{"id":15284,"date":"2025-05-09T19:18:50","date_gmt":"2025-05-10T02:18:50","guid":{"rendered":"https:\/\/siliconvalleymarriagecounseling.com\/?page_id=15284"},"modified":"2025-05-09T20:52:16","modified_gmt":"2025-05-10T03:52:16","slug":"silicon-valley-intake-form","status":"publish","type":"page","link":"https:\/\/cms-staginglink3.com\/aziza-client-site\/silicon-valley\/silicon-valley-intake-form\/","title":{"rendered":"Silicon Valley Intake Form"},"content":{"rendered":"\t\t<div data-elementor-type=\"wp-page\" data-elementor-id=\"15284\" class=\"elementor elementor-15284\" data-elementor-post-type=\"page\">\n\t\t\t\t<div class=\"elementor-element elementor-element-04f0cc9 e-flex e-con-boxed e-con e-parent\" data-id=\"04f0cc9\" data-element_type=\"container\" data-e-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-3090566 elementor-widget elementor-widget-spacer\" data-id=\"3090566\" data-element_type=\"widget\" data-e-type=\"widget\" data-widget_type=\"spacer.default\">\n\t\t\t\t\t\t\t<div class=\"elementor-spacer\">\n\t\t\t<div class=\"elementor-spacer-inner\"><\/div>\n\t\t<\/div>\n\t\t\t\t\t\t<\/div>\n\t\t\t\t<div class=\"elementor-element elementor-element-c2f745e elementor-widget elementor-widget-text-editor\" data-id=\"c2f745e\" data-element_type=\"widget\" data-e-type=\"widget\" data-widget_type=\"text-editor.default\">\n\t\t\t\t\t\t\t\t\t<h1><span style=\"color: #ffffff;\">New Clients<\/span><\/h1>\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t<div class=\"elementor-element elementor-element-daf8205 elementor-widget elementor-widget-spacer\" data-id=\"daf8205\" data-element_type=\"widget\" data-e-type=\"widget\" data-widget_type=\"spacer.default\">\n\t\t\t\t\t\t\t<div class=\"elementor-spacer\">\n\t\t\t<div class=\"elementor-spacer-inner\"><\/div>\n\t\t<\/div>\n\t\t\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-4220252 e-flex e-con-boxed e-con e-parent\" data-id=\"4220252\" data-element_type=\"container\" data-e-type=\"container\">\n\t\t\t\t\t<div class=\"e-con-inner\">\n\t\t\t\t<div class=\"elementor-element elementor-element-32140b3 elementor-widget elementor-widget-spacer\" data-id=\"32140b3\" data-element_type=\"widget\" data-e-type=\"widget\" data-widget_type=\"spacer.default\">\n\t\t\t\t\t\t\t<div class=\"elementor-spacer\">\n\t\t\t<div class=\"elementor-spacer-inner\"><\/div>\n\t\t<\/div>\n\t\t\t\t\t\t<\/div>\n\t\t\t\t<div class=\"elementor-element elementor-element-bbceb2a fluent-form-widget-step-header-yes fluent-form-widget-step-progressbar-yes fluentform-widget-submit-button-custom elementor-widget elementor-widget-fluent-form-widget\" data-id=\"bbceb2a\" data-element_type=\"widget\" data-e-type=\"widget\" data-widget_type=\"fluent-form-widget.default\">\n\t\t\t\t<div class=\"elementor-widget-container\">\n\t\t\t\t\t\n            <div class=\"fluentform-widget-wrapper fluentform-widget-custom-radio-checkbox fluentform-widget-align-default\">\n\n            \n            <div class='fluentform ff-default fluentform_wrapper_5 ffs_default_wrap'><form data-form_id=\"5\" id=\"fluentform_5\" class=\"frm-fluent-form fluent_form_5 ff-el-form-top ff_form_instance_5_1 ff-form-loading ffs_default\" data-form_instance=\"ff_form_instance_5_1\" method=\"POST\" ><fieldset  style=\"border: none!important;margin: 0!important;padding: 0!important;background-color: transparent!important;box-shadow: none!important;outline: none!important; min-inline-size: 100%;\">\n                    <legend class=\"ff_screen_reader_title\" style=\"display: block; margin: 0!important;padding: 0!important;height: 0!important;text-indent: -999999px;width: 0!important;overflow:hidden;\">New Client Intake Form (Silicon Valley)<\/legend><input