{"id":211,"date":"2021-09-04T13:07:09","date_gmt":"2021-09-04T18:07:09","guid":{"rendered":"https:\/\/www.sacandfoxnationvictimservices.org\/?page_id=211"},"modified":"2021-10-19T11:33:50","modified_gmt":"2021-10-19T16:33:50","slug":"intake","status":"publish","type":"page","link":"https:\/\/www.sacandfoxnationvictimservices.org\/intake\/","title":{"rendered":"Intake"},"content":{"rendered":"<script type=\"text\/javascript\">var gform;gform||(document.addEventListener(\"gform_main_scripts_loaded\",function(){gform.scriptsLoaded=!0}),window.addEventListener(\"DOMContentLoaded\",function(){gform.domLoaded=!0}),gform={domLoaded:!1,scriptsLoaded:!1,initializeOnLoaded:function(o){gform.domLoaded&&gform.scriptsLoaded?o():!gform.domLoaded&&gform.scriptsLoaded?window.addEventListener(\"DOMContentLoaded\",o):document.addEventListener(\"gform_main_scripts_loaded\",o)},hooks:{action:{},filter:{}},addAction:function(o,n,r,t){gform.addHook(\"action\",o,n,r,t)},addFilter:function(o,n,r,t){gform.addHook(\"filter\",o,n,r,t)},doAction:function(o){gform.doHook(\"action\",o,arguments)},applyFilters:function(o){return gform.doHook(\"filter\",o,arguments)},removeAction:function(o,n){gform.removeHook(\"action\",o,n)},removeFilter:function(o,n,r){gform.removeHook(\"filter\",o,n,r)},addHook:function(o,n,r,t,i){null==gform.hooks[o][n]&&(gform.hooks[o][n]=[]);var e=gform.hooks[o][n];null==i&&(i=n+\"_\"+e.length),gform.hooks[o][n].push({tag:i,callable:r,priority:t=null==t?10:t})},doHook:function(n,o,r){var t;if(r=Array.prototype.slice.call(r,1),null!=gform.hooks[n][o]&&((o=gform.hooks[n][o]).sort(function(o,n){return o.priority-n.priority}),o.forEach(function(o){\"function\"!=typeof(t=o.callable)&&(t=window[t]),\"action\"==n?t.apply(null,r):r[0]=t.apply(null,r)})),\"filter\"==n)return r[0]},removeHook:function(o,n,t,i){var r;null!=gform.hooks[o][n]&&(r=(r=gform.hooks[o][n]).filter(function(o,n,r){return!!(null!=i&&i!=o.tag||null!=t&&t!=o.priority)}),gform.hooks[o][n]=r)}});<\/script>\n                <div class='gf_browser_unknown gform_wrapper gravity-theme gform-theme--no-framework' data-form-theme='gravity-theme' data-form-index='0' id='gform_wrapper_2' style='display:none'><div id='gf_2' class='gform_anchor' tabindex='-1'><\/div>\n                        <div class='gform_heading'>\n                            <h2 class=\"gform_title\">New Client Intake<\/h2>\n                            <p class='gform_description'><\/p>\n                        <\/div><form method='post' enctype='multipart\/form-data'  id='gform_2'  action='\/wp-json\/wp\/v2\/pages\/211#gf_2' data-formid='2' novalidate><input id=\"gw_page_progression\" name=\"gw_page_progression\" value=\"1\" type=\"hidden\" \/><div id='gf_page_steps_2' class='gf_page_steps'><div id='gf_step_2_1' class='gf_step gf_step_active gf_step_first'><span class='gf_step_number'>1<\/span><span class='gf_step_label'>Primary Client Information<\/span><\/div><div id='gf_step_2_2' class='gf_step gf_step_next gf_step_pending'><span class='gf_step_number'>2<\/span><span class='gf_step_label'>Assault Information<\/span><\/div><div id='gf_step_2_3' class='gf_step gf_step_pending'><span class='gf_step_number'>3<\/span><span class='gf_step_label'>Assailant Information<\/span><\/div><div id='gf_step_2_4' class='gf_step gf_step_pending'><span class='gf_step_number'>4<\/span><span class='gf_step_label'>Inter-Agency Information<\/span><\/div><div id='gf_step_2_5' class='gf_step gf_step_last gf_step_pending'><span class='gf_step_number'>5<\/span><span class='gf_step_label'>Secondary Contact Information<\/span><\/div><\/div>\n                        <div class='gform-body gform_body'><div id='gform_page_2_1' class='gform_page ' data-js='page-field-id-1' >\n                                    <div class='gform_page_fields'><div id='gform_fields_2' class='gform_fields top_label form_sublabel_below description_below validation_below'><div id=\"field_2_85\" class=\"gfield gfield--type-section gsection field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_2_85\" ><h3 class=\"gsection_title\">Primary Client Information<\/h3><\/div><fieldset id=\"field_2_3\" class=\"gfield gfield--type-name field_sublabel_hidden_label gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_2_3\" ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Name<\/legend><div class='ginput_complex ginput_container ginput_container--name no_prefix has_first_name no_middle_name has_last_name has_suffix gf_name_has_3 ginput_container_name gform-grid-row' id='input_2_3'>\n                            \n                            <span id='input_2_3_3_container' class='name_first gform-grid-col gform-grid-col--size-auto' >\n                                                    <input type='text' name='input_3.3' id='input_2_3_3' value=''   aria-required='false'   placeholder='First'  \/>\n                                                    <label for='input_2_3_3' class='gform-field-label gform-field-label--type-sub hidden_sub_label screen-reader-text'>First<\/label>\n                                                <\/span>\n                            \n                            <span id='input_2_3_6_container' class='name_last gform-grid-col gform-grid-col--size-auto' >\n                                                    <input type='text' name='input_3.6' id='input_2_3_6' value=''   aria-required='false'   placeholder='Last'  \/>\n                                                    <label for='input_2_3_6' class='gform-field-label gform-field-label--type-sub hidden_sub_label screen-reader-text'>Last<\/label>\n                                                <\/span>\n                            <span id='input_2_3_8_container' class='name_suffix  gform-grid-col gform-grid-col--size-auto' >\n                                                    <input type='text' name='input_3.8' id='input_2_3_8' value=''   aria-required='false'   placeholder='Maiden'  \/>\n                                                    <label for='input_2_3_8' class='gform-field-label gform-field-label--type-sub hidden_sub_label screen-reader-text'>Maiden<\/label>\n                                                <\/span>\n                        <\/div><\/fieldset><div id=\"field_2_4\" class=\"gfield gfield--type-phone gfield--width-five-twelfths field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_2_4\" ><label class='gfield_label gform-field-label' for='input_2_4'>Phone<\/label><div class='ginput_container ginput_container_phone'><input name='input_4' id='input_2_4' type='tel' value='' class='large'  placeholder='Phone Number'  aria-invalid=\"false\"   \/><\/div><\/div><fieldset id=\"field_2_5\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield--width-seven-twelfths field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_2_5\" ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Contact Method<\/legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox' id='input_2_5'><div class='gchoice gchoice_2_5_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_5.1' type='checkbox'  value='Safe to call'  id='choice_2_5_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_2_5_1' id='label_2_5_1' class='gform-field-label gform-field-label--type-inline'>Safe to call<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_2_5_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_5.2' type='checkbox'  value='Safe to leave message'  id='choice_2_5_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_2_5_2' id='label_2_5_2' class='gform-field-label gform-field-label--type-inline'>Safe to leave message<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_2_7\" class=\"gfield gfield--type-date gfield--input-type-datepicker gfield--datepicker-no-icon gfield--width-third field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_2_7\" ><label class='gfield_label gform-field-label' for='input_2_7'>DOB<\/label><div class='ginput_container ginput_container_date'>\n                            <input name='input_7' id='input_2_7' type='text' value='' class='datepicker gform-datepicker mdy datepicker_no_icon gdatepicker-no-icon'   placeholder='mm\/dd\/yyyy' aria-describedby=\"input_2_7_date_format\" aria-invalid=\"false\" \/>\n                            <span id='input_2_7_date_format' class='screen-reader-text'>MM slash DD slash YYYY<\/span>\n                        <\/div>\n                        <input type='hidden' id='gforms_calendar_icon_input_2_7' class='gform_hidden' value='https:\/\/www.sacandfoxnationvictimservices.org\/wp-content\/plugins\/gravityforms\/images\/datepicker\/datepicker.svg'\/><\/div><div id=\"field_2_8\" class=\"gfield gfield--type-number gfield--width-third field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_2_8\" ><label class='gfield_label gform-field-label' for='input_2_8'>Age<\/label><div class='ginput_container ginput_container_number'><input name='input_8' id='input_2_8' type='number' step='any'  max='100' value='' class='large'    placeholder='99'  aria-invalid=\"false\" aria-describedby=\"gfield_instruction_2_8\" \/><div class='gfield_description instruction ' id='gfield_instruction_2_8'>Please enter a number less than or equal to <strong>100<\/strong>.