpr-sticky-section-no e-con e-child\" data-id=\"c36bd0f\" data-element_type=\"container\">\n\t\t\t\t<\/div>\n\t\t<div class=\"elementor-element elementor-element-7aee8dd e-con-full e-flex wpr-particle-no wpr-jarallax-no wpr-parallax-no wpr-sticky-section-no e-con e-child\" data-id=\"7aee8dd\" data-element_type=\"container\">\n\t\t\t\t<div class=\"elementor-element elementor-element-2eab037 elementor-widget elementor-widget-image\" data-id=\"2eab037\" data-element_type=\"widget\" data-widget_type=\"image.default\">\n\t\t\t\t<div class=\"elementor-widget-container\">\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<img fetchpriority=\"high\" decoding=\"async\" width=\"400\" height=\"267\" src=\"https:\/\/www.capoecounselingllc.com\/demo\/wp-content\/uploads\/2025\/02\/thumb-37372917.jpg\" class=\"attachment-large size-large wp-image-1413\" alt=\"\" srcset=\"https:\/\/www.capoecounselingllc.com\/demo\/wp-content\/uploads\/2025\/02\/thumb-37372917.jpg 400w, https:\/\/www.capoecounselingllc.com\/demo\/wp-content\/uploads\/2025\/02\/thumb-37372917-300x200.jpg 300w\" sizes=\"(max-width: 400px) 100vw, 400px\" \/>\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t<div class=\"elementor-element elementor-element-ab6c091 e-con-full e-flex wpr-particle-no wpr-jarallax-no wpr-parallax-no wpr-sticky-section-no e-con e-child\" data-id=\"ab6c091\" data-element_type=\"container\">\n\t\t\t\t<\/div>\n\t\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t<div class=\"elementor-element elementor-element-025b83e e-flex e-con-boxed wpr-particle-no wpr-jarallax-no wpr-parallax-no wpr-sticky-section-no e-con e-parent\" data-id=\"025b83e\" data-element_type=\"container\">\n\t\t\t\t\t<div class=\"e-con-inner\">\n\t\t<div class=\"elementor-element elementor-element-9c193d9 e-con-full e-flex wpr-particle-no wpr-jarallax-no wpr-parallax-no wpr-sticky-section-no e-con e-child\" data-id=\"9c193d9\" data-element_type=\"container\">\n\t\t\t\t<div class=\"elementor-element elementor-element-9f3ce50 elementor-widget elementor-widget-text-editor\" data-id=\"9f3ce50\" data-element_type=\"widget\" data-widget_type=\"text-editor.default\">\n\t\t\t\t<div class=\"elementor-widget-container\">\n\t\t\t\t\t\t\t\t\tThis Questionnaire should be filled out completely and returned before your first Premarital Counseling Session begins. After the forms are reviewed, an appointment will be made to meet with Dr. Cecil Poe. At this time, we will schedule an appointment to begin the pre-marriage counseling BIBLICALLY BASED program which will include the following content:\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t<div class=\"elementor-element elementor-element-940fcca elementor-widget elementor-widget-heading\" data-id=\"940fcca\" data-element_type=\"widget\" data-widget_type=\"heading.default\">\n\t\t\t\t<div class=\"elementor-widget-container\">\n\t\t\t\t\t<h2 class=\"elementor-heading-title elementor-size-default\">This program is approximately 9-12 hours (not including breaks)<\/h2>\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t<div class=\"elementor-element elementor-element-67024d4 e-grid e-con-full wpr-particle-no wpr-jarallax-no wpr-parallax-no wpr-sticky-section-no e-con e-child\" data-id=\"67024d4\" data-element_type=\"container\">\n\t\t\t\t<div class=\"elementor-element elementor-element-942a670 elementor-widget elementor-widget-text-editor\" data-id=\"942a670\" data-element_type=\"widget\" data-widget_type=\"text-editor.default\">\n\t\t\t\t<div class=\"elementor-widget-container\">\n\t\t\t\t\t\t\t\t\t<ul><li>COMMUNICATION<\/li><li>CONFLICT RESOLUTION<\/li><li>PARTNER STYLE AND HABITS<\/li><li>FINANCIAL MANAGEMENT<\/li><li>LEISURE ACTIVITIES<\/li><\/ul>\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t<div class=\"elementor-element elementor-element-4d27302 elementor-widget elementor-widget-text-editor\" data-id=\"4d27302\" data-element_type=\"widget\" data-widget_type=\"text-editor.default\">\n\t\t\t\t<div class=\"elementor-widget-container\">\n\t\t\t\t\t\t\t\t\t<ul><li>SEXUALITY AND AFFECTION<\/li><li>FAMILY AND FRIENDS RELATIONSHIP<\/li><li>ROLES CHILDREN AND PARENTING<\/li><li>SPIRITUAL BELIEFS<\/li><li>PRE-MARRIAGE AWARENESS QUESTIONNAIRE<\/li><\/ul>\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t<div class=\"elementor-element elementor-element-9f45b8f e-flex e-con-boxed wpr-particle-no wpr-jarallax-no wpr-parallax-no wpr-sticky-section-no e-con e-parent\" data-id=\"9f45b8f\" data-element_type=\"container\">\n\t\t\t\t\t<div class=\"e-con-inner\">\n\t\t\t\t<div class=\"elementor-element elementor-element-3c3f9be elementor-widget elementor-widget-heading\" data-id=\"3c3f9be\" data-element_type=\"widget\" data-widget_type=\"heading.default\">\n\t\t\t\t<div class=\"elementor-widget-container\">\n\t\t\t\t\t<h2 class=\"elementor-heading-title elementor-size-default\">**** Both you and your fianc\u00e9 should complete the Premarital Form and Questionnaire separately, but both must be present for the actual Pre-Marriage counseling sessions with Dr. Cecil Poe.<\/h2>\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t<div class=\"elementor-element elementor-element-579659d elementor-widget elementor-widget-shortcode\" data-id=\"579659d\" data-element_type=\"widget\" data-widget_type=\"shortcode.default\">\n\t\t\t\t<div class=\"elementor-widget-container\">\n\t\t\t\t\t\t\t<div class=\"elementor-shortcode\"><div class=\"wpforms-container wpforms-container-full wpforms-render-modern\" id=\"wpforms-890\"><form id=\"wpforms-form-890\" class=\"wpforms-validate wpforms-form wpforms-ajax-form\" data-formid=\"890\" method=\"post\" enctype=\"multipart\/form-data\" action=\"\/demo\/wp-json\/wp\/v2\/pages\/1407\" data-token=\"e0bbbc9935cf94fe54b0e0f1b53c7ec9\" data-token-time=\"1776609330\"><noscript class=\"wpforms-error-noscript\">Please enable JavaScript in your browser to complete this form.<\/noscript><div class=\"wpforms-hidden\" id=\"wpforms-error-noscript\">Please enable JavaScript in your browser to complete this form.<\/div><div class=\"wpforms-field-container\"><div id=\"wpforms-890-field_1-container\" class=\"wpforms-field wpforms-field-name\" data-field-id=\"1\"><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-two-fifths\"><input type=\"text\" id=\"wpforms-890-field_1\" class=\"wpforms-field-name-first wpforms-field-required\" name=\"wpforms[fields][1][first]\" placeholder=\"First Name\" aria-errormessage=\"wpforms-890-field_1-error\" required><label for=\"wpforms-890-field_1\" class=\"wpforms-field-sublabel after\">First<\/label><\/div><div class=\"wpforms-field-row-block wpforms-one-fifth\"><input type=\"text\" id=\"wpforms-890-field_1-middle\" class=\"wpforms-field-name-middle\" name=\"wpforms[fields][1][middle]\" placeholder=\"Middle Name\" aria-errormessage=\"wpforms-890-field_1-middle-error\" ><label for=\"wpforms-890-field_1-middle\" class=\"wpforms-field-sublabel after\">Middle<\/label><\/div><div class=\"wpforms-field-row-block wpforms-two-fifths\"><input type=\"text\" id=\"wpforms-890-field_1-last\" class=\"wpforms-field-name-last wpforms-field-required\" name=\"wpforms[fields][1][last]\" placeholder=\"Last Name\" aria-errormessage=\"wpforms-890-field_1-last-error\" required><label for=\"wpforms-890-field_1-last\" class=\"wpforms-field-sublabel after\">Last<\/label><\/div><\/div><\/fieldset><\/div><div id=\"wpforms-890-field_8-container\" class=\"wpforms-field wpforms-field-name\" data-field-id=\"8\"><fieldset><legend class=\"wpforms-field-label\">Name of parent\/guardian (if under 18 years)<\/legend><div class=\"wpforms-field-row wpforms-field-medium\"><div class=\"wpforms-field-row-block wpforms-first wpforms-two-fifths\"><input type=\"text\" id=\"wpforms-890-field_8\" class=\"wpforms-field-name-first\" name=\"wpforms[fields][8][first]\" placeholder=\"First Name\" aria-errormessage=\"wpforms-890-field_8-error\" ><label for=\"wpforms-890-field_8\" class=\"wpforms-field-sublabel after\">First<\/label><\/div><div class=\"wpforms-field-row-block wpforms-one-fifth\"><input type=\"text\" id=\"wpforms-890-field_8-middle\" class=\"wpforms-field-name-middle\" name=\"wpforms[fields][8][middle]\" placeholder=\"Middle Name\" aria-errormessage=\"wpforms-890-field_8-middle-error\" ><label for=\"wpforms-890-field_8-middle\" class=\"wpforms-field-sublabel after\">Middle<\/label><\/div><div class=\"wpforms-field-row-block wpforms-two-fifths\"><input type=\"text\" id=\"wpforms-890-field_8-last\" class=\"wpforms-field-name-last\" name=\"wpforms[fields][8][last]\" placeholder=\"Last Name\" aria-errormessage=\"wpforms-890-field_8-last-error\" ><label for=\"wpforms-890-field_8-last\" class=\"wpforms-field-sublabel after\">Last<\/label><\/div><\/div><\/fieldset><\/div><div id=\"wpforms-890-field_9-container\" class=\"wpforms-field wpforms-field-text\" data-field-id=\"9\"><label class=\"wpforms-field-label\" for=\"wpforms-890-field_9\"> Birth Date <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/label><input type=\"text\" id=\"wpforms-890-field_9\" class=\"wpforms-field-medium