type='hidden' name='__fluent_form_embded_post_id' value='15284' \/><input type=\"hidden\" id=\"_fluentform_5_fluentformnonce\" name=\"_fluentform_5_fluentformnonce\" value=\"44b1a81301\" \/><input type=\"hidden\" name=\"_wp_http_referer\" value=\"\/aziza-client-site\/wp-json\/wp\/v2\/pages\/15284\" \/><div class=\"ff-el-group ff-el-section-break  ff_left\" data-name=\"section_break-5_1\" ><h3 class='ff-el-section-title'>New Client Intake Form<\/h3><div class='ff-section_break_desk'><p>The New Client Intake Form helps us get to know you, your current circumstances, and what you\u2019re hoping to gain from our work together. Your responses help us tailor our approach to best support your goals and ensure our sessions are as effective and meaningful as possible.<\/p><\/div><hr \/><\/div><div class=\"ff-el-group ff-el-section-break  ff_left\" data-name=\"section_break-5_2\" ><h3 class='ff-el-section-title'><\/h3><div class='ff-section_break_desk'><h4>Your Name<\/h4><\/div><hr \/><\/div><div data-type=\"name-element\" data-name=\"names\" class=\" ff-field_container ff-name-field-wrapper\" ><div class='ff-t-container'><div class='ff-t-cell '><div class='ff-el-group ff-el-form-top'><div class=\"ff-el-input--label asterisk-right\"><label for='ff_5_names_first_name_' id='label_ff_5_names_first_name_' >First Name<\/label><\/div><div class='ff-el-input--content'><input type=\"text\" name=\"names[first_name]\" id=\"ff_5_names_first_name_\" class=\"ff-el-form-control\" placeholder=\"Enter Your First Name\" aria-invalid=\"false\" aria-required=false><\/div><\/div><\/div><div class='ff-t-cell '><div class='ff-el-group ff-el-form-top'><div class=\"ff-el-input--label asterisk-right\"><label for='ff_5_names_last_name_' id='label_ff_5_names_last_name_' >Last Name<\/label><\/div><div class='ff-el-input--content'><input type=\"text\" name=\"names[last_name]\" id=\"ff_5_names_last_name_\" class=\"ff-el-form-control\" placeholder=\"Enter Your Last Name\" aria-invalid=\"false\" aria-required=false><\/div><\/div><\/div><\/div><\/div><div class=\"ff-el-group ff-el-section-break  ff_left\" data-name=\"section_break-5_3\" ><h3 class='ff-el-section-title'><\/h3><div class='ff-section_break_desk'><h4>Your Partner's Name<\/h4><\/div><hr \/><\/div><div data-name=\"ff_cn_id_1\"  class='ff-t-container ff-column-container ff_columns_total_2 '><div class='ff-t-cell ff-t-column-1' style='flex-basis: 50%;'><div class='ff-el-group'><div class=\"ff-el-input--label ff-el-is-required asterisk-right\"><label for='ff_5_input_text_9' id='label_ff_5_input_text_9' aria-label=\"Your partner&#039;s first name\">Your partner's first name<\/label><\/div><div class='ff-el-input--content'><input type=\"text\" name=\"input_text_9\" class=\"ff-el-form-control\" data-name=\"input_text_9\" id=\"ff_5_input_text_9\"  aria-invalid=\"false\" aria-required=true><\/div><\/div><\/div><div class='ff-t-cell ff-t-column-2' style='flex-basis: 50%;'><div class='ff-el-group'><div class=\"ff-el-input--label ff-el-is-required asterisk-right\"><label for='ff_5_input_text_10' id='label_ff_5_input_text_10' aria-label=\"Your partner&#039;s last name\">Your partner's last name<\/label><\/div><div class='ff-el-input--content'><input type=\"text\" name=\"input_text_10\" class=\"ff-el-form-control\" data-name=\"input_text_10\" id=\"ff_5_input_text_10\"  aria-invalid=\"false\" aria-required=true><\/div><\/div><\/div><\/div><div class='ff-el-group'><div class=\"ff-el-input--label ff-el-is-required asterisk-right\"><label for='ff_5_image-upload_1' id='label_ff_5_image-upload_1' aria-label=\"Please upload a photo of the couple together.\">Please upload a photo of the couple together.