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Marital status: Currently [select value="married|in long term relationship|single|divorced|widowed"][textarea rows="1"][select value= first|second|third|fourth|fifth||"]
[select name="spouse" value="husband|wife"]. [select value="0|1|2|3|4|5|6|7|"] previous marriage(s)
[select name="variable_1" value="ended in divorce|remarried after spouse died|never remarried after spouse died|"]
Children:[select value="0|1|2|3|4|5|6|7|"]
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"].
Housing Concerns:[select value="none|unstable housing situation related to |"][textarea rows="1"].
Social Supports:[checkbox value="none|significant other|extended family|adult children|neighbors|friends|church members|hired caregivers|limited support system|limited local supports|limited positive supports|concerns related to support system:"].
Education: number of years completed [select value="0|1|2|3|4|5|6|7|8|9|10
11|12|12+"] highest degree:
[checklist name="degree" value=",obtained High school diploma|,obtained GED|, Undergraduate Degree|,Masters Degree|,Vocational training|Some college|Vocational degree|Currently in school|Doctorate"]
Employment: [select value="on disability|retired|unemployed|employed"]. Field/Occupation:
[textarea rows="1"].
Financial Concerns:[select value="none|related to healthcare costs|related to supporting family|"][textarea rows="1"].
Source of Income: [select value="disability|social security|unemployment|work|family support|"][textarea rows="1"].
Military:[select value="denied|retired |active |"][textarea rows="1"].
Legal Concerns:[select value="denied|"][textarea rows="1"]
Trauma history:
Trauma History: Sexual abuse [checklist name="sextrauma" value="in childhood|as adult|rape/sexual assault|witnessed|experienced|"]. Physical abuse [checklist name="phystrauma" value="in childhood|as adult|domestic violence|witnessed|experienced|"]. Emotional abuse [checklist name="emotrauma" value="in childhood|as adult|bullying|domestic partner abuse| witnessed|experienced|"]. Other traumatic experiences:
[checkbox name="trauma" value="natural disaster|violent crime |serious accident|serious medical event|combat|crime victim|near death experience|witnessed death|experienced|witnessed"].
Marital status: Currently
. previous marriage(s)

Living situation: .
Housing Concerns:.
Social Supports: .
Education: number of years completed highest degree:

Employment: . Field/Occupation:
Financial Concerns:.
Source of Income: .
Legal Concerns:
Trauma history:
Trauma History: Sexual abuse . Physical abuse . Emotional abuse . Other traumatic experiences:

Result - Copy and paste this output:

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