Raw Score for this Application:  out of  - % <br /><br/>Q1. Please enter the following: First Name, Last Name  <br/><b>First Name:</b><input type="text" name="fname" value="" size="40" /><br/> <br />
                <b>Last Name:</b> <input type="text" name="lname" value="" size="40" /> <br/><br />Q2. I am submitting an application to attend the CAP Respite Center because:  <br/>
                    <textarea rows="3" name="2" cols="50" style="margin-right: 40px; vertical-align: middle;"></textarea>
        <br /><br />Q3. Are you currently taking any psychotropic medications (type(s) and dosage)?  <br/>
                    <textarea rows="3" name="9" cols="50" style="margin-right: 40px; vertical-align: middle;"></textarea>
        <br /><br />Q4. Have you ever been treated for drug (recreational or prescribed) or alcohol abuse? If yes, what type of abuse is/was it?   <br/>
                    <textarea rows="3" name="10" cols="50" style="margin-right: 40px; vertical-align: middle;"></textarea>
        <br /><br />Q5. When, Where and What was your treatment?  <br/>
                    <textarea rows="3" name="11" cols="50" style="margin-right: 40px; vertical-align: middle;"></textarea>
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