wpforms-field-required\" name=\"wpforms[fields][9]\" placeholder=\"dd\/mm\/yyyy\" aria-errormessage=\"wpforms-890-field_9-error\" required><\/div><div id=\"wpforms-890-field_10-container\" class=\"wpforms-field wpforms-field-text\" data-field-id=\"10\"><label class=\"wpforms-field-label\" for=\"wpforms-890-field_10\">Age <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/label><input type=\"text\" id=\"wpforms-890-field_10\" class=\"wpforms-field-medium wpforms-field-required\" name=\"wpforms[fields][10]\" aria-errormessage=\"wpforms-890-field_10-error\" required><\/div><div id=\"wpforms-890-field_4-container\" class=\"wpforms-field wpforms-field-radio wpforms-list-2-columns\" data-field-id=\"4\"><fieldset><legend class=\"wpforms-field-label\">Gender <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/legend><ul id=\"wpforms-890-field_4\" class=\"wpforms-field-required\"><li class=\"choice-1 depth-1\"><input type=\"radio\" id=\"wpforms-890-field_4_1\" name=\"wpforms[fields][4]\" value=\"Female\" aria-errormessage=\"wpforms-890-field_4_1-error\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-890-field_4_1\">Female<\/label><\/li><li class=\"choice-2 depth-1\"><input type=\"radio\" id=\"wpforms-890-field_4_2\" name=\"wpforms[fields][4]\" value=\"Male\" aria-errormessage=\"wpforms-890-field_4_2-error\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-890-field_4_2\">Male<\/label><\/li><\/ul><\/fieldset><\/div><div id=\"wpforms-890-field_5-container\" class=\"wpforms-field wpforms-field-checkbox wpforms-list-3-columns\" data-field-id=\"5\"><fieldset><legend class=\"wpforms-field-label\">Marital Status <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/legend><ul id=\"wpforms-890-field_5\" class=\"wpforms-field-required\"><li class=\"choice-1 depth-1\"><input type=\"checkbox\" id=\"wpforms-890-field_5_1\" name=\"wpforms[fields][5][]\" value=\"Never Married\" aria-errormessage=\"wpforms-890-field_5_1-error\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-890-field_5_1\">Never Married<\/label><\/li><li class=\"choice-2 depth-1\"><input type=\"checkbox\" id=\"wpforms-890-field_5_2\" name=\"wpforms[fields][5][]\" value=\"Domestic Partnership\" aria-errormessage=\"wpforms-890-field_5_2-error\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-890-field_5_2\">Domestic Partnership<\/label><\/li><li class=\"choice-3 depth-1\"><input type=\"checkbox\" id=\"wpforms-890-field_5_3\" name=\"wpforms[fields][5][]\" value=\"Married\" aria-errormessage=\"wpforms-890-field_5_3-error\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-890-field_5_3\">Married<\/label><\/li><li class=\"choice-7 depth-1\"><input type=\"checkbox\" id=\"wpforms-890-field_5_7\" name=\"wpforms[fields][5][]\" value=\"Separated\" aria-errormessage=\"wpforms-890-field_5_7-error\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-890-field_5_7\">Separated<\/label><\/li><li class=\"choice-6 depth-1\"><input type=\"checkbox\" id=\"wpforms-890-field_5_6\" name=\"wpforms[fields][5][]\" value=\"Divorced\" aria-errormessage=\"wpforms-890-field_5_6-error\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-890-field_5_6\">Divorced<\/label><\/li><li class=\"choice-5 depth-1\"><input type=\"checkbox\" id=\"wpforms-890-field_5_5\" name=\"wpforms[fields][5][]\" value=\"Widowed\" aria-errormessage=\"wpforms-890-field_5_5-error\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-890-field_5_5\">Widowed<\/label><\/li><\/ul><\/fieldset><\/div><div id=\"wpforms-890-field_3-container\" class=\"wpforms-field wpforms-field-text\" data-field-id=\"3\"><label class=\"wpforms-field-label\" for=\"wpforms-890-field_3\">Please list any children\/age <\/label><input type=\"text\" id=\"wpforms-890-field_3\" class=\"wpforms-field-medium\" name=\"wpforms[fields][3]\" aria-errormessage=\"wpforms-890-field_3-error\" ><\/div><div id=\"wpforms-890-field_11-container\" class=\"wpforms-field wpforms-field-text\" data-field-id=\"11\"><label class=\"wpforms-field-label\" for=\"wpforms-890-field_11\"> Street Address  <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/label><input type=\"text\" id=\"wpforms-890-field_11\" class=\"wpforms-field-medium wpforms-field-required\" name=\"wpforms[fields][11]\" aria-errormessage=\"wpforms-890-field_11-error\" required><\/div><div id=\"wpforms-890-field_12-container\" class=\"wpforms-field wpforms-field-text wpforms-one-third wpforms-first\" data-field-id=\"12\"><label class=\"wpforms-field-label\" for=\"wpforms-890-field_12\">City  <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/label><input type=\"text\" id=\"wpforms-890-field_12\" class=\"wpforms-field-medium wpforms-field-required\" name=\"wpforms[fields][12]\" aria-errormessage=\"wpforms-890-field_12-error\" required><\/div><div id=\"wpforms-890-field_14-container\" class=\"wpforms-field wpforms-field-select wpforms-one-third wpforms-field-select-style-classic\" data-field-id=\"14\"><label class=\"wpforms-field-label\" for=\"wpforms-890-field_14\">State  <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/label><select id=\"wpforms-890-field_14\" class=\"wpforms-field-medium wpforms-field-required\" name=\"wpforms[fields][14]\" required=\"required\"><option value=\"First Choice\" >First Choice<\/option><option value=\"Second Choice\" >Second Choice<\/option><option value=\"Third Choice\" >Third Choice<\/option><\/select><\/div><div id=\"wpforms-890-field_15-container\" class=\"wpforms-field wpforms-field-text wpforms-one-third\" data-field-id=\"15\"><label class=\"wpforms-field-label\" for=\"wpforms-890-field_15\">Zip Code <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/label><input type=\"text\" id=\"wpforms-890-field_15\" class=\"wpforms-field-medium wpforms-field-required\" name=\"wpforms[fields][15]\" aria-errormessage=\"wpforms-890-field_15-error\" required><\/div><div id=\"wpforms-890-field_16-container\" class=\"wpforms-field wpforms-field-number\" data-field-id=\"16\"><label class=\"wpforms-field-label\" for=\"wpforms-890-field_16\"> Home Phone <\/label><input type=\"number\" id=\"wpforms-890-field_16\" class=\"wpforms-field-medium\" name=\"wpforms[fields][16]\" aria-errormessage=\"wpforms-890-field_16-error\" ><\/div><div id=\"wpforms-890-field_17-container\" class=\"wpforms-field wpforms-field-radio wpforms-list-2-columns\" data-field-id=\"17\"><fieldset><legend class=\"wpforms-field-label\">May we leave a message? <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/legend><ul id=\"wpforms-890-field_17\" class=\"wpforms-field-required\"><li class=\"choice-1 depth-1\"><input type=\"radio\" id=\"wpforms-890-field_17_1\" name=\"wpforms[fields][17]\" value=\"Yes\" aria-errormessage=\"wpforms-890-field_17_1-error\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-890-field_17_1\">Yes<\/label><\/li><li class=\"choice-2 depth-1\"><input type=\"radio\" id=\"wpforms-890-field_17_2\" name=\"wpforms[fields][17]\" value=\"No\" aria-errormessage=\"wpforms-890-field_17_2-error\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-890-field_17_2\">No<\/label><\/li><\/ul><\/fieldset><\/div><div id=\"wpforms-890-field_18-container\" class=\"wpforms-field wpforms-field-number\" data-field-id=\"18\"><label class=\"wpforms-field-label\" for=\"wpforms-890-field_18\">Cell\/Other Phone <\/label><input type=\"number\" id=\"wpforms-890-field_18\" class=\"wpforms-field-medium\" name=\"wpforms[fields][18]\" aria-errormessage=\"wpforms-890-field_18-error\" ><\/div><div id=\"wpforms-890-field_19-container\" class=\"wpforms-field wpforms-field-radio wpforms-list-2-columns\" data-field-id=\"19\"><fieldset><legend class=\"wpforms-field-label\">May we leave a message? <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/legend><ul id=\"wpforms-890-field_19\" class=\"wpforms-field-required\"><li class=\"choice-1 depth-1\"><input type=\"radio\" id=\"wpforms-890-field_19_1\" name=\"wpforms[fields][19]\" value=\"Yes\" aria-errormessage=\"wpforms-890-field_19_1-error\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-890-field_19_1\">Yes<\/label><\/li><li class=\"choice-2 depth-1\"><input type=\"radio\" id=\"wpforms-890-field_19_2\" name=\"wpforms[fields][19]\" value=\"No\" aria-errormessage=\"wpforms-890-field_19_2-error\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-890-field_19_2\">No<\/label><\/li><\/ul><\/fieldset><\/div><div id=\"wpforms-890-field_2-container\" class=\"wpforms-field wpforms-field-email\" data-field-id=\"2\"><label class=\"wpforms-field-label\" for=\"wpforms-890-field_2\"> Email Address <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/label><input type=\"email\" id=\"wpforms-890-field_2\" class=\"wpforms-field-medium wpforms-field-required\" name=\"wpforms[fields][2]\" spellcheck=\"false\" aria-errormessage=\"wpforms-890-field_2-error\" required><\/div><div id=\"wpforms-890-field_20-container\" class=\"wpforms-field wpforms-field-radio wpforms-list-2-columns\" data-field-id=\"20\"><fieldset><legend class=\"wpforms-field-label\">May we email you?  <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/legend><ul id=\"wpforms-890-field_20\" class=\"wpforms-field-required\"><li class=\"choice-1 depth-1\"><input type=\"radio\" id=\"wpforms-890-field_20_1\" name=\"wpforms[fields][20]\" value=\"Yes\" aria-errormessage=\"wpforms-890-field_20_1-error\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-890-field_20_1\">Yes<\/label><\/li><li class=\"choice-2 depth-1\"><input type=\"radio\" id=\"wpforms-890-field_20_2\" name=\"wpforms[fields][20]\" value=\"No\" aria-errormessage=\"wpforms-890-field_20_2-error\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-890-field_20_2\">No<\/label><\/li><\/ul><\/fieldset><\/div><div id=\"wpforms-890-field_21-container\" class=\"wpforms-field wpforms-field-radio wpforms-list-2-columns\" data-field-id=\"21\"><fieldset><legend class=\"wpforms-field-label\"> Have you previously received any type of mental health services (psychotherapy, psychiatric services, etc.)? <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/legend><ul id=\"wpforms-890-field_21\" class=\"wpforms-field-required\"><li class=\"choice-1 depth-1\"><input type=\"radio\" id=\"wpforms-890-field_21_1\" name=\"wpforms[fields][21]\" value=\"Yes\" aria-errormessage=\"wpforms-890-field_21_1-error\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-890-field_21_1\">Yes<\/label><\/li><li class=\"choice-2 depth-1\"><input type=\"radio\" id=\"wpforms-890-field_21_2\" name=\"wpforms[fields][21]\" value=\"No\" aria-errormessage=\"wpforms-890-field_21_2-error\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-890-field_21_2\">No<\/label><\/li><\/ul><\/fieldset><\/div><div id=\"wpforms-890-field_22-container\" class=\"wpforms-field wpforms-field-radio wpforms-list-2-columns\" data-field-id=\"22\"><fieldset><legend class=\"wpforms-field-label\"> Are you currently taking any prescription medication?  <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/legend><ul id=\"wpforms-890-field_22\" class=\"wpforms-field-required\"><li class=\"choice-1 depth-1\"><input type=\"radio\" id=\"wpforms-890-field_22_1\" name=\"wpforms[fields][22]\" value=\"Yes\" aria-errormessage=\"wpforms-890-field_22_1-error\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-890-field_22_1\">Yes<\/label><\/li><li class=\"choice-2 depth-1\"><input type=\"radio\" id=\"wpforms-890-field_22_2\" name=\"wpforms[fields][22]\" value=\"No\" aria-errormessage=\"wpforms-890-field_22_2-error\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-890-field_22_2\">No<\/label><\/li><\/ul><\/fieldset><\/div><div id=\"wpforms-890-field_25-container\" class=\"wpforms-field wpforms-field-radio wpforms-list-2-columns\" data-field-id=\"25\"><fieldset><legend class=\"wpforms-field-label\"> Have you ever been prescribed psychiatric medication?  <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/legend><ul id=\"wpforms-890-field_25\" class=\"wpforms-field-required\"><li class=\"choice-1 depth-1\"><input type=\"radio\" id=\"wpforms-890-field_25_1\" name=\"wpforms[fields][25]\" value=\"Yes\" aria-errormessage=\"wpforms-890-field_25_1-error\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-890-field_25_1\">Yes<\/label><\/li><li class=\"choice-2 depth-1\"><input type=\"radio\" id=\"wpforms-890-field_25_2\" name=\"wpforms[fields][25]\" value=\"No\" aria-errormessage=\"wpforms-890-field_25_2-error\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-890-field_25_2\">No<\/label><\/li><\/ul><\/fieldset><\/div><div id=\"wpforms-890-field_26-container\" class=\"wpforms-field wpforms-field-radio wpforms-list-2-columns\" data-field-id=\"26\"><fieldset><legend class=\"wpforms-field-label\">GENERAL HEALTH AND MENTAL HEALTH INFORMATION<\/legend><ul id=\"wpforms-890-field_26\"><li class=\"choice-1 depth-1\"><input type=\"radio\" id=\"wpforms-890-field_26_1\" name=\"wpforms[fields][26]\" value=\"Yes\" aria-errormessage=\"wpforms-890-field_26_1-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-890-field_26_1\">Yes<\/label><\/li><\/ul><\/fieldset><\/div><div id=\"wpforms-890-field_27-container\" class=\"wpforms-field wpforms-field-radio wpforms-list-2-columns\" data-field-id=\"27\"><fieldset><legend class=\"wpforms-field-label\">1. How would you rate your current physical health? <\/legend><ul id=\"wpforms-890-field_27\"><li class=\"choice-1 depth-1\"><input type=\"radio\" id=\"wpforms-890-field_27_1\" name=\"wpforms[fields][27]\" value=\"Poor\" aria-errormessage=\"wpforms-890-field_27_1-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-890-field_27_1\">Poor<\/label><\/li><li class=\"choice-5 depth-1\"><input type=\"radio\" id=\"wpforms-890-field_27_5\" name=\"wpforms[fields][27]\" value=\"Unsatisfactory\" aria-errormessage=\"wpforms-890-field_27_5-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-890-field_27_5\">Unsatisfactory<\/label><\/li><li class=\"choice-4 depth-1\"><input type=\"radio\" id=\"wpforms-890-field_27_4\" name=\"wpforms[fields][27]\" value=\"Satisfactory\" aria-errormessage=\"wpforms-890-field_27_4-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-890-field_27_4\">Satisfactory<\/label><\/li><li class=\"choice-3 depth-1\"><input type=\"radio\" id=\"wpforms-890-field_27_3\" name=\"wpforms[fields][27]\" value=\"Good\" aria-errormessage=\"wpforms-890-field_27_3-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-890-field_27_3\">Good<\/label><\/li><li class=\"choice-6 depth-1\"><input type=\"radio\" id=\"wpforms-890-field_27_6\" name=\"wpforms[fields][27]\" value=\"Very good\" aria-errormessage=\"wpforms-890-field_27_6-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-890-field_27_6\">Very good<\/label><\/li><\/ul><\/fieldset><\/div><div id=\"wpforms-890-field_29-container\" class=\"wpforms-field wpforms-field-text\" data-field-id=\"29\"><label class=\"wpforms-field-label\" for=\"wpforms-890-field_29\"> Please list any specific health problems you are currently experiencing <\/label><input type=\"text\" id=\"wpforms-890-field_29\" class=\"wpforms-field-medium\" name=\"wpforms[fields][29]\" placeholder=\"Enter Details here\" aria-errormessage=\"wpforms-890-field_29-error\" ><\/div><div id=\"wpforms-890-field_30-container\" class=\"wpforms-field wpforms-field-radio wpforms-list-2-columns\" data-field-id=\"30\"><fieldset><legend class=\"wpforms-field-label\"> 2. How would you rate your current sleeping habits? <\/legend><ul id=\"wpforms-890-field_30\"><li class=\"choice-1 depth-1\"><input type=\"radio\" id=\"wpforms-890-field_30_1\" name=\"wpforms[fields][30]\" value=\"Poor\" aria-errormessage=\"wpforms-890-field_30_1-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-890-field_30_1\">Poor<\/label><\/li><li class=\"choice-5 depth-1\"><input type=\"radio\" id=\"wpforms-890-field_30_5\" name=\"wpforms[fields][30]\" value=\"Unsatisfactory\" aria-errormessage=\"wpforms-890-field_30_5-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-890-field_30_5\">Unsatisfactory<\/label><\/li><li class=\"choice-4 depth-1\"><input type=\"radio\" id=\"wpforms-890-field_30_4\" name=\"wpforms[fields][30]\" value=\"Satisfactory\" aria-errormessage=\"wpforms-890-field_30_4-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-890-field_30_4\">Satisfactory<\/label><\/li><li class=\"choice-3 depth-1\"><input type=\"radio\" id=\"wpforms-890-field_30_3\" name=\"wpforms[fields][30]\" value=\"Good\" aria-errormessage=\"wpforms-890-field_30_3-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-890-field_30_3\">Good<\/label><\/li><li class=\"choice-6 depth-1\"><input type=\"radio\" id=\"wpforms-890-field_30_6\" name=\"wpforms[fields][30]\" value=\"Very good\" aria-errormessage=\"wpforms-890-field_30_6-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-890-field_30_6\">Very good<\/label><\/li><\/ul><\/fieldset><\/div><div id=\"wpforms-890-field_31-container\" class=\"wpforms-field wpforms-field-text\" data-field-id=\"31\"><label class=\"wpforms-field-label\" for=\"wpforms-890-field_31\">Please list any specific sleep problems you are currently experiencing <\/label><input type=\"text\" id=\"wpforms-890-field_31\" class=\"wpforms-field-medium\" name=\"wpforms[fields][31]\" placeholder=\"Enter Details here\" aria-errormessage=\"wpforms-890-field_31-error\" ><\/div><div id=\"wpforms-890-field_32-container\" class=\"wpforms-field wpforms-field-text\" data-field-id=\"32\"><label class=\"wpforms-field-label\" for=\"wpforms-890-field_32\"> 3. How many times per week do you generally exercise? <\/label><input type=\"text\" id=\"wpforms-890-field_32\" class=\"wpforms-field-medium\" name=\"wpforms[fields][32]\" placeholder=\"Enter Details here\" aria-errormessage=\"wpforms-890-field_32-error\" ><\/div><div id=\"wpforms-890-field_33-container\" class=\"wpforms-field wpforms-field-text\" data-field-id=\"33\"><label class=\"wpforms-field-label\" for=\"wpforms-890-field_33\"> What types of exercise to you participate in <\/label><input type=\"text\" id=\"wpforms-890-field_33\" class=\"wpforms-field-medium\" name=\"wpforms[fields][33]\" placeholder=\"Enter Details here\" aria-errormessage=\"wpforms-890-field_33-error\" ><\/div><div