<\/label><\/div><div class='ff-el-input--content'><label for='ff_5_image-upload_1' class='ff_file_upload_holder'><span class='ff_upload_btn ff-btn' tabindex='0'>Choose File<\/span> <input type=\"file\" name=\"image-upload\" id=\"ff_5_image-upload_1\" class=\"ff-el-form-control  ff-screen-reader-element\" accept=\"image\/*\" data-name=\"image-upload\" multiple=\"1\"  aria-invalid='false' aria-required=true><\/label><\/div><\/div><div class=\"ff-el-group ff-el-section-break  ff_left\" data-name=\"section_break-5_4\" ><h3 class='ff-el-section-title'>About You<\/h3><div class='ff-section_break_desk'><\/div><hr \/><\/div><div data-name=\"ff_cn_id_2\"  class='ff-t-container ff-column-container ff_columns_total_2 '><div class='ff-t-cell ff-t-column-1' style='flex-basis: 50%;'><div class='ff-el-group'><div class=\"ff-el-input--label ff-el-is-required asterisk-right\"><label for='ff_5_input_text' id='label_ff_5_input_text' aria-label=\"Gender Identity\">Gender Identity<\/label><\/div><div class='ff-el-input--content'><input type=\"text\" name=\"input_text\" class=\"ff-el-form-control\" data-name=\"input_text\" id=\"ff_5_input_text\"  aria-invalid=\"false\" aria-required=true><\/div><\/div><\/div><div class='ff-t-cell ff-t-column-2' style='flex-basis: 50%;'><div class='ff-el-group'><div class=\"ff-el-input--label ff-el-is-required asterisk-right\"><label for='ff_5_input_text_11' id='label_ff_5_input_text_11' aria-label=\"Date of Birth\">Date of Birth<\/label><\/div><div class='ff-el-input--content'><input type=\"text\" name=\"input_text_11\" class=\"ff-el-form-control\" placeholder=\"MM\/DD\/YYYY\" data-name=\"input_text_11\" id=\"ff_5_input_text_11\"  aria-invalid=\"false\" aria-required=true><\/div><\/div><\/div><\/div><div data-name=\"ff_cn_id_3\"  class='ff-t-container ff-column-container ff_columns_total_3 '><div class='ff-t-cell ff-t-column-1' style='flex-basis: 33.33%;'><div class='ff-el-group'><div class=\"ff-el-input--label ff-el-is-required asterisk-right\"><label for='ff_5_email' id='label_ff_5_email' aria-label=\"Your Email\">Your Email<\/label><\/div><div class='ff-el-input--content'><input type=\"email\" name=\"email\" id=\"ff_5_email\" class=\"ff-el-form-control\" placeholder=\"Email Address\" data-name=\"email\"  aria-invalid=\"false\" aria-required=true><\/div><\/div><\/div><div class='ff-t-cell ff-t-column-2' style='flex-basis: 33.33%;'><div class='ff-el-group'><div class=\"ff-el-input--label ff-el-is-required asterisk-right\"><label for='ff_5_phone' id='label_ff_5_phone' aria-label=\"Mobile Phone\">Mobile Phone<\/label><\/div><div class='ff-el-input--content'><input name=\"phone\" class=\"ff-el-form-control ff-el-phone\" type=\"tel\" placeholder=\"Mobile Number\" data-name=\"phone\" id=\"ff_5_phone\" inputmode=\"tel\"  aria-invalid='false' aria-required=true><\/div><\/div><\/div><div class='ff-t-cell ff-t-column-3' style='flex-basis: 33.33%;'><div class='ff-el-group'><div class=\"ff-el-input--label asterisk-right\"><label for='ff_5_phone_1' id='label_ff_5_phone_1' aria-label=\"Home Phone\">Home Phone<\/label><\/div><div class='ff-el-input--content'><input name=\"phone_1\" class=\"ff-el-form-control ff-el-phone\" type=\"tel\" placeholder=\"Home Number\" data-name=\"phone_1\" id=\"ff_5_phone_1\" inputmode=\"tel\"  aria-invalid='false' aria-required=false><\/div><\/div><\/div><\/div><div class=\"ff-name-address-wrapper fluent-address\" data-type=\"address-element\" data-name=\"address_1\" ><div class='ff-el-input--label'><label aria-label=\"Address\">Address<\/label><\/div><div class='ff-el-input--content'><div class='ff-t-container'><div class='ff-t-cell'><div class='ff-el-group'><div class=\"ff-el-input--label asterisk-right\"><label