<%@ Language=VBScript %>
<%
	'form.html 
	'Created Date:			04/15/2009
	'Modification History:
    
    'Updated by ISTCHQS 08/27/2010 to add custom theme to Google ReCaptcha
    
	'File Purpose:			Enables user to submit survey form to Colleen Garrahan.
		'Updated By ISADRPN  01/22/2010 to add Google Recaptcha
	' 1. Line 517 - 550 declares, initializes and tests the IsGoodCaptcha variable 
	' 2. Block Line 825 - 829 ends conditional if-then test block
	' 3. Block Line 845 - 846 Focus cursor on Recaptcha input box upon error	 
	' 4. Block 1681 - instructs user to enter Recaptcha text for security reasons
	' 5. Block Line 1684 - 1694 displays the Recaptcha form for input.

%>
<!-- METADATA TYPE="TypeLib" UUID="CD000000-8B95-11D1-82DB-00C04FB1625D" NAME="CDO for Windows 2000 Library" -->
<%
Response.Buffer = True

Dim strSelected
strSelected = " selected=""selected"" "
Dim strChecked
strChecked = " checked=""checked"" "

Dim strFirst
Dim strLast
Dim strTitle
Dim strOrganization
Dim strCounty 
Dim strAddress 
Dim strCity 
Dim strState 
Dim strZip
Dim strEmail
Dim strPhone
Dim strBoard
Dim strService
Dim strFamily
Dim strBoardtwo
Dim strServicetwo
Dim strFamilytwo
Dim strAone
Dim strBone
Dim strCone
Dim strDone
Dim strEone
Dim strFone
Dim strGone
Dim strHone
Dim strIone
Dim strJone
Dim strKone
Dim strLone
Dim strMone
Dim strNone
Dim strOone
Dim strPone
Dim strQone
Dim strRone
Dim strSone
Dim strTone
Dim strUone
Dim strVone
Dim strWone
Dim strXone
Dim strYone
Dim strZone
Dim strAAone
Dim strABone
Dim strACone
Dim strADone
Dim strAEone
Dim strAFone
Dim strAGone
Dim strAHone
Dim strAIone
Dim strAJone
Dim strAKone
Dim strALone
Dim strAMone
Dim strANone
Dim strAOone
Dim strAPone
Dim strAQone
Dim strARone
Dim strASone
Dim strATone
Dim strAUone
Dim strAVone
Dim strAWone
Dim strAXone
Dim strAYone
Dim strAZone
Dim strAAAone
Dim strAABone
Dim strAACone
Dim strAADone
Dim strAAEone
Dim strAAFone
Dim strAAGone
Dim strAAHone
Dim strAAIone
Dim strAAJone
Dim strAAKone
Dim strAALone
Dim strAAMone
Dim strAANone
Dim strAAOone
Dim strAAPone
Dim strAAQone
Dim strAARone
Dim strAASone
Dim strAATone
Dim strAAUone
Dim strAAVone
Dim strAAWone
Dim strAAXone
Dim strAAYone
Dim strAAZone
Dim strAtwo
Dim strBtwo
Dim strCtwo
Dim strDtwo
Dim strEtwo
Dim strFtwo
Dim strGtwo
Dim strHtwo
Dim strItwo
Dim strJtwo
Dim strKtwo
Dim strLtwo
Dim strMtwo
Dim strNtwo
Dim strOtwo
Dim strPtwo
Dim strQtwo
Dim strRtwo
Dim strStwo
Dim strTtwo
Dim strUtwo
Dim strVtwo
Dim strWtwo
Dim strXtwo
Dim strYtwo
Dim strZtwo
Dim strAAtwo
Dim strABtwo
Dim strACtwo
Dim strADtwo
Dim strAEtwo
Dim strAFtwo
Dim strAGtwo
Dim strAHtwo
Dim strAItwo
Dim strAJtwo
Dim strAKtwo
Dim strALtwo
Dim strAMtwo
Dim strANtwo
Dim strAOtwo
Dim strAPtwo
Dim strAQtwo
Dim strARtwo
Dim strAStwo
Dim strATtwo
Dim strAUtwo
Dim strAVtwo
Dim strAWtwo
Dim strAXtwo
Dim strAYtwo
Dim strAZtwo
Dim strAAAtwo
Dim strAABtwo
Dim strAACtwo
Dim strAADtwo
Dim strAAEtwo
Dim strAAFtwo
Dim strAAGtwo
Dim strAAHtwo
Dim strAAItwo
Dim strAAJtwo
Dim strAAKtwo
Dim strAALtwo
Dim strAAMtwo
Dim strAANtwo
Dim strAAOtwo
Dim strAAPtwo
Dim strAAQtwo
Dim strAARtwo
Dim strAAStwo
Dim strAATtwo
Dim strAAUtwo
Dim strAAVtwo
Dim strAAWtwo
Dim strAAXtwo
Dim strAAYtwo
Dim strAAZtwo
Dim strAthree
Dim strBthree
Dim strCthree
Dim strDthree
Dim strEthree
Dim strFthree
Dim strGthree
Dim strHthree
Dim strIthree
Dim strJthree
Dim strKthree
Dim strLthree
Dim strMthree
Dim strNthree
Dim strOthree
Dim strPthree
Dim strQthree
Dim strRthree
Dim strSthree
Dim strTthree
Dim strUthree
Dim strVthree
Dim strWthree
Dim strXthree
Dim strYthree
Dim strZthree
Dim strAAthree
Dim strABthree
Dim strACthree
Dim strADthree
Dim strAEthree
Dim strAFthree
Dim strAGthree
Dim strAHthree
Dim strAIthree
Dim strAJthree
Dim strAKthree
Dim strALthree
Dim strAMthree
Dim strANthree
Dim strAOthree
Dim strAPthree
Dim strAQthree
Dim strARthree
Dim strASthree
Dim strATthree
Dim strAUthree
Dim strAVthree
Dim strAWthree
Dim strAXthree
Dim strAYthree
Dim strAZthree
Dim strAAAthree
Dim strAABthree
Dim strAACthree
Dim strAADthree
Dim strAAEthree
Dim strAAFthree
Dim strAAGthree
Dim strAAHthree
Dim strAAIthree
Dim strAAJthree
Dim strAAKthree
Dim strAALthree
Dim strAAMthree
Dim strAANthree
Dim strAAOthree
Dim strAAPthree
Dim strAAQthree
Dim strAARthree
Dim strAASthree
Dim strAATthree
Dim strAAUthree
Dim strAAVthree
Dim strAAWthree
Dim strAAXthree
Dim strAAYthree
Dim strAAZthree
   
    strFirst = Trim(Request.Form("txtFirst"))
	'strLast = Trim(Request.Form("txtLast"))
	strTitle = Trim(Request.Form("txtTitle"))
	strOrganization = Trim(Request.Form("txtOrganization"))
    strCounty  = Trim(Request.Form("ddCounty"))
    strAddress  = Trim(Request.Form("txtAddress"))
    strCity = Trim(Request.Form("txtCity"))
    strState  = Trim(Request.Form("ddState"))
    strZip = Trim(Request.Form("txtZip"))
	strEmail = Trim(Request.Form("txtEmail"))
	strPhone = Trim(Request.Form("txtPhone"))
    strBoard = Trim(Request.Form("ckbBoard"))
    strService = Trim(Request.Form("ckbService"))
    strFamily = Trim(Request.Form("ckbFamily"))
    strBoardtwo = Trim(Request.Form("ckbBoardtwo"))
    strServicetwo = Trim(Request.Form("ckbServicetwo"))
    strFamilytwo = Trim(Request.Form("ckbFamilytwo"))
    strAone = Trim(Request.Form("ckbAone"))
    strBone = Trim(Request.Form("ckbBone"))
    strCone = Trim(Request.Form("ckbCone"))
    strDone = Trim(Request.Form("ckbDone"))
    strEone = Trim(Request.Form("ckbEone"))
    strFone = Trim(Request.Form("ckbFone"))
    strGone = Trim(Request.Form("ckbGone"))
    strHone = Trim(Request.Form("ckbHone"))
    strIone = Trim(Request.Form("ckbIone"))
    strJone = Trim(Request.Form("ckbJone"))
    strKone = Trim(Request.Form("ckbKone"))
    strLone = Trim(Request.Form("ckbLone"))
    strMone = Trim(Request.Form("ckbMone"))
    strNone = Trim(Request.Form("ckbNone"))
    strOone = Trim(Request.Form("ckbOone"))
    strPone = Trim(Request.Form("ckbPone"))
    strQone = Trim(Request.Form("ckbQone"))
    strRone = Trim(Request.Form("ckbRone"))
    strSone = Trim(Request.Form("ckbSone"))
    strTone = Trim(Request.Form("ckbTone"))
    strUone = Trim(Request.Form("ckbUone"))
    strVone = Trim(Request.Form("ckbVone"))
    strWone = Trim(Request.Form("ckbWone"))
    strXone = Trim(Request.Form("ckbXone"))
    strYone = Trim(Request.Form("ckbYone"))
    strZone = Trim(Request.Form("ckbZone"))
    strAAone = Trim(Request.Form("ckbAAone"))
    strABone = Trim(Request.Form("ckbABone"))
    strACone = Trim(Request.Form("ckbACone"))
    strADone = Trim(Request.Form("ckbADone"))
    strAEone = Trim(Request.Form("ckbAEone"))
    strAFone = Trim(Request.Form("ckbAFone"))
    strAGone = Trim(Request.Form("ckbAGone"))
    strAHone = Trim(Request.Form("ckbAHone"))
    strAIone = Trim(Request.Form("ckbAIone"))
    strAJone = Trim(Request.Form("ckbAJone"))
    strAKone = Trim(Request.Form("ckbAKone"))
    strALone = Trim(Request.Form("ckbALone"))
    strAMone = Trim(Request.Form("ckbAMone"))
    strANone = Trim(Request.Form("ckbANone"))
    strAOone = Trim(Request.Form("ckbAOone"))
    strAPone = Trim(Request.Form("ckbAPone"))
    strAQone = Trim(Request.Form("ckbAQone"))
    strARone = Trim(Request.Form("ckbARone"))
    strASone = Trim(Request.Form("ckbASone"))
    strATone = Trim(Request.Form("ckbATone"))
    strAUone = Trim(Request.Form("ckbAUone"))
    strAVone = Trim(Request.Form("ckbAVone"))
    strAWone = Trim(Request.Form("ckbAWone"))
    strAXone = Trim(Request.Form("ckbAXone"))
    strAYone = Trim(Request.Form("ckbAYone"))
    strAZone = Trim(Request.Form("ckbAZone"))
    strAAAone = Trim(Request.Form("ckbAAAone"))
    strAABone = Trim(Request.Form("ckbAABone"))
    strAACone = Trim(Request.Form("ckbAACone"))
    strAADone = Trim(Request.Form("ckbAADone"))
    strAAEone = Trim(Request.Form("ckbAAEone"))
    strAAFone = Trim(Request.Form("ckbAAFone"))
    strAAGone = Trim(Request.Form("ckbAAGone"))
    strAAHone = Trim(Request.Form("ckbAAHone"))
    strAAIone = Trim(Request.Form("ckbAAIone"))
    strAAJone = Trim(Request.Form("ckbAAJone"))
    strAAKone = Trim(Request.Form("ckbAAKone"))
    strAALone = Trim(Request.Form("ckbAALone"))
    strAAMone = Trim(Request.Form("ckbAAMone"))
    strAANone = Trim(Request.Form("ckbAANone"))
    strAAOone = Trim(Request.Form("ckbAAOone"))
    strAAPone = Trim(Request.Form("ckbAAPone"))
    strAAQone = Trim(Request.Form("ckbAAQone"))
    strAARone = Trim(Request.Form("ckbAARone"))
    strAASone = Trim(Request.Form("ckbAASone"))
    strAATone = Trim(Request.Form("ckbAATone"))
    strAAUone = Trim(Request.Form("ckbAAUone"))
    strAAVone = Trim(Request.Form("ckbAAVone"))
    strAAWone = Trim(Request.Form("ckbAAWone"))
    strAAXone = Trim(Request.Form("ckbAAXone"))
    strAAYone = Trim(Request.Form("ckbAAYone"))
    strAAZone = Trim(Request.Form("ckbAAZone"))    
    strAtwo = Trim(Request.Form("ckbAtwo"))
    strBtwo = Trim(Request.Form("ckbBtwo"))
    strCtwo = Trim(Request.Form("ckbCtwo"))
    strDtwo = Trim(Request.Form("ckbDtwo"))
    strEtwo = Trim(Request.Form("ckbEtwo"))
    strFtwo = Trim(Request.Form("ckbFtwo"))
    strGtwo = Trim(Request.Form("ckbGtwo"))
    strHtwo = Trim(Request.Form("ckbHtwo"))
    strItwo = Trim(Request.Form("ckbItwo"))
    strJtwo = Trim(Request.Form("ckbJtwo"))
    strKtwo = Trim(Request.Form("ckbKtwo"))
    strLtwo = Trim(Request.Form("ckbLtwo"))
    strMtwo = Trim(Request.Form("ckbMtwo"))
    strNtwo = Trim(Request.Form("ckbNtwo"))
    strOtwo = Trim(Request.Form("ckbOtwo"))
    strPtwo = Trim(Request.Form("ckbPtwo"))
    strQtwo = Trim(Request.Form("ckbQtwo"))
    strRtwo = Trim(Request.Form("ckbRtwo"))
    strStwo = Trim(Request.Form("ckbStwo"))
    strTtwo = Trim(Request.Form("ckbTtwo"))
    strUtwo = Trim(Request.Form("ckbUtwo"))
    strVtwo = Trim(Request.Form("ckbVtwo"))
    strWtwo = Trim(Request.Form("ckbWtwo"))
    strXtwo = Trim(Request.Form("ckbXtwo"))
    strYtwo = Trim(Request.Form("ckbYtwo"))
    strZtwo = Trim(Request.Form("ckbZtwo"))
    strAAtwo = Trim(Request.Form("ckbAAtwo"))
    strABtwo = Trim(Request.Form("ckbABtwo"))
    strACtwo = Trim(Request.Form("ckbACtwo"))
    strADtwo = Trim(Request.Form("ckbADtwo"))
    strAEtwo = Trim(Request.Form("ckbAEtwo"))
    strAFtwo = Trim(Request.Form("ckbAFtwo"))
    strAGtwo = Trim(Request.Form("ckbAGtwo"))
    strAHtwo = Trim(Request.Form("ckbAHtwo"))
    strAItwo = Trim(Request.Form("ckbAItwo"))
    strAJtwo = Trim(Request.Form("ckbAJtwo"))
    strAKtwo = Trim(Request.Form("ckbAKtwo"))
    strALtwo = Trim(Request.Form("ckbALtwo"))
    strAMtwo = Trim(Request.Form("ckbAMtwo"))
    strANtwo = Trim(Request.Form("ckbANtwo"))
    strAOtwo = Trim(Request.Form("ckbAOtwo"))
    strAPtwo = Trim(Request.Form("ckbAPtwo"))
    strAQtwo = Trim(Request.Form("ckbAQtwo"))
    strARtwo = Trim(Request.Form("ckbARtwo"))
    strAStwo = Trim(Request.Form("ckbAStwo"))
    strATtwo = Trim(Request.Form("ckbATtwo"))
    strAUtwo = Trim(Request.Form("ckbAUtwo"))
    strAVtwo = Trim(Request.Form("ckbAVtwo"))
    strAWtwo = Trim(Request.Form("ckbAWtwo"))
    strAXtwo = Trim(Request.Form("ckbAXtwo"))
    strAYtwo = Trim(Request.Form("ckbAYtwo"))
    strAZtwo = Trim(Request.Form("ckbAZtwo"))
    strAAAtwo = Trim(Request.Form("ckbAAAtwo"))
    strAABtwo = Trim(Request.Form("ckbAABtwo"))
    strAACtwo = Trim(Request.Form("ckbAACtwo"))
    strAADtwo = Trim(Request.Form("ckbAADtwo"))
    strAAEtwo = Trim(Request.Form("ckbAAEtwo"))
    strAAFtwo = Trim(Request.Form("ckbAAFtwo"))
    strAAGtwo = Trim(Request.Form("ckbAAGtwo"))
    strAAHtwo = Trim(Request.Form("ckbAAHtwo"))
    strAAItwo = Trim(Request.Form("ckbAAItwo"))
    strAAJtwo = Trim(Request.Form("ckbAAJtwo"))
    strAAKtwo = Trim(Request.Form("ckbAAKtwo"))
    strAALtwo = Trim(Request.Form("ckbAALtwo"))
    strAAMtwo = Trim(Request.Form("ckbAAMtwo"))
    strAANtwo = Trim(Request.Form("ckbAANtwo"))
    strAAOtwo = Trim(Request.Form("ckbAAOtwo"))
    strAAPtwo = Trim(Request.Form("ckbAAPtwo"))
    strAAQtwo = Trim(Request.Form("ckbAAQtwo"))
    strAARtwo = Trim(Request.Form("ckbAARtwo"))
    strAAStwo = Trim(Request.Form("ckbAAStwo"))
    strAATtwo = Trim(Request.Form("ckbAATtwo"))
    strAAUtwo = Trim(Request.Form("ckbAAUtwo"))
    strAAVtwo = Trim(Request.Form("ckbAAVtwo"))
    strAAWtwo = Trim(Request.Form("ckbAAWtwo"))
    strAAXtwo = Trim(Request.Form("ckbAAXtwo"))
    strAAYtwo = Trim(Request.Form("ckbAAYtwo"))
    strAAZtwo = Trim(Request.Form("ckbAAZtwo"))        
    strAthree = Trim(Request.Form("ckbAthree"))
    strBthree = Trim(Request.Form("ckbBthree"))
    strCthree = Trim(Request.Form("ckbCthree"))
    strDthree = Trim(Request.Form("ckbDthree"))
    strEthree = Trim(Request.Form("ckbEthree"))
    strFthree = Trim(Request.Form("ckbFthree"))
    strGthree = Trim(Request.Form("ckbGthree"))
    strHthree = Trim(Request.Form("ckbHthree"))
    strIthree = Trim(Request.Form("ckbIthree"))
    strJthree = Trim(Request.Form("ckbJthree"))
    strKthree = Trim(Request.Form("ckbKthree"))
    strLthree = Trim(Request.Form("ckbLthree"))
    strMthree = Trim(Request.Form("ckbMthree"))
    strNthree = Trim(Request.Form("ckbNthree"))
    strOthree = Trim(Request.Form("ckbOthree"))
    strPthree = Trim(Request.Form("ckbPthree"))
    strQthree = Trim(Request.Form("ckbQthree"))
    strRthree = Trim(Request.Form("ckbRthree"))
    strSthree = Trim(Request.Form("ckbSthree"))
    strTthree = Trim(Request.Form("ckbTthree"))
    strUthree = Trim(Request.Form("ckbUthree"))
    strVthree = Trim(Request.Form("ckbVthree"))
    strWthree = Trim(Request.Form("ckbWthree"))
    strXthree = Trim(Request.Form("ckbXthree"))
    strYthree = Trim(Request.Form("ckbYthree"))
    strZthree = Trim(Request.Form("ckbZthree"))
    strAAthree = Trim(Request.Form("ckbAAthree"))
    strABthree = Trim(Request.Form("ckbABthree"))
    strACthree = Trim(Request.Form("ckbACthree"))
    strADthree = Trim(Request.Form("ckbADthree"))
    strAEthree = Trim(Request.Form("ckbAEthree"))
    strAFthree = Trim(Request.Form("ckbAFthree"))
    strAGthree = Trim(Request.Form("ckbAGthree"))
    strAHthree = Trim(Request.Form("ckbAHthree"))
    strAIthree = Trim(Request.Form("ckbAIthree"))
    strAJthree = Trim(Request.Form("ckbAJthree"))
    strAKthree = Trim(Request.Form("ckbAKthree"))
    strALthree = Trim(Request.Form("ckbALthree"))
    strAMthree = Trim(Request.Form("ckbAMthree"))
    strANthree = Trim(Request.Form("ckbANthree"))
    strAOthree = Trim(Request.Form("ckbAOthree"))
    strAPthree = Trim(Request.Form("ckbAPthree"))
    strAQthree = Trim(Request.Form("ckbAQthree"))
    strARthree = Trim(Request.Form("ckbARthree"))
    strASthree = Trim(Request.Form("ckbASthree"))
    strATthree = Trim(Request.Form("ckbATthree"))
    strAUthree = Trim(Request.Form("ckbAUthree"))
    strAVthree = Trim(Request.Form("ckbAVthree"))
    strAWthree = Trim(Request.Form("ckbAWthree"))
    strAXthree = Trim(Request.Form("ckbAXthree"))
    strAYthree = Trim(Request.Form("ckbAYthree"))
    strAZthree = Trim(Request.Form("ckbAZthree"))
    strAAAthree = Trim(Request.Form("ckbAAAthree"))
    strAABthree = Trim(Request.Form("ckbAABthree"))
    strAACthree = Trim(Request.Form("ckbAACthree"))
    strAADthree = Trim(Request.Form("ckbAADthree"))
    strAAEthree = Trim(Request.Form("ckbAAEthree"))
    strAAFthree = Trim(Request.Form("ckbAAFthree"))
    strAAGthree = Trim(Request.Form("ckbAAGthree"))
    strAAHthree = Trim(Request.Form("ckbAAHthree"))
    strAAIthree = Trim(Request.Form("ckbAAIthree"))
    strAAJthree = Trim(Request.Form("ckbAAJthree"))
    strAAKthree = Trim(Request.Form("ckbAAKthree"))
    strAALthree = Trim(Request.Form("ckbAALthree"))
    strAAMthree = Trim(Request.Form("ckbAAMthree"))
    strAANthree = Trim(Request.Form("ckbAANthree"))
    strAAOthree = Trim(Request.Form("ckbAAOthree"))
    strAAPthree = Trim(Request.Form("ckbAAPthree"))
    strAAQthree = Trim(Request.Form("ckbAAQthree"))
    strAARthree = Trim(Request.Form("ckbAARthree"))
    strAASthree = Trim(Request.Form("ckbAASthree"))
    strAATthree = Trim(Request.Form("ckbAATthree"))
    strAAUthree = Trim(Request.Form("ckbAAUthree"))
    strAAVthree = Trim(Request.Form("ckbAAVthree"))
    strAAWthree = Trim(Request.Form("ckbAAWthree"))
    strAAXthree = Trim(Request.Form("ckbAAXthree"))
    strAAYthree = Trim(Request.Form("ckbAAYthree"))
    strAAZthree = Trim(Request.Form("ckbAAZthree"))        


