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. Have you ever had inpatient or outpatient psychotherapy? If yes, what was your diagnosis?   <br/>
                    <textarea rows="3" name="3" cols="50" style="margin-right: 40px; vertical-align: middle;"></textarea>
        <br /><br />Q4. Was the treatment inpatient or outpatient?  <br/><input type="radio" id="1545" value="1545" name="4" checked=""> <label for="1545"> Inpatient  </label><br />
    <input type="radio" id="1546" value="1546" name="4" checked=""> <label for="1546"> Outpatient  </label><br />
    <br />Q5. When was your treatment? (MM/DD/YY)  <br/>
                    <textarea rows="3" name="5" cols="50" style="margin-right: 40px; vertical-align: middle;"></textarea>
        <br /><br />Q6. Where was treatment given?  <br/>
                    <textarea rows="3" name="6" cols="50" style="margin-right: 40px; vertical-align: middle;"></textarea>
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