for='ff_5_address_1_address_line_1_' id='label_ff_5_address_1_address_line_1_' aria-label=\"Address Line 1\">Address Line 1<\/label><\/div><div class='ff-el-input--content'><input type=\"text\" name=\"address_1[address_line_1]\" id=\"ff_5_address_1_address_line_1_\" class=\"ff-el-form-control\" placeholder=\"Address Line 1\" data-key_name=\"address_line_1\"  aria-invalid=\"false\" aria-required=false><\/div><\/div><\/div><div class='ff-t-cell'><div class='ff-el-group'><div class=\"ff-el-input--label asterisk-right\"><label for='ff_5_address_1_address_line_2_' id='label_ff_5_address_1_address_line_2_' aria-label=\"Address Line 2\">Address Line 2<\/label><\/div><div class='ff-el-input--content'><input type=\"text\" name=\"address_1[address_line_2]\" id=\"ff_5_address_1_address_line_2_\" class=\"ff-el-form-control\" placeholder=\"Address Line 2\" data-key_name=\"address_line_2\"  aria-invalid=\"false\" aria-required=false><\/div><\/div><\/div><\/div><div class='ff-t-container'><div class='ff-t-cell'><div class='ff-el-group'><div class=\"ff-el-input--label asterisk-right\"><label for='ff_5_address_1_city_' id='label_ff_5_address_1_city_' aria-label=\"City\">City<\/label><\/div><div class='ff-el-input--content'><input type=\"text\" name=\"address_1[city]\" id=\"ff_5_address_1_city_\" class=\"ff-el-form-control\" placeholder=\"City\" data-key_name=\"city\"  aria-invalid=\"false\" aria-required=false><\/div><\/div><\/div><div class='ff-t-cell'><div class='ff-el-group'><div class=\"ff-el-input--label asterisk-right\"><label for='ff_5_address_1_state_' id='label_ff_5_address_1_state_' aria-label=\"State\">State<\/label><\/div><div class='ff-el-input--content'><input type=\"text\" name=\"address_1[state]\" id=\"ff_5_address_1_state_\" class=\"ff-el-form-control\" placeholder=\"State\" data-key_name=\"state\"  aria-invalid=\"false\" aria-required=false><\/div><\/div><\/div><\/div><div class='ff-t-container'><div class='ff-t-cell'><div class='ff-el-group'><div class=\"ff-el-input--label asterisk-right\"><label for='ff_5_address_1_zip_' id='label_ff_5_address_1_zip_' aria-label=\"Zip Code\">Zip Code<\/label><\/div><div class='ff-el-input--content'><input type=\"text\" name=\"address_1[zip]\" id=\"ff_5_address_1_zip_\" class=\"ff-el-form-control\" placeholder=\"Zip\" data-key_name=\"zip\"  aria-invalid=\"false\" aria-required=false><\/div><\/div><\/div><\/div><\/div><\/div><div class='ff-el-group'><div class=\"ff-el-input--label ff-el-is-required asterisk-right\"><label for='ff_5_input_text_13' id='label_ff_5_input_text_13' aria-label=\"Country\">Country<\/label><\/div><div class='ff-el-input--content'><input type=\"text\" name=\"input_text_13\" class=\"ff-el-form-control\" data-name=\"input_text_13\" id=\"ff_5_input_text_13\"  aria-invalid=\"false\" aria-required=true><\/div><\/div><div class=\"ff-el-group ff-el-section-break  ff_left\" data-name=\"section_break-5_5\" ><h3 class='ff-el-section-title'><\/h3><div class='ff-section_break_desk'><h4>Education and Occupation.<\/h4><\/div><hr \/><\/div><div data-name=\"ff_cn_id_4\"  class='ff-t-container ff-column-container ff_columns_total_2 '><div class='ff-t-cell ff-t-column-1' style='flex-basis: 50%;'><div class='ff-el-group'><div class=\"ff-el-input--label ff-el-is-required asterisk-right\"><label for='ff_5_input_text_12' id='label_ff_5_input_text_12' aria-label=\"Education Level\">Education Level<\/label><\/div><div class='ff-el-input--content'><input type=\"text\" name=\"input_text_12\" class=\"ff-el-form-control\" data-name=\"input_text_12\" id=\"ff_5_input_text_12\"  aria-invalid=\"false\" aria-required=true><\/div><\/div><\/div><div class='ff-t-cell ff-t-column-2' style='flex-basis: 50%;'><div