' Test the captcha field
Dim IsGoodCaptcha
IsGoodCaptcha = True

If Request.Form("txtPostBack") = "Yes" Then
	' This is a Post Back of the registration form.
  
  	strLast = Trim(Request.Form("txtLast"))
    
	' Test the captcha field
    Dim strCaptchaError
	
	Dim privateKey
    privateKey = "6LdXFQkAAAAAAFUm3Ry0zlzfBTPP8IAaYgsP6NzK"

    Dim VarString
    VarString = _
    	"privatekey=" & privateKey & _
		"&remoteip=" & Request.ServerVariables("REMOTE_ADDR") & _
		"&challenge=" & Request.Form("recaptcha_challenge_field") & _
		"&response=" & Request.Form("recaptcha_response_field")

    Dim objXmlHttp
    Set objXmlHttp = Server.CreateObject("Msxml2.ServerXMLHTTP")
    objXmlHttp.open "POST", "http://api-verify.recaptcha.net/verify",False
    objXmlHttp.setRequestHeader "Content-Type","application/x-www-form-urlencoded"
    objXmlHttp.send VarString

	Dim ResponseString
    ResponseString = split(objXmlHttp.responseText,vblf)
    Set objXmlHttp = Nothing
    if ResponseString(0) = "true" then
    	' User answered reCAPTCHA correctly - do input validation.
		IsGoodCaptcha = True
        strCaptchaError = ""
    ' End Recaptcha

    ' Server side input validation
    Dim strErrMsgHTML
    Dim intLenErrMsgHTML
    
	' First Name
	If strFirst = "" Then
		strErrMsgHTML = strErrMsgHTML & "Please enter your first name.<br />"
	End If	
    
	' Last Name
	If strLast = "" Then
		strErrMsgHTML = strErrMsgHTML & "Please enter your last name.<br />"
	End If
    
	' Organization
	If strOrganization = "" Then
		strErrMsgHTML = strErrMsgHTML & "Please enter an organization.<br />"
	End If
    
    ' County
	If strCounty = "**" Then
		strErrMsgHTML = strErrMsgHTML & "Please select a county.<br />"
	End If
    
    ' Address
	If strAddress = "" Then
		strErrMsgHTML = strErrMsgHTML & "Please enter an address.<br />"
	End If
    
    ' City
	If strCity = "" Then
		strErrMsgHTML = strErrMsgHTML & "Please enter a city.<br />"
	End If
    
    ' State
	If strState = "**" Then
		strErrMsgHTML = strErrMsgHTML & "Please select a state.<br />"
	End If
    
    ' Zip
	If strZip = "" Then
		strErrMsgHTML = strErrMsgHTML & "Please enter a zip code.<br />"
	End If
    
	' Email
	If strEmail = "" Then
		strErrMsgHTML = strErrMsgHTML & "Please enter an e-mail address.<br />"
	''ElseIf (Instr(1,strEmail,"@") = 0) Or (Instr(1,strEmail,".") = 0) Then
	Else
		Set objRegExp = New RegExp  'Create the RegExp object
		objRegExp.Pattern = "\w+([-+.']\w+)*@\w+([-.]\w+)*\.\w+([-.]\w+)*"              
		objRegExp.IgnoreCase = True
		If objRegExp.Test(strEmail) = False Then
			strErrMsgHTML = strErrMsgHTML & "Please enter a valid e-mail address.<br />"
		End If
	End If
        
