{"id":593,"date":"2024-02-14T10:56:54","date_gmt":"2024-02-14T16:56:54","guid":{"rendered":"https:\/\/uabforms.hs.uab.edu\/blogs\/greyform\/?page_id=593"},"modified":"2024-02-14T10:56:54","modified_gmt":"2024-02-14T16:56:54","slug":"slp-student-internship-application","status":"publish","type":"page","link":"https:\/\/uabforms.hs.uab.edu\/blogs\/greyform\/index.php\/slp-student-internship-application\/","title":{"rendered":"SLP Student Internship Application"},"content":{"rendered":"<script type=\"text\/javascript\">if(!gform){document.addEventListener(\"gform_main_scripts_loaded\",function(){gform.scriptsLoaded=!0}),window.addEventListener(\"DOMContentLoaded\",function(){gform.domLoaded=!0});var gform={domLoaded:!1,scriptsLoaded:!1,initializeOnLoaded:function(o){gform.domLoaded&&gform.scriptsLoaded?o():!gform.domLoaded&&gform.scriptsLoaded?window.addEventListener(\"DOMContentLoaded\",o):document.addEventListener(\"gform_main_scripts_loaded\",o)},hooks:{action:{},filter:{}},addAction:function(o,n,r,t){gform.addHook(\"action\",o,n,r,t)},addFilter:function(o,n,r,t){gform.addHook(\"filter\",o,n,r,t)},doAction:function(o){gform.doHook(\"action\",o,arguments)},applyFilters:function(o){return gform.doHook(\"filter\",o,arguments)},removeAction:function(o,n){gform.removeHook(\"action\",o,n)},removeFilter:function(o,n,r){gform.removeHook(\"filter\",o,n,r)},addHook:function(o,n,r,t,i){null==gform.hooks[o][n]&&(gform.hooks[o][n]=[]);var e=gform.hooks[o][n];null==i&&(i=n+\"_\"+e.length),null==t&&(t=10),gform.hooks[o][n].push({tag:i,callable:r,priority:t})},doHook:function(o,n,r){if(r=Array.prototype.slice.call(r,1),null!=gform.hooks[o][n]){var t,i=gform.hooks[o][n];i.sort(function(o,n){return o.priority-n.priority});for(var e=0;e<i.length;e++)\"function\"!=typeof(t=i[e].callable)&#038;&#038;(t=window[t]),\"action\"==o?t.apply(null,r):r[0]=t.apply(null,r)}if(\"filter\"==o)return r[0]},removeHook:function(o,n,r,t){if(null!=gform.hooks[o][n])for(var i=gform.hooks[o][n],e=i.length-1;0<=e;e--)null!=t&#038;&#038;t!=i[e].tag||null!=r&#038;&#038;r!=i[e].priority||i.splice(e,1)}}}<\/script>\n                <div class='gf_browser_gecko gform_wrapper gravity-theme' id='gform_wrapper_157' style='display:none'><div id='gf_157' class='gform_anchor' tabindex='-1'><\/div><form method='post' enctype='multipart\/form-data' target='gform_ajax_frame_157' id='gform_157'  action='\/blogs\/greyform\/index.php\/wp-json\/wp\/v2\/pages\/593#gf_157' novalidate>\n                        <div class='gform_body gform-body'><div id='gform_fields_157' class='gform_fields top_label form_sublabel_below description_below'><div id=\"field_157_37\" class=\"gfield gfield--width-full gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below field_description_below gfield_visibility_visible\" >The UAB Medicine Speech-Language Pathologist Internship Program includes comprehensive training and hands-on experience. The application periods are listed below. This application is for graduate students only.\n<\/br><\/br>\n<ul>\n<li>Spring semester: Applications accepted in April for selection in May<\/li>\n\n<li>Summer semester: Applications accepted in February for interviews and selection in March<\/li>\n\n<li>Fall semester: Applications accepted in March for interviews and selection in April<\/li>\n<\/ul><\/div><fieldset id=\"field_157_33\" class=\"gfield gfield--width-full gfield_contains_required field_sublabel_below field_description_below gfield_visibility_visible\" ><legend class='gfield_label gfield_label_before_complex'  >Name<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/legend><div class='ginput_complex ginput_container no_prefix has_first_name no_middle_name has_last_name no_suffix gf_name_has_2 ginput_container_name' id='input_157_33'>\n                            \n                            <span id='input_157_33_3_container' class='name_first' >\n                                                    <input type='text' name='input_33.3' id='input_157_33_3' value='' aria-label='First name'   aria-required='true'     \/>\n                                                    <label for='input_157_33_3' >First<\/label>\n                                                <\/span>\n                            \n                            <span id='input_157_33_6_container' class='name_last' >\n                                                    <input type='text' name='input_33.6' id='input_157_33_6' value='' aria-label='Last name'   aria-required='true'     \/>\n                                                    <label for='input_157_33_6' >Last<\/label>\n                                                <\/span>\n                            \n                        <\/div><\/fieldset><div