id=\"wpforms-890-field_34-container\" class=\"wpforms-field wpforms-field-text\" data-field-id=\"34\"><label class=\"wpforms-field-label\" for=\"wpforms-890-field_34\"> 4. Please list any difficulties you experience with your appetite or eating patterns. <\/label><input type=\"text\" id=\"wpforms-890-field_34\" class=\"wpforms-field-medium\" name=\"wpforms[fields][34]\" placeholder=\"Enter Details here\" aria-errormessage=\"wpforms-890-field_34-error\" ><\/div><div id=\"wpforms-890-field_35-container\" class=\"wpforms-field wpforms-field-radio wpforms-list-2-columns\" data-field-id=\"35\"><fieldset><legend class=\"wpforms-field-label\"> 5. Are you currently experiencing overwhelming sadness, grief or depression? <\/legend><ul id=\"wpforms-890-field_35\"><li class=\"choice-1 depth-1\"><input type=\"radio\" id=\"wpforms-890-field_35_1\" name=\"wpforms[fields][35]\" value=\"yes\" aria-errormessage=\"wpforms-890-field_35_1-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-890-field_35_1\">yes<\/label><\/li><li class=\"choice-5 depth-1\"><input type=\"radio\" id=\"wpforms-890-field_35_5\" name=\"wpforms[fields][35]\" value=\"No\" aria-errormessage=\"wpforms-890-field_35_5-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-890-field_35_5\">No<\/label><\/li><\/ul><\/fieldset><\/div><div id=\"wpforms-890-field_36-container\" class=\"wpforms-field wpforms-field-radio wpforms-list-2-columns\" data-field-id=\"36\"><fieldset><legend class=\"wpforms-field-label\"> 6. Are you currently experiencing anxiety, panic attacks or have any phobias? <\/legend><ul id=\"wpforms-890-field_36\"><li class=\"choice-1 depth-1\"><input type=\"radio\" id=\"wpforms-890-field_36_1\" name=\"wpforms[fields][36]\" value=\"yes\" aria-errormessage=\"wpforms-890-field_36_1-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-890-field_36_1\">yes<\/label><\/li><li class=\"choice-5 depth-1\"><input type=\"radio\" id=\"wpforms-890-field_36_5\" name=\"wpforms[fields][36]\" value=\"No\" aria-errormessage=\"wpforms-890-field_36_5-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-890-field_36_5\">No<\/label><\/li><\/ul><\/fieldset><\/div><div id=\"wpforms-890-field_39-container\" class=\"wpforms-field wpforms-field-radio wpforms-list-2-columns\" data-field-id=\"39\"><fieldset><legend class=\"wpforms-field-label\"> 7. Are you currently experiencing any chronic pain? <\/legend><ul id=\"wpforms-890-field_39\"><li class=\"choice-1 depth-1\"><input type=\"radio\" id=\"wpforms-890-field_39_1\" name=\"wpforms[fields][39]\" value=\"yes\" aria-errormessage=\"wpforms-890-field_39_1-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-890-field_39_1\">yes<\/label><\/li><li class=\"choice-5 depth-1\"><input type=\"radio\" id=\"wpforms-890-field_39_5\" name=\"wpforms[fields][39]\" value=\"No\" aria-errormessage=\"wpforms-890-field_39_5-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-890-field_39_5\">No<\/label><\/li><\/ul><\/fieldset><\/div><div id=\"wpforms-890-field_38-container\" class=\"wpforms-field wpforms-field-radio wpforms-list-2-columns\" data-field-id=\"38\"><fieldset><legend class=\"wpforms-field-label\"> 8. Do you drink alcohol more than once a week? <\/legend><ul id=\"wpforms-890-field_38\"><li class=\"choice-1 depth-1\"><input type=\"radio\" id=\"wpforms-890-field_38_1\" name=\"wpforms[fields][38]\" value=\"yes\" aria-errormessage=\"wpforms-890-field_38_1-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-890-field_38_1\">yes<\/label><\/li><li class=\"choice-5 depth-1\"><input type=\"radio\" id=\"wpforms-890-field_38_5\" name=\"wpforms[fields][38]\" value=\"No\" aria-errormessage=\"wpforms-890-field_38_5-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-890-field_38_5\">No<\/label><\/li><\/ul><\/fieldset><\/div><div id=\"wpforms-890-field_40-container\" class=\"wpforms-field wpforms-field-checkbox wpforms-list-3-columns\" data-field-id=\"40\"><fieldset><legend class=\"wpforms-field-label\"> 9. How often do you engage recreational drug use?  <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/legend><ul id=\"wpforms-890-field_40\" class=\"wpforms-field-required\"><li class=\"choice-1 depth-1\"><input type=\"checkbox\" id=\"wpforms-890-field_40_1\" name=\"wpforms[fields][40][]\" value=\"Daily\" aria-errormessage=\"wpforms-890-field_40_1-error\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-890-field_40_1\">Daily<\/label><\/li><li class=\"choice-2 depth-1\"><input type=\"checkbox\" id=\"wpforms-890-field_40_2\" name=\"wpforms[fields][40][]\" value=\"Weekly\" aria-errormessage=\"wpforms-890-field_40_2-error\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-890-field_40_2\">Weekly<\/label><\/li><li class=\"choice-3 depth-1\"><input type=\"checkbox\" id=\"wpforms-890-field_40_3\" name=\"wpforms[fields][40][]\" value=\"Monthly\" aria-errormessage=\"wpforms-890-field_40_3-error\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-890-field_40_3\">Monthly<\/label><\/li><li class=\"choice-7 depth-1\"><input type=\"checkbox\" id=\"wpforms-890-field_40_7\" name=\"wpforms[fields][40][]\" value=\"Infrequently\" aria-errormessage=\"wpforms-890-field_40_7-error\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-890-field_40_7\">Infrequently<\/label><\/li><li class=\"choice-6 depth-1\"><input type=\"checkbox\" id=\"wpforms-890-field_40_6\" name=\"wpforms[fields][40][]\" value=\"Never\" aria-errormessage=\"wpforms-890-field_40_6-error\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-890-field_40_6\">Never<\/label><\/li><\/ul><\/fieldset><\/div><div id=\"wpforms-890-field_41-container\" class=\"wpforms-field wpforms-field-radio wpforms-list-2-columns\" data-field-id=\"41\"><fieldset><legend class=\"wpforms-field-label\"> 10. Are you currently in a romantic relationship?<\/legend><ul id=\"wpforms-890-field_41\"><li class=\"choice-1 depth-1\"><input type=\"radio\" id=\"wpforms-890-field_41_1\" name=\"wpforms[fields][41]\" value=\"yes\" aria-errormessage=\"wpforms-890-field_41_1-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-890-field_41_1\">yes<\/label><\/li><li class=\"choice-5 depth-1\"><input type=\"radio\" id=\"wpforms-890-field_41_5\" name=\"wpforms[fields][41]\" value=\"No\" aria-errormessage=\"wpforms-890-field_41_5-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-890-field_41_5\">No<\/label><\/li><\/ul><\/fieldset><\/div><div id=\"wpforms-890-field_42-container\" class=\"wpforms-field wpforms-field-text\" data-field-id=\"42\"><label class=\"wpforms-field-label\" for=\"wpforms-890-field_42\"> On a scale of 1-10, how would you rate your relationship? <\/label><input type=\"text\" id=\"wpforms-890-field_42\" class=\"wpforms-field-medium\" name=\"wpforms[fields][42]\" aria-errormessage=\"wpforms-890-field_42-error\" ><\/div><div id=\"wpforms-890-field_43-container\" class=\"wpforms-field wpforms-field-text\" data-field-id=\"43\"><label class=\"wpforms-field-label\" for=\"wpforms-890-field_43\">11. What significant life changes or stressful events have you experienced recently <\/label><input type=\"text\" id=\"wpforms-890-field_43\" class=\"wpforms-field-medium\" name=\"wpforms[fields][43]\" aria-errormessage=\"wpforms-890-field_43-error\" ><\/div><div id=\"wpforms-890-field_46-container\" class=\"wpforms-field wpforms-field-checkbox\" data-field-id=\"46\"><fieldset><legend class=\"wpforms-field-label\">FAMILY MENTAL HEALTH HISTORY<\/legend><ul id=\"wpforms-890-field_46\"><li class=\"choice-1 depth-1\"><input type=\"checkbox\" id=\"wpforms-890-field_46_1\" name=\"wpforms[fields][46][]\" value=\"First Choice\" aria-errormessage=\"wpforms-890-field_46_1-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-890-field_46_1\">First Choice<\/label><\/li><\/ul><\/fieldset><\/div><div id=\"wpforms-890-field_47-container\" class=\"wpforms-field wpforms-field-textarea\" data-field-id=\"47\"><label class=\"wpforms-field-label wpforms-label-hide\" for=\"wpforms-890-field_47\" aria-hidden=\"false\">Paragraph Text<\/label><textarea id=\"wpforms-890-field_47\" class=\"wpforms-field-medium wpforms-limit-words-enabled\" data-form-id=\"890\" data-field-id=\"47\" data-text-limit=\"1\" name=\"wpforms[fields][47]\" placeholder=\"In the section below identify if there is a family history of any of the following. If yes, please indicate the family member&#039;s relationship to you in the space provided (father, grandmother, uncle, etc.). \" aria-errormessage=\"wpforms-890-field_47-error\" ><\/textarea><\/div><div id=\"wpforms-890-field_48-container\" class=\"wpforms-field wpforms-field-radio wpforms-one-half wpforms-first wpforms-list-2-columns\" data-field-id=\"48\"><fieldset><legend class=\"wpforms-field-label\"> Alcohol\/Substance Abuse <\/legend><ul id=\"wpforms-890-field_48\"><li class=\"choice-1 depth-1\"><input type=\"radio\" id=\"wpforms-890-field_48_1\" name=\"wpforms[fields][48]\" value=\"yes\" aria-errormessage=\"wpforms-890-field_48_1-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-890-field_48_1\">yes<\/label><\/li><li class=\"choice-5 depth-1\"><input