	intLenErrMsgHTML = Len(strErrMsgHTML)
	If intLenErrMsgHTML = 0 Then
        Dim strMessageBody ' E-mail message body text with the user's responses to items on the form.
	    strMessageBody = "Name:" & vbCrLf & _
			vbTab & strFirst & " " & strLast & vbCrLf & _
	        "Organization:" & vbCrLf & _
	        vbTab & strOrganization & vbCrLf & _
            "County:" & vbCrLf & _
	        vbTab & strCounty & vbCrLf & _
            "Address:" & vbCrLf & _
	        vbTab & strAddress& vbCrLf & _
            "City:" & vbCrLf & _
	        vbTab & strCity & vbCrLf & _
            "State:" & vbCrLf & _
	        vbTab & strState & vbCrLf & _
            "Zip:" & vbCrLf & _
	        vbTab & strZip & vbCrLf & _
	        "Phone:" & vbCrLf & _
	        vbTab & strPhone & vbCrLf & _
	        "Email:" & vbCrLf & _
	        vbTab & strEmail & vbCrLf & _
            "Would you be willing to serve on Boards or Committees?" & vbCrLf & _
	        vbTab & strBoard & vbTab & strBoardtwo & vbCrLf & _
            "Do you self-identify as someone who has used mental health services?" & vbCrLf & _
	        vbTab & strService & vbTab & strServicetwo & vbCrLf & _
           "Do you self-identify as a family member of someone who has used services?" & vbCrLf & _
	        vbTab & strFamily & vbTab & strFamilytwo & vbCrLf & _
            vbCrLf & _
            "***** Clinical Issues *****" & vbCrLf & _
            vbCrLf & _
            "Advanced Directives: " & vbCrLf & _
            vbTab & strAone & vbTab & strAtwo & vbTab & strAthree & vbCrLf & _
	       "Child Welfare: " & vbCrLf & _
            vbTab & strBone & vbTab & strBtwo & vbTab & strBthree & vbCrLf & _
	        "Civil Commitment: " & vbCrLf & _
            vbTab & strCone & vbTab & strCtwo & vbTab & strCthree & vbCrLf & _
	        "Cultural Competence: " & vbCrLf & _
            vbTab & strDone & vbTab & strDtwo & vbTab & strDthree & vbCrLf & _
	        "Disaster Response: " & vbCrLf & _
            vbTab & strEone & vbTab & strEtwo & vbTab & strEthree & vbCrLf & _
	        "Electroconvulsive Therapy (ECT):" & vbCrLf & _
            vbTab & strFone & vbTab & strFtwo & vbTab & strFthree & vbCrLf & _
	        "Education:" & vbCrLf & _
            vbTab & strGone & vbTab & strGtwo & vbTab & strGthree & vbCrLf & _
	        "Elder Issues:" & vbCrLf & _
            vbTab & strHone & vbTab & strHtwo & vbTab & strHthree & vbCrLf & _
	        "Employment:" & vbCrLf & _
            vbTab & strIone & vbTab & strItwo & vbTab & strIthree & vbCrLf & _
	        "Forced Medication:" & vbCrLf & _
            vbTab & strJone & vbTab & strJtwo & vbTab & strJthree & vbCrLf & _
	        "Forensic:" & vbCrLf & _
            vbTab & strKone & vbTab & strKtwo & vbTab & strKthree & vbCrLf & _
	        "Gay/Lesbian/Bi/Transgender/Transexual Issues:" & vbCrLf & _
            vbTab & strLone & vbTab & strLtwo & vbTab & strLthree & vbCrLf & _
	        "Homelessness:" & vbCrLf & _
            vbTab & strMone & vbTab & strMtwo & vbTab & strMthree & vbCrLf & _
	        "Informed Consent:" & vbCrLf & _
            vbTab & strNone & vbTab & strNtwo & vbTab & strNthree & vbCrLf & _
	        "Literacy:" & vbCrLf & _
            vbTab & strOone & vbTab & strOtwo & vbTab & strOthree & vbCrLf & _
	        "Outreach:" & vbCrLf & _
            vbTab & strPone & vbTab & strPtwo & vbTab & strPthree & vbCrLf & _
	        "Participation in Treatment Planning:" & vbCrLf & _
            vbTab & strQone & vbTab & strQtwo & vbTab & strQthree & vbCrLf & _
	        "Restraint and Seclusion:" & vbCrLf & _
            vbTab & strRone & vbTab & strRtwo & vbTab & strRthree & vbCrLf & _
	        "Rural Issues:" & vbCrLf & _
            vbTab & strSone & vbTab & strStwo & vbTab & strSthree & vbCrLf & _
	        "Stigma:" & vbCrLf & _
            vbTab & strTone & vbTab & strTtwo & vbTab & strTthree & vbCrLf & _
	        "Tobacco Cessation/Reduction" & vbCrLf & _
            vbTab & strUone & vbTab & strUtwo & vbTab & strUthree & vbCrLf & _
	        "Training Development:" & vbCrLf & _
            vbTab & strVone & vbTab & strVtwo & vbTab & strVthree & vbCrLf & _
	        "Training CME/GRE:" & vbCrLf & _
            vbTab & strWone & vbTab & strWtwo & vbTab & strWthree & vbCrLf & _
	        "Transition Age Youth:" & vbCrLf & _
            vbTab & strXone & vbTab & strXtwo & vbTab & strXthree & vbCrLf & _
	        "Trauma:" & vbCrLf & _
            vbTab & strYone & vbTab & strYtwo & vbTab & strYthree & vbCrLf & _
	        "Treatment Compliance:" & vbCrLf & _
            vbTab & strZone & vbTab & strZtwo & vbTab & strZthree & vbCrLf & _
	        "Veterans Issues:" & vbCrLf & _
            vbTab & strAAone & vbTab & strAAtwo & vbTab & strAAthree & vbCrLf & _
	        "Women's Issues:" & vbCrLf & _
            vbTab & strABone & vbTab & strABtwo & vbTab & strABthree & vbCrLf & _
            vbCrLf & _
            "***** Entitlements *****" & vbCrLf & _
            vbCrLf & _
            "Social Security Administration Retirement:" & vbCrLf & _
            vbTab & strACone & vbTab & strACtwo & vbTab & strACthree & vbCrLf & _
            "Supplemental Security Income (SSI):" & vbCrLf & _
            vbTab & strADone & vbTab & strADtwo & vbTab & strADthree & vbCrLf & _
            "Social Security Disability Insurance (SSDI):" & vbCrLf & _
            vbTab & strAEone & vbTab & strAEtwo & vbTab & strAEthree & vbCrLf & _
            "Medicaid:" & vbCrLf & _
            vbTab & strAFone & vbTab & strAFtwo & vbTab & strAFthree & vbCrLf & _
            "Medicare:" & vbCrLf & _
            vbTab & strAGone & vbTab & strAGtwo & vbTab & strAGthree & vbCrLf & _
            "SSA Plan to Achieve Self-Sufficiency (PASS):" & vbCrLf & _
            vbTab & strAHone & vbTab & strAHtwo & vbTab & strAHthree & vbCrLf & _
            "SSA Impariment Related Work Expenses (IRWE):" & vbCrLf & _
            vbTab & strAIone & vbTab & strAItwo & vbTab & strAIthree & vbCrLf & _
            "1619B/1915B Extended Eligibility:" & vbCrLf & _
            vbTab & strAJone & vbTab & strAJtwo & vbTab & strAJthree & vbCrLf & _
            "Ticket to Work:" & vbCrLf & _
            vbTab & strAKone & vbTab & strAKtwo & vbTab & strAKthree & vbCrLf & _
            "Section 8 Vouchers:" & vbCrLf & _
            vbTab & strALone & vbTab & strALtwo & vbTab & strALthree & vbCrLf & _
            "Social Services:" & vbCrLf & _
            vbTab & strAMone & vbTab & strAMtwo & vbTab & strAMthree & vbCrLf & _
            "Aid to Families with Dependent Children (AFDC):" & vbCrLf & _
            vbTab & strANone & vbTab & strANtwo & vbTab & strANthree & vbCrLf & _
            "Energy Assistance:" & vbCrLf & _
            vbTab & strAOone & vbTab & strAOtwo & vbTab & strAOthree & vbCrLf & _
            "Enterprise Zones:" & vbCrLf & _
            vbTab & strAPone & vbTab & strAPtwo & vbTab & strAPthree & vbCrLf & _
            "Food Stamps:" & vbCrLf & _
            vbTab & strAQone & vbTab & strAQtwo & vbTab & strAQthree & vbCrLf & _
            "Temporary Assistance/Special Needs Accounts:" & vbCrLf & _
            vbTab & strARone & vbTab & strARtwo & vbTab & strARthree & vbCrLf & _
            "Veterans Benefits:" & vbCrLf & _
            vbTab & strASone & vbTab & strAStwo & vbTab & strASthree & vbCrLf & _
            "Workforce Investment Act:" & vbCrLf & _
            vbTab & strATone & vbTab & strATtwo & vbTab & strATthree & vbCrLf & _
            vbCrLf & _
            "***** Evidence Based Practices *****" & vbCrLf & _
            vbCrLf & _
            "Assertive Community Treatment (ACT):" & vbCrLf & _
            vbTab & strAUone & vbTab & strAUtwo & vbTab & strAUthree & vbCrLf & _
            "Family Psycho-Education:" & vbCrLf & _
            vbTab & strAVone & vbTab & strAVtwo & vbTab & strAVthree & vbCrLf & _
            "Integrated Treatment Co-occuring Disorders:" & vbCrLf & _
            vbTab & strAWone & vbTab & strAWtwo & vbTab & strAWthree & vbCrLf & _
            "Intensive Case Management (ICM):" & vbCrLf & _
            vbTab & strAXone & vbTab & strAXtwo & vbTab & strAXthree & vbCrLf & _
            "Medication:" & vbCrLf & _
            vbTab & strAYone & vbTab & strAYtwo & vbTab & strAYthree & vbCrLf & _
            "Post Traumatic Stress Disorder Treatment:" & vbCrLf & _
            vbTab & strAZone & vbTab & strAZtwo & vbTab & strAZthree & vbCrLf & _
            "Supported Employment:" & vbCrLf & _
            vbTab & strAAAone & vbTab & strAAAtwo & vbTab & strAAAthree & vbCrLf & _
            "Self-Help Peer Support Services:" & vbCrLf & _
            vbTab & strAABone & vbTab & strAABtwo & vbTab & strAABthree & vbCrLf & _
            "Wellness Self-Management:" & vbCrLf & _
            vbTab & strAACone & vbTab & strAACtwo & vbTab & strAACthree & vbCrLf & _
            "Childrens: EB Prescribing Practices:" & vbCrLf & _
            vbTab & strAADone & vbTab & strAADtwo & vbTab & strAADthree & vbCrLf & _
            "Childrens: Family Ed. and Support Services:" & vbCrLf & _
            vbTab & strAAEone & vbTab & strAAEtwo & vbTab & strAAEthree & vbCrLf & _
            "Childrens: Functional Family Therapy:" & vbCrLf & _
            vbTab & strAAFone & vbTab & strAAFtwo & vbTab & strAAFthree & vbCrLf & _
            "Childrens: Homes Based Crisis Intervention:" & vbCrLf & _
            vbTab & strAAGone & vbTab & strAAGtwo & vbTab & strAAGthree & vbCrLf & _
            "Childrens: Home & Community Based Services:" & vbCrLf & _
            vbTab & strAAHone & vbTab & strAAHtwo & vbTab & strAAHthree & vbCrLf & _
            "Childrens: Intensive Case Management (ICM):" & vbCrLf & _
            vbTab & strAAIone & vbTab & strAAItwo & vbTab & strAAIthree & vbCrLf & _
            "Childrens: School Based Mental Health Services:" & vbCrLf & _
            vbTab & strAAJone & vbTab & strAAJtwo & vbTab & strAAJthree & vbCrLf & _
            "Childrens: PTSD Treatment:" & vbCrLf & _
            vbTab & strAAKone & vbTab & strAAKtwo & vbTab & strAAKthree & vbCrLf & _
            vbCrLf & _
            "***** Other Issues of Importance *****" & vbCrLf & _
            vbCrLf & _
            "Child Custody / Parental Rights:" & vbCrLf & _
            vbTab & strAALone & vbTab & strAALtwo & vbTab & strAALthree & vbCrLf & _
            "Confidentiality:" & vbCrLf & _
            vbTab & strAAMone & vbTab & strAAMtwo & vbTab & strAAMthree & vbCrLf & _
            "Consumer/Survivor/Ex-Patients as staff:" & vbCrLf & _
            vbTab & strAANone & vbTab & strAANtwo & vbTab & strAANthree & vbCrLf & _
            "Creative Arts:" & vbCrLf & _
            vbTab & strAAOone & vbTab & strAAOtwo & vbTab & strAAOthree & vbCrLf & _
            "Cross Disability Issues:" & vbCrLf & _
            vbTab & strAAPone & vbTab & strAAPtwo & vbTab & strAAPthree & vbCrLf & _
            "Family Issues:" & vbCrLf & _
            vbTab & strAAQone & vbTab & strAAQtwo & vbTab & strAAQthree & vbCrLf & _
            "Involuntary Treatment:" & vbCrLf & _
            vbTab & strAARone & vbTab & strAARtwo & vbTab & strAARthree & vbCrLf & _
            "Mental Health Insurance Parity:" & vbCrLf & _
            vbTab & strAASone & vbTab & strAAStwo & vbTab & strAASthree & vbCrLf & _
            "Parenting Skills:" & vbCrLf & _
            vbTab & strAATone & vbTab & strAATtwo & vbTab & strAATthree & vbCrLf & _
            "Public Relations:" & vbCrLf & _
            vbTab & strAAUone & vbTab & strAAUtwo & vbTab & strAAUthree & vbCrLf & _
            "Rights Protection:" & vbCrLf & _
            vbTab & strAAVone & vbTab & strAAVtwo & vbTab & strAAVthree & vbCrLf & _
            "Self-Help Alternatives:" & vbCrLf & _
            vbTab & strAAWone & vbTab & strAAWtwo & vbTab & strAAWthree & vbCrLf & _
            "Suicide:" & vbCrLf & _
            vbTab & strAAXone & vbTab & strAAXtwo & vbTab & strAAXthree & vbCrLf & _
            "Transportation:" & vbCrLf & _
            vbTab & strAAYone & vbTab & strAAYtwo & vbTab & strAAYthree & vbCrLf & _
            "Voter Registration:" & vbCrLf & _
            vbTab & strAAZone & vbTab & strAAZtwo & vbTab & strAAZthree

       Dim objCdoConfig
        Set objCdoConfig = CreateObject("CDO.Configuration")
        With objCdoConfig.Fields
	        .Item(cdoSendUsingMethod) = cdoSendUsingPort
	        .Item(cdoSMTPServer) = "mailscan.omh.ny.gov"
	        .Update
        End With
		Set objMail = Server.CreateObject("CDO.Message")
		Set objMail.Configuration = objCdoConfig
		objMail.From = "webunit@omh.ny.gov"
		objMail.To = "Recipientaffairs@omh.ny.gov"
		objMail.Subject = "Mail List Form Response"
		objMail.TextBody = strMessageBody
		objMail.Send
		Set objMail = Nothing
		Set objCdoConfig = Nothing

		' Display thank you page.
		Response.Redirect("thankyou.html")
	Else
		' Input is not valid, display the page along with a message.
	End If 
	
	      Else
                ' User answered reCAPTCHA incorrectly.
                IsGoodCaptcha = False
                strCaptchaError = "&error=" & ResponseString(1)               
      End If 
	
End If
%>
<!DOCTYPE html PUBLIC "-//W3C//DTD XHTML 1.0 Transitional//EN" "http://www.w3.org/TR/xhtml1/DTD/xhtml1-transitional.dtd">
<html xmlns="http://www.w3.org/1999/xhtml" xml:lang="en-US" lang="en-US">
<head>
<meta http-equiv="X-UA-Compatible" content="IE=edge">
<meta charset="utf-8">

<link rel="stylesheet" href="/omhweb/common/main.css" type="text/css" />
<title>Mail List Form</title>
<script type="text/javascript">
<!--
function initialize() {
<%If intLenErrMsgHTML > 0 Then%>
	document.getElementById('spnReset').innerHTML = '<input type="reset" id="btnReset" name="btnReset" value="Clear Form" onclick="clearErrorMsg()" />';
<%End If%>
	document.form.reset();
		document.getElementById("txtLast").focus();
<%If IsGoodCaptcha = False Then%>	document.getElementById('recaptcha_response_field').focus();<%End If%>
}
		
function Trim$(stringValue) {
	//	Function to Trim a String 
	//	using the regular expression feature of Javascript. 
	return stringValue.replace(/^\s+/g, '').replace(/\s+$/g, '');
}

function validateInput() {
	//	Function to validate input
	//	Validate controls in the reverse order of data entry.
	//	Set focus to control that fails, so that the first field having 
	//	an invalid entry will have the focus at the end of validation.

	var strErrMsgHTML = '';

	// Email
	var strEmail = '';
	strEmail = document.getElementById('txtEmail').value;
	var strEmailMatch = strEmail.match(/\w+([-+.']\w+)*@\w+([-.]\w+)*\.\w+([-.]\w+)*/);	                                   
	if (Trim$(strEmail) == '') {
		strErrMsgHTML = 'Please enter an e-mail address.<br />' + strErrMsgHTML;
		document.getElementById('txtEmail').focus(); 
	}  else if (strEmailMatch == null){
		strErrMsgHTML = "Please enter a valid e-mail address.<br />" + strErrMsgHTML;
		document.getElementById("txtEmail").focus(); }
	
	// Zip
	var strZip = '';
	strZip = document.getElementById('txtZip').value;
	if (strZip == '') {
		strErrMsgHTML = 'Please enter a zip code.<br />' + strErrMsgHTML;
		document.getElementById('txtZip').focus(); 
	} 
	
	
			// State
	var strState = '';
	strState = document.getElementById('ddState').value;
	if (strState == '**') {
		strErrMsgHTML = 'Please selecta state.<br />' + strErrMsgHTML;
		document.getElementById('ddState').focus(); 
	} 
	