<\/div><\/div><\/div><div id=\"field_2_9\" class=\"gfield gfield--type-text gfield--width-third field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_2_9\" ><label class='gfield_label gform-field-label' for='input_2_9'>Gender<\/label><div class='ginput_container ginput_container_text'><input name='input_9' id='input_2_9' type='text' value='' class='large'      aria-invalid=\"false\"   \/> <\/div><\/div><div id=\"field_2_10\" class=\"gfield gfield--type-text gfield--width-half field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_2_10\" ><label class='gfield_label gform-field-label' for='input_2_10'>Race<\/label><div class='ginput_container ginput_container_text'><input name='input_10' id='input_2_10' type='text' value='' class='large'      aria-invalid=\"false\"   \/> <\/div><\/div><div id=\"field_2_11\" class=\"gfield gfield--type-text gfield--width-half field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_2_11\" ><label class='gfield_label gform-field-label' for='input_2_11'>If Native American, Tribal Affiliation<\/label><div class='ginput_container ginput_container_text'><input name='input_11' id='input_2_11' type='text' value='' class='large'      aria-invalid=\"false\"   \/> <\/div><\/div><fieldset id=\"field_2_12\" class=\"gfield gfield--type-address gfield--width-full field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_2_12\" ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Address<\/legend>    \n                    <div class='ginput_complex ginput_container has_street has_street2 has_city has_state has_zip has_country ginput_container_address gform-grid-row' id='input_2_12' >\n                         <span class='ginput_full address_line_1 ginput_address_line_1 gform-grid-col' id='input_2_12_1_container' >\n                                        <input type='text' name='input_12.1' id='input_2_12_1' value=''    aria-required='false'    \/>\n                                        <label for='input_2_12_1' id='input_2_12_1_label' class='gform-field-label gform-field-label--type-sub '>Street Address<\/label>\n                                    <\/span><span class='ginput_full address_line_2 ginput_address_line_2 gform-grid-col' id='input_2_12_2_container' >\n                                        <input type='text' name='input_12.2' id='input_2_12_2' value=''     aria-required='false'   \/>\n                                        <label for='input_2_12_2' id='input_2_12_2_label' class='gform-field-label gform-field-label--type-sub '>Address Line 2<\/label>\n                                    <\/span><span class='ginput_left address_city ginput_address_city gform-grid-col' id='input_2_12_3_container' >\n                                    <input type='text' name='input_12.3' id='input_2_12_3' value=''    aria-required='false'    \/>\n                                    <label for='input_2_12_3' id='input_2_12_3_label' class='gform-field-label gform-field-label--type-sub '>City<\/label>\n                                 <\/span><span class='ginput_right address_state ginput_address_state gform-grid-col' id='input_2_12_4_container' >\n                                        <input type='text' name='input_12.4' id='input_2_12_4' value=''      aria-required='false'    \/>\n                                        <label for='input_2_12_4' id='input_2_12_4_label' class='gform-field-label gform-field-label--type-sub '>State \/ Province \/ Region<\/label>\n                                      <\/span><span class='ginput_left address_zip ginput_address_zip gform-grid-col' id='input_2_12_5_container' >\n                                    <input type='text' name='input_12.5' id='input_2_12_5' value=''    aria-required='false'    \/>\n                                    <label for='input_2_12_5' id='input_2_12_5_label' class='gform-field-label gform-field-label--type-sub '>ZIP \/ Postal Code<\/label>\n                                <\/span><span class='ginput_right address_country ginput_address_country gform-grid-col' id='input_2_12_6_container' >\n                                        <select name='input_12.6' id='input_2_12_6'   aria-required='false'    ><option value='' selected='selected'><\/option><option value='Afghanistan' >Afghanistan<\/option><option value='Albania' >Albania<\/option><option value='Algeria' >Algeria<\/option><option value='American Samoa' >American Samoa<\/option><option value='Andorra' >Andorra<\/option><option value='Angola' >Angola<\/option><option value='Anguilla' >Anguilla<\/option><option value='Antarctica' >Antarctica<\/option><option value='Antigua and Barbuda' >Antigua and Barbuda<\/option><option value='Argentina' >Argentina<\/option><option value='Armenia' >Armenia<\/option><option value='Aruba' >Aruba<\/option><option value='Australia' >Australia<\/option><option value='Austria' >Austria<\/option><option value='Azerbaijan' >Azerbaijan<\/option><option value='Bahamas' >Bahamas<\/option><option value='Bahrain' >Bahrain<\/option><option value='Bangladesh' >Bangladesh<\/option><option value='Barbados' >Barbados<\/option><option value='Belarus' >Belarus<\/option><option value='Belgium' >Belgium<\/option><option value='Belize' >Belize<\/option><option value='Benin' >Benin<\/option><option value='Bermuda' >Bermuda<\/option><option value='Bhutan' >Bhutan<\/option><option value='Bolivia' >Bolivia<\/option><option value='Bonaire, Sint Eustatius and Saba' >Bonaire, Sint Eustatius and Saba<\/option><option value='Bosnia and Herzegovina' >Bosnia and Herzegovina<\/option><option value='Botswana' >Botswana<\/option><option value='Bouvet Island' >Bouvet Island<\/option><option value='Brazil' >Brazil<\/option><option value='British Indian Ocean Territory' >British Indian Ocean Territory<\/option><option value='Brunei Darussalam' >Brunei Darussalam<\/option><option value='Bulgaria' >Bulgaria<\/option><option value='Burkina Faso' >Burkina Faso<\/option><option value='Burundi' >Burundi<\/option><option value='Cabo Verde' >Cabo Verde<\/option><option value='Cambodia' >Cambodia<\/option><option value='Cameroon' >Cameroon<\/option><option value='Canada' >Canada<\/option><option value='Cayman Islands' >Cayman Islands<\/option><option value='Central African Republic' >Central African Republic<\/option><option value='Chad' >Chad<\/option><option value='Chile' >Chile<\/option><option value='China' >China<\/option><option value='Christmas Island' >Christmas Island<\/option><option value='Cocos Islands' >Cocos Islands<\/option><option value='Colombia' >Colombia<\/option><option value='Comoros' >Comoros<\/option><option value='Congo' >Congo<\/option><option value='Congo, Democratic Republic of the' >Congo, Democratic Republic of the<\/option><option value='Cook Islands' >Cook Islands<\/option><option value='Costa Rica' >Costa Rica<\/option><option value='Croatia' >Croatia<\/option><option value='Cuba' >Cuba<\/option><option value='Cura\u00e7ao' >Cura\u00e7ao<\/option><option value='Cyprus' >Cyprus<\/option><option value='Czechia' >Czechia<\/option><option value='C\u00f4te d&#039;Ivoire' >C\u00f4te d&#039;Ivoire<\/option><option value='Denmark' >Denmark<\/option><option value='Djibouti' >Djibouti<\/option><option value='Dominica' >Dominica<\/option><option value='Dominican Republic' >Dominican Republic<\/option><option value='Ecuador' >Ecuador<\/option><option value='Egypt' >Egypt<\/option><option value='El Salvador' >El Salvador<\/option><option value='Equatorial Guinea' >Equatorial Guinea<\/option><option value='Eritrea' >Eritrea<\/option><option value='Estonia' >Estonia<\/option><option value='Eswatini' >Eswatini<\/option><option value='Ethiopia' >Ethiopia<\/option><option value='Falkland Islands' >Falkland Islands<\/option><option value='Faroe Islands' >Faroe Islands<\/option><option value='Fiji' >Fiji<\/option><option value='Finland' >Finland<\/option><option value='France' >France<\/option><option value='French Guiana' >French Guiana<\/option><option value='French Polynesia' >French Polynesia<\/option><option value='French Southern Territories' >French Southern Territories<\/option><option value='Gabon' >Gabon<\/option><option value='Gambia' >Gambia<\/option><option value='Georgia' >Georgia<\/option><option value='Germany' >Germany<\/option><option value='Ghana' >Ghana<\/option><option value='Gibraltar' >Gibraltar<\/option><option value='Greece' >Greece<\/option><option value='Greenland' >Greenland<\/option><option value='Grenada' >Grenada<\/option><option value='Guadeloupe' >Guadeloupe<\/option><option value='Guam' >Guam<\/option><option value='Guatemala' >Guatemala<\/option><option value='Guernsey' >Guernsey<\/option><option value='Guinea' >Guinea<\/option><option value='Guinea-Bissau' >Guinea-Bissau<\/option><option value='Guyana' >Guyana<\/option><option value='Haiti' >Haiti<\/option><option value='Heard Island and McDonald Islands' >Heard Island and McDonald Islands<\/option><option value='Holy See' >Holy See<\/option><option value='Honduras' >Honduras<\/option><option value='Hong Kong' >Hong Kong<\/option><option value='Hungary' >Hungary<\/option><option value='Iceland' >Iceland<\/option><option value='India' >India<\/option><option value='Indonesia' >Indonesia<\/option><option value='Iran' >Iran<\/option><option value='Iraq' >Iraq<\/option><option value='Ireland' >Ireland<\/option><option value='Isle of Man' >Isle of Man<\/option><option value='Israel' >Israel<\/option><option value='Italy' >Italy<\/option><option value='Jamaica' >Jamaica<\/option><option value='Japan' >Japan<\/option><option value='Jersey' >Jersey<\/option><option value='Jordan' >Jordan<\/option><option value='Kazakhstan' >Kazakhstan<\/option><option value='Kenya' >Kenya<\/option><option value='Kiribati' >Kiribati<\/option><option value='Korea, Democratic People&#039;s Republic of' >Korea, Democratic People&#039;s Republic of<\/option><option value='Korea, Republic of' >Korea, Republic of<\/option><option value='Kuwait' >Kuwait<\/option><option value='Kyrgyzstan' >Kyrgyzstan<\/option><option value='Lao People&#039;s Democratic Republic' >Lao People&#039;s Democratic Republic<\/option><option value='Latvia' >Latvia<\/option><option value='Lebanon' >Lebanon<\/option><option value='Lesotho' >Lesotho<\/option><option value='Liberia' >Liberia<\/option><option value='Libya' >Libya<\/option><option value='Liechtenstein' >Liechtenstein<\/option><option value='Lithuania' >Lithuania<\/option><option value='Luxembourg' >Luxembourg<\/option><option value='Macao' >Macao<\/option><option value='Madagascar' >Madagascar<\/option><option value='Malawi' >Malawi<\/option><option value='Malaysia' >Malaysia<\/option><option value='Maldives' >Maldives<\/option><option value='Mali' >Mali<\/option><option value='Malta' >Malta<\/option><option value='Marshall Islands' >Marshall Islands<\/option><option value='Martinique' >Martinique<\/option><option value='Mauritania' >Mauritania<\/option><option value='Mauritius' >Mauritius<\/option><option value='Mayotte' >Mayotte<\/option><option value='Mexico' >Mexico<\/option><option value='Micronesia' >Micronesia<\/option><option value='Moldova' >Moldova<\/option><option value='Monaco' >Monaco<\/option><option value='Mongolia' >Mongolia<\/option><option value='Montenegro' >Montenegro<\/option><option value='Montserrat' >Montserrat<\/option><option value='Morocco' >Morocco<\/option><option value='Mozambique' >Mozambique<\/option><option value='Myanmar' >Myanmar<\/option><option value='Namibia' >Namibia<\/option><option value='Nauru' >Nauru<\/option><option value='Nepal' >Nepal<\/option><option value='Netherlands' >Netherlands<\/option><option value='New Caledonia' >New Caledonia<\/option><option value='New Zealand' >New Zealand<\/option><option value='Nicaragua' >Nicaragua<\/option><option