class='ff-el-group'><div class=\"ff-el-input--label ff-el-is-required asterisk-right\"><label for='ff_5_input_text_1' id='label_ff_5_input_text_1' aria-label=\"Occupation\">Occupation<\/label><\/div><div class='ff-el-input--content'><input type=\"text\" name=\"input_text_1\" class=\"ff-el-form-control\" data-name=\"input_text_1\" id=\"ff_5_input_text_1\"  aria-invalid=\"false\" aria-required=true><\/div><\/div><\/div><\/div><div data-name=\"ff_cn_id_5\"  class='ff-t-container ff-column-container ff_columns_total_2 '><div class='ff-t-cell ff-t-column-1' style='flex-basis: 50%;'><div class='ff-el-group'><div class=\"ff-el-input--label ff-el-is-required asterisk-right\"><label for='ff_5_input_text_2' id='label_ff_5_input_text_2' aria-label=\"Employer\/Company\">Employer\/Company<\/label><\/div><div class='ff-el-input--content'><input type=\"text\" name=\"input_text_2\" class=\"ff-el-form-control\" data-name=\"input_text_2\" id=\"ff_5_input_text_2\"  aria-invalid=\"false\" aria-required=true><\/div><\/div><\/div><div class='ff-t-cell ff-t-column-2' style='flex-basis: 50%;'><div class='ff-el-group'><div class=\"ff-el-input--label asterisk-right\"><label for='ff_5_phone_2' id='label_ff_5_phone_2' aria-label=\"Work Phone\">Work Phone<\/label><\/div><div class='ff-el-input--content'><input name=\"phone_2\" class=\"ff-el-form-control ff-el-phone\" type=\"tel\" placeholder=\"Mobile Number\" data-name=\"phone_2\" id=\"ff_5_phone_2\" inputmode=\"tel\"  aria-invalid='false' aria-required=false><\/div><\/div><\/div><\/div><div class=\"ff-el-group ff-el-section-break  ff_left\" data-name=\"section_break-5_6\" ><h3 class='ff-el-section-title'><\/h3><div class='ff-section_break_desk'><h4>About Your Relationship<\/h4><\/div><hr \/><\/div><div data-name=\"ff_cn_id_6\"  class='ff-t-container ff-column-container ff_columns_total_2 '><div class='ff-t-cell ff-t-column-1' style='flex-basis: 50%;'><div class='ff-el-group'><div class=\"ff-el-input--label ff-el-is-required asterisk-right\"><label for='ff_5_dropdown_2' id='label_ff_5_dropdown_2' aria-label=\"Marital Status\">Marital Status<\/label><\/div><div class='ff-el-input--content'><select name=\"dropdown_2\" id=\"ff_5_dropdown_2\" class=\"ff-el-form-control\" data-name=\"dropdown_2\" data-calc_value=\"0\"  aria-invalid=\"false\" aria-required=\"true\" aria-labelledby=\"label_ff_5_dropdown_2\"><option value=\"\">- Select -<\/option><option value=\" Single (never married)\"  >Single (never married)<\/option><option value=\" Married (legally or common-law)\"  >Married (legally or common-law)<\/option><option value=\" In a domestic partnership\"  >In a domestic partnership<\/option><option value=\" In a relationship but not married\"  >In a relationship but not married<\/option><option value=\" Separated\"  >Separated<\/option><option value=\" Divorced\"  >Divorced<\/option><option value=\" Widowed\"  >Widowed<\/option><option value=\" Prefer not to say\"  >Prefer not to say<\/option><\/select><\/div><\/div><\/div><div class='ff-t-cell ff-t-column-2' style='flex-basis: 50%;'><div class='ff-el-group'><div class=\"ff-el-input--label ff-el-is-required asterisk-right\"><label for='ff_5_input_text_4' id='label_ff_5_input_text_4' aria-label=\"Length of your relationship.\">Length of your relationship.<\/label><\/div><div class='ff-el-input--content'><input type=\"text\" name=\"input_text_4\" class=\"ff-el-form-control\" data-name=\"input_text_4\" id=\"ff_5_input_text_4\"  aria-invalid=\"false\" aria-required=true><\/div><\/div><\/div><\/div><div class=\"ff-el-group ff-el-section-break  ff_left\" data-name=\"section_break-5_7\" ><h3 class='ff-el-section-title'><\/h3><div class='ff-section_break_desk'><h4>About Your Children (if any)<\/h4><\/div><hr \/><\/div><div data-name=\"ff_cn_id_7\"  class='ff-t-container ff-column-container ff_columns_total_3 '><div class='ff-t-cell ff-t-column-1' style='flex-basis: 33.33%;'><div class='ff-el-group'><div class=\"ff-el-input--label ff-el-is-required asterisk-right\"><label for='ff_5_input_text_5' id='label_ff_5_input_text_5' aria-label=\"Number of children.