	
		// City
	var strCity = '';
	strCity = document.getElementById('txtCity').value;
	if (strCity == '') {
		strErrMsgHTML = 'Please enter a city.<br />' + strErrMsgHTML;
		document.getElementById('txtCity').focus(); 
	} 
	
	// Address
	var strAddress = '';
	strAddress = document.getElementById('txtAddress').value;
	if (strAddress == '') {
		strErrMsgHTML = 'Please enter an address.<br />' + strErrMsgHTML;
		document.getElementById('txtAddress').focus(); 
	} 
	
		// County
	var strCounty = '**';
	strCounty = document.getElementById('ddCounty').value;
	if (strCounty == '**') {
		strErrMsgHTML = 'Pleaseselect a county.<br />' + strErrMsgHTML;
		document.getElementById('ddCounty').focus(); 
	} 
	
	// Organization
	var strOrganization = '';
	strOrganization = document.getElementById('txtOrganization').value;
	if (strOrganization == '') {
		strErrMsgHTML = 'Please enter an organization.<br />' + strErrMsgHTML;
		document.getElementById('txtOrganization').focus(); 
	} 
	// Last Name
	var strLast = '';
	strLast = document.getElementById('txtLast').value;
	if (Trim$(strLast) == '') {
		strErrMsgHTML = 'Please enter your last name.<br />' + strErrMsgHTML;
		document.getElementById('txtLast').focus(); 
	} 
	// First Name
	var strFirst = '';
	strFirst = document.getElementById('txtFirst').value;
	if (Trim$(strFirst) == '') {
		strErrMsgHTML = 'Please enter your first name.<br />' + strErrMsgHTML;
		document.getElementById('txtFirst').focus(); 
	} 
	if (strErrMsgHTML.length > 0) {
		document.getElementById('spnError').innerHTML = strErrMsgHTML;
		return false; 
	} else {
		// Clear Error Messages
		clearErrorMsg();
		// Display 'Please wait...' message
		document.getElementById('spnStatus').innerHTML = 'Please wait... Submitting.';
		// Submit
		return true; 
	}
}
function clearErrorMsg() {
	// Clear Error Messages
	document.getElementById('spnError').innerHTML = '';
}

-->
</script>

<!---set theme option  to custom-->
 <script type="text/javascript">
 var RecaptchaOptions = {
    theme : 'custom',
    custom_theme_widget: 'recaptcha_widget'
 };
 </script>