type=\"radio\" id=\"wpforms-890-field_48_5\" name=\"wpforms[fields][48]\" value=\"No\" aria-errormessage=\"wpforms-890-field_48_5-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-890-field_48_5\">No<\/label><\/li><\/ul><\/fieldset><\/div><div id=\"wpforms-890-field_49-container\" class=\"wpforms-field wpforms-field-text wpforms-one-half\" data-field-id=\"49\"><label class=\"wpforms-field-label\" for=\"wpforms-890-field_49\">List Family Member <\/label><input type=\"text\" id=\"wpforms-890-field_49\" class=\"wpforms-field-medium\" name=\"wpforms[fields][49]\" placeholder=\"Enetr family member here\" aria-errormessage=\"wpforms-890-field_49-error\" ><\/div><div id=\"wpforms-890-field_50-container\" class=\"wpforms-field wpforms-field-radio wpforms-one-half wpforms-first wpforms-list-2-columns\" data-field-id=\"50\"><fieldset><legend class=\"wpforms-field-label\">Anxiety <\/legend><ul id=\"wpforms-890-field_50\"><li class=\"choice-1 depth-1\"><input type=\"radio\" id=\"wpforms-890-field_50_1\" name=\"wpforms[fields][50]\" value=\"yes\" aria-errormessage=\"wpforms-890-field_50_1-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-890-field_50_1\">yes<\/label><\/li><li class=\"choice-5 depth-1\"><input type=\"radio\" id=\"wpforms-890-field_50_5\" name=\"wpforms[fields][50]\" value=\"No\" aria-errormessage=\"wpforms-890-field_50_5-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-890-field_50_5\">No<\/label><\/li><\/ul><\/fieldset><\/div><div id=\"wpforms-890-field_51-container\" class=\"wpforms-field wpforms-field-text wpforms-one-half\" data-field-id=\"51\"><label class=\"wpforms-field-label\" for=\"wpforms-890-field_51\">List Family Member<\/label><input type=\"text\" id=\"wpforms-890-field_51\" class=\"wpforms-field-medium\" name=\"wpforms[fields][51]\" placeholder=\"Enetr family member here\" aria-errormessage=\"wpforms-890-field_51-error\" ><\/div><div id=\"wpforms-890-field_52-container\" class=\"wpforms-field wpforms-field-radio wpforms-one-half wpforms-first wpforms-list-2-columns\" data-field-id=\"52\"><fieldset><legend class=\"wpforms-field-label\">Depression <\/legend><ul id=\"wpforms-890-field_52\"><li class=\"choice-1 depth-1\"><input type=\"radio\" id=\"wpforms-890-field_52_1\" name=\"wpforms[fields][52]\" value=\"yes\" aria-errormessage=\"wpforms-890-field_52_1-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-890-field_52_1\">yes<\/label><\/li><li class=\"choice-5 depth-1\"><input type=\"radio\" id=\"wpforms-890-field_52_5\" name=\"wpforms[fields][52]\" value=\"No\" aria-errormessage=\"wpforms-890-field_52_5-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-890-field_52_5\">No<\/label><\/li><\/ul><\/fieldset><\/div><div id=\"wpforms-890-field_61-container\" class=\"wpforms-field wpforms-field-text wpforms-one-half\" data-field-id=\"61\"><label class=\"wpforms-field-label\" for=\"wpforms-890-field_61\">List Family Member<\/label><input type=\"text\" id=\"wpforms-890-field_61\" class=\"wpforms-field-medium\" name=\"wpforms[fields][61]\" placeholder=\"Enetr family member here\" aria-errormessage=\"wpforms-890-field_61-error\" ><\/div><div id=\"wpforms-890-field_56-container\" class=\"wpforms-field wpforms-field-radio wpforms-one-half wpforms-first wpforms-list-2-columns\" data-field-id=\"56\"><fieldset><legend class=\"wpforms-field-label\">Domestic Violence <\/legend><ul id=\"wpforms-890-field_56\"><li class=\"choice-1 depth-1\"><input type=\"radio\" id=\"wpforms-890-field_56_1\" name=\"wpforms[fields][56]\" value=\"yes\" aria-errormessage=\"wpforms-890-field_56_1-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-890-field_56_1\">yes<\/label><\/li><li class=\"choice-5 depth-1\"><input type=\"radio\" id=\"wpforms-890-field_56_5\" name=\"wpforms[fields][56]\" value=\"No\" aria-errormessage=\"wpforms-890-field_56_5-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-890-field_56_5\">No<\/label><\/li><\/ul><\/fieldset><\/div><div id=\"wpforms-890-field_64-container\" class=\"wpforms-field wpforms-field-text wpforms-one-half\" data-field-id=\"64\"><label class=\"wpforms-field-label\" for=\"wpforms-890-field_64\">List Family Member<\/label><input type=\"text\" id=\"wpforms-890-field_64\" class=\"wpforms-field-medium\" name=\"wpforms[fields][64]\" placeholder=\"Enetr family member here\" aria-errormessage=\"wpforms-890-field_64-error\" ><\/div><div id=\"wpforms-890-field_67-container\" class=\"wpforms-field wpforms-field-radio wpforms-one-half wpforms-first wpforms-list-2-columns\" data-field-id=\"67\"><fieldset><legend class=\"wpforms-field-label\">Eating Disorders <\/legend><ul id=\"wpforms-890-field_67\"><li class=\"choice-1 depth-1\"><input type=\"radio\" id=\"wpforms-890-field_67_1\" name=\"wpforms[fields][67]\" value=\"yes\" aria-errormessage=\"wpforms-890-field_67_1-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-890-field_67_1\">yes<\/label><\/li><li class=\"choice-5 depth-1\"><input type=\"radio\" id=\"wpforms-890-field_67_5\" name=\"wpforms[fields][67]\" value=\"No\" aria-errormessage=\"wpforms-890-field_67_5-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-890-field_67_5\">No<\/label><\/li><\/ul><\/fieldset><\/div><div id=\"wpforms-890-field_68-container\" class=\"wpforms-field wpforms-field-text wpforms-one-half\" data-field-id=\"68\"><label class=\"wpforms-field-label\" for=\"wpforms-890-field_68\">List Family Member <\/label><input type=\"text\" id=\"wpforms-890-field_68\" class=\"wpforms-field-medium\" name=\"wpforms[fields][68]\" placeholder=\"Enetr family member here\" aria-errormessage=\"wpforms-890-field_68-error\" ><\/div><div id=\"wpforms-890-field_55-container\" class=\"wpforms-field wpforms-field-radio wpforms-one-half wpforms-first wpforms-list-2-columns\" data-field-id=\"55\"><fieldset><legend class=\"wpforms-field-label\">Obesity <\/legend><ul id=\"wpforms-890-field_55\"><li class=\"choice-1 depth-1\"><input type=\"radio\" id=\"wpforms-890-field_55_1\" name=\"wpforms[fields][55]\" value=\"yes\" aria-errormessage=\"wpforms-890-field_55_1-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-890-field_55_1\">yes<\/label><\/li><li class=\"choice-5 depth-1\"><input type=\"radio\" id=\"wpforms-890-field_55_5\" name=\"wpforms[fields][55]\" value=\"No\" aria-errormessage=\"wpforms-890-field_55_5-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-890-field_55_5\">No<\/label><\/li><\/ul><\/fieldset><\/div><div id=\"wpforms-890-field_63-container\" class=\"wpforms-field wpforms-field-text wpforms-one-half\" data-field-id=\"63\"><label class=\"wpforms-field-label\" for=\"wpforms-890-field_63\">List Family Member<\/label><input type=\"text\" id=\"wpforms-890-field_63\" class=\"wpforms-field-medium\" name=\"wpforms[fields][63]\" placeholder=\"Enetr family member here\" aria-errormessage=\"wpforms-890-field_63-error\" ><\/div><div id=\"wpforms-890-field_54-container\" class=\"wpforms-field wpforms-field-radio wpforms-one-half wpforms-first wpforms-list-2-columns\" data-field-id=\"54\"><fieldset><legend class=\"wpforms-field-label\">Obsessive Compulsive Behavior <\/legend><ul id=\"wpforms-890-field_54\"><li class=\"choice-1 depth-1\"><input type=\"radio\" id=\"wpforms-890-field_54_1\" name=\"wpforms[fields][54]\" value=\"yes\" aria-errormessage=\"wpforms-890-field_54_1-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-890-field_54_1\">yes<\/label><\/li><li class=\"choice-5 depth-1\"><input type=\"radio\" id=\"wpforms-890-field_54_5\" name=\"wpforms[fields][54]\" value=\"No\" aria-errormessage=\"wpforms-890-field_54_5-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-890-field_54_5\">No<\/label><\/li><\/ul><\/fieldset><\/div><div id=\"wpforms-890-field_62-container\" class=\"wpforms-field wpforms-field-text wpforms-one-half\" data-field-id=\"62\"><label class=\"wpforms-field-label\" for=\"wpforms-890-field_62\">List Family Member<\/label><input type=\"text\" id=\"wpforms-890-field_62\" class=\"wpforms-field-medium\" name=\"wpforms[fields][62]\" placeholder=\"Enetr family member here\" aria-errormessage=\"wpforms-890-field_62-error\" ><\/div><div id=\"wpforms-890-field_53-container\" class=\"wpforms-field wpforms-field-radio wpforms-one-half wpforms-first wpforms-list-2-columns\" data-field-id=\"53\"><fieldset><legend class=\"wpforms-field-label\">Schizophrenia <\/legend><ul id=\"wpforms-890-field_53\"><li class=\"choice-1 depth-1\"><input type=\"radio\" id=\"wpforms-890-field_53_1\" name=\"wpforms[fields][53]\" value=\"yes\" aria-errormessage=\"wpforms-890-field_53_1-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-890-field_53_1\">yes<\/label><\/li><li class=\"choice-5 depth-1\"><input type=\"radio\" id=\"wpforms-890-field_53_5\" name=\"wpforms[fields][53]\" value=\"No\" aria-errormessage=\"wpforms-890-field_53_5-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-890-field_53_5\">No<\/label><\/li><\/ul><\/fieldset><\/div><div id=\"wpforms-890-field_60-container\" class=\"wpforms-field wpforms-field-text wpforms-one-half\" data-field-id=\"60\"><label class=\"wpforms-field-label\" for=\"wpforms-890-field_60\">List