value='Niger' >Niger<\/option><option value='Nigeria' >Nigeria<\/option><option value='Niue' >Niue<\/option><option value='Norfolk Island' >Norfolk Island<\/option><option value='North Macedonia' >North Macedonia<\/option><option value='Northern Mariana Islands' >Northern Mariana Islands<\/option><option value='Norway' >Norway<\/option><option value='Oman' >Oman<\/option><option value='Pakistan' >Pakistan<\/option><option value='Palau' >Palau<\/option><option value='Palestine, State of' >Palestine, State of<\/option><option value='Panama' >Panama<\/option><option value='Papua New Guinea' >Papua New Guinea<\/option><option value='Paraguay' >Paraguay<\/option><option value='Peru' >Peru<\/option><option value='Philippines' >Philippines<\/option><option value='Pitcairn' >Pitcairn<\/option><option value='Poland' >Poland<\/option><option value='Portugal' >Portugal<\/option><option value='Puerto Rico' >Puerto Rico<\/option><option value='Qatar' >Qatar<\/option><option value='Romania' >Romania<\/option><option value='Russian Federation' >Russian Federation<\/option><option value='Rwanda' >Rwanda<\/option><option value='R\u00e9union' >R\u00e9union<\/option><option value='Saint Barth\u00e9lemy' >Saint Barth\u00e9lemy<\/option><option value='Saint Helena, Ascension and Tristan da Cunha' >Saint Helena, Ascension and Tristan da Cunha<\/option><option value='Saint Kitts and Nevis' >Saint Kitts and Nevis<\/option><option value='Saint Lucia' >Saint Lucia<\/option><option value='Saint Martin' >Saint Martin<\/option><option value='Saint Pierre and Miquelon' >Saint Pierre and Miquelon<\/option><option value='Saint Vincent and the Grenadines' >Saint Vincent and the Grenadines<\/option><option value='Samoa' >Samoa<\/option><option value='San Marino' >San Marino<\/option><option value='Sao Tome and Principe' >Sao Tome and Principe<\/option><option value='Saudi Arabia' >Saudi Arabia<\/option><option value='Senegal' >Senegal<\/option><option value='Serbia' >Serbia<\/option><option value='Seychelles' >Seychelles<\/option><option value='Sierra Leone' >Sierra Leone<\/option><option value='Singapore' >Singapore<\/option><option value='Sint Maarten' >Sint Maarten<\/option><option value='Slovakia' >Slovakia<\/option><option value='Slovenia' >Slovenia<\/option><option value='Solomon Islands' >Solomon Islands<\/option><option value='Somalia' >Somalia<\/option><option value='South Africa' >South Africa<\/option><option value='South Georgia and the South Sandwich Islands' >South Georgia and the South Sandwich Islands<\/option><option value='South Sudan' >South Sudan<\/option><option value='Spain' >Spain<\/option><option value='Sri Lanka' >Sri Lanka<\/option><option value='Sudan' >Sudan<\/option><option value='Suriname' >Suriname<\/option><option value='Svalbard and Jan Mayen' >Svalbard and Jan Mayen<\/option><option value='Sweden' >Sweden<\/option><option value='Switzerland' >Switzerland<\/option><option value='Syria Arab Republic' >Syria Arab Republic<\/option><option value='Taiwan' >Taiwan<\/option><option value='Tajikistan' >Tajikistan<\/option><option value='Tanzania, the United Republic of' >Tanzania, the United Republic of<\/option><option value='Thailand' >Thailand<\/option><option value='Timor-Leste' >Timor-Leste<\/option><option value='Togo' >Togo<\/option><option value='Tokelau' >Tokelau<\/option><option value='Tonga' >Tonga<\/option><option value='Trinidad and Tobago' >Trinidad and Tobago<\/option><option value='Tunisia' >Tunisia<\/option><option value='Turkmenistan' >Turkmenistan<\/option><option value='Turks and Caicos Islands' >Turks and Caicos Islands<\/option><option value='Tuvalu' >Tuvalu<\/option><option value='T\u00fcrkiye' >T\u00fcrkiye<\/option><option value='US Minor Outlying Islands' >US Minor Outlying Islands<\/option><option value='Uganda' >Uganda<\/option><option value='Ukraine' >Ukraine<\/option><option value='United Arab Emirates' >United Arab Emirates<\/option><option value='United Kingdom' >United Kingdom<\/option><option value='United States' >United States<\/option><option value='Uruguay' >Uruguay<\/option><option value='Uzbekistan' >Uzbekistan<\/option><option value='Vanuatu' >Vanuatu<\/option><option value='Venezuela' >Venezuela<\/option><option value='Viet Nam' >Viet Nam<\/option><option value='Virgin Islands, British' >Virgin Islands, British<\/option><option value='Virgin Islands, U.S.' >Virgin Islands, U.S.<\/option><option value='Wallis and Futuna' >Wallis and Futuna<\/option><option value='Western Sahara' >Western Sahara<\/option><option value='Yemen' >Yemen<\/option><option value='Zambia' >Zambia<\/option><option value='Zimbabwe' >Zimbabwe<\/option><option value='\u00c5land Islands' >\u00c5land Islands<\/option><\/select>\n                                        <label for='input_2_12_6' id='input_2_12_6_label' class='gform-field-label gform-field-label--type-sub '>Country<\/label>\n                                    <\/span>\n                    <div class='gf_clear gf_clear_complex'><\/div>\n                <\/div><\/fieldset><fieldset id=\"field_2_13\" class=\"gfield gfield--type-checkbox gfield--type-choice gf_list_inline field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_2_13\" ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Marital Status<\/legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox' id='input_2_13'><div class='gchoice gchoice_2_13_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_13.1' type='checkbox'  value='Married'  id='choice_2_13_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_2_13_1' id='label_2_13_1' class='gform-field-label gform-field-label--type-inline'>Married<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_2_13_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_13.2' type='checkbox'  value='Single'  id='choice_2_13_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_2_13_2' id='label_2_13_2' class='gform-field-label gform-field-label--type-inline'>Single<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_2_13_3'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_13.3' type='checkbox'  value='Separated'  id='choice_2_13_3'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_2_13_3' id='label_2_13_3' class='gform-field-label gform-field-label--type-inline'>Separated<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_2_13_4'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_13.4' type='checkbox'  value='Divorced'  id='choice_2_13_4'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_2_13_4' id='label_2_13_4' class='gform-field-label gform-field-label--type-inline'>Divorced<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_2_13_5'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_13.5' type='checkbox'  value='Widowed'  id='choice_2_13_5'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_2_13_5' id='label_2_13_5' class='gform-field-label gform-field-label--type-inline'>Widowed<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_2_13_6'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_13.6' type='checkbox'  value='Unknown'  id='choice_2_13_6'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_2_13_6' id='label_2_13_6' class='gform-field-label gform-field-label--type-inline'>Unknown<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_2_13_7'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_13.7' type='checkbox'  value='Living as married'  id='choice_2_13_7'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_2_13_7' id='label_2_13_7' class='gform-field-label gform-field-label--type-inline'>Living as married<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_2_14\" class=\"gfield gfield--type-text gfield--width-half field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_2_14\" ><label class='gfield_label gform-field-label' for='input_2_14'>Employer<\/label><div class='ginput_container ginput_container_text'><input name='input_14' id='input_2_14' type='text' value='' class='large'      aria-invalid=\"false\"   \/> <\/div><\/div><div id=\"field_2_15\" class=\"gfield gfield--type-text gfield--width-half field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_2_15\" ><label class='gfield_label gform-field-label' for='input_2_15'>Occupation<\/label><div class='ginput_container ginput_container_text'><input name='input_15' id='input_2_15' type='text' value='' class='large'      aria-invalid=\"false\"   \/> <\/div><\/div><fieldset id=\"field_2_16\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield--width-full gf_list_2col field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_2_16\" ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Requested needs<\/legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox' id='input_2_16'><div class='gchoice gchoice_2_16_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_16.1' type='checkbox'  value='Court services'  id='choice_2_16_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_2_16_1' id='label_2_16_1' class='gform-field-label gform-field-label--type-inline'>Court services<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_2_16_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_16.2' type='checkbox'  value='Counseling'  id='choice_2_16_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_2_16_2' id='label_2_16_2' class='gform-field-label gform-field-label--type-inline'>Counseling<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_2_16_3'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_16.3' type='checkbox'  value='Relocation'  id='choice_2_16_3'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_2_16_3' id='label_2_16_3' class='gform-field-label gform-field-label--type-inline'>Relocation<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_2_16_4'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_16.4' type='checkbox'  value='Emergency shelter'  id='choice_2_16_4'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_2_16_4' id='label_2_16_4' class='gform-field-label gform-field-label--type-inline'>Emergency shelter<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_2_16_5'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_16.5' type='checkbox'  value='Emergency protective order'  id='choice_2_16_5'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_2_16_5' id='label_2_16_5' class='gform-field-label gform-field-label--type-inline'>Emergency protective order<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_2_16_6'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_16.6' type='checkbox'  