  <!--#include virtual="/omhweb/common/google.asp"-->
</head>
<body onload="initialize()">
<!--#include virtual="/omhweb/common/top_subpage_acc.asp"-->
<h1 class="pageTitle">Consumer Survey</h1>
<p> Completing this form will enable the Office of Consumer Affairs to prioritize issues for a recipient and family
  agenda, identify individuals like you who may be a resource to aid in policy and other discussions, and identify
  information and resource needs that exist.</p>
<p>Fields in <strong>bold</strong> are required. Place a check  in each column next to each issue that you feel is appropriate. You may check more then one box
  for each issue. Once finished click on the &quot;Submit&quot; button located at the bottom of the page.</p>
<div style="border:medium; border-style:outset; width:70%; padding:.5em; margin-left:18%; margin-right:auto;">
<form action="" method="post" name="form" id="form" onsubmit="return validateInput();">
  <input id="txtPostBack" type="hidden" name="txtPostBack" value="Yes" />
  <p>
    <label for="txtFirst"><strong><acronym title="required">First Name</acronym></strong></label>
    <br />
    <input type="text" id="txtFirst" name="txtFirst"  value="<%=Server.HTMLEncode(strFirst)%>" size="40" />
  </p>
  <p>
    <label for="txtLast"><strong><acronym title="required">Last Name</acronym></strong> </label>
    <br />
    <input type="text" id="txtLast" name="txtLast"  value="<%=Server.HTMLEncode(strLast)%>" size="40" />
  </p>
  <p>
    <label for="txtOrganization"><strong><acronym title="required">Organization</acronym></strong></label>
    <br />
    <input type="text" id="txtOrganization" name="txtOrganization" value="<%=Server.HTMLEncode(strOrganization)%>" size="80" />
  </p>
  <p>
    <label for="ddCounty"><strong><acronym title="required">County</acronym></strong></label>
    <br />
    <select id="ddCounty" name="ddCounty" size="1" onchange="ddCounty_onClick()">
      <option value="**"<%If strCounty="**" Then Response.Write(strSelected)%>>Select a County</option>
      <option value="Albany County"<%If strCounty="Albany County" Then Response.Write(strSelected)%>>Albany County</option>
      <option value="Allegany County"<%If strCounty="Allegany County" Then Response.Write(strSelected)%>>Allegany County</option>
      <option value="Bronx County"<%If strCounty="Bronx County" Then Response.Write(strSelected)%>>Bronx County</option>
      <option value="Broome County"<%If strCounty="Broome County" Then Response.Write(strSelected)%>>Broome County</option>
      <option value="Cattaraugus County"<%If strCounty="Cattaraugus County" Then Response.Write(strSelected)%>>Cattaraugus County</option>
      <option value="Cayuga County"<%If strCounty="Cayuga County" Then Response.Write(strSelected)%>>Cayuga County</option>
      <option value="Chautauqua County"<%If strCounty="Chautauqua County" Then Response.Write(strSelected)%>>Chautauqua County</option>
      <option value="Chemung County"<%If strCounty="Chemung County" Then Response.Write(strSelected)%>>Chemung County</option>
      <option value="Chenango County"<%If strCounty="Chenango County" Then Response.Write(strSelected)%>>Chenango County</option>
      <option value="Clinton County"<%If strCounty="Clinton County" Then Response.Write(strSelected)%>>Clinton County</option>
      <option value="Columbia County"<%If strCounty="Columbia County" Then Response.Write(strSelected)%>>Columbia County</option>
      <option value="Cortland County"<%If strCounty="Cortland County" Then Response.Write(strSelected)%>>Cortland County</option>
      <option value="Delaware County"<%If strCounty="Delaware County" Then Response.Write(strSelected)%>>Delaware County</option>
      <option value="Dutchess County"<%If strCounty="Dutchess County" Then Response.Write(strSelected)%>>Dutchess County</option>
      <option value="Erie County"<%If strCounty="Erie County" Then Response.Write(strSelected)%>>Erie County</option>
      <option value="Essex County"<%If strCounty="Essex County" Then Response.Write(strSelected)%>>Essex County</option>
      <option value="Franklin County"<%If strCounty="Franklin County" Then Response.Write(strSelected)%>>Franklin County</option>
      <option value="Fulton County"<%If strCounty="Fulton County" Then Response.Write(strSelected)%>>Fulton County</option>
      <option value="Genesee County"<%If strCounty="Genesee County" Then Response.Write(strSelected)%>>Genesee County</option>
      <option value="Greene County"<%If strCounty="Greene County" Then Response.Write(strSelected)%>>Greene County</option>
      <option value="Hamilton County"<%If strCounty="Hamilton County" Then Response.Write(strSelected)%>>Hamilton County</option>
      <option value="Herkimer County"<%If strCounty="Herkimer County" Then Response.Write(strSelected)%>>Herkimer County</option>
      <option value="Jefferson County"<%If strCounty="Jefferson County" Then Response.Write(strSelected)%>>Jefferson County</option>
      <option value="Kings County"<%If strCounty="Kings County" Then Response.Write(strSelected)%>>Kings County</option>
      <option value="Lewis County"<%If strCounty="Lewis County" Then Response.Write(strSelected)%>>Lewis County</option>
      <option value="Livingston County"<%If strCounty="Livingston County" Then Response.Write(strSelected)%>>Livingston County</option>
      <option value="Madison County"<%If strCounty="Madison County" Then Response.Write(strSelected)%>>Madison County</option>
      <option value="Monroe County"<%If strCounty="Monroe County" Then Response.Write(strSelected)%>>Monroe County</option>
      <option value="Montgomery County"<%If strCounty="Montgomery County" Then Response.Write(strSelected)%>>Montgomery County</option>
      <option value="Nassau County"<%If strCounty="Nassau County" Then Response.Write(strSelected)%>>Nassau County</option>
      <option value="New York City"<%If strCounty="New York City" Then Response.Write(strSelected)%>>New York City</option>
      <option value="Niagara County"<%If strCounty="Niagara County" Then Response.Write(strSelected)%>>Niagara County</option>
      <option value="Oneida County"<%If strCounty="Oneida County" Then Response.Write(strSelected)%>>Oneida County</option>
      <option value="Onondaga County"<%If strCounty="Onondaga County" Then Response.Write(strSelected)%>>Onondaga County</option>
      <option value="Ontario County"<%If strCounty="Ontario County" Then Response.Write(strSelected)%>>Ontario County</option>
      <option value="Orange County"<%If strCounty="Orange County" Then Response.Write(strSelected)%>>Orange County</option>
      <option value="Orleans County"<%If strCounty="Orleans County" Then Response.Write(strSelected)%>>Orleans County</option>
      <option value="Oswego County"<%If strCounty="Oswego County" Then Response.Write(strSelected)%>>Oswego County</option>
      <option value="Otsego County"<%If strCounty="Otsego County" Then Response.Write(strSelected)%>>Otsego County</option>
      <option value="Putnam County"<%If strCounty="Putnam County" Then Response.Write(strSelected)%>>Putnam County</option>
      <option value="Queens County"<%If strCounty="Queens County" Then Response.Write(strSelected)%>>Queens County</option>
      <option value="Rensselaer County"<%If strCounty="Rensselaer County" Then Response.Write(strSelected)%>>Rensselaer County</option>
      <option value="Richmond County"<%If strCounty="Richmond County" Then Response.Write(strSelected)%>>Richmond County</option>
      <option value="Rockland County"<%If strCounty="Rockland County" Then Response.Write(strSelected)%>>Rockland County</option>
      <option value="St. Lawrence County"<%If strCounty="St. Lawrence County" Then Response.Write(strSelected)%>>St. Lawrence County</option>
      <option value="Saratoga County"<%If strCounty="Saratoga County" Then Response.Write(strSelected)%>>Saratoga County</option>
      <option value="Schenectady County"<%If strCounty="Schenectady County" Then Response.Write(strSelected)%>>Schenectady County</option>
      <option value="Schoharie County"<%If strCounty="Schoharie County" Then Response.Write(strSelected)%>>Schoharie County</option>
      <option value="Schuyler County"<%If strCounty="Schuyler County" Then Response.Write(strSelected)%>>Schuyler County</option>
      <option value="Seneca County"<%If strCounty="Seneca County" Then Response.Write(strSelected)%>>Seneca County</option>
      <option value="Steuben County"<%If strCounty="Steuben County" Then Response.Write(strSelected)%>>Steuben County</option>
      <option value="Suffolk County"<%If strCounty="Suffolk County" Then Response.Write(strSelected)%>>Suffolk County</option>
      <option value="Sullivan County"<%If strCounty="Sullivan County" Then Response.Write(strSelected)%>>Sullivan County</option>
      <option value="Tioga County"<%If strCounty="Tioga County" Then Response.Write(strSelected)%>>Tioga County</option>
      <option value="Tompkins County"<%If strCounty="Tompkins County" Then Response.Write(strSelected)%>>Tompkins County</option>
      <option value="Ulster County"<%If strCounty="Ulster County" Then Response.Write(strSelected)%>>Ulster County</option>
      <option value="Warren County"<%If strCounty="Warren County" Then Response.Write(strSelected)%>>Warren County</option>
      <option value="Washington County"<%If strCounty="Washington County" Then Response.Write(strSelected)%>>Washington County</option>
      <option value="Wayne County"<%If strCounty="Wayne County" Then Response.Write(strSelected)%>>Wayne County</option>
      <option value="Westchester County"<%If strCounty="Westchester County" Then Response.Write(strSelected)%>>Westchester County</option>
      <option value="Wyoming County"<%If strCounty="Wyoming County" Then Response.Write(strSelected)%>>Wyoming County</option>
      <option value="Yates County"<%If strCounty="Yates County" Then Response.Write(strSelected)%>>Yates County</option>
    </select>
  </p>
  <p>
    <label for="txtAddress"><strong><acronym title="required">Address</acronym></strong></label>
    <br />
    <input type="text" id="txtAddress" name="txtAddress" value="<%=Server.HTMLEncode(strAddress)%>" size="80" />
  </p>
  <p>
    <label for="txtCity"><strong><acronym title="required">City</acronym></strong></label>
    <br />
    <input type="text" id="txtCity" name="txtCity" value="<%=Server.HTMLEncode(strCity)%>" size="80" />
  </p>
  <p>
    <label for="ddState"><strong><acronym title="required">State</acronym></strong></label>
    <br />
    <select id="ddState" name="ddState" size="1" onchange="ddState_onClick()">
      <option value="**"<%If strState="**" Then Response.Write(strSelected)%>>Select a State</option>
      <option value="Alaska"<%If strState="Alaska" Then Response.Write(strSelected)%>>Alaska</option>
      <option value="Arizona"<%If strState="Arizona" Then Response.Write(strSelected)%>>Arizona</option>
      <option value="Arkansas"<%If strState="Arkansas" Then Response.Write(strSelected)%>>Arkansas</option>
      <option value="California"<%If strState="California" Then Response.Write(strSelected)%>>California</option>
      <option value="Colorado"<%If strState="Colorado" Then Response.Write(strSelected)%>>Colorado</option>
      <option value="Connecticut"<%If strState="Connecticut" Then Response.Write(strSelected)%>>Connecticut</option>
      <option value="Delaware"<%If strState="Delaware" Then Response.Write(strSelected)%>>Delaware</option>
      <option value="District of Columbia"<%If strState="District of Columbia" Then Response.Write(strSelected)%>>District of Columbia</option>
      <option value="Florida"<%If strState="Florida" Then Response.Write(strSelected)%>>Florida</option>
      <option value="Georgia"<%If strState="Georgia" Then Response.Write(strSelected)%>>Georgia</option>
      <option value="Hawaii"<%If strState="Hawaii" Then Response.Write(strSelected)%>>Hawaii</option>
      <option value="Idaho"<%If strState="Idaho" Then Response.Write(strSelected)%>>Idaho</option>
      <option value="Illinois"<%If strState="Illinois" Then Response.Write(strSelected)%>>Illinois</option>
      <option value="Indiana"<%If strState="Indiana" Then Response.Write(strSelected)%>>Indiana</option>
      <option value="Iowa"<%If strState="Iowa" Then Response.Write(strSelected)%>>Iowa</option>
      <option value="Kansas"<%If strState="Kansas" Then Response.Write(strSelected)%>>Kansas</option>
      <option value="Kentucky"<%If strState="Kentucky" Then Response.Write(strSelected)%>>Kentucky</option>
      <option value="Louisiana"<%If strState="Louisiana" Then Response.Write(strSelected)%>>Louisiana</option>
      <option value="Maine"<%If strState="Maine" Then Response.Write(strSelected)%>>Maine</option>
      <option value="Maryland"<%If strState="Maryland" Then Response.Write(strSelected)%>>Maryland</option>
      <option value="Massachusetts"<%If strState="Massachusetts" Then Response.Write(strSelected)%>>Massachusetts</option>
      <option value="Michigan"<%If strState="Michigan" Then Response.Write(strSelected)%>>Michigan</option>
      <option value="Minnesota"<%If strState="Minnesota" Then Response.Write(strSelected)%>>Minnesota</option>
      <option value="Mississippi"<%If strState="Mississippi" Then Response.Write(strSelected)%>>Mississippi</option>
      <option value="Missouri"<%If strState="Missouri" Then Response.Write(strSelected)%>>Missouri</option>
      <option value="Montana"<%If strState="Montana" Then Response.Write(strSelected)%>>Montana</option>
      <option value="Nebraska"<%If strState="Nebraska" Then Response.Write(strSelected)%>>Nebraska</option>
      <option value="Nevada"<%If strState="Nevada" Then Response.Write(strSelected)%>>Nevada</option>
      <option value="New Hampshire"<%If strState="New Hampshire" Then Response.Write(strSelected)%>>New Hampshire</option>
      <option value="New Jersey"<%If strState="New Jersey" Then Response.Write(strSelected)%>>New Jersey</option>
      <option value="New Mexico"<%If strState="New Mexico" Then Response.Write(strSelected)%>>New Mexico</option>
      <option value="New York"<%If strState="New York" Then Response.Write(strSelected)%>>New York</option>
      <option value="North Carolina"<%If strState="North Carolina" Then Response.Write(strSelected)%>>North Carolina</option>
      <option value="North Dakota"<%If strState="North Dakota" Then Response.Write(strSelected)%>>North Dakota</option>
      <option value="Ohio"<%If strState="Ohio" Then Response.Write(strSelected)%>>Ohio</option>
      <option value="Oklahoma"<%If strState="Oklahoma" Then Response.Write(strSelected)%>>Oklahoma</option>
      <option value="Oregon"<%If strState="Oregon" Then Response.Write(strSelected)%>>Oregon</option>
      <option value="Pennsylvania"<%If strState="Pennsylvania" Then Response.Write(strSelected)%>>Pennsylvania</option>
      <option value="Rhode Island"<%If strState="Rhode Island" Then Response.Write(strSelected)%>>Rhode Island</option>
      <option value="South Carolina"<%If strState="South Carolina" Then Response.Write(strSelected)%>>South Carolina</option>
      <option value="South Dakota"<%If strState="South Dakota" Then Response.Write(strSelected)%>>South Dakota</option>
      <option value="Tennessee"<%If strState="Tennessee" Then Response.Write(strSelected)%>>Tennessee</option>
      <option value="Texas"<%If strState="Texas" Then Response.Write(strSelected)%>>Texas</option>
      <option value="Utah"<%If strState="Utah" Then Response.Write(strSelected)%>>Utah</option>
      <option value="Vermont"<%If strState="Vermont" Then Response.Write(strSelected)%>>Vermont</option>
      <option value="Virginia"<%If strState="Virginia" Then Response.Write(strSelected)%>>Virginia</option>
      <option value="Washington"<%If strState="Washington" Then Response.Write(strSelected)%>>Washington</option>
      <option value="West Virginia"<%If strState="West Virginia" Then Response.Write(strSelected)%>>West Virginia</option>
      <option value="Wisconsin"<%If strState="Wisconsin" Then Response.Write(strSelected)%>>Wisconsin</option>
      <option value="Wyoming"<%If strState="Wyoming" then response.write "selected=""selected""" end if%>>Wyoming</option>
    </select>
  </p>
  <p>
    <label for="txtZip"><strong><acronym title="required">Zip</acronym></strong></label>
    <br />
    <input type="text" id="txtZip" name="txtZip" value="<%=Server.HTMLEncode(strZip)%>" size="20" />
  </p>
  <p>
    <label for="txtPhone">Telephone Number</label>
    <br />
    <input type="text" id="txtPhone" name="txtPhone" value="<%=Server.HTMLEncode(strPhone)%>"  size="80"/>
  </p>
  <p>
    <label for="txtEmail"><strong><acronym title="required">E-mail Address</acronym></strong></label>
    <br />
    <input type="text" id="txtEmail" name="txtEmail" value="<%=Server.HTMLEncode(strEmail)%>" size="80" />
  </p>
  <table summary="questions" width="90%" border="0">
    <tr>
      <td scope="row" style="text-align:left;">Would you be willing to serve on Boards or Committees?</td>
      <td><label for="ckbBoard">
          <input type="checkbox" id="ckbBoard" name="ckbBoard" value="yes" <%If strBoard = "yes" Then Response.Write(strChecked)%>/>
          Yes</label></td>
      <td><label for="ckbBoardtwo">
          <input type="checkbox" id="ckbBoardtwo" name="ckbBoardtwo" <%If strBoardtwo="no" Then Response.Write(strChecked)%>value="no" />
          No</label></td>
    </tr>
    <tr>
      <td scope="row" style="text-align:left;">Do you self-identify as someone who has used mental health services?</td>
      <td><label for="ckbService">
          <input type="checkbox" id="ckbService" name="ckbService" <%If strService="yes" Then Response.Write(strChecked)%>value="yes" />
          Yes</label></td>
      <td><label for="ckbServicetwo">
          <input type="checkbox" id="ckbServicetwo" name="ckbServicetwo" <%If strServicetwo="no" Then Response.Write(strChecked)%>value="no" />
          No</label></td>
    </tr>
    <tr>
      <td scope="row" style="text-align:left;">Do you self-identify as a family member of someone who has used services?</td>
      <td><label for="ckbFamily">
          <input type="checkbox" id="ckbFamily" name="ckbFamily" <%If strFamily="yes" Then Response.Write(strChecked)%>value="yes" />
          Yes</label></td>
      <td><label for="ckbFamilytwo">
          <input type="checkbox" id="ckbFamilytwo" name="ckbFamilytwo" <%If strFamilytwo="no" Then Response.Write(strChecked)%>value="no" />
          No</label></td>
    </tr>
  </table>
  <p style="text-align:center;"><strong>Clinical Issues</strong></p>
  <table border="1" cellspacing="0" cellpadding="0" summary="Survey Questions" width="90%" style="margin-left:auto; margin-right:auto; text-align:center; margin-top:15px;">
    <tr>
      <th scope="col">Issues</th>
      <th scope="col">Would like more<br />
        information on<br />
        this issue</th>
      <th scope="col">Would like to be<br />
        involved with<br />
        this issue</th>
      <th scope="col">Thinks this issue<br />
        is very important</th>
    </tr>
    <tr>
      <td scope="row" style="text-align:left;"><label for="ckbA">Advanced Directives</label></td>
      <td><input type="checkbox" name="ckbAone" id="ckbAone" <%If strAone="more information" Then Response.Write(strChecked)%>value="more information" /></td>
      <td><input type="checkbox" name="ckbAtwo" id="ckbAtwo" <%If strAtwo="be involved" Then Response.Write(strChecked)%>value="be involved" /></td>
      <td><input type="checkbox" name="ckbAthree" id="ckbAthree" <%If strAthree="very important" Then Response.Write(strChecked)%>value="very important" /></td>
    </tr>
    <tr>
      <td scope="row" style="text-align:left;"><label for="ckbB">Child Welfare</label></td>
      <td><input type="checkbox" name="ckbBone" id="ckbBone" <%If strBone="more information" Then Response.Write(strChecked)%>value="more information" /></td>
      <td><input type="checkbox" name="ckbBtwo" id="ckbBtwo" <%If strBtwo="be involved" Then Response.Write(strChecked)%>value="be involved" /></td>
      <td><input type="checkbox" name="ckbBthree" id="ckbBthree" <%If strBthree="very important" Then Response.Write(strChecked)%>value="very important" /></td>
    </tr>
    <tr>
      <td scope="row" style="text-align:left;"><label for="ckbC">Civil Commitment</label></td>
      <td><input type="checkbox" name="ckbCone" id="ckbCone" <%If strCone="more information" Then Response.Write(strChecked)%>value="more information" /></td>
      <td><input type="checkbox" name="ckbCtwo" id="ckbCtwo" <%If strCtwo="be involved" Then Response.Write(strChecked)%>value="be involved" /></td>
      <td><input type="checkbox" name="ckbCthree" id="ckbCthree" <%If strCthree="very important" Then Response.Write(strChecked)%>value="very important" /></td>
    </tr>
    <tr>
      <td scope="row" style="text-align:left;"><label for="ckbD">Cultural Competence</label></td>
      <td><input type="checkbox" name="ckbDone" id="ckbDone" <%If strDone="more information" Then Response.Write(strChecked)%>value="more information" /></td>
      <td><input type="checkbox" name="ckbDtwo" id="ckbDtwo" <%If strDtwo="be involved" Then Response.Write(strChecked)%>value="be involved" /></td>
      <td><input type="checkbox" name="ckbDthree" id="ckbDthree" <%If strDthree="very important" Then Response.Write(strChecked)%>value="very important" /></td>
    </tr>
    <tr>
      <td scope="row" style="text-align:left;"><label for="ckbE">Disaster Response</label></td>
      <td><input type="checkbox" name="ckbEone" id="ckbEone" <%If strEone="more information" Then Response.Write(strChecked)%>value="more information" /></td>
      <td><input type="checkbox" name="ckbEtwo" id="ckbEtwo" <%If strEtwo="be involved" Then Response.Write(strChecked)%>value="be involved" /></td>
      <td><input type="checkbox" name="ckbEthree" id="ckbEthree" <%If strEthree="very important" Then Response.Write(strChecked)%>value="very important" /></td>
    </tr>