Family Member<\/label><input type=\"text\" id=\"wpforms-890-field_60\" class=\"wpforms-field-medium\" name=\"wpforms[fields][60]\" placeholder=\"Enetr family member here\" aria-errormessage=\"wpforms-890-field_60-error\" ><\/div><div id=\"wpforms-890-field_65-container\" class=\"wpforms-field wpforms-field-radio wpforms-one-half wpforms-first wpforms-list-2-columns\" data-field-id=\"65\"><fieldset><legend class=\"wpforms-field-label\">Suicide Attempts <\/legend><ul id=\"wpforms-890-field_65\"><li class=\"choice-1 depth-1\"><input type=\"radio\" id=\"wpforms-890-field_65_1\" name=\"wpforms[fields][65]\" value=\"yes\" aria-errormessage=\"wpforms-890-field_65_1-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-890-field_65_1\">yes<\/label><\/li><li class=\"choice-5 depth-1\"><input type=\"radio\" id=\"wpforms-890-field_65_5\" name=\"wpforms[fields][65]\" value=\"No\" aria-errormessage=\"wpforms-890-field_65_5-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-890-field_65_5\">No<\/label><\/li><\/ul><\/fieldset><\/div><div id=\"wpforms-890-field_66-container\" class=\"wpforms-field wpforms-field-text wpforms-one-half\" data-field-id=\"66\"><label class=\"wpforms-field-label\" for=\"wpforms-890-field_66\">List Family Member<\/label><input type=\"text\" id=\"wpforms-890-field_66\" class=\"wpforms-field-medium\" name=\"wpforms[fields][66]\" placeholder=\"Enetr family member here\" aria-errormessage=\"wpforms-890-field_66-error\" ><\/div><div id=\"wpforms-890-field_69-container\" class=\"wpforms-field wpforms-field-radio wpforms-one-half wpforms-first wpforms-list-2-columns\" data-field-id=\"69\"><fieldset><legend class=\"wpforms-field-label\">ADDITIONAL INFORMATION<\/legend><ul id=\"wpforms-890-field_69\"><li class=\"choice-1 depth-1\"><input type=\"radio\" id=\"wpforms-890-field_69_1\" name=\"wpforms[fields][69]\" value=\"yes\" aria-errormessage=\"wpforms-890-field_69_1-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-890-field_69_1\">yes<\/label><\/li><\/ul><\/fieldset><\/div><div id=\"wpforms-890-field_70-container\" class=\"wpforms-field wpforms-field-radio wpforms-one-half wpforms-first wpforms-list-2-columns\" data-field-id=\"70\"><fieldset><legend class=\"wpforms-field-label\">1. Are you currently employed? <\/legend><ul id=\"wpforms-890-field_70\"><li class=\"choice-1 depth-1\"><input type=\"radio\" id=\"wpforms-890-field_70_1\" name=\"wpforms[fields][70]\" value=\"yes\" aria-errormessage=\"wpforms-890-field_70_1-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-890-field_70_1\">yes<\/label><\/li><li class=\"choice-7 depth-1\"><input type=\"radio\" id=\"wpforms-890-field_70_7\" name=\"wpforms[fields][70]\" value=\"No\" aria-errormessage=\"wpforms-890-field_70_7-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-890-field_70_7\">No<\/label><\/li><\/ul><\/fieldset><\/div><div id=\"wpforms-890-field_71-container\" class=\"wpforms-field wpforms-field-text wpforms-one-half\" data-field-id=\"71\"><label class=\"wpforms-field-label\" for=\"wpforms-890-field_71\">Do you enjoy your work? Is there anything stressful about your current work? <\/label><input type=\"text\" id=\"wpforms-890-field_71\" class=\"wpforms-field-medium\" name=\"wpforms[fields][71]\" placeholder=\"Enetr family member here\" aria-errormessage=\"wpforms-890-field_71-error\" ><\/div><div id=\"wpforms-890-field_72-container\" class=\"wpforms-field wpforms-field-radio wpforms-one-half wpforms-first wpforms-list-2-columns\" data-field-id=\"72\"><fieldset><legend class=\"wpforms-field-label\"> 2. Do you consider yourself to be spiritual or religious? <\/legend><ul id=\"wpforms-890-field_72\"><li class=\"choice-1 depth-1\"><input type=\"radio\" id=\"wpforms-890-field_72_1\" name=\"wpforms[fields][72]\" value=\"yes\" aria-errormessage=\"wpforms-890-field_72_1-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-890-field_72_1\">yes<\/label><\/li><li class=\"choice-7 depth-1\"><input type=\"radio\" id=\"wpforms-890-field_72_7\" name=\"wpforms[fields][72]\" value=\"No\" aria-errormessage=\"wpforms-890-field_72_7-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-890-field_72_7\">No<\/label><\/li><\/ul><\/fieldset><\/div><div id=\"wpforms-890-field_73-container\" class=\"wpforms-field wpforms-field-text wpforms-one-half\" data-field-id=\"73\"><label class=\"wpforms-field-label\" for=\"wpforms-890-field_73\"> 3. What do you consider to be some of your strengths? <\/label><input type=\"text\" id=\"wpforms-890-field_73\" class=\"wpforms-field-medium\" name=\"wpforms[fields][73]\" placeholder=\"Enetr family member here\" aria-errormessage=\"wpforms-890-field_73-error\" ><\/div><div id=\"wpforms-890-field_74-container\" class=\"wpforms-field wpforms-field-text wpforms-one-half\" data-field-id=\"74\"><label class=\"wpforms-field-label\" for=\"wpforms-890-field_74\">4. What do you consider to be some of your weakness? <\/label><input type=\"text\" id=\"wpforms-890-field_74\" class=\"wpforms-field-medium\" name=\"wpforms[fields][74]\" placeholder=\"Enetr family member here\" aria-errormessage=\"wpforms-890-field_74-error\" ><\/div><div id=\"wpforms-890-field_75-container\" class=\"wpforms-field wpforms-field-text wpforms-one-half\" data-field-id=\"75\"><label class=\"wpforms-field-label\" for=\"wpforms-890-field_75\"> 5. What would you like to accomplish out of your time in therapy? <\/label><input type=\"text\" id=\"wpforms-890-field_75\" class=\"wpforms-field-medium\" name=\"wpforms[fields][75]\" placeholder=\"Enetr family member here\" aria-errormessage=\"wpforms-890-field_75-error\" ><\/div><div id=\"wpforms-890-field_76-container\" class=\"wpforms-field wpforms-field-textarea\" data-field-id=\"76\"><label class=\"wpforms-field-label\" for=\"wpforms-890-field_76\">Limits of Confidentiality<\/label><textarea id=\"wpforms-890-field_76\" class=\"wpforms-field-large\" name=\"wpforms[fields][76]\" placeholder=\"  Contents of all therapy sessions are considered to be confidential. Both verbal information and written records about a client cannot be shared with another party without the written consent of the client or the client&#039;s legal guardian. Noted exceptions are as follows:  Duty to Warn and Protect When a client discloses intentions or a plan to harm another person, the mental health professional is required to warn the intended victim and report this information to legal authorities, In cases in which the client discloses or implies a plan for suicide, the health care professional is required to notify legal authorities and make reasonable attempts to notify the family of the client. Abuse of Children and Vulnerable Adults If a client states or suggests that he or she is abusing a child (or vulnerable adult) or has recently abused a child (or vulnerable adult), or a child (or vulnerable adult) is in danger of abuse, the mental health professional is required to report this information to the appropriate social service and\/or legal authorities. Prenatal Exposure to Controlled Substances Mental Health care professionals are required to report admitted prenatal exposure to controlled substances that are potentially harmful. Minors\/Guardianship Parents or legal guardians of non-emancipated minor clients have the right to access the clients&#039; records. Insurance Providers (when applicable) Insurance companies and other third-party payers are given information that they request regarding services to clients. Information that may be requested includes type of services, dates\/times of services, diagnosis, treatment plan, and description of impairment, progress of therapy, case notes, and summaries.\" aria-errormessage=\"wpforms-890-field_76-error\" ><\/textarea><\/div><div id=\"wpforms-890-field_77-container\" class=\"wpforms-field wpforms-field-checkbox\" data-field-id=\"77\"><fieldset><legend class=\"wpforms-field-label wpforms-label-hide\" aria-hidden=\"false\"> I agree to the above limits of confidentiality and understand their meanings and ramifications.<\/legend><ul id=\"wpforms-890-field_77\"><li class=\"choice-1 depth-1\"><input type=\"checkbox\" id=\"wpforms-890-field_77_1\" name=\"wpforms[fields][77][]\" value=\"I agree to the above limits of confidentiality and understand their meanings and ramifications.\" aria-errormessage=\"wpforms-890-field_77_1-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-890-field_77_1\">I agree to the above limits of confidentiality and understand their meanings and ramifications.<\/label><\/li><\/ul><\/fieldset><\/div><div id=\"wpforms-890-field_78-container\" class=\"wpforms-field wpforms-field-checkbox\" data-field-id=\"78\"><fieldset><legend class=\"wpforms-field-label wpforms-label-hide\" aria-hidden=\"false\"> I agree to the above limits of confidentiality and understand their meanings and ramifications. (copy)<\/legend><ul id=\"wpforms-890-field_78\"><li class=\"choice-1 depth-1\"><input type=\"checkbox\" id=\"wpforms-890-field_78_1\" name=\"wpforms[fields][78][]\" value=\"By submitting this form you agree to the terms of the Privacy Policy.