Sorry Jules i must have had only a bit copied from testing here is the code:
<h3>Details</h3>
<label> Your Full Name (including any middle names) (required)
[text* your-name] </label>
<label> Age (required)
[text* age] </label>
<label> Address (required)
[text* address-number Placeholder “Number or Name”]</label>
<label>[text* address-street Placeholder “Street”]</label>
<label>[text* address-town Placeholder “Town”]</label>
<label>[text* address-postcode Placeholder “Postcode”] </label>
<label> Home Phone (required)
[tel* home-phone placeholder “02088888888”] </label>
<label> Mobile (required)
[tel* mobile placeholder “0777777777”] </label>
<label> Your Email (required)
[email* your-email] </label>
<label> Date of Birth (required)
[date* DOB placeholder “dd/mm/yy”] </label>
Marital Status (required)
[checkbox* marital exclusive “Married” “Single” “Seperated” “Divorced” “Domestic Partnership” “Widowed” “Prefer not to say”]
<label> Referred by if any
[text* referredby] </label>
<h3>History</h3>
Have you previously received any type of mental health services (psychotherapy, psychiatric services, etc.)? (required)
[checkbox* mental exclusive “Yes” “No”]
[group mentalgroup]
Please list the services you have received
[textarea* mental-textarea][/group]
Are you currently taking any prescription medication? (required)
[checkbox* medication exclusive “Yes” “No”]
[group medicationgroup]
Please name previous therapist/s or practitioner/s
[textarea* medication-textarea][/group]
Have you ever been prescibed psychiatric medication? (required)
[checkbox* pyschmedication exclusive “Yes” “No”]
[group psychmedicationgroup]
Please list the madication you were prescribed and choose the date you were first prescribed this medication
[text* psychmedication-text]
When were you first prescribed this medication?
[date* pyschdate placeholder “dd/mm/yyyy”][/group]
<h3>General</h3>
How would you describe your current physical health? (required)
[checkbox* physical-health exclusive “Very Good” “Good” “Satisfactory” “Unsatisfacroty” “Poor”]
<label> Please list any specific health problems you are currently experiencing (required)
[text* health-problems placeholder “If none please type none”]</label>
How would you describe your current sleeping habbits? (required)
[checkbox* sleeping exclusive “Very Good” “Good” “Satisfactory” “Unsatisfacroty” “Poor”]
<label> Please list any specific sleeping issues you are currently experiencing (required)
[text* sleeping-problems placeholder “If none please type none”]</label>
<label> How many days a week do you typically excercise? (required)
[text* days-excercise placeholder “If none please type none”]</label>
<label> Please list the types of excercise you currently participate in (required)
[text* type-excercise placeholder “If none please type none”]</label>
<label> Please list any difficulties you experience with your appetite (required)
[text* eating placeholder “If none please type none”]</label>
Are you currently experiencing overwhelming sadnees, grief or depression? (required)
[checkbox* feeling exclusive “Yes” “No”]
[group feelinggroup]
How long have you experienced this for?
[text* feeling-time placeholder “2 weeks”][/group]
Are you currently experiencing anxiety, panic attacks or have any phobias? (required)
[checkbox* phobia exclusive “Yes” “No”]
[group phobiagroup]
When did you begin experiencing this?
[date* phobia-time placeholder “dd/mm/yyyy”][/group]
Are you currently experiencing any chronic pain? (required)
[checkbox* chronic exclusive “Yes” “No”]
[group chronicgroup]
Please describe
[textarea* chronic-area][/group]
Do you consume alchohol more than once a week? (required)
[checkbox* alchohol exclusive “Yes” “No”]
How often do you engage in recreational drug use? (required)
[checkbox* drugs exclusive “Daily” “Weekly” “Monthly” “Rarely” “Never”]
Are you currently in a romantic relationship? (required)
[checkbox* romantic exclusive “Yes” “No”]
[group romanticgroup]
How long for?
[text* romantic-time placeholder “1 year”][/group]
How would you rate your relationship on a scale of 1-10 (1 being poor and 10 being exceptional)? (required)
[checkbox* relationship exclusive “1” “2” “3” “4” “5” “6” “7” “8” “9” “10” “im not in a relatonship”]
<label> Please list significant life changes and/or stressful events you have recently experienced
[textarea* changes placeholder “Please list anthing you feel necessary”] </label>
<h3>Family Mental health History</h3>
<h6>Please identify any family history for the following below:</h6>
Alchohol/Substance abuse (required)
[checkbox* familyalchohol exclusive “Yes” “No”]
[group familyachoholgroup]
Please list family member
[text* family-alchohol-name placeholder “Name or relation”][/group]
Anxiety (required)
[checkbox* familyanxiety exclusive “Yes” “No”]
[group familyanxietygroup]
Please list family member
[text* family-anxiety-name placeholder “Name or relation”][/group]
Depression (required)
[checkbox* familydepression exclusive “Yes” “No”]
[group familydepressiongroup]
Please list family member
[text* family-Depression-name placeholder “Name or relation”][/group]
Domestic Violence (required)
[checkbox* familydomesticviolence exclusive “Yes” “No”]
[group familydomesticviolencegroup]
Please list family member
[text* family-domesticviolence-name placeholder “Name or relation”][/group]
Eating Disorders (required)
[checkbox* familyeatingdisorder exclusive “Yes” “No”]
[group familyeatingdisordergroup]
Please list family member
[text* family-eatingdisorder-name placeholder “Name or relation”][/group]
Obesity (required)
[checkbox* familyobesity exclusive “Yes” “No”]
[group familyobesitygroup]
Please list family member
[text* family-obesity-name placeholder “Name or relation”][/group]
Obsessive Compulsive Behaviour (required)
[checkbox* familyocb exclusive “Yes” “No”]
[group familyocbgroup]
Please list family member
[text* family-ocb-name placeholder “Name or relation”][/group]
Schizophrenia (required)
[checkbox* familyschizophrenia exclusive “Yes” “No”]
[group familyschizophreniagroup]
Please list family member
[text* family-schizophrenia-name placeholder “Name or relation”][/group]
Suicide Attempts (required)
[checkbox* familysuicide exclusive “Yes” “No”]
[group familysuicidegroup]
Please list family member
[text* family-suicide-name placeholder “Name or relation”][/group]
<h3>Additional Information</h3>
Are you currently employed? (required)
[checkbox* employed exclusive “Yes” “No”]
[group employedgroup]
What is your current employment situation?
[text* employed-text]
Do you enjoy your job?
[checkbox* employed-enjoyment exclusive “Yes” “No”]
What do you find stressful about your work?
[textarea* employed-stress placeholder “If none then type none”][/group]
Do you condifer yourself to be spiritual or religious? (required)
[checkbox* religion exclusive “Yes” “No”]
[group religiongroup]
Please describe your faith or belief
[textarea* religion-area][/group]
<label> What do you condider to be your strengths? (required)
[textarea* strengths-area]</label>
<label> What do you condider to be your weaknesses? (required)
[textarea* weaknesses-area]</label>
<label> What would you like to achieve or accomplish with your time in therapy? (required)
[textarea* results-area]</label>
[recaptcha]
[submit “Send”]