    <tr>
      <td scope="row" style="text-align:left;"><label for="ckbF">Electroconvulsive Therapy (ECT)</label></td>
      <td><input type="checkbox" name="ckbFone" id="ckbFone" <%If strFone="more information" Then Response.Write(strChecked)%>value="more information" /></td>
      <td><input type="checkbox" name="ckbFtwo" id="ckbFtwo" <%If strFtwo="be involved" Then Response.Write(strChecked)%>value="be involved" /></td>
      <td><input type="checkbox" name="ckbFthree" id="ckbFthree" <%If strFthree="very important" Then Response.Write(strChecked)%>value="very important" /></td>
    </tr>
    <tr>
      <td scope="row" style="text-align:left;"><label for="ckbG">Education</label></td>
      <td><input type="checkbox" name="ckbGone" id="ckbGone" <%If strGone="more information" Then Response.Write(strChecked)%>value="more information" /></td>
      <td><input type="checkbox" name="ckbGtwo" id="ckbGtwo" <%If strGtwo="be involved" Then Response.Write(strChecked)%>value="be involved" /></td>
      <td><input type="checkbox" name="ckbGthree" id="ckbGthree" <%If strGthree="very important" Then Response.Write(strChecked)%>value="very important" /></td>
    </tr>
    <tr>
      <td scope="row" style="text-align:left;"><label for="ckbH">Elder Issues</label></td>
      <td><input type="checkbox" name="ckbHone" id="ckbHone" <%If strHone="more information" Then Response.Write(strChecked)%>value="more information" /></td>
      <td><input type="checkbox" name="ckbHtwo" id="ckbHtwo" <%If strHtwo="be involved" Then Response.Write(strChecked)%>value="be involved" /></td>
      <td><input type="checkbox" name="ckbHthree" id="ckbHthree" <%If strHthree="very important" Then Response.Write(strChecked)%>value="very important" /></td>
    </tr>
    <tr>
      <td scope="row" style="text-align:left;"><label for="ckbI">Employment</label></td>
      <td><input type="checkbox" name="ckbIone" id="ckbIone" <%If strIone="more information" Then Response.Write(strChecked)%>value="more information" /></td>
      <td><input type="checkbox" name="ckbItwo" id="ckbItwo" <%If strItwo="be involved" Then Response.Write(strChecked)%>value="be involved" /></td>
      <td><input type="checkbox" name="ckbIthree" id="ckbIthree" <%If strIthree="very important" Then Response.Write(strChecked)%>value="very important" /></td>
    </tr>
    <tr>
      <td scope="row" style="text-align:left;"><label for="ckbJ">Forced Medication</label></td>
      <td><input type="checkbox" name="ckbJone" id="ckbJone" <%If strJone="more information" Then Response.Write(strChecked)%>value="more information" /></td>
      <td><input type="checkbox" name="ckbJtwo" id="ckbJtwo" <%If strJtwo="be involved" Then Response.Write(strChecked)%>value="be involved" /></td>
      <td><input type="checkbox" name="ckbJthree" id="ckbJthree" <%If strJthree="very important" Then Response.Write(strChecked)%>value="very important" /></td>
    </tr>
    <tr>
      <td scope="row" style="text-align:left;"><label for="ckbK">Forensic</label></td>
      <td><input type="checkbox" name="ckbKone" id="ckbKone" <%If strKone="more information" Then Response.Write(strChecked)%>value="more information" /></td>
      <td><input type="checkbox" name="ckbKtwo" id="ckbKtwo" <%If strKtwo="be involved" Then Response.Write(strChecked)%>value="be involved" /></td>
      <td><input type="checkbox" name="ckbKthree" id="ckbKthree" <%If strKthree="very important" Then Response.Write(strChecked)%>value="very important" /></td>
    </tr>
    <tr>
      <td scope="row" style="text-align:left;"><label for="ckbL">Gay/Lesbian/Bi/Transgender/Transexual Issues</label></td>
      <td><input type="checkbox" name="ckbLone" id="ckbLone" <%If strLone="more information" Then Response.Write(strChecked)%>value="more information" /></td>
      <td><input type="checkbox" name="ckbLtwo" id="ckbLtwo" <%If strLtwo="be involved" Then Response.Write(strChecked)%>value="be involved" /></td>
      <td><input type="checkbox" name="ckbLthree" id="ckbLthree" <%If strLthree="very important" Then Response.Write(strChecked)%>value="very important" /></td>
    </tr>
    <tr>
      <td scope="row" style="text-align:left;"><label for="ckbM">Homelessness</label></td>
      <td><input type="checkbox" name="ckbMone" id="ckbMone" <%If strMone="more information" Then Response.Write(strChecked)%>value="more information" /></td>
      <td><input type="checkbox" name="ckbMtwo" id="ckbMtwo" <%If strMtwo="be involved" Then Response.Write(strChecked)%>value="be involved" /></td>
      <td><input type="checkbox" name="ckbMthree" id="ckbMthree" <%If strMthree="very important" Then Response.Write(strChecked)%>value="very important" /></td>
    </tr>
    <tr>
      <td scope="row" style="text-align:left;"><label for="ckbN">Informed Consent</label></td>
      <td><input type="checkbox" name="ckbNone" id="ckbNone" <%If strNone="more information" Then Response.Write(strChecked)%>value="more information" /></td>
      <td><input type="checkbox" name="ckbNtwo" id="ckbNtwo" <%If strNtwo="be involved" Then Response.Write(strChecked)%>value="be involved" /></td>
      <td><input type="checkbox" name="ckbNthree" id="ckbNthree" <%If strNthree="very important" Then Response.Write(strChecked)%>value="very important" /></td>
    </tr>
    <tr>
      <td scope="row" style="text-align:left;"><label for="ckbO">Literacy</label></td>
      <td><input type="checkbox" name="ckbOone" id="ckbOone" <%If strOone="more information" Then Response.Write(strChecked)%>value="more information" /></td>
      <td><input type="checkbox" name="ckbOtwo" id="ckbOtwo" <%If strOtwo="be involved" Then Response.Write(strChecked)%>value="be involved" /></td>
      <td><input type="checkbox" name="ckbOthree" id="ckbOthree" <%If strOthree="very important" Then Response.Write(strChecked)%>value="very important" /></td>
    </tr>
    <tr>
      <td scope="row" style="text-align:left;"><label for="ckbP">Outreach</label></td>
      <td><input type="checkbox" name="ckbPone" id="ckbPone" <%If strPone="more information" Then Response.Write(strChecked)%>value="more information" /></td>
      <td><input type="checkbox" name="ckbPtwo" id="ckbPtwo" <%If strPtwo="be involved" Then Response.Write(strChecked)%>value="be involved" /></td>
      <td><input type="checkbox" name="ckbPthree" id="ckbPthree" <%If strPthree="very important" Then Response.Write(strChecked)%>value="very important" /></td>
    </tr>
    <tr>
      <td scope="row" style="text-align:left;"><label for="ckbQ">Participation in Treatment Planning</label></td>
      <td><input type="checkbox" name="ckbQone" id="ckbQone" <%If strone="more information" Then Response.Write(strChecked)%>value="more information" /></td>
      <td><input type="checkbox" name="ckbQtwo" id="ckbQtwo" <%If strtwo="be involved" Then Response.Write(strChecked)%>value="be involved" /></td>
      <td><input type="checkbox" name="ckbQthree" id="ckbQthree" <%If strthree="very important" Then Response.Write(strChecked)%>value="very important" /></td>
    </tr>
    <tr>
      <td scope="row" style="text-align:left;"><label for="ckbR">Restraint and Seclusion</label></td>
      <td><input type="checkbox" name="ckbRone" id="ckbRone" <%If strRone="more information" Then Response.Write(strChecked)%>value="more information" /></td>
      <td><input type="checkbox" name="ckbRtwo" id="ckbRtwo" <%If strRtwo="be involved" Then Response.Write(strChecked)%>value="be involved" /></td>
      <td><input type="checkbox" name="ckbRthree" id="ckbRthree" <%If strRthree="very important" Then Response.Write(strChecked)%>value="very important" /></td>
    </tr>
    <tr>
      <td scope="row" style="text-align:left;"><label for="ckbS">Rural Issues</label></td>
      <td><input type="checkbox" name="ckbSone" id="ckbSone" <%If strSone="more information" Then Response.Write(strChecked)%>value="more information" /></td>
      <td><input type="checkbox" name="ckbStwo" id="ckbStwo" <%If strStwo="be involved" Then Response.Write(strChecked)%>value="be involved" /></td>
      <td><input type="checkbox" name="ckbSthree" id="ckbSthree" <%If strSthree="very important" Then Response.Write(strChecked)%>value="very important" /></td>
    </tr>
    <tr>
      <td scope="row" style="text-align:left;"><label for="ckbT">Stigma</label></td>
      <td><input type="checkbox" name="ckbTone" id="ckbTone" <%If strTone="more information" Then Response.Write(strChecked)%>value="more information" /></td>
      <td><input type="checkbox" name="ckbTtwo" id="ckbTtwo" <%If strTtwo="be involved" Then Response.Write(strChecked)%>value="be involved" /></td>
      <td><input type="checkbox" name="ckbTthree" id="ckbTthree" <%If strTthree="very important" Then Response.Write(strChecked)%>value="very important" /></td>
    </tr>
        <tr>
      <td scope="row" style="text-align:left;"><label for="ckbU">Tobacco Cessation/Reduction</label></td>
      <td><input type="checkbox" name="ckbUone" id="ckbUone" <%If strUone="more information" Then Response.Write(strChecked)%>value="more information" /></td>
      <td><input type="checkbox" name="ckbUtwo" id="ckbUtwo" <%If strUtwo="be involved" Then Response.Write(strChecked)%>value="be involved" /></td>
      <td><input type="checkbox" name="ckbUthree" id="ckbUthree" <%If strUthree="very important" Then Response.Write(strChecked)%>value="very important" /></td>
    </tr>
    <tr>
      <td scope="row" style="text-align:left;"><label for="ckbV">Training Development</label></td>
      <td><input type="checkbox" name="ckbVone" id="ckbVone" <%If strVone="more information" Then Response.Write(strChecked)%>value="more information" /></td>
      <td><input type="checkbox" name="ckbVtwo" id="ckbVtwo" <%If strVtwo="be involved" Then Response.Write(strChecked)%>value="be involved" /></td>
      <td><input type="checkbox" name="ckbVthree" id="ckbVthree" <%If strVthree="very important" Then Response.Write(strChecked)%>value="very important" /></td>
    </tr>
    <tr>
      <td scope="row" style="text-align:left;"><label for="ckbW">Training <acronym title="Continuing Medical Education">CME</acronym>/<acronym title="Graduate Record Exam">GRE</acronym></label></td>
      <td><input type="checkbox" name="ckbWone" id="ckbWone" <%If strWone="more information" Then Response.Write(strChecked)%>value="more information" /></td>
      <td><input type="checkbox" name="ckbWtwo" id="ckbWtwo" <%If strWtwo="be involved" Then Response.Write(strChecked)%>value="be involved" /></td>
      <td><input type="checkbox" name="ckbWthree" id="ckbWthree" <%If strWthree="very important" Then Response.Write(strChecked)%>value="very important" /></td>
    </tr>
    <tr>
      <td scope="row" style="text-align:left;"><label for="ckbX">Transition Age Youth</label></td>
      <td><input type="checkbox" name="ckbXone" id="ckbXone" <%If strXone="more information" Then Response.Write(strChecked)%>value="more information" /></td>
      <td><input type="checkbox" name="ckbXtwo" id="ckbXtwo" <%If strXtwo="be involved" Then Response.Write(strChecked)%>value="be involved" /></td>
      <td><input type="checkbox" name="ckbXthree" id="ckbXthree" <%If strXthree="very important" Then Response.Write(strChecked)%>value="very important" /></td>
    </tr>
    <tr>
      <td scope="row" style="text-align:left;"><label for="ckbY">Trauma</label></td>
      <td><input type="checkbox" name="ckbYone" id="ckbYone" <%If strYone="more information" Then Response.Write(strChecked)%>value="more information" /></td>
      <td><input type="checkbox" name="ckbYtwo" id="ckbYtwo" <%If strYtwo="be involved" Then Response.Write(strChecked)%>value="be involved" /></td>
      <td><input type="checkbox" name="ckbYthree" id="ckbYthree" <%If strYthree="very important" Then Response.Write(strChecked)%>value="very important" /></td>
    </tr>
    <tr>
      <td scope="row" style="text-align:left;"><label for="ckbZ">Treatment Compliance</label></td>
      <td><input type="checkbox" name="ckbZone" id="ckbZone" <%If strZone="more information" Then Response.Write(strChecked)%>value="more information" /></td>
      <td><input type="checkbox" name="ckbZtwo" id="ckbZtwo" <%If strZtwo="be involved" Then Response.Write(strChecked)%>value="be involved" /></td>
      <td><input type="checkbox" name="ckbZthree" id="ckbZthree" <%If strZthree="very important" Then Response.Write(strChecked)%>value="very important" /></td>
    </tr>
    <tr>
      <td scope="row" style="text-align:left;"><label for="ckbAA">Veterans Issues</label></td>
      <td><input type="checkbox" name="ckbAAone" id="ckbAAone" <%If strAAone="more information" Then Response.Write(strChecked)%>value="more information" /></td>
      <td><input type="checkbox" name="ckbAAtwo" id="ckbAAtwo" <%If strAAtwo="be involved" Then Response.Write(strChecked)%>value="be involved" /></td>
      <td><input type="checkbox" name="ckbAAthree" id="ckbAAthree" <%If strAAthree="very important" Then Response.Write(strChecked)%>value="very important" /></td>
    </tr>
    <tr>
      <td scope="row" style="text-align:left;"><label for="ckbAB">Women's Issues</label></td>
      <td><input type="checkbox" name="ckbABone" id="ckbABone" <%If strABone="more information" Then Response.Write(strChecked)%>value="more information" /></td>
      <td><input type="checkbox" name="ckbABtwo" id="ckbABtwo" <%If strABtwo="be involved" Then Response.Write(strChecked)%>value="be involved" /></td>
      <td><input type="checkbox" name="ckbABthree" id="ckbABthree" <%If strABthree="very important" Then Response.Write(strChecked)%>value="very important" /></td>
    </tr>
  </table>
  <p style="text-align:center;"><strong>Entitlements</strong></p>
  <table border="1" cellspacing="0" cellpadding="0" summary="Survey Questions" width="90%" style="margin-left:auto; margin-right:auto; text-align:center;">
    <tr>
      <th scope="col">Issues</th>
      <th scope="col">Would like more<br />
        information on<br />
        this issue</th>
      <th scope="col">Would like to be<br />
        involved with<br />
        this issue</th>
      <th scope="col">Thinks this issue<br />
        is very important</th>
    </tr>
    <tr>
      <td scope="row" style="text-align:left;"><label for="ckbAC">Social Security Administration Retirement</label></td>
      <td><input type="checkbox" name="ckbACone" id="ckbACone" <%If strACone="more information" Then Response.Write(strChecked)%>value="more information" /></td>
      <td><input type="checkbox" name="ckbACtwo" id="ckbACtwo" <%If strACtwo="be involved" Then Response.Write(strChecked)%>value="be involved" /></td>
      <td><input type="checkbox" name="ckbACthree" id="ckbACthree" <%If strACthree="very important" Then Response.Write(strChecked)%>value="very important" /></td>
    </tr>
    <tr>
      <td scope="row" style="text-align:left;"><label for="ckbAD">Supplemental Security Income (SSI)</label></td>
      <td><input type="checkbox" name="ckbADone" id="ckbADone" <%If strADone="more information" Then Response.Write(strChecked)%>value="more information" /></td>
      <td><input type="checkbox" name="ckbADtwo" id="ckbADtwo" <%If strADtwo="be involved" Then Response.Write(strChecked)%>value="be involved" /></td>
      <td><input type="checkbox" name="ckbADthree" id="ckbADthree" <%If strADthree="very important" Then Response.Write(strChecked)%>value="very important" /></td>
    </tr>
    <tr>
      <td scope="row" style="text-align:left;"><label for="ckbAE">Social Security Disability Insurance (SSDI)</label></td>
      <td><input type="checkbox" name="ckbAEone" id="ckbAEone" <%If strAEone="more information" Then Response.Write(strChecked)%>value="more information" /></td>
      <td><input type="checkbox" name="ckbAEtwo" id="ckbAEtwo" <%If strAEtwo="be involved" Then Response.Write(strChecked)%>value="be involved" /></td>
      <td><input type="checkbox" name="ckbAEthree" id="ckbAEthree" <%If strAEthree="very important" Then Response.Write(strChecked)%>value="very important" /></td>
    </tr>
    <tr>
      <td scope="row" style="text-align:left;"><label for="ckbAF">Medicaid</label></td>
      <td><input type="checkbox" name="ckbAFone" id="ckbAFone" <%If strAFone="more information" Then Response.Write(strChecked)%>value="more information" /></td>
      <td><input type="checkbox" name="ckbAFtwo" id="ckbAFtwo" <%If strAFtwo="be involved" Then Response.Write(strChecked)%>value="be involved" /></td>
      <td><input type="checkbox" name="ckbAFthree" id="ckbAFthree" <%If strAFthree="very important" Then Response.Write(strChecked)%>value="very important" /></td>
    </tr>
    <tr>
      <td scope="row" style="text-align:left;"><label for="ckbAG">Medicare</label></td>
      <td><input type="checkbox" name="ckbAGone" id="ckbAGone" <%If strAGone="more information" Then Response.Write(strChecked)%>value="more information" /></td>
      <td><input type="checkbox" name="ckbAGtwo" id="ckbAGtwo" <%If strAGtwo="be involved" Then Response.Write(strChecked)%>value="be involved" /></td>
      <td><input type="checkbox" name="ckbAGthree" id="ckbAGthree" <%If strAGthree="very important" Then Response.Write(strChecked)%>value="very important" /></td>
    </tr>
    <tr>
      <td scope="row" style="text-align:left;"><label for="ckbAH"><acronym title="Social Security Administration">SSA</acronym> Plan to Achieve Self-Sufficiency (PASS)</label></td>
      <td><input type="checkbox" name="ckbAHone" id="ckbAHone" <%If strAHone="more information" Then Response.Write(strChecked)%>value="more information" /></td>
      <td><input type="checkbox" name="ckbAHtwo" id="ckbAHtwo" <%If strAHtwo="be involved" Then Response.Write(strChecked)%>value="be involved" /></td>
      <td><input type="checkbox" name="ckbAHthree" id="ckbAHthree" <%If strAHthree="very important" Then Response.Write(strChecked)%>value="very important" /></td>
    </tr>
    <tr>
      <td scope="row" style="text-align:left;"><label for="ckbAI"><acronym title="Social Security Administration">SSA</acronym> Impariment Related Work Expenses (IRWE)</label></td>
      <td><input type="checkbox" name="ckbAIone" id="ckbAIone" <%If strAIone="more information" Then Response.Write(strChecked)%>value="more information" /></td>
      <td><input type="checkbox" name="ckbAItwo" id="ckbAItwo" <%If strAItwo="be involved" Then Response.Write(strChecked)%>value="be involved" /></td>
      <td><input type="checkbox" name="ckbAIthree" id="ckbAIthree" <%If strAIthree="very important" Then Response.Write(strChecked)%>value="very important" /></td>
    </tr>
    <tr>
      <td scope="row" style="text-align:left;"><label for="ckbAJ">1619B/1915B Extended Eligibility</label></td>
      <td><input type="checkbox" name="ckbAJone" id="ckbAJone" <%If strAJone="more information" Then Response.Write(strChecked)%>value="more information" /></td>
      <td><input type="checkbox" name="ckbAJtwo" id="ckbAJtwo" <%If strAJtwo="be involved" Then Response.Write(strChecked)%>value="be involved" /></td>
      <td><input type="checkbox" name="ckbAJthree" id="ckbAJthree" <%If strAJthree="very important" Then Response.Write(strChecked)%>value="very important" /></td>
    </tr>
    <tr>
      <td scope="row" style="text-align:left;"><label for="ckbAK">Ticket to Work</label></td>
      <td><input type="checkbox" name="ckbAKone" id="ckbAKone" <%If strAKone="more information" Then Response.Write(strChecked)%>value="more information" /></td>
      <td><input type="checkbox" name="ckbAKtwo" id="ckbAKtwo" <%If strAKtwo="be involved" Then Response.Write(strChecked)%>value="be involved" /></td>
      <td><input type="checkbox" name="ckbAKthree" id="ckbAKthree" <%If strAKthree="very important" Then Response.Write(strChecked)%>value="very important" /></td>
    </tr>
    <tr>
      <td scope="row" style="text-align:left;"><label for="ckbAL">Section 8 Vouchers</label></td>
      <td><input type="checkbox" name="ckbALone" id="ckbALone" <%If strALone="more information" Then Response.Write(strChecked)%>value="more information" /></td>
      <td><input type="checkbox" name="ckbALtwo" id="ckbALtwo" <%If strALtwo="be involved" Then Response.Write(strChecked)%>value="be involved" /></td>
      <td><input type="checkbox" name="ckbALthree" id="ckbALthree" <%If strALthree="very important" Then Response.Write(strChecked)%>value="very important" /></td>
    </tr>
    <tr>
      <td scope="row" style="text-align:left;"><label for="ckbAM">Social Services</label></td>
      <td><input type="checkbox" name="ckbAMone" id="ckbAMone" <%If strAMone="more information" Then Response.Write(strChecked)%>value="more information" /></td>
      <td><input type="checkbox" name="ckbAMtwo" id="ckbAMtwo" <%If strAMtwo="be involved" Then Response.Write(strChecked)%>value="be involved" /></td>
      <td><input type="checkbox" name="ckbAMthree" id="ckbAMthree" <%If strAMthree="very important" Then Response.Write(strChecked)%>value="very important" /></td>
    </tr>
    <tr>
      <td scope="row" style="text-align:left;"><label for="ckbAN">Aid to Families with Dependent Children (AFDC)</label></td>
      <td><input type="checkbox" name="ckbANone" id="ckbANone" <%If strANone="more information" Then Response.Write(strChecked)%>value="more information" /></td>
      <td><input type="checkbox" name="ckbANtwo" id="ckbANtwo" <%If strANtwo="be involved" Then Response.Write(strChecked)%>value="be involved" /></td>
      <td><input type="checkbox" name="ckbANthree" id="ckbANthree" <%If strANthree="very important" Then Response.Write(strChecked)%>value="very important" /></td>
    </tr>
    <tr>
      <td scope="row" style="text-align:left;"><label for="ckbAO">Energy Assistance</label></td>
      <td><input type="checkbox" name="ckbAOone" id="ckbAOone" <%If strAOone="more information" Then Response.Write(strChecked)%>value="more information" /></td>
      <td><input type="checkbox" name="ckbAOtwo" id="ckbAOtwo" <%If strAOtwo="be involved" Then Response.Write(strChecked)%>value="be involved" /></td>
      <td><input type="checkbox" name="ckbAOthree" id="ckbAOthree" <%If strAOthree="very important" Then Response.Write(strChecked)%>value="very important" /></td>