\" aria-errormessage=\"wpforms-890-field_78_1-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-890-field_78_1\">By submitting this form you agree to the terms of the Privacy Policy.<\/label><\/li><\/ul><\/fieldset><\/div><\/div><!-- .wpforms-field-container --><div class=\"wpforms-submit-container\" ><input type=\"hidden\" name=\"wpforms[id]\" value=\"890\"><input type=\"hidden\" name=\"page_title\" value=\"\"><input type=\"hidden\" name=\"page_url\" value=\"https:\/\/www.capoecounselingllc.com\/demo\/wp-json\/wp\/v2\/pages\/1407\"><button type=\"submit\" name=\"wpforms[submit]\" id=\"wpforms-submit-890\" class=\"wpforms-submit\" data-alt-text=\"Sending...\" data-submit-text=\"Submit\" aria-live=\"assertive\" value=\"wpforms-submit\">Submit<\/button><img decoding=\"async\" src=\"https:\/\/www.capoecounselingllc.com\/demo\/wp-content\/plugins\/wpforms-lite\/assets\/images\/submit-spin.svg\" class=\"wpforms-submit-spinner\" style=\"display: none;\" width=\"26\" height=\"26\" alt=\"Loading\"><\/div><\/form><\/div>  <!-- .wpforms-container --><\/div>\n\t\t\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t<div class=\"elementor-element elementor-element-a00986e e-con-full e-flex wpr-particle-no wpr-jarallax-no wpr-parallax-no wpr-sticky-section-no e-con e-parent\" data-id=\"a00986e\" data-element_type=\"container\">\n\t\t\t\t<div class=\"elementor-element elementor-element-28c2216 elementor-widget elementor-widget-shortcode\" data-id=\"28c2216\" data-element_type=\"widget\" data-widget_type=\"shortcode.default\">\n\t\t\t\t<div class=\"elementor-widget-container\">\n\t\t\t\t\t\t\t<div class=\"elementor-shortcode\">\t\t<div data-elementor-type=\"wp-post\" data-elementor-id=\"1661\" class=\"elementor elementor-1661\">\n\t\t\t\t<div class=\"elementor-element elementor-element-188dd77 e-flex e-con-boxed wpr-particle-no wpr-jarallax-no wpr-parallax-no wpr-sticky-section-no e-con e-parent\" data-id=\"188dd77\" data-element_type=\"container\" data-settings=\"{&quot;background_background&quot;:&quot;classic&quot;}\">\n\t\t\t\t\t<div class=\"e-con-inner\">\n\t\t<div class=\"elementor-element elementor-element-4ff61b4 e-grid e-con-full wpr-particle-no wpr-jarallax-no wpr-parallax-no wpr-sticky-section-no e-con e-child\" data-id=\"4ff61b4\" data-element_type=\"container\">\n\t\t<div class=\"elementor-element elementor-element-66ff086 e-con-full e-flex wpr-particle-no wpr-jarallax-no wpr-parallax-no wpr-sticky-section-no e-con e-child\" data-id=\"66ff086\" data-element_type=\"container\">\n\t\t\t\t<div class=\"elementor-element elementor-element-bbbe167 elementor-widget elementor-widget-heading\" data-id=\"bbbe167\" data-element_type=\"widget\" data-widget_type=\"heading.default\">\n\t\t\t\t<div class=\"elementor-widget-container\">\n\t\t\t\t\t<h2 class=\"elementor-heading-title elementor-size-default\">Get In Touch! <\/h2>\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t<div class=\"elementor-element elementor-element-6cdc7fb elementor-widget elementor-widget-heading\" data-id=\"6cdc7fb\" data-element_type=\"widget\" data-widget_type=\"heading.default\">\n\t\t\t\t<div class=\"elementor-widget-container\">\n\t\t\t\t\t<h2 class=\"elementor-heading-title elementor-size-default\">Contact Details<\/h2>\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t<div class=\"elementor-element elementor-element-2bdad41 elementor-widget elementor-widget-text-editor\" data-id=\"2bdad41\" data-element_type=\"widget\" data-widget_type=\"text-editor.default\">\n\t\t\t\t<div class=\"elementor-widget-container\">\n\t\t\t\t\t\t\t\t\tYou can reach out to us with our number and email.\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t<div class=\"elementor-element elementor-element-7d833b0 e-con-full e-flex wpr-particle-no wpr-jarallax-no wpr-parallax-no wpr-sticky-section-no e-con e-child\" data-id=\"7d833b0\" data-element_type=\"container\">\n\t\t\t\t<div class=\"elementor-element elementor-element-727599a elementor-position-left elementor-view-default elementor-mobile-position-top elementor-vertical-align-top elementor-widget elementor-widget-icon-box\" data-id=\"727599a\" data-element_type=\"widget\" data-widget_type=\"icon-box.default\">\n\t\t\t\t<div class=\"elementor-widget-container\">\n\t\t\t\t\t\t\t<div class=\"elementor-icon-box-wrapper\">\n\n\t\t\t\t\t\t<div class=\"elementor-icon-box-icon\">\n\t\t\t\t<span  class=\"elementor-icon\">\n\t\t\t\t<svg aria-hidden=\"true\" class=\"e-font-icon-svg e-fab-whatsapp\" viewBox=\"0 0 448 512\" xmlns=\"http:\/\/www.w3.org\/2000\/svg\"><path d=\"M380.9 97.1C339 55.1 283.2 32 223.9 32c-122.4 0-222 99.6-222 222 0 39.1 10.2 77.3 29.6 111L0 480l117.7-30.9c32.4 17.7 68.9 27 106.1 27h.1c122.3 0 224.1-99.6 224.1-222 0-59.3-25.2-115-67.1-157zm-157 341.6c-33.2 0-65.7-8.9-94-25.7l-6.7-4-69.8 18.3L72 359.2l-4.4-7c-18.5-29.4-28.2-63.3-28.2-98.2 0-101.7 82.8-184.5 184.6-184.5 49.3 0 95.6 19.2 130.4 54.1 34.8 34.9 56.2 81.2 56.1 130.5 0 101.8-84.9 184.6-186.6 184.6zm101.2-138.2c-5.5-2.8-32.8-16.2-37.9-18-5.1-1.9-8.8-2.8-12.5 2.8-3.7 5.6-14.3 18-17.6 21.8-3.2 3.7-6.5 4.2-12 1.4-32.6-16.3-54-29.1-75.5-66-5.7-9.8 5.7-9.1 16.3-30.3 1.8-3.7.9-6.9-.5-9.7-1.4-2.8-12.5-30.1-17.1-41.2-4.5-10.8-9.1-9.3-12.5-9.5-3.2-.2-6.9-.2-10.6-.2-3.7 0-9.7 1.4-14.8 6.9-5.1 5.6-19.4 19-19.4 46.3 0 27.3 19.9 53.7 22.6 57.4 2.8 3.7 39.1 59.7 94.8 83.8 35.2 15.2 49 16.5 66.6 13.9 10.7-1.6 32.8-13.4 37.4-26.4 4.6-13 4.6-24.1 3.2-26.4-1.3-2.5-5-3.9-10.5-6.6z\"><\/path><\/svg>\t\t\t\t<\/span>\n\t\t\t<\/div>\n\t\t\t\n\t\t\t\t\t\t<div class=\"elementor-icon-box-content\">\n\n\t\t\t\t\t\t\t\t\t<h3 class=\"elementor-icon-box-title\">\n\t\t\t\t\t\t<span  >\n\t\t\t\t\t\t\tPhone: \t\t\t\t\t\t<\/span>\n\t\t\t\t\t<\/h3>\n\t\t\t\t\n\t\t\t\t\t\t\t\t\t<p class=\"elementor-icon-box-description\">\n\t\t\t\t\t\t404-436-4597\n404-772-5858\t\t\t\t\t<\/p>\n\t\t\t\t\n\t\t\t<\/div>\n\t\t\t\n\t\t<\/div>\n\t\t\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t<div class=\"elementor-element elementor-element-75a484f elementor-position-left elementor-view-default elementor-mobile-position-top elementor-vertical-align-top elementor-widget elementor-widget-icon-box\" data-id=\"75a484f\" data-element_type=\"widget\" data-widget_type=\"icon-box.default\">\n\t\t\t\t<div class=\"elementor-widget-container\">\n\t\t\t\t\t\t\t<div class=\"elementor-icon-box-wrapper\">\n\n\t\t\t\t\t\t<div class=\"elementor-icon-box-icon\">\n\t\t\t\t<span  class=\"elementor-icon\">\n\t\t\t\t<svg aria-hidden=\"true\" class=\"e-font-icon-svg e-fas-envelope-open\" viewBox=\"0 0 512 512\" xmlns=\"http:\/\/www.w3.org\/2000\/svg\"><path d=\"M512 464c0 26.51-21.49 48-48 48H48c-26.51 0-48-21.49-48-48V200.724a48 48 0 0 1 18.387-37.776c24.913-19.529 45.501-35.365 164.2-121.511C199.412 29.17 232.797-.347 256 .003c23.198-.354 56.596 29.172 73.413 41.433 118.687 86.137 139.303 101.995 164.2 121.512A48 48 0 0 1 512 200.724V464zm-65.666-196.605c-2.563-3.728-7.7-4.595-11.339-1.907-22.845 16.873-55.462 40.705-105.582 77.079-16.825 12.266-50.21 41.781-73.413 41.43-23.211.344-56.559-29.143-73.413-41.43-50.114-36.37-82.734-60.204-105.582-77.079-3.639-2.688-8.776-1.821-11.339 1.907l-9.072 13.196a7.998 7.998 0 0 0 1.839 10.967c22.887 16.899 55.454 40.69 105.303 76.868 20.274 14.781 56.524 47.813 92.264 47.573 35.724.242 71.961-32.771 92.263-47.573 49.85-36.179 82.418-59.97 105.303-76.868a7.998 7.998 0 0 0 1.839-10.967l-9.071-13.196z\"><\/path><\/svg>\t\t\t\t<\/span>\n\t\t\t<\/div>\n\t\t\t\n\t\t\t\t\t\t<div class=\"elementor-icon-box-content\">\n\n\t\t\t\t\t\t\t\t\t<h3 class=\"elementor-icon-box-title\">\n\t\t\t\t\t\t<span  >\n\t\t\t\t\t\t\tEmail Address: \t\t\t\t\t\t<\/span>\n\t\t\t\t\t<\/h3>\n\t\t\t\t\n\t\t\t\t\t\t\t\t\t<p class=\"elementor-icon-box-description\">\n\t\t\t\t\t\tcapcivic@att.net\t\t\t\t\t<\/p>\n\t\t\t\t\n\t\t\t<\/div>\n\t\t\t\n\t\t<\/div>\n\t\t\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t<div class=\"elementor-element elementor-element-c57cb75 elementor-position-left elementor-vertical-align-middle elementor-view-default elementor-mobile-position-top elementor-widget elementor-widget-icon-box\" data-id=\"c57cb75\" data-element_type=\"widget\" data-widget_type=\"icon-box.default\">\n\t\t\t\t<div class=\"elementor-widget-container\">\n\t\t\t\t\t\t\t<div class=\"elementor-icon-box-wrapper\">\n\n\t\t\t\t\t\t<div class=\"elementor-icon-box-icon\">\n\t\t\t\t<span  class=\"elementor-icon\">\n\t\t\t\t<svg aria-hidden=\"true\" class=\"e-font-icon-svg e-fas-map-marker\" viewBox=\"0 0 384 512\" xmlns=\"http:\/\/www.w3.org\/2000\/svg\"><path d=\"M172.268 501.67C26.97 291.031 0 269.413 0 192 0 85.961 85.961 0 192 0s192 85.961 192 192c0 77.413-26.97 99.031-172.268 309.67-9.535 13.774-29.93 13.773-39.464 0z\"><\/path><\/svg>\t\t\t\t<\/span>\n\t\t\t<\/div>\n\t\t\t\n\t\t\t\t\t\t<div class=\"elementor-icon-box-content\">\n\n\t\t\t\t\t\t\t\t\t<h3 class=\"elementor-icon-box-title\">\n\t\t\t\t\t\t<span  >\n\t\t\t\t\t\t\tAddress: \t\t\t\t\t\t<\/span>\n\t\t\t\t\t<\/h3>\n\t\t\t\t\n\t\t\t\t\t\t\t\t\t<p class=\"elementor-icon-box-description\">\n\t\t\t\t\t\tNew