\">Number of children.<\/label><\/div><div class='ff-el-input--content'><input type=\"text\" name=\"input_text_5\" class=\"ff-el-form-control\" data-name=\"input_text_5\" id=\"ff_5_input_text_5\"  aria-invalid=\"false\" aria-required=true><\/div><\/div><\/div><div class='ff-t-cell ff-t-column-2' style='flex-basis: 33.33%;'><div class='ff-el-group'><div class=\"ff-el-input--label ff-el-is-required asterisk-right\"><label for='ff_5_input_text_7' id='label_ff_5_input_text_7' aria-label=\"Ages of your children in birth order.\">Ages of your children in birth order.<\/label><\/div><div class='ff-el-input--content'><input type=\"text\" name=\"input_text_7\" class=\"ff-el-form-control\" data-name=\"input_text_7\" id=\"ff_5_input_text_7\"  aria-invalid=\"false\" aria-required=true><\/div><\/div><\/div><div class='ff-t-cell ff-t-column-3' style='flex-basis: 33.33%;'><div class='ff-el-group'><div class=\"ff-el-input--label ff-el-is-required asterisk-right\"><label for='ff_5_input_text_6' id='label_ff_5_input_text_6' aria-label=\"Gender of your children in birth order.\">Gender of your children in birth order.<\/label><\/div><div class='ff-el-input--content'><input type=\"text\" name=\"input_text_6\" class=\"ff-el-form-control\" data-name=\"input_text_6\" id=\"ff_5_input_text_6\"  aria-invalid=\"false\" aria-required=true><\/div><\/div><\/div><\/div><div class=\"ff-el-group ff-el-section-break  ff_left\" data-name=\"section_break-5_8\" ><h3 class='ff-el-section-title'><\/h3><div class='ff-section_break_desk'><h4>Miscellaneous Information.<\/h4><\/div><hr \/><\/div><div class='ff-el-group'><div class=\"ff-el-input--label ff-el-is-required asterisk-right\"><label for='ff_5_description' id='label_ff_5_description' aria-label=\"Current or history of substance abuse or prescription medications.\">Current or history of substance abuse or prescription medications.<\/label><\/div><div class='ff-el-input--content'><textarea aria-required=\"true\" aria-labelledby=\"label_ff_5_description\" name=\"description\" id=\"ff_5_description\" class=\"ff-el-form-control\" rows=\"3\" cols=\"2\" data-name=\"description\" ><\/textarea><\/div><\/div><div class='ff-el-group'><div class=\"ff-el-input--label ff-el-is-required asterisk-right\"><label for='ff_5_description_1' id='label_ff_5_description_1' aria-label=\"What is the reason that you are seeking therapy?\">What is the reason that you are seeking therapy?<\/label><\/div><div class='ff-el-input--content'><textarea aria-required=\"true\" aria-labelledby=\"label_ff_5_description_1\" name=\"description_1\" id=\"ff_5_description_1\" class=\"ff-el-form-control\" rows=\"3\" cols=\"2\" data-name=\"description_1\" ><\/textarea><\/div><\/div><div class='ff-el-group'><div class=\"ff-el-input--label ff-el-is-required asterisk-right\"><label for='ff_5_description_2' id='label_ff_5_description_2' aria-label=\"What would you like to accomplish through therapy?\">What would you like to accomplish through therapy?<\/label><\/div><div class='ff-el-input--content'><textarea aria-required=\"true\" aria-labelledby=\"label_ff_5_description_2\" name=\"description_2\" id=\"ff_5_description_2\" class=\"ff-el-form-control\" rows=\"3\" cols=\"2\" data-name=\"description_2\" ><\/textarea><\/div><\/div><div 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