value='Protective order'  id='choice_2_16_6'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_2_16_6' id='label_2_16_6' class='gform-field-label gform-field-label--type-inline'>Protective order<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_2_16_7'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_16.7' type='checkbox'  value='Already have a protective order'  id='choice_2_16_7'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_2_16_7' id='label_2_16_7' class='gform-field-label gform-field-label--type-inline'>Already have a protective order<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_2_17\" class=\"gfield gfield--type-text gfield--width-third field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_2_17\" ><label class='gfield_label gform-field-label' for='input_2_17'>Case number<\/label><div class='ginput_container ginput_container_text'><input name='input_17' id='input_2_17' type='text' value='' class='large'      aria-invalid=\"false\"   \/> <\/div><\/div><div id=\"field_2_18\" class=\"gfield gfield--type-text gfield--width-five-twelfths field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_2_18\" ><label class='gfield_label gform-field-label' for='input_2_18'>County<\/label><div class='ginput_container ginput_container_text'><input name='input_18' id='input_2_18' type='text' value='' class='large'      aria-invalid=\"false\"   \/> <\/div><\/div><div id=\"field_2_19\" class=\"gfield gfield--type-date gfield--input-type-datepicker gfield--datepicker-no-icon gfield--width-quarter field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_2_19\" ><label class='gfield_label gform-field-label' for='input_2_19'>Next court date<\/label><div class='ginput_container ginput_container_date'>\n                            <input name='input_19' id='input_2_19' type='text' value='' class='datepicker gform-datepicker mdy datepicker_no_icon gdatepicker-no-icon'   placeholder='mm\/dd\/yyyy' aria-describedby=\"input_2_19_date_format\" aria-invalid=\"false\" \/>\n                            <span id='input_2_19_date_format' class='screen-reader-text'>MM slash DD slash YYYY<\/span>\n                        <\/div>\n                        <input type='hidden' id='gforms_calendar_icon_input_2_19' class='gform_hidden' value='https:\/\/www.sacandfoxnationvictimservices.org\/wp-content\/plugins\/gravityforms\/images\/datepicker\/datepicker.svg'\/><\/div><\/div>\n                    <\/div>\n                    <div class='gform_page_footer top_label'>\n                         <button type=\"button\" id=\"gform_next_button_2_86\" class=\"gform_next_button gform-theme-button button\" onclick='jQuery(\"#gform_target_page_number_2\").val(\"2\");  jQuery(\"#gform_2\").trigger(\"submit\",[true]); ' onkeypress='if( event.keyCode == 13 ){ jQuery(\"#gform_target_page_number_2\").val(\"2\");  jQuery(\"#gform_2\").trigger(\"submit\",[true]); } '>Next<\/button> <button type='button'  id='gform_save_2_2_link' class='gform_save_link gform-theme-button gform-theme-button--secondary button'  onclick='if(window[\"gf_submitting_2\"]){return false;}  if( !jQuery(\"#gform_2\")[0].checkValidity || jQuery(\"#gform_2\")[0].checkValidity()){window[\"gf_submitting_2\"]=true;} jQuery(\"#gform_save_2\").val(1); jQuery(\"#gform_2\").trigger(\"submit\",[true]);' onkeypress='if( event.keyCode == 13 ){ if(window[\"gf_submitting_2\"]){return false;} if( !jQuery(\"#gform_2\")[0].checkValidity || jQuery(\"#gform_2\")[0].checkValidity()){window[\"gf_submitting_2\"]=true;} jQuery(\"#gform_save_2\").val(1); jQuery(\"#gform_2\").trigger(\"submit\",[true]); }'><svg aria-hidden=\"true\" focusable=\"false\" width=\"16\" height=\"16\" fill=\"none\" xmlns=\"http:\/\/www.w3.org\/2000\/svg\"><path fill-rule=\"evenodd\" clip-rule=\"evenodd\" d=\"M0 8a4 4 0 004 4h3v3a1 1 0 102 0v-3h3a4 4 0 100-8 4 4 0 10-8 0 4 4 0 00-4 4zm9 4H7V7.414L5.707 8.707a1 1 0 01-1.414-1.414l3-3a1 1 0 011.414 0l3 3a1 1 0 01-1.414 1.414L9 7.414V12z\" fill=\"#6B7280\"\/><\/svg> Save and Continue Later<\/button>\n                    <\/div>\n                <\/div>\n                <div id='gform_page_2_2' class='gform_page' data-js='page-field-id-86' style='display:none;'>\n                    <div class='gform_page_fields'>\n                        <div id='gform_fields_2_2' class='gform_fields top_label form_sublabel_below description_below validation_below'><div id=\"field_2_20\" class=\"gfield gfield--type-section gsection field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_2_20\" ><h3 class=\"gsection_title\">Assault Information - Complete as much as you know<\/h3><\/div><fieldset id=\"field_2_21\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield--width-full field_sublabel_below gfield--no-description field_description_below hidden_label field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_2_21\" ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Unknown assault information<\/legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox' id='input_2_21'><div class='gchoice gchoice_2_21_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_21.1' type='checkbox'  value='Unknown assault information'  id='choice_2_21_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_2_21_1' id='label_2_21_1' class='gform-field-label gform-field-label--type-inline'>Unknown assault information<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_2_22\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield--width-full gf_list_2col field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_2_22\" ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Assault Type (check all that apply)<\/legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox' id='input_2_22'><div class='gchoice gchoice_2_22_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_22.1' type='checkbox'  value='Rape\/Sexual assault'  id='choice_2_22_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_2_22_1' id='label_2_22_1' class='gform-field-label gform-field-label--type-inline'>Rape\/Sexual assault<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_2_22_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_22.2' type='checkbox'  value='Domestic Violence'  id='choice_2_22_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_2_22_2' id='label_2_22_2' class='gform-field-label gform-field-label--type-inline'>Domestic Violence<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_2_22_3'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_22.3' type='checkbox'  value='Stalking'  id='choice_2_22_3'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_2_22_3' id='label_2_22_3' class='gform-field-label gform-field-label--type-inline'>Stalking<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_2_22_4'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_22.4' type='checkbox'  value='Aggravated assault'  id='choice_2_22_4'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_2_22_4' id='label_2_22_4' class='gform-field-label gform-field-label--type-inline'>Aggravated assault<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_2_22_5'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_22.5' type='checkbox'  value='Homicide'  id='choice_2_22_5'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_2_22_5' id='label_2_22_5' class='gform-field-label gform-field-label--type-inline'>Homicide<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_2_22_6'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_22.6' type='checkbox'  value='Suicide'  id='choice_2_22_6'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_2_22_6' id='label_2_22_6' class='gform-field-label gform-field-label--type-inline'>Suicide<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_2_22_7'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_22.7' type='checkbox'  value='Robbery\/Burglary'  id='choice_2_22_7'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_2_22_7' id='label_2_22_7' class='gform-field-label gform-field-label--type-inline'>Robbery\/Burglary<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_2_22_8'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_22.8' type='checkbox'  value='Elder abuse\/Neglect'  id='choice_2_22_8'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_2_22_8' id='label_2_22_8' class='gform-field-label gform-field-label--type-inline'>Elder abuse\/Neglect<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_2_22_9'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_22.9' type='checkbox'  value='Other'  id='choice_2_22_9'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_2_22_9' id='label_2_22_9' class='gform-field-label gform-field-label--type-inline'>Other<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_2_23\" class=\"gfield gfield--type-date gfield--input-type-datepicker gfield--datepicker-no-icon gfield--width-half field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_2_23\" ><label class='gfield_label gform-field-label' for='input_2_23'>Date of incident<\/label><div class='ginput_container ginput_container_date'>\n                            <input name='input_23' id='input_2_23' type='text' value='' class='datepicker gform-datepicker mdy datepicker_no_icon gdatepicker-no-icon'   placeholder='mm\/dd\/yyyy' aria-describedby=\"input_2_23_date_format\" aria-invalid=\"false\" \/>\n                            <span id='input_2_23_date_format' class='screen-reader-text'>MM slash DD slash YYYY<\/span>\n                        <\/div>\n                        <input type='hidden' id='gforms_calendar_icon_input_2_23' class='gform_hidden' value='https:\/\/www.sacandfoxnationvictimservices.org\/wp-content\/plugins\/gravityforms\/images\/datepicker\/datepicker.svg'\/><\/div><fieldset id=\"field_2_24\" class=\"gfield gfield--type-time gfield--width-half field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_2_24\" ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Time of incident<\/legend><div class=\"ginput_container ginput_complex gform-grid-row\">\n                        <div class='gfield_time_hour ginput_container ginput_container_time gform-grid-col' id='input_2_24'>\n                            <input type='number' maxlength='2' name='input_24[]' id='input_2_24_1' value=''  min='0' max='12' step='1'  placeholder='HH' aria-required='false'   \/> \n                            <label class='gform-field-label gform-field-label--type-sub hour_label screen-reader-text' for='input_2_24_1'>Hours<\/label>\n                        <\/div>\n                        <div class=\"below hour_minute_colon gform-grid-col\">:<\/div>\n                        <div class='gfield_time_minute ginput_container ginput_container_time gform-grid-col'>\n                            <input type='number' maxlength='2' name='input_24[]' id='input_2_24_2' value=''  min='0' max='59' step='1'  placeholder='MM' aria-required='false'  \/>\n                            <label class='gform-field-label gform-field-label--type-sub minute_label screen-reader-text' for='input_2_24_2'>Minutes<\/label>\n                        <\/div>\n                        <div class='gfield_time_ampm ginput_container ginput_container_time below gform-grid-col' >\n                                \n                                <select name='input_24[]' id='input_2_24_3'  >\n                                    <option value='am' >AM<\/option>\n                                    <option value='pm' >PM<\/option>\n                                <\/select> \n                                <label class='gform-field-label gform-field-label--type-sub am_pm_label screen-reader-text' for='input_2_24_3'>AM\/PM<\/label>                                \n                           <\/div>\n                    <\/div><\/fieldset><div id=\"field_2_25\" class=\"gfield gfield--type-text gfield--width-two-thirds field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_2_25\" ><label class='gfield_label gform-field-label' for='input_2_25'>Location of incident (if known)<\/label><div class='ginput_container ginput_container_text'><input name='input_25' id='input_2_25' type='text' value='' class='large'      aria-invalid=\"false\"   \/> <\/div><\/div><div id=\"field_2_26\" class=\"gfield gfield--type-text gfield--width-third field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_2_26\" ><label class='gfield_label gform-field-label' for='input_2_26'>City, State (if known)<\/label><div class='ginput_container ginput_container_text'><input name='input_26' id='input_2_26' type='text' value='' class='large'      aria-invalid=\"false\"   \/> <\/div><\/div><\/div>\n                    <\/div>\n                    <div class='gform_page_footer top_label'>\n                        <button type=\"button\" id=\"gform_previous_button_2_87\" class=\"gform_previous_button gform-theme-button gform-theme-button--secondary button\" onclick='jQuery(\"#gform_target_page_number_2\").val(\"1\");  jQuery(\"#gform_2\").trigger(\"submit\",[true]); ' onkeypress='if( event.keyCode == 13 ){ jQuery(\"#gform_target_page_number_2\").val(\"1\");  jQuery(\"#gform_2\").trigger(\"submit\",[true]); } '>Previous<\/button> <button type=\"button\" id=\"gform_next_button_2_87\" class=\"gform_next_button gform-theme-button button\" onclick='jQuery(\"#gform_target_page_number_2\").val(\"3\");  jQuery(\"#gform_2\").trigger(\"submit\",[true]); ' onkeypress='if( event.keyCode == 13 ){ jQuery(\"#gform_target_page_number_2\").val(\"3\");  jQuery(\"#gform_2\").trigger(\"submit\",[true]); } '>Next<\/button> <button type='button'  id='gform_save_2_3_link' class='gform_save_link gform-theme-button gform-theme-button--secondary button'  onclick='if(window[\"gf_submitting_2\"]){return false;}  if( !jQuery(\"#gform_2\")[0].checkValidity || jQuery(\"#gform_2\")[0].checkValidity()){window[\"gf_submitting_2\"]=true;} jQuery(\"#gform_save_2\").val(1); jQuery(\"#gform_2\").trigger(\"submit\",[true]);' onkeypress='if( event.keyCode == 13 ){ if(window[\"gf_submitting_2\"]){return false;} if( !jQuery(\"#gform_2\")[0].checkValidity || jQuery(\"#gform_2\")[0].checkValidity()){window[\"gf_submitting_2\"]=true;} jQuery(\"#gform_save_2\").val(1); jQuery(\"#gform_2\").trigger(\"submit\",[true]); }'><svg aria-hidden=\"true\" focusable=\"false\" width=\"16\" height=\"16\" fill=\"none\" xmlns=\"http:\/\/www.w3.org\/2000\/svg\"><path fill-rule=\"evenodd\" clip-rule=\"evenodd\" d=\"M0 8a4 4 0 004 4h3v3a1 1 0 102 0v-3h3a4 4 0 100-8 4 4 0 10-8 0 4 4 0 00-4 4zm9 4H7V7.414L5.707 8.707a1 1 0 01-1.414-1.414l3-3a1 1 0 011.414 0l3 3a1 1 0 01-1.414 1.414L9 7.414V12z\" fill=\"#6B7280\"\/><\/svg> Save and Continue Later<\/button>\n                    <\/div>\n                <\/div>\n                <div id='gform_page_2_3' class='gform_page' data-js='page-field-id-87' style='display:none;'>\n                    <div class='gform_page_fields'>\n                        <div id='gform_fields_2_3' class='gform_fields top_label form_sublabel_below description_below validation_below'><div id=\"field_2_27\" class=\"gfield gfield--type-section gsection field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_2_27\" ><h3 class=\"gsection_title\">Assailant Information - Complete As Much As You Know<\/h3><\/div><fieldset id=\"field_2_28\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield--width-full field_sublabel_below gfield--no-description field_description_below hidden_label field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_2_28\" ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Assailant<\/legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox' id='input_2_28'><div class='gchoice gchoice_2_28_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_28.1' type='checkbox'  value='Client chose to not report assailant information'  id='choice_2_28_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_2_28_1' id='label_2_28_1' class='gform-field-label gform-field-label--type-inline'>Client chose to not report assailant information<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_2_28_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_28.2' type='checkbox'  value='Unknown assailant information'  id='choice_2_28_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_2_28_2' id='label_2_28_2' class='gform-field-label gform-field-label--type-inline'>Unknown assailant information<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_2_29\" class=\"gfield gfield--type-text gfield--width-two-thirds field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_2_29\" ><label class='gfield_label gform-field-label' for='input_2_29'>Name 1 (if known)<\/label><div class='ginput_container ginput_container_text'><input name='input_29' id='input_2_29' type='text' value='' class='large'      aria-invalid=\"false\"   \/> <\/div><\/div><fieldset id=\"field_2_30\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield--width-quarter gf_list_inline field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_2_30\" ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Gender<\/legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox' id='input_2_30'><div class='gchoice gchoice_2_30_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_30.1' type='checkbox'  value='Female'  id='choice_2_30_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_2_30_1' id='label_2_30_1' class='gform-field-label gform-field-label--type-inline'>Female<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_2_30_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_30.2' type='checkbox'  value='Male'  id='choice_2_30_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_2_30_2' id='label_2_30_2' class='gform-field-label gform-field-label--type-inline'>Male<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_2_32\" class=\"gfield gfield--type-number gfield--width-quarter field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_2_32\" ><label class='gfield_label gform-field-label' for='input_2_32'>Age<\/label><div class='ginput_container ginput_container_number'><input name='input_32' id='input_2_32' type='number' step='any'   value='' class='large'      aria-invalid=\"false\"  \/><\/div><\/div><div id=\"field_2_33\" class=\"gfield gfield--type-text gfield--width-half field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_2_33\" ><label class='gfield_label gform-field-label' for='input_2_33'>Race<\/label><div class='ginput_container ginput_container_text'><input name='input_33' id='input_2_33' type='text' value='' class='large'      aria-invalid=\"false\"   \/> <\/div><\/div><fieldset id=\"field_2_34\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield--width-quarter field_sublabel_below gfield--no-description field_description_below hidden_label field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_2_34\" ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Unknown<\/legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox' id='input_2_34'><div class='gchoice gchoice_2_34_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_34.1' type='checkbox'  value='Unknown'  id='choice_2_34_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_2_34_1' id='label_2_34_1' class='gform-field-label gform-field-label--type-inline'>Unknown<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_2_35\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield--width-full gf_list_2col field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_2_35\" ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Relationship to abuser<\/legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox' id='input_2_35'><div class='gchoice gchoice_2_35_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_35.1' type='checkbox'  value='Dating relationship'  id='choice_2_35_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_2_35_1' id='label_2_35_1' class='gform-field-label gform-field-label--type-inline'>Dating relationship<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_2_35_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_35.2' type='checkbox'  value='Current\/Former spouse'  id='choice_2_35_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_2_35_2' id='label_2_35_2' class='gform-field-label gform-field-label--type-inline'>Current\/Former spouse<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_2_35_3'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_35.3' type='checkbox'  value='Child'  id='choice_2_35_3'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_2_35_3' id='label_2_35_3' class='gform-field-label gform-field-label--type-inline'>Child<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_2_35_4'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_35.4' type='checkbox'  value='Stranger\/Unknown'  id='choice_2_35_4'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_2_35_4' id='label_2_35_4' class='gform-field-label gform-field-label--type-inline'>Stranger\/Unknown<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_2_35_5'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_35.5' type='checkbox'  