    </tr>
    <tr>
      <td scope="row" style="text-align:left;"><label for="ckbAP">Enterprise Zones</label></td>
      <td><input type="checkbox" name="ckbAPone" id="ckbAPone" <%If strAPone="more information" Then Response.Write(strChecked)%>value="more information" /></td>
      <td><input type="checkbox" name="ckbAPtwo" id="ckbAPtwo" <%If strAPtwo="be involved" Then Response.Write(strChecked)%>value="be involved" /></td>
      <td><input type="checkbox" name="ckbAPthree" id="ckbAPthree" <%If strAPthree="very important" Then Response.Write(strChecked)%>value="very important" /></td>
    </tr>
    <tr>
      <td scope="row" style="text-align:left;"><label for="ckbAQ">Food Stamps</label></td>
      <td><input type="checkbox" name="ckbAQone" id="ckbAQone" <%If strAQone="more information" Then Response.Write(strChecked)%>value="more information" /></td>
      <td><input type="checkbox" name="ckbAQtwo" id="ckbAQtwo" <%If strAQtwo="be involved" Then Response.Write(strChecked)%>value="be involved" /></td>
      <td><input type="checkbox" name="ckbAQthree" id="ckbAQthree" <%If strAQthree="very important" Then Response.Write(strChecked)%>value="very important" /></td>
    </tr>
    <tr>
      <td scope="row" style="text-align:left;"><label for="ckbAR">Temporary Assistance / Special Needs Accounts</label></td>
      <td><input type="checkbox" name="ckbARone" id="ckbARone" <%If strARone="more information" Then Response.Write(strChecked)%>value="more information" /></td>
      <td><input type="checkbox" name="ckbARtwo" id="ckbARtwo" <%If strARtwo="be involved" Then Response.Write(strChecked)%>value="be involved" /></td>
      <td><input type="checkbox" name="ckbARthree" id="ckbARthree" <%If strARthree="very important" Then Response.Write(strChecked)%>value="very important" /></td>
    </tr>
    <tr>
      <td scope="row" style="text-align:left;"><label for="ckbAS">Veterans Benefits</label></td>
      <td><input type="checkbox" name="ckbASone" id="ckbASone" <%If strASone="more information" Then Response.Write(strChecked)%>value="more information" /></td>
      <td><input type="checkbox" name="ckbAStwo" id="ckbAStwo" <%If strAStwo="be involved" Then Response.Write(strChecked)%>value="be involved" /></td>
      <td><input type="checkbox" name="ckbASthree" id="ckbASthree" <%If strASthree="very important" Then Response.Write(strChecked)%>value="very important" /></td>
    </tr>
    <tr>
      <td scope="row" style="text-align:left;"><label for="ckbAT">Workforce Investment Act</label></td>
      <td><input type="checkbox" name="ckbATone" id="ckbATone" <%If strATone="more information" Then Response.Write(strChecked)%>value="more information" /></td>
      <td><input type="checkbox" name="ckbATtwo" id="ckbATtwo" <%If strATtwo="be involved" Then Response.Write(strChecked)%>value="be involved" /></td>
      <td><input type="checkbox" name="ckbATthree" id="ckbATthree" <%If strATthree="very important" Then Response.Write(strChecked)%>value="very important" /></td>
    </tr>
  </table>
  <p style="text-align:center;"><strong>Evidence Based Practices</strong></p>
  <table border="1" cellspacing="0" cellpadding="0" summary="Survey Questions" width="90%" style="margin-left:auto; margin-right:auto; text-align:center;">
    <tr>
      <th scope="col">Issues</th>
      <th scope="col">Would like more<br />
        information on<br />
        this issue</th>
      <th scope="col">Would like to be<br />
        involved with<br />
        this issue</th>
      <th scope="col">Thinks this issue<br />
        is very important</th>
    </tr>
    <tr>
      <td scope="row" style="text-align:left;"><label for="ckbAU">Assertive Community Treatment (ACT)</label></td>
      <td><input type="checkbox" name="ckbAUone" id="ckbAUone" <%If strAUone="more information" Then Response.Write(strChecked)%>value="more information" /></td>
      <td><input type="checkbox" name="ckbAUtwo" id="ckbAUtwo" <%If strAUtwo="be involved" Then Response.Write(strChecked)%>value="be involved" /></td>
      <td><input type="checkbox" name="ckbAUthree" id="ckbAUthree" <%If strAUthree="very important" Then Response.Write(strChecked)%>value="very important" /></td>
    </tr>
    <tr>
      <td scope="row" style="text-align:left;"><label for="ckbAV">Family Psycho-Education</label></td>
      <td><input type="checkbox" name="ckbAVone" id="ckbAVone" <%If strAVone="more information" Then Response.Write(strChecked)%>value="more information" /></td>
      <td><input type="checkbox" name="ckbAVtwo" id="ckbAVtwo" <%If strAVtwo="be involved" Then Response.Write(strChecked)%>value="be involved" /></td>
      <td><input type="checkbox" name="ckbAVthree" id="ckbAVthree" <%If strAVthree="very important" Then Response.Write(strChecked)%>value="very important" /></td>
    </tr>
    <tr>
      <td scope="row" style="text-align:left;"><label for="ckbAW">Integrated Treatment Co-occuring Disorders</label></td>
      <td><input type="checkbox" name="ckbAWone" id="ckbAWone" <%If strAWone="more information" Then Response.Write(strChecked)%>value="more information" /></td>
      <td><input type="checkbox" name="ckbAWtwo" id="ckbAWtwo" <%If strAWtwo="be involved" Then Response.Write(strChecked)%>value="be involved" /></td>
      <td><input type="checkbox" name="ckbAWthree" id="ckbAWthree" <%If strAWthree="very important" Then Response.Write(strChecked)%>value="very important" /></td>
    </tr>
    <tr>
      <td scope="row" style="text-align:left;"><label for="ckbAX">Intensive Case Management (ICM)</label></td>
      <td><input type="checkbox" name="ckbAXone" id="ckbAXone" <%If strAXone="more information" Then Response.Write(strChecked)%>value="more information" /></td>
      <td><input type="checkbox" name="ckbAXtwo" id="ckbAXtwo" <%If strAXtwo="be involved" Then Response.Write(strChecked)%>value="be involved" /></td>
      <td><input type="checkbox" name="ckbAXthree" id="ckbAXthree" <%If strAXthree="very important" Then Response.Write(strChecked)%>value="very important" /></td>
    </tr>
    <tr>
      <td scope="row" style="text-align:left;"><label for="ckbAY">Medication</label></td>
      <td><input type="checkbox" name="ckbAYone" id="ckbAYone" <%If strAYone="more information" Then Response.Write(strChecked)%>value="more information" /></td>
      <td><input type="checkbox" name="ckbAYtwo" id="ckbAYtwo" <%If strAYtwo="be involved" Then Response.Write(strChecked)%>value="be involved" /></td>
      <td><input type="checkbox" name="ckbAYthree" id="ckbAYthree" <%If strAYthree="very important" Then Response.Write(strChecked)%>value="very important" /></td>
    </tr>
    <tr>
      <td scope="row" style="text-align:left;"><label for="ckbAZ">Post Traumatic Stress Disorder Treatment</label></td>
      <td><input type="checkbox" name="ckbAZone" id="ckbAZone" <%If strAZone="more information" Then Response.Write(strChecked)%>value="more information" /></td>
      <td><input type="checkbox" name="ckbAZtwo" id="ckbAZtwo" <%If strAZtwo="be involved" Then Response.Write(strChecked)%>value="be involved" /></td>
      <td><input type="checkbox" name="ckbAZthree" id="ckbAZthree" <%If strAZthree="very important" Then Response.Write(strChecked)%>value="very important" /></td>
    </tr>
    <tr>
      <td scope="row" style="text-align:left;"><label for="ckbAAA">Supported Employment</label></td>
      <td><input type="checkbox" name="ckbAAAone" id="ckbAAAone" <%If strAAAone="more information" Then Response.Write(strChecked)%>value="more information" /></td>
      <td><input type="checkbox" name="ckbAAAtwo" id="ckbAAAtwo" <%If strAAAtwo="be involved" Then Response.Write(strChecked)%>value="be involved" /></td>
      <td><input type="checkbox" name="ckbAAAthree" id="ckbAAAthree" <%If strAAAthree="very important" Then Response.Write(strChecked)%>value="very important" /></td>
    </tr>
    <tr>
      <td scope="row" style="text-align:left;"><label for="ckbAAB">Self-Help Peer Support Services</label></td>
      <td><input type="checkbox" name="ckbAABone" id="ckbAABone" <%If strAABone="more information" Then Response.Write(strChecked)%>value="more information" /></td>
      <td><input type="checkbox" name="ckbAABtwo" id="ckbAABtwo" <%If strAABtwo="be involved" Then Response.Write(strChecked)%>value="be involved" /></td>
      <td><input type="checkbox" name="ckbAABthree" id="ckbAABthree" <%If strAABthree="very important" Then Response.Write(strChecked)%>value="very important" /></td>
    </tr>
    <tr>
      <td scope="row" style="text-align:left;"><label for="ckbAAC">Wellness Self-Management</label></td>
      <td><input type="checkbox" name="ckbAACone" id="ckbAACone" <%If strAACone="more information" Then Response.Write(strChecked)%>value="more information" /></td>
      <td><input type="checkbox" name="ckbAACtwo" id="ckbAACtwo" <%If strAACtwo="be involved" Then Response.Write(strChecked)%>value="be involved" /></td>
      <td><input type="checkbox" name="ckbAACthree" id="ckbAACthree" <%If strAACthree="very important" Then Response.Write(strChecked)%>value="very important" /></td>
    </tr>
    <tr>
      <td scope="row" style="text-align:left;"><label for="ckbAAD">Childrens: EB Prescribing Practices</label></td>
      <td><input type="checkbox" name="ckbAADone" id="ckbAADone" <%If strAADone="more information" Then Response.Write(strChecked)%>value="more information" /></td>
      <td><input type="checkbox" name="ckbAADtwo" id="ckbAADtwo" <%If strAADtwo="be involved" Then Response.Write(strChecked)%>value="be involved" /></td>
      <td><input type="checkbox" name="ckbAADthree" id="ckbAADthree" <%If strAADthree="very important" Then Response.Write(strChecked)%>value="very important" /></td>
    </tr>
    <tr>
      <td scope="row" style="text-align:left;"><label for="ckbAAE">Childrens: Family Ed. and Support Services</label></td>
      <td><input type="checkbox" name="ckbAAEone" id="ckbAAEone" <%If strAAEone="more information" Then Response.Write(strChecked)%>value="more information" /></td>
      <td><input type="checkbox" name="ckbAAEtwo" id="ckbAAEtwo" <%If strAAEtwo="be involved" Then Response.Write(strChecked)%>value="be involved" /></td>
      <td><input type="checkbox" name="ckbAAEthree" id="ckbAAEthree" <%If strAAEthree="very important" Then Response.Write(strChecked)%>value="very important" /></td>
    </tr>
    <tr>
      <td scope="row" style="text-align:left;"><label for="ckbAAF">Childrens: Functional Family Therapy</label></td>
      <td><input type="checkbox" name="ckbAAFone" id="ckbAAFone" <%If strAAFone="more information" Then Response.Write(strChecked)%>value="more information" /></td>
      <td><input type="checkbox" name="ckbAAFtwo" id="ckbAAF" <%If strAAFtwo="be involved" Then Response.Write(strChecked)%>value="be involved" /></td>
      <td><input type="checkbox" name="ckbAAFthree" id="ckbAAFthree" <%If strAAFthree="very important" Then Response.Write(strChecked)%>value="very important" /></td>
    </tr>
    <tr>
      <td scope="row" style="text-align:left;"><label for="ckbAAG">Childrens: Homes Based Crisis Intervention</label></td>
      <td><input type="checkbox" name="ckbAAGone" id="ckbAAGone" <%If strAAGone="more information" Then Response.Write(strChecked)%>value="more information" /></td>
      <td><input type="checkbox" name="ckbAAGtwo" id="ckbAAGtwo" <%If strAAGtwo="be involved" Then Response.Write(strChecked)%>value="be involved" /></td>
      <td><input type="checkbox" name="ckbAAGthree" id="ckbAAGthree" <%If strAAGthree="very important" Then Response.Write(strChecked)%>value="very important" /></td>
    </tr>
    <tr>
      <td scope="row" style="text-align:left;"><label for="ckbAAH">Childrens: Home &amp; Community Based Services</label></td>
      <td><input type="checkbox" name="ckbAAHone" id="ckbAAHone" <%If strAAHone="more information" Then Response.Write(strChecked)%>value="more information" /></td>
      <td><input type="checkbox" name="ckbAAHtwo" id="ckbAAHtwo" <%If strAAHtwo="be involved" Then Response.Write(strChecked)%>value="be involved" /></td>
      <td><input type="checkbox" name="ckbAAHthree" id="ckbAAHthree" <%If strAAHthree="very important" Then Response.Write(strChecked)%>value="very important" /></td>
    </tr>
    <tr>
      <td scope="row" style="text-align:left;"><label for="ckbAAI">Childrens: Intensive Case Management (ICM)</label></td>
      <td><input type="checkbox" name="ckbAAIone" id="ckbAAIone" <%If strAAIone="more information" Then Response.Write(strChecked)%>value="more information" /></td>
      <td><input type="checkbox" name="ckbAAItwo" id="ckbAAItwo" <%If strAAItwo="be involved" Then Response.Write(strChecked)%>value="be involved" /></td>
      <td><input type="checkbox" name="ckbAAIthree" id="ckbAAIthree" <%If strAAIthree="very important" Then Response.Write(strChecked)%>value="very important" /></td>
    </tr>
    <tr>
      <td scope="row" style="text-align:left;"><label for="ckbAAJ">Childrens: School Based Mental Health Services</label></td>
      <td><input type="checkbox" name="ckbAAJone" id="ckbAAJone" <%If strAAJone="more information" Then Response.Write(strChecked)%>value="more information" /></td>
      <td><input type="checkbox" name="ckbAAJtwo" id="ckbAAJtwo" <%If strAAJtwo="be involved" Then Response.Write(strChecked)%>value="be involved" /></td>
      <td><input type="checkbox" name="ckbAAJthree" id="ckbAAJthree" <%If strAAJthree="very important" Then Response.Write(strChecked)%>value="very important" /></td>
    </tr>
    <tr>
      <td scope="row" style="text-align:left;"><label for="ckbAAK">Childrens: <acronym title="Post Traumatic Stress Disorder">PTSD</acronym> Treatment</label></td>
      <td><input type="checkbox" name="ckbAAKone" id="ckbAAKone" <%If strAAKone="more information" Then Response.Write(strChecked)%>value="more information" /></td>
      <td><input type="checkbox" name="ckbAAKtwo" id="ckbAAKtwo" <%If strAAKtwo="be involved" Then Response.Write(strChecked)%>value="be involved" /></td>
      <td><input type="checkbox" name="ckbAAKthree" id="ckbAAKthree" <%If strAAKthree="very important" Then Response.Write(strChecked)%>value="very important" /></td>
    </tr>
  </table>
  <p style="text-align:center;"><strong>Other Issues of Importance</strong></p>
  <table border="1" cellspacing="0" cellpadding="0" summary="Survey Questions" width="90%" style="margin-left:auto; margin-right:auto; text-align:center; margin-bottom:15px;">
    <tr>
      <th scope="col">Issues</th>
      <th scope="col">Would like more<br />
        information on<br />
        this issue</th>
      <th scope="col">Would like to be<br />
        involved with<br />
        this issue</th>
      <th scope="col">Thinks this issue<br />
        is very important</th>
    </tr>
    <tr>
      <td scope="row" style="text-align:left;"><label for="ckbAAL">Child Custody / Parental Rights</label></td>
      <td><input type="checkbox" name="ckbAALone" id="ckbAALone" <%If strAALone="more information" Then Response.Write(strChecked)%>value="more information" /></td>
      <td><input type="checkbox" name="ckbAALtwo" id="ckbAALtwo" <%If strAALtwo="be involved" Then Response.Write(strChecked)%>value="be involved" /></td>
      <td><input type="checkbox" name="ckbAALthree" id="ckbAALthree" <%If strAALthree="very important" Then Response.Write(strChecked)%>value="very important" /></td>
    </tr>
    <tr>
      <td scope="row" style="text-align:left;"><label for="ckbAAM">Confidentiality</label></td>
      <td><input type="checkbox" name="ckbAAMone" id="ckbAAMone" <%If strAAMone="more information" Then Response.Write(strChecked)%>value="more information" /></td>
      <td><input type="checkbox" name="ckbAAMtwo" id="ckbAAMtwo" <%If strAAMtwo="be involved" Then Response.Write(strChecked)%>value="be involved" /></td>
      <td><input type="checkbox" name="ckbAAMthree" id="ckbAAMthree" <%If strAAMthree="very important" Then Response.Write(strChecked)%>value="very important" /></td>
    </tr>
    <tr>
      <td scope="row" style="text-align:left;"><label for="ckbAAN">Consumer/Survivor/Ex-Patients as staff</label></td>
      <td><input type="checkbox" name="ckbAANone" id="ckbAANone" <%If strAANone="more information" Then Response.Write(strChecked)%>value="more information" /></td>
      <td><input type="checkbox" name="ckbAANtwo" id="ckbAANtwo" <%If strAANtwo="be involved" Then Response.Write(strChecked)%>value="be involved" /></td>
      <td><input type="checkbox" name="ckbAANthree" id="ckbAANthree" <%If strAANthree="very important" Then Response.Write(strChecked)%>value="very important" /></td>
    </tr>
    <tr>
      <td scope="row" style="text-align:left;"><label for="ckbAAO">Creative Arts</label></td>
      <td><input type="checkbox" name="ckbAAOone" id="ckbAAOone" <%If strAAOone="more information" Then Response.Write(strChecked)%>value="more information" /></td>
      <td><input type="checkbox" name="ckbAAOtwo" id="ckbAAOtwo" <%If strAAOtwo="be involved" Then Response.Write(strChecked)%>value="be involved" /></td>
      <td><input type="checkbox" name="ckbAAOthree" id="ckbAAOthree" <%If strAAOthree="very important" Then Response.Write(strChecked)%>value="very important" /></td>
    </tr>
    <tr>
      <td scope="row" style="text-align:left;"><label for="ckbAAP">Cross Disability Issues</label></td>
      <td><input type="checkbox" name="ckbAAPone" id="ckbAAPone" <%If strAAPone="more information" Then Response.Write(strChecked)%>value="more information" /></td>
      <td><input type="checkbox" name="ckbAAPtwo" id="ckbAAPtwo" <%If strAAPtwo="be involved" Then Response.Write(strChecked)%>value="be involved" /></td>
      <td><input type="checkbox" name="ckbAAPthree" id="ckbAAPthree" <%If strAAPthree="very important" Then Response.Write(strChecked)%>value="very important" /></td>
    </tr>
    <tr>
      <td scope="row" style="text-align:left;"><label for="ckbAAQ">Family Issues</label></td>
      <td><input type="checkbox" name="ckbAAQone" id="ckbAAQone" <%If strAAQone="more information" Then Response.Write(strChecked)%>value="more information" /></td>
      <td><input type="checkbox" name="ckbAAQtwo" id="ckbAAQtwo" <%If strAAQtwo="be involved" Then Response.Write(strChecked)%>value="be involved" /></td>
      <td><input type="checkbox" name="ckbAAQthree" id="ckbAAQthree" <%If strAAQthree="very important" Then Response.Write(strChecked)%>value="very important" /></td>
    </tr>
    <tr>
      <td scope="row" style="text-align:left;"><label for="ckbAAR">Involuntary Treatment</label></td>
      <td><input type="checkbox" name="ckbAARone" id="ckbAARone" <%If strAARone="more information" Then Response.Write(strChecked)%>value="more information" /></td>
      <td><input type="checkbox" name="ckbAARtwo" id="ckbAARtwo" <%If strAARtwo="be involved" Then Response.Write(strChecked)%>value="be involved" /></td>
      <td><input type="checkbox" name="ckbAARthree" id="ckbAARthree" <%If strAARthree="very important" Then Response.Write(strChecked)%>value="very important" /></td>
    </tr>
    <tr>
      <td scope="row" style="text-align:left;"><label for="ckbAAS">Mental Health Insurance Parity</label></td>
      <td><input type="checkbox" name="ckbAASone" id="ckbAASone" <%If strAASone="more information" Then Response.Write(strChecked)%>value="more information" /></td>
      <td><input type="checkbox" name="ckbAAStwo" id="ckbAAStwo" <%If strAAStwo="be involved" Then Response.Write(strChecked)%>value="be involved" /></td>
      <td><input type="checkbox" name="ckbAASthree" id="ckbAASthree" <%If strAASthree="very important" Then Response.Write(strChecked)%>value="very important" /></td>
    </tr>
    <tr>
      <td scope="row" style="text-align:left;"><label for="ckbAAT">Parenting Skills</label></td>
      <td><input type="checkbox" name="ckbAATone" id="ckbAATone" <%If strAATone="more information" Then Response.Write(strChecked)%>value="more information" /></td>
      <td><input type="checkbox" name="ckbAATtwo" id="ckbAATtwo" <%If strAATtwo="be involved" Then Response.Write(strChecked)%>value="be involved" /></td>
      <td><input type="checkbox" name="ckbAATthree" id="ckbAATthree" <%If strAATthree="very important" Then Response.Write(strChecked)%>value="very important" /></td>
    </tr>
    <tr>
      <td scope="row" style="text-align:left;"><label for="ckbAAU">Public Relations</label></td>
      <td><input type="checkbox" name="ckbAAUone" id="ckbAAUone" <%If strAAUone="more information" Then Response.Write(strChecked)%>value="more information" /></td>
      <td><input type="checkbox" name="ckbAAUtwo" id="ckbAAUtwo" <%If strAAUtwo="be involved" Then Response.Write(strChecked)%>value="be involved" /></td>
      <td><input type="checkbox" name="ckbAAUthree" id="ckbAAUthree" <%If strAAUthree="very important" Then Response.Write(strChecked)%>value="very important" /></td>
    </tr>
    <tr>
      <td scope="row" style="text-align:left;"><label for="ckbAAV">Rights Protection</label></td>
      <td><input type="checkbox" name="ckbAAVone" id="ckbAAVone" <%If strAAVone="more information" Then Response.Write(strChecked)%>value="more information" /></td>
      <td><input type="checkbox" name="ckbAAVtwo" id="ckbAAVtwo" <%If strAAVtwo="be involved" Then Response.Write(strChecked)%>value="be involved" /></td>
      <td><input type="checkbox" name="ckbAAVthree" id="ckbAAVthree" <%If strAAVthree="very important" Then Response.Write(strChecked)%>value="very important" /></td>
    </tr>
    <tr>
      <td scope="row" style="text-align:left;"><label for="ckbAAW">Self-Help Alternatives</label></td>
      <td><input type="checkbox" name="ckbAAWone" id="ckbAAWone" <%If strAAWone="more information" Then Response.Write(strChecked)%>value="more information" /></td>
      <td><input type="checkbox" name="ckbAAWtwo" id="ckbAAWtwo" <%If strAAWtwo="be involved" Then Response.Write(strChecked)%>value="be involved" /></td>
      <td><input type="checkbox" name="ckbAAWthree" id="ckbAAWthree" <%If strAAWthree="very important" Then Response.Write(strChecked)%>value="very important" /></td>
    </tr>
    
