Relationship status: [select value="married||single|divorced|widowed"] [select value="; not currently in relationship|; currently in relationship|for X years to current spouse|since XXX after X years of marriage"]; [select value="no|1|2|3|4|5|6|7|"] [select value="|previous marriages|previous marriages ended in divorce|previous marriages, longest relationship ever was XX| x widowed and remarried"].
Children: [select value="none|1|2|3|4|5|6|7|"] [checkbox value="adult children|sons|son|daughters|daughter"][checkbox value="living|"][checkbox value=", 1|, 2|, 3|, 4|, 5|, 6|, 7|"] [checkbox value="sons|son|daughters|daughter|children|child|"] [checkbox value="- deceased|- died in childhood|close with step-children|not close with step-children"]
Living situation: [checkbox name="residence" value="home|apartment|group home|duplex|memory care unit|skilled nursing facility|homeless, most recently|assisted living facility|nursing home|apartment in senior housing|dormitory"][select value="|staying with friends/family|staying at Mission|sleeping on streets|in homeless encampment|staying at hotel|, lives with spouse/significant other|, lives alone|, lives with roommates|, lives with family|, lives with parents|, lives with"][textarea rows="1"].
Social Supports: [checkbox value="none|spouse/significant other|extended family|adult children|neighbors|friends|church members|hired caregivers|limited support system|limited local supports|limited positive supports"].
Education: [select value="0|1|2|3|4|5|6|7|8|9|10
|11|12|12+"] years of formal education, [checkbox value="dropped out before finishing, no GED|high school diploma|GED|undergraduate degree|master's degree|vocational training|some college|vocational degree/certification|doctorate|currently in school"]
Employment: [checkbox value="retired|currently unemployed|not looking for work|looking for work|in process of applying for disability|disabled due to psychiatric illness|disabled due to medical problems|homemaker|currently employed|on maternity leave|on medical leave of absence"].
Field/Occupation: [textarea rows="1"].
Source of Income: [checkbox value="none|disability|social security|unemployment|work|savings|retirement|family support|"][textarea rows="1"].
Military: [checkbox value="no reported history|denies history|retired|active|Army|Navy|Air Force|Marines|National Guard"][textarea rows="1"].
Legal History: active issues- [checkbox value="none reported|denies active legal issues| reports active legal issues related to|currently on probation|currently on parole|upcoming court date"]; past history- [checkbox value="none reported| denies| previous incarceration| previous felony conviction|past history of violent offenses|denies past history of violent offenses|denies history of sex crimes|convicted sex offender"].
Trauma History: [checkbox name="sextrauma" value="|denies history|none reported|sexual abuse in childhood|sexual abuse as adult|history of rape/sexual assault|physical abuse in childhood|physical abuse as adult|witnessed domestic violence in childhood|domestic violence in past relationship|emotional abuse in childhood|emotional abuse as adult|history of being bullied|natural disaster|violent crime |serious accident|serious medical event|combat|crime victim|near death experience|witnessed death"].