value='Caregiver'  id='choice_2_35_5'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_2_35_5' id='label_2_35_5' class='gform-field-label gform-field-label--type-inline'>Caregiver<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_2_35_6'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_35.6' type='checkbox'  value='Other family or household member'  id='choice_2_35_6'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_2_35_6' id='label_2_35_6' class='gform-field-label gform-field-label--type-inline'>Other family or household member<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_2_35_7'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_35.7' type='checkbox'  value='Acquaintance'  id='choice_2_35_7'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_2_35_7' id='label_2_35_7' class='gform-field-label gform-field-label--type-inline'>Acquaintance<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_2_35_8'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_35.8' type='checkbox'  value='Other'  id='choice_2_35_8'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_2_35_8' id='label_2_35_8' class='gform-field-label gform-field-label--type-inline'>Other<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_2_38\" class=\"gfield gfield--type-text gfield--width-two-thirds field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_2_38\" ><label class='gfield_label gform-field-label' for='input_2_38'>Name 2 (if known)<\/label><div class='ginput_container ginput_container_text'><input name='input_38' id='input_2_38' type='text' value='' class='large'      aria-invalid=\"false\"   \/> <\/div><\/div><fieldset id=\"field_2_40\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield--width-third gf_list_inline field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_2_40\" ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Gender<\/legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox' id='input_2_40'><div class='gchoice gchoice_2_40_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_40.1' type='checkbox'  value='Female'  id='choice_2_40_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_2_40_1' id='label_2_40_1' class='gform-field-label gform-field-label--type-inline'>Female<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_2_40_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_40.2' type='checkbox'  value='Male'  id='choice_2_40_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_2_40_2' id='label_2_40_2' class='gform-field-label gform-field-label--type-inline'>Male<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_2_41\" class=\"gfield gfield--type-number gfield--width-quarter field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_2_41\" ><label class='gfield_label gform-field-label' for='input_2_41'>Age<\/label><div class='ginput_container ginput_container_number'><input name='input_41' id='input_2_41' type='number' step='any'   value='' class='large'      aria-invalid=\"false\"  \/><\/div><\/div><div id=\"field_2_43\" class=\"gfield gfield--type-text gfield--width-half field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_2_43\" ><label class='gfield_label gform-field-label' for='input_2_43'>Race<\/label><div class='ginput_container ginput_container_text'><input name='input_43' id='input_2_43' type='text' value='' class='large'      aria-invalid=\"false\"   \/> <\/div><\/div><fieldset id=\"field_2_44\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield--width-quarter field_sublabel_below gfield--no-description field_description_below hidden_label field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_2_44\" ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Unknown<\/legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox' id='input_2_44'><div class='gchoice gchoice_2_44_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_44.1' type='checkbox'  value='Unknown'  id='choice_2_44_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_2_44_1' id='label_2_44_1' class='gform-field-label gform-field-label--type-inline'>Unknown<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_2_39\" class=\"gfield gfield--type-checkbox gfield--type-choice gf_list_2col field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_2_39\" ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Relationship to abuser<\/legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox' id='input_2_39'><div class='gchoice gchoice_2_39_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_39.1' type='checkbox'  value='Dating relationship'  id='choice_2_39_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_2_39_1' id='label_2_39_1' class='gform-field-label gform-field-label--type-inline'>Dating relationship<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_2_39_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_39.2' type='checkbox'  value='Current\/Former spouse'  id='choice_2_39_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_2_39_2' id='label_2_39_2' class='gform-field-label gform-field-label--type-inline'>Current\/Former spouse<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_2_39_3'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_39.3' type='checkbox'  value='Child'  id='choice_2_39_3'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_2_39_3' id='label_2_39_3' class='gform-field-label gform-field-label--type-inline'>Child<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_2_39_4'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_39.4' type='checkbox'  value='Stranger\/Unknown'  id='choice_2_39_4'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_2_39_4' id='label_2_39_4' class='gform-field-label gform-field-label--type-inline'>Stranger\/Unknown<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_2_39_5'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_39.5' type='checkbox'  value='Caregiver'  id='choice_2_39_5'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_2_39_5' id='label_2_39_5' class='gform-field-label gform-field-label--type-inline'>Caregiver<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_2_39_6'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_39.6' type='checkbox'  value='Other family or household member'  id='choice_2_39_6'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_2_39_6' id='label_2_39_6' class='gform-field-label gform-field-label--type-inline'>Other family or household member<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_2_39_7'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_39.7' type='checkbox'  value='Acquaintance'  id='choice_2_39_7'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_2_39_7' id='label_2_39_7' class='gform-field-label gform-field-label--type-inline'>Acquaintance<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_2_39_8'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_39.8' type='checkbox'  value='Other'  id='choice_2_39_8'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_2_39_8' id='label_2_39_8' class='gform-field-label gform-field-label--type-inline'>Other<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_2_45\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield--width-full gf_list_inline field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_2_45\" ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Was a weapon used during the assault?<\/legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox' id='input_2_45'><div class='gchoice gchoice_2_45_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_45.1' type='checkbox'  value='Yes'  id='choice_2_45_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_2_45_1' id='label_2_45_1' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_2_45_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_45.2' type='checkbox'  value='No'  id='choice_2_45_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_2_45_2' id='label_2_45_2' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_2_46\" class=\"gfield gfield--type-text gfield--width-full field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_2_46\" ><label class='gfield_label gform-field-label' for='input_2_46'>Type of weapon<\/label><div class='ginput_container ginput_container_text'><input name='input_46' id='input_2_46' type='text' value='' class='large'      aria-invalid=\"false\"   \/> <\/div><\/div><div id=\"field_2_47\" class=\"gfield gfield--type-textarea gfield--width-full field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_2_47\" ><label class='gfield_label gform-field-label' for='input_2_47'>Additional information about assailant(s)<\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_47' id='input_2_47' class='textarea large'      aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/div><\/div>\n                    <\/div>\n                    <div class='gform_page_footer top_label'>\n                        <button type=\"button\" id=\"gform_previous_button_2_88\" class=\"gform_previous_button gform-theme-button gform-theme-button--secondary button\" onclick='jQuery(\"#gform_target_page_number_2\").val(\"2\");  jQuery(\"#gform_2\").trigger(\"submit\",[true]); ' onkeypress='if( event.keyCode == 13 ){ jQuery(\"#gform_target_page_number_2\").val(\"2\");  jQuery(\"#gform_2\").trigger(\"submit\",[true]); } '>Previous<\/button> <button type=\"button\" id=\"gform_next_button_2_88\" class=\"gform_next_button gform-theme-button button\" onclick='jQuery(\"#gform_target_page_number_2\").val(\"4\");  jQuery(\"#gform_2\").trigger(\"submit\",[true]); ' onkeypress='if( event.keyCode == 13 ){ jQuery(\"#gform_target_page_number_2\").val(\"4\");  jQuery(\"#gform_2\").trigger(\"submit\",[true]); } '>Next<\/button> <button type='button'  id='gform_save_2_4_link' class='gform_save_link gform-theme-button gform-theme-button--secondary button'  onclick='if(window[\"gf_submitting_2\"]){return false;}  if( !jQuery(\"#gform_2\")[0].checkValidity || jQuery(\"#gform_2\")[0].checkValidity()){window[\"gf_submitting_2\"]=true;} jQuery(\"#gform_save_2\").val(1); jQuery(\"#gform_2\").trigger(\"submit\",[true]);' onkeypress='if( event.keyCode == 13 ){ if(window[\"gf_submitting_2\"]){return false;} if( !jQuery(\"#gform_2\")[0].checkValidity || jQuery(\"#gform_2\")[0].checkValidity()){window[\"gf_submitting_2\"]=true;} jQuery(\"#gform_save_2\").val(1); jQuery(\"#gform_2\").trigger(\"submit\",[true]); }'><svg