Black Wall Street Market 8109 Mall Parkway, Suite 112, Madam CJ WalkerStonecrest\",\" Georgia 30038\t\t\t\t\t<\/p>\n\t\t\t\t\n\t\t\t<\/div>\n\t\t\t\n\t\t<\/div>\n\t\t\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t<div class=\"elementor-element elementor-element-069b219 e-flex e-con-boxed wpr-particle-no wpr-jarallax-no wpr-parallax-no wpr-sticky-section-no e-con e-parent\" data-id=\"069b219\" data-element_type=\"container\" data-settings=\"{&quot;background_background&quot;:&quot;classic&quot;}\">\n\t\t\t\t\t<div class=\"e-con-inner\">\n\t\t\t\t<div class=\"elementor-element elementor-element-0bfd037 elementor-widget-divider--view-line elementor-widget elementor-widget-divider\" data-id=\"0bfd037\" data-element_type=\"widget\" data-widget_type=\"divider.default\">\n\t\t\t\t<div class=\"elementor-widget-container\">\n\t\t\t\t\t\t\t<div class=\"elementor-divider\">\n\t\t\t<span class=\"elementor-divider-separator\">\n\t\t\t\t\t\t<\/span>\n\t\t<\/div>\n\t\t\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t<div class=\"elementor-element elementor-element-8a5fac2 e-flex e-con-boxed wpr-particle-no wpr-jarallax-no wpr-parallax-no wpr-sticky-section-no e-con e-parent\" data-id=\"8a5fac2\" data-element_type=\"container\" data-settings=\"{&quot;background_background&quot;:&quot;classic&quot;}\">\n\t\t\t\t\t<div class=\"e-con-inner\">\n\t\t\t\t<div class=\"elementor-element elementor-element-6bc2913 wpr-main-menu-align-center wpr-main-menu-align--tabletleft wpr-main-menu-align--mobileleft wpr-pointer-underline wpr-pointer-line-fx wpr-pointer-fx-fade wpr-sub-icon-caret-down wpr-sub-menu-fx-fade wpr-nav-menu-bp-mobile wpr-mobile-menu-full-width wpr-mobile-menu-item-align-center wpr-mobile-toggle-v1 wpr-sub-divider-yes wpr-mobile-divider-yes elementor-widget elementor-widget-wpr-nav-menu\" data-id=\"6bc2913\" data-element_type=\"widget\" data-settings=\"{&quot;menu_layout&quot;:&quot;horizontal&quot;}\" data-widget_type=\"wpr-nav-menu.default\">\n\t\t\t\t<div class=\"elementor-widget-container\">\n\t\t\t\t\t<nav class=\"wpr-nav-menu-container wpr-nav-menu-horizontal\" data-trigger=\"hover\"><ul id=\"menu-1-6bc2913\" class=\"wpr-nav-menu\"><li class=\"menu-item menu-item-type-post_type menu-item-object-page menu-item-home menu-item-35\"><a href=\"https:\/\/www.capoecounselingllc.com\/demo\/\" class=\"wpr-menu-item wpr-pointer-item\">Home<\/a><\/li>\n<li class=\"menu-item menu-item-type-custom menu-item-object-custom menu-item-1822\"><a href=\"https:\/\/calendly.com\/drcecilpoe\" class=\"wpr-menu-item wpr-pointer-item\">Schedule Appointments<\/a><\/li>\n<li class=\"menu-item menu-item-type-post_type menu-item-object-page menu-item-33\"><a href=\"https:\/\/www.capoecounselingllc.com\/demo\/about\/\" class=\"wpr-menu-item wpr-pointer-item\">About<\/a><\/li>\n<li class=\"menu-item menu-item-type-post_type menu-item-object-page menu-item-1779\"><a href=\"https:\/\/www.capoecounselingllc.com\/demo\/programs\/\" class=\"wpr-menu-item wpr-pointer-item\">Programs<\/a><\/li>\n<li class=\"menu-item menu-item-type-post_type menu-item-object-page menu-item-1777\"><a href=\"https:\/\/www.capoecounselingllc.com\/demo\/resources\/\" class=\"wpr-menu-item wpr-pointer-item\">Resources<\/a><\/li>\n<li class=\"menu-item menu-item-type-post_type menu-item-object-page menu-item-1778\"><a href=\"https:\/\/www.capoecounselingllc.com\/demo\/blog\/\" class=\"wpr-menu-item wpr-pointer-item\">Blog<\/a><\/li>\n<li class=\"menu-item menu-item-type-post_type menu-item-object-page menu-item-155\"><a href=\"https:\/\/www.capoecounselingllc.com\/demo\/contact-us\/\" class=\"wpr-menu-item wpr-pointer-item\">Contact<\/a><\/li>\n<li class=\"menu-item menu-item-type-post_type menu-item-object-page menu-item-privacy-policy menu-item-1580\"><a rel=\"privacy-policy\" href=\"https:\/\/www.capoecounselingllc.com\/demo\/privacy-policy\/\" class=\"wpr-menu-item wpr-pointer-item\">Privacy Policy<\/a><\/li>\n<\/ul><\/nav><nav class=\"wpr-mobile-nav-menu-container\"><div class=\"wpr-mobile-toggle-wrap\"><div class=\"wpr-mobile-toggle\"><span class=\"wpr-mobile-toggle-line\"><\/span><span class=\"wpr-mobile-toggle-line\"><\/span><span class=\"wpr-mobile-toggle-line\"><\/span><\/div><\/div><ul id=\"mobile-menu-2-6bc2913\" class=\"wpr-mobile-nav-menu\"><li class=\"menu-item menu-item-type-post_type menu-item-object-page menu-item-home menu-item-35\"><a href=\"https:\/\/www.capoecounselingllc.com\/demo\/\" class=\"wpr-mobile-menu-item\">Home<\/a><\/li>\n<li class=\"menu-item menu-item-type-custom menu-item-object-custom menu-item-1822\"><a href=\"https:\/\/calendly.com\/drcecilpoe\" class=\"wpr-mobile-menu-item\">Schedule Appointments<\/a><\/li>\n<li class=\"menu-item menu-item-type-post_type menu-item-object-page menu-item-33\"><a href=\"https:\/\/www.capoecounselingllc.com\/demo\/about\/\" class=\"wpr-mobile-menu-item\">About<\/a><\/li>\n<li class=\"menu-item menu-item-type-post_type menu-item-object-page menu-item-1779\"><a href=\"https:\/\/www.capoecounselingllc.com\/demo\/programs\/\" class=\"wpr-mobile-menu-item\">Programs<\/a><\/li>\n<li class=\"menu-item menu-item-type-post_type menu-item-object-page menu-item-1777\"><a href=\"https:\/\/www.capoecounselingllc.com\/demo\/resources\/\" class=\"wpr-mobile-menu-item\">Resources<\/a><\/li>\n<li class=\"menu-item menu-item-type-post_type menu-item-object-page menu-item-1778\"><a href=\"https:\/\/www.capoecounselingllc.com\/demo\/blog\/\" class=\"wpr-mobile-menu-item\">Blog<\/a><\/li>\n<li class=\"menu-item menu-item-type-post_type menu-item-object-page menu-item-155\"><a href=\"https:\/\/www.capoecounselingllc.com\/demo\/contact-us\/\" class=\"wpr-mobile-menu-item\">Contact<\/a><\/li>\n<li class=\"menu-item menu-item-type-post_type menu-item-object-page menu-item-privacy-policy menu-item-1580\"><a rel=\"privacy-policy\" href=\"https:\/\/www.capoecounselingllc.com\/demo\/privacy-policy\/\" class=\"wpr-mobile-menu-item\">Privacy Policy<\/a><\/li>\n<\/ul><\/nav>\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t<div class=\"elementor-element elementor-element-bf600dd e-flex e-con-boxed wpr-particle-no wpr-jarallax-no wpr-parallax-no wpr-sticky-section-no e-con e-parent\" data-id=\"bf600dd\" data-element_type=\"container\" data-settings=\"{&quot;background_background&quot;:&quot;classic&quot;}\">\n\t\t\t\t\t<div class=\"e-con-inner\">\n\t\t\t\t<div class=\"elementor-element elementor-element-eca528a elementor-widget elementor-widget-text-editor\" data-id=\"eca528a\" data-element_type=\"widget\" data-widget_type=\"text-editor.default\">\n\t\t\t\t<div class=\"elementor-widget-container\">\n\t\t\t\t\t\t\t\t\t<p>\u00a9 Copyright 2024 &#8211; 2025 <strong>CAPOE LLC<\/strong> Designed by Proweaver<\/p>\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t<\/div>\n\t\t\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t","protected":false},"excerpt":{"rendered":"<p>This Questionnaire should be filled out completely and returned before your first Premarital Counseling Session begins. After the forms are reviewed, an appointment will be made to meet with Dr. Cecil Poe. At this time, we will schedule an appointment to begin the pre-marriage counseling BIBLICALLY BASED program which will include the following content: This program is approximately 9-12 hours (not including breaks) COMMUNICATION CONFLICT RESOLUTION PARTNER STYLE AND HABITS FINANCIAL MANAGEMENT LEISURE ACTIVITIES SEXUALITY AND AFFECTION FAMILY AND FRIENDS RELATIONSHIP ROLES CHILDREN AND PARENTING SPIRITUAL BELIEFS PRE-MARRIAGE AWARENESS QUESTIONNAIRE **** Both you and your fianc\u00e9 should complete the Premarital Form and Questionnaire separately, but both must be present for the actual Pre-Marriage counseling sessions with Dr. Cecil Poe.<\/p>\n","protected":false},"author":1,"featured_media":0,"parent":0,"menu_order":0,"comment_status":"closed","ping_status":"closed","template":"elementor_header_footer","meta":{"footnotes":""},"class_list":["post-1407","page","type-page","status-publish","hentry"],"_links":{"self":[{"href":"https:\/\/www.capoecounselingllc.com\/demo\/wp-json\/wp\/v2\/pages\/1407","targetHints":{"allow":["GET"]}}],"collection":[{"href":"https:\/\/www.capoecounselingllc.com\/demo\/wp-json\/wp\/v2\/pages"}],"about":[{"href":"https:\/\/www.capoecounselingllc.com\/demo\/wp-json\/wp\/v2\/types\/page"}],"author":[{"embeddable":true,"href":"https:\/\/www.capoecounselingllc.com\/demo\/wp-json\/wp\/v2\/users\/1"}],"replies":[{"embeddable":true,"href":"https:\/\/www.capoecounselingllc.com\/demo\/wp-json\/wp\/v2\/comments?post=1407"}],"version-history":[{"count":16,"href":"https:\/\/www.capoecounselingllc.com\/demo\/wp-json\/wp\/v2\/pages\/1407\/revisions"}],"predecessor-version":[{"id":1743,"href":"https:\/\/www.capoecounselingllc.com\/demo\/wp-json\/wp\/v2\/pages\/1407\/revisions\/1743"}],"wp:attachment":[{"href":"https:\/\/www.capoecounselingllc.com\/demo\/wp-json\/wp\/v2\/media?parent=1407"}],"curies":[{"name":"wp","href":"https:\/\/api.w.org\/{rel}","templated":true}]}}