        <tr>
      <td scope="row" style="text-align:left;"><label for="ckbAAX">Suicide (Prevention, Grief Counseling, etc.)</label></td>
      <td><input type="checkbox" name="ckbAAXone" id="ckbAAXone" <%If strAAXone="more information" Then Response.Write(strChecked)%>value="more information" /></td>
      <td><input type="checkbox" name="ckbAAXtwo" id="ckbAAXtwo" <%If strAAXtwo="be involved" Then Response.Write(strChecked)%>value="be involved" /></td>
      <td><input type="checkbox" name="ckbAAXthree" id="ckbAAXthree" <%If strAAXthree="very important" Then Response.Write(strChecked)%>value="very important" /></td>
    </tr>
        <tr>
      <td scope="row" style="text-align:left;"><label for="ckbAAY">Transportation</label></td>
      <td><input type="checkbox" name="ckbAAYone" id="ckbAAYone" <%If strAAYone="more information" Then Response.Write(strChecked)%>value="more information" /></td>
      <td><input type="checkbox" name="ckbAAYtwo" id="ckbAAYtwo" <%If strAAYtwo="be involved" Then Response.Write(strChecked)%>value="be involved" /></td>
      <td><input type="checkbox" name="ckbAAYthree" id="ckbAAYthree" <%If strAAYthree="very important" Then Response.Write(strChecked)%>value="very important" /></td>
    </tr>
    
    <tr>
      <td scope="row" style="text-align:left;"><label for="ckbAAZ">Voter Registration</label></td>
      <td><input type="checkbox" name="ckbAAZone" id="ckbAAZone" <%If strAAZone="more information" Then Response.Write(strChecked)%>value="more information" /></td>
      <td><input type="checkbox" name="ckbAAZtwo" id="ckbAAZtwo" <%If strAAZtwo="be involved" Then Response.Write(strChecked)%>value="be involved" /></td>
      <td><input type="checkbox" name="ckbAAZthree" id="ckbAAZthree" <%If strAAZthree="very important" Then Response.Write(strChecked)%>value="very important" /></td>
    </tr>
  </table>
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