aria-hidden=\"true\" focusable=\"false\" width=\"16\" height=\"16\" fill=\"none\" xmlns=\"http:\/\/www.w3.org\/2000\/svg\"><path fill-rule=\"evenodd\" clip-rule=\"evenodd\" d=\"M0 8a4 4 0 004 4h3v3a1 1 0 102 0v-3h3a4 4 0 100-8 4 4 0 10-8 0 4 4 0 00-4 4zm9 4H7V7.414L5.707 8.707a1 1 0 01-1.414-1.414l3-3a1 1 0 011.414 0l3 3a1 1 0 01-1.414 1.414L9 7.414V12z\" fill=\"#6B7280\"\/><\/svg> Save and Continue Later<\/button>\n                    <\/div>\n                <\/div>\n                <div id='gform_page_2_4' class='gform_page' data-js='page-field-id-88' style='display:none;'>\n                    <div class='gform_page_fields'>\n                        <div id='gform_fields_2_4' class='gform_fields top_label form_sublabel_below description_below validation_below'><div id=\"field_2_51\" class=\"gfield gfield--type-section gsection field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_2_51\" ><h3 class=\"gsection_title\">Inter-Agency Information - Complete as much as you know<\/h3><\/div><fieldset id=\"field_2_53\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield--width-full field_sublabel_below gfield--no-description field_description_below hidden_label field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_2_53\" ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Report to law enforcement<\/legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox' id='input_2_53'><div class='gchoice gchoice_2_53_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_53.1' type='checkbox'  value='Client chose to not report to law enforcement'  id='choice_2_53_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_2_53_1' id='label_2_53_1' class='gform-field-label gform-field-label--type-inline'>Client chose to not report to law enforcement<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_2_54\" class=\"gfield gfield--type-text gfield--width-full gf_left_half gfield--width-half field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_2_54\" ><label class='gfield_label gform-field-label' for='input_2_54'>Law enforcement agency<\/label><div class='ginput_container ginput_container_text'><input name='input_54' id='input_2_54' type='text' value='' class='large'      aria-invalid=\"false\"   \/> <\/div><\/div><div id=\"field_2_55\" class=\"gfield gfield--type-text gfield--width-full gf_right_half gfield--width-half field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_2_55\" ><label class='gfield_label gform-field-label' for='input_2_55'>Patrol officer&#039;s name<\/label><div class='ginput_container ginput_container_text'><input name='input_55' id='input_2_55' type='text' value='' class='large'      aria-invalid=\"false\"   \/> <\/div><\/div><div id=\"field_2_56\" class=\"gfield gfield--type-text gfield--width-full gf_left_half gfield--width-half field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_2_56\" ><label class='gfield_label gform-field-label' for='input_2_56'>Investigator&#039;s\/Detective&#039;s name<\/label><div class='ginput_container ginput_container_text'><input name='input_56' id='input_2_56' type='text' value='' class='large'      aria-invalid=\"false\"   \/> <\/div><\/div><div id=\"field_2_57\" class=\"gfield gfield--type-text gfield--width-full gf_right_half gfield--width-half field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_2_57\" ><label class='gfield_label gform-field-label' for='input_2_57'>SANE nurse&#039;s name<\/label><div class='ginput_container ginput_container_text'><input name='input_57' id='input_2_57' type='text' value='' class='large'      aria-invalid=\"false\"   \/> <\/div><\/div><div id=\"field_2_58\" class=\"gfield gfield--type-text gfield--width-full gf_left_half gfield--width-half field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_2_58\" ><label class='gfield_label gform-field-label' for='input_2_58'>Other agency(s) involved<\/label><div class='ginput_container ginput_container_text'><input name='input_58' id='input_2_58' type='text' value='' class='large'      aria-invalid=\"false\"   \/> <\/div><\/div><div id=\"field_2_59\" class=\"gfield gfield--type-text gfield--width-full gf_right_half gfield--width-half field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_2_59\" ><label class='gfield_label gform-field-label' for='input_2_59'>Referrals<\/label><div class='ginput_container ginput_container_text'><input name='input_59' id='input_2_59' type='text' value='' class='large'      aria-invalid=\"false\"   \/> <\/div><\/div><div id=\"field_2_60\" class=\"gfield gfield--type-textarea gfield--width-full field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_2_60\" ><label class='gfield_label gform-field-label' for='input_2_60'>Please explain if you had any concerns regarding the services the survivor received at the hospital<\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_60' id='input_2_60' class='textarea large'      aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/div><\/div>\n                    <\/div>\n                    <div class='gform_page_footer top_label'>\n                        <button type=\"button\" id=\"gform_previous_button_2_89\" class=\"gform_previous_button gform-theme-button gform-theme-button--secondary button\" onclick='jQuery(\"#gform_target_page_number_2\").val(\"3\");  jQuery(\"#gform_2\").trigger(\"submit\",[true]); ' onkeypress='if( event.keyCode == 13 ){ jQuery(\"#gform_target_page_number_2\").val(\"3\");  jQuery(\"#gform_2\").trigger(\"submit\",[true]); } '>Previous<\/button> <button type=\"button\" id=\"gform_next_button_2_89\" class=\"gform_next_button gform-theme-button button\" onclick='jQuery(\"#gform_target_page_number_2\").val(\"5\");  jQuery(\"#gform_2\").trigger(\"submit\",[true]); ' onkeypress='if( event.keyCode == 13 ){ jQuery(\"#gform_target_page_number_2\").val(\"5\");  jQuery(\"#gform_2\").trigger(\"submit\",[true]); } '>Next<\/button> <button type='button'  id='gform_save_2_5_link' class='gform_save_link gform-theme-button gform-theme-button--secondary button'  onclick='if(window[\"gf_submitting_2\"]){return false;}  if( !jQuery(\"#gform_2\")[0].checkValidity || jQuery(\"#gform_2\")[0].checkValidity()){window[\"gf_submitting_2\"]=true;} jQuery(\"#gform_save_2\").val(1); jQuery(\"#gform_2\").trigger(\"submit\",[true]);' onkeypress='if( event.keyCode == 13 ){ if(window[\"gf_submitting_2\"]){return false;} if( !jQuery(\"#gform_2\")[0].checkValidity || jQuery(\"#gform_2\")[0].checkValidity()){window[\"gf_submitting_2\"]=true;} jQuery(\"#gform_save_2\").val(1); jQuery(\"#gform_2\").trigger(\"submit\",[true]); }'><svg aria-hidden=\"true\" focusable=\"false\" width=\"16\" height=\"16\" fill=\"none\" xmlns=\"http:\/\/www.w3.org\/2000\/svg\"><path fill-rule=\"evenodd\" clip-rule=\"evenodd\" d=\"M0 8a4 4 0 004 4h3v3a1 1 0 102 0v-3h3a4 4 0 100-8 4 4 0 10-8 0 4 4 0 00-4 4zm9 4H7V7.414L5.707 8.707a1 1 0 01-1.414-1.414l3-3a1 1 0 011.414 0l3 3a1 1 0 01-1.414 1.414L9 7.414V12z\" fill=\"#6B7280\"\/><\/svg> Save and Continue Later<\/button>\n                    <\/div>\n                <\/div>\n                <div id='gform_page_2_5' class='gform_page' data-js='page-field-id-89' style='display:none;'>\n                    <div class='gform_page_fields'>\n                        <div id='gform_fields_2_5' class='gform_fields top_label form_sublabel_below description_below validation_below'><div id=\"field_2_61\" class=\"gfield gfield--type-section gsection field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_2_61\" ><h3 class=\"gsection_title\">Secondary Contact Information (If available)<\/h3><\/div><fieldset id=\"field_2_64\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield--width-full field_sublabel_below gfield--no-description field_description_below hidden_label field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_2_64\" ><legend class='gfield_label gform-field-label gfield_label_before_complex' >secondary follow up<\/legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox' id='input_2_64'><div class='gchoice gchoice_2_64_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_64.1' type='checkbox'  value='The secondary client would like a follow-up phone call'  id='choice_2_64_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_2_64_1' id='label_2_64_1' class='gform-field-label gform-field-label--type-inline'>The secondary client would like a follow-up phone call<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_2_90\" class=\"gfield gfield--type-name gfield--width-full field_sublabel_hidden_label gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_2_90\" ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Name<\/legend><div class='ginput_complex ginput_container ginput_container--name no_prefix has_first_name no_middle_name has_last_name has_suffix gf_name_has_3 ginput_container_name gform-grid-row' id='input_2_90'>\n                            \n                            <span id='input_2_90_3_container' class='name_first gform-grid-col gform-grid-col--size-auto' >\n                                                    <input type='text' name='input_90.3' id='input_2_90_3' value=''   aria-required='false'   placeholder='First'  \/>\n                                                    <label for='input_2_90_3' class='gform-field-label gform-field-label--type-sub hidden_sub_label screen-reader-text'>First<\/label>\n                                                <\/span>\n                            \n                            <span id='input_2_90_6_container' class='name_last gform-grid-col gform-grid-col--size-auto' >\n                                                    <input type='text' name='input_90.6' id='input_2_90_6' value=''   aria-required='false'   placeholder='Last'  \/>\n                                                    <label for='input_2_90_6' class='gform-field-label gform-field-label--type-sub hidden_sub_label screen-reader-text'>Last<\/label>\n                                                <\/span>\n                            <span id='input_2_90_8_container' class='name_suffix  gform-grid-col gform-grid-col--size-auto' >\n                                                    <input type='text' name='input_90.8' id='input_2_90_8' value=''   aria-required='false'   placeholder='Maiden'  \/>\n                                                    <label for='input_2_90_8' class='gform-field-label gform-field-label--type-sub hidden_sub_label screen-reader-text'>Maiden<\/label>\n                                                <\/span>\n                        <\/div><\/fieldset><div id=\"field_2_68\" class=\"gfield gfield--type-phone gfield--width-half field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_2_68\" ><label class='gfield_label gform-field-label' for='input_2_68'>Phone<\/label><div class='ginput_container ginput_container_phone'><input name='input_68' id='input_2_68' type='tel' value='' class='large'    aria-invalid=\"false\"   \/><\/div><\/div><fieldset id=\"field_2_69\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield--width-half field_sublabel_below gfield--no-description field_description_below hidden_label field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_2_69\" ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Safe<\/legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox' id='input_2_69'><div class='gchoice gchoice_2_69_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_69.1' type='checkbox'  value='Safe to call'  id='choice_2_69_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_2_69_1' id='label_2_69_1' class='gform-field-label gform-field-label--type-inline'>Safe to call<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_2_69_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_69.2' type='checkbox'  value='Safe to leave message'  id='choice_2_69_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_2_69_2' id='label_2_69_2' class='gform-field-label gform-field-label--type-inline'>Safe to leave message<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_2_77\" class=\"gfield gfield--type-text gfield--width-five-twelfths field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_2_77\" ><label class='gfield_label gform-field-label' for='input_2_77'>Address<\/label><div class='ginput_container ginput_container_text'><input name='input_77' id='input_2_77' type='text' value='' class='large'      aria-invalid=\"false\"   \/> <\/div><\/div><div id=\"field_2_78\" class=\"gfield gfield--type-text gfield--width-third field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_2_78\" ><label class='gfield_label gform-field-label' for='input_2_78'>City<\/label><div class='ginput_container ginput_container_text'><input name='input_78' id='input_2_78' type='text' value='' class='large'      aria-invalid=\"false\"   \/> <\/div><\/div><div id=\"field_2_79\" class=\"gfield gfield--type-number gfield--width-quarter field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_2_79\" ><label class='gfield_label gform-field-label' for='input_2_79'>Zip code<\/label><div class='ginput_container ginput_container_number'><input name='input_79' id='input_2_79' type='number' step='any'   value='' class='large'      aria-invalid=\"false\"  \/><\/div><\/div><div id=\"field_2_70\" class=\"gfield gfield--type-date gfield--input-type-datepicker gfield--datepicker-no-icon gfield--width-quarter field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_2_70\" ><label class='gfield_label gform-field-label' for='input_2_70'>DOB<\/label><div class='ginput_container ginput_container_date'>\n                            <input name='input_70' id='input_2_70' type='text' value='' class='datepicker gform-datepicker mdy datepicker_no_icon gdatepicker-no-icon'   placeholder='mm\/dd\/yyyy' aria-describedby=\"input_2_70_date_format\" aria-invalid=\"false\" \/>\n                            <span id='input_2_70_date_format' class='screen-reader-text'>MM slash DD slash YYYY<\/span>\n                        <\/div>\n                        <input type='hidden' id='gforms_calendar_icon_input_2_70' class='gform_hidden' value='https:\/\/www.sacandfoxnationvictimservices.org\/wp-content\/plugins\/gravityforms\/images\/datepicker\/datepicker.svg'\/><\/div><div id=\"field_2_72\" class=\"gfield gfield--type-number gfield--width-quarter field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_2_72\" ><label class='gfield_label gform-field-label' for='input_2_72'>Age<\/label><div class='ginput_container ginput_container_number'><input name='input_72' id='input_2_72' type='number' step='any'   value='' class='large'      aria-invalid=\"false\"  \/><\/div><\/div><div id=\"field_2_73\" class=\"gfield gfield--type-text gfield--width-quarter field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_2_73\" ><label class='gfield_label gform-field-label' for='input_2_73'>Gender<\/label><div class='ginput_container ginput_container_text'><input name='input_73' id='input_2_73' type='text' value='' class='large'      aria-invalid=\"false\"   \/> <\/div><\/div><div id=\"field_2_74\" class=\"gfield gfield--type-text gfield--width-quarter field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_2_74\" ><label class='gfield_label gform-field-label' for='input_2_74'>Race<\/label><div class='ginput_container ginput_container_text'><input name='input_74' id='input_2_74' type='text' value='' class='large'      aria-invalid=\"false\"   \/> <\/div><\/div><fieldset id=\"field_2_75\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield--width-quarter gf_list_inline field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_2_75\" ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Student?<\/legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox' id='input_2_75'><div class='gchoice gchoice_2_75_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_75.1' type='checkbox'  value='Yes'  id='choice_2_75_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_2_75_1' id='label_2_75_1' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_2_75_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_75.2' type='checkbox'  value='No'  id='choice_2_75_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_2_75_2' id='label_2_75_2' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_2_76\" class=\"gfield gfield--type-text gfield--width-three-quarter field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_2_76\" ><label class='gfield_label gform-field-label' for='input_2_76'>If yes, where?<\/label><div class='ginput_container ginput_container_text'><input name='input_76' id='input_2_76' type='text' value='' class='large'      aria-invalid=\"false\"   \/> <\/div><\/div><fieldset id=\"field_2_80\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield--width-full gf_list_inline field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_2_80\" ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Marital status<\/legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox' id='input_2_80'><div class='gchoice gchoice_2_80_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_80.1' type='checkbox'  value='Married'  id='choice_2_80_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_2_80_1' id='label_2_80_1' class='gform-field-label gform-field-label--type-inline'>Married<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_2_80_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_80.2' type='checkbox'  value='Single'  id='choice_2_80_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_2_80_2' id='label_2_80_2' class='gform-field-label gform-field-label--type-inline'>Single<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_2_80_3'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_80.3' type='checkbox'  value='Separated'  id='choice_2_80_3'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_2_80_3' id='label_2_80_3' class='gform-field-label gform-field-label--type-inline'>Separated<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_2_80_4'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_80.4' type='checkbox'  value='Divorced'  id='choice_2_80_4'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_2_80_4' id='label_2_80_4' class='gform-field-label gform-field-label--type-inline'>Divorced<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_2_80_5'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_80.5' type='checkbox'  value='Widowed'  id='choice_2_80_5'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_2_80_5' id='label_2_80_5' class='gform-field-label gform-field-label--type-inline'>Widowed<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_2_80_6'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_80.6' type='checkbox'  value='Unknown'  id='choice_2_80_6'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_2_80_6' id='label_2_80_6' class='gform-field-label gform-field-label--type-inline'>Unknown<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_2_80_7'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_80.7' type='checkbox'  value='Living as married'  id='choice_2_80_7'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_2_80_7' id='label_2_80_7' class='gform-field-label gform-field-label--type-inline'>Living as married<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_2_81\" class=\"gfield gfield--type-text gfield--width-half field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_2_81\" ><label class='gfield_label gform-field-label' for='input_2_81'>Employer<\/label><div class='ginput_container ginput_container_text'><input name='input_81' id='input_2_81' type='text' value='' class='large'      aria-invalid=\"false\"   \/> <\/div><\/div><div id=\"field_2_82\" class=\"gfield gfield--type-text gfield--width-half field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_2_82\" ><label class='gfield_label gform-field-label' for='input_2_82'>Occupation<\/label><div class='ginput_container ginput_container_text'><input name='input_82' id='input_2_82' type='text' value='' class='large'      aria-invalid=\"false\"   \/> <\/div><\/div><div id=\"field_2_83\" class=\"gfield gfield--type-text gfield--width-full field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_2_83\" ><label class='gfield_label gform-field-label' for='input_2_83'>Relationship to primary client<\/label><div class='ginput_container ginput_container_text'><input name='input_83' id='input_2_83' type='text' value='' class='large'      aria-invalid=\"false\"   \/> <\/div><\/div><div id=\"field_2_84\" class=\"gfield gfield--type-textarea gfield--width-full field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_2_84\" ><label class='gfield_label gform-field-label' for='input_2_84'>Summary of events<\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_84' id='input_2_84' class='textarea large'      aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/div><div id=\"field_2_91\" class=\"gfield gfield--type-captcha gfield--width-full field_sublabel_below gfield--no-description field_description_below 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