id=\"field_157_35\" class=\"gfield gfield--width-full gfield_contains_required field_sublabel_below field_description_below gfield_visibility_visible\" ><label class='gfield_label' for='input_157_35' >Email<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/label><div class='ginput_container ginput_container_email'>\n                            <input name='input_35' id='input_157_35' type='email' value='' class='large'    aria-required=\"true\" aria-invalid=\"false\"  \/>\n                        <\/div><\/div><div id=\"field_157_34\" class=\"gfield gfield--width-full gfield_contains_required field_sublabel_below field_description_below gfield_visibility_visible\" ><label class='gfield_label' for='input_157_34' >Phone<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/label><div class='ginput_container ginput_container_phone'><input name='input_34' id='input_157_34' type='tel' value='' class='large'   aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_157_36\" class=\"gfield gfield--width-full gfield_contains_required field_sublabel_below field_description_below gfield_visibility_visible\" ><label class='gfield_label' for='input_157_36' >School<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_36' id='input_157_36' type='text' value='' class='large'     aria-required=\"true\" aria-invalid=\"false\"   \/> <\/div><\/div><div id=\"field_157_1\" class=\"gfield gfield_contains_required field_sublabel_below field_description_below gfield_visibility_visible\" ><label class='gfield_label' for='input_157_1' >What semester and year are you applying for?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_1' id='input_157_1' type='text' value='' class='large'     aria-required=\"true\" aria-invalid=\"false\"   \/> <\/div><\/div><fieldset id=\"field_157_2\" class=\"gfield gfield--width-half gfield_contains_required field_sublabel_below field_description_below gfield_visibility_visible\" ><legend class='gfield_label gfield_label_before_complex'  >What venue of care are you applying for<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox' id='input_157_2'><div class='gchoice gchoice_157_2_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_2.1' type='checkbox'  value='Acute care adults'  id='choice_157_2_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_157_2_1' id='label_157_2_1'>Acute care adults<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_157_2_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_2.2' type='checkbox'  value='Neonate'  id='choice_157_2_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_157_2_2' id='label_157_2_2'>Neonate<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_157_2_3'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_2.3' type='checkbox'  value='Inpatient Rehab'  id='choice_157_2_3'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_157_2_3' id='label_157_2_3'>Inpatient Rehab<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_157_2_4'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_2.4' type='checkbox'  value='Outpatient'  id='choice_157_2_4'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_157_2_4' id='label_157_2_4'>Outpatient<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_157_4\" class=\"gfield gfield--width-half gfield_contains_required field_sublabel_below field_description_below gfield_visibility_visible\" ><label class='gfield_label' for='input_157_4' >Why are you applying for this venue of care?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_4' id='input_157_4' class='textarea large'     aria-required=\"true\" aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/div><div id=\"field_157_31\" class=\"gfield gfield--width-full gfield_contains_required field_sublabel_below field_description_below gfield_visibility_visible\" ><label class='gfield_label' for='input_157_31' >What experience do you have with healthy term infants (e.g., feeding, babysitting)?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_31' id='input_157_31' class='textarea large'     aria-required=\"true\" aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/div><div id=\"field_157_32\" class=\"gfield gfield--width-full gfield_contains_required field_sublabel_below field_description_below gfield_visibility_visible\" ><label class='gfield_label' for='input_157_32' >What excites you most about a NICU experience? What fears do you have about a NICU internship?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_32' id='input_157_32' class='textarea large'     aria-required=\"true\" aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/div><div id=\"field_157_5\" class=\"gfield gfield_contains_required field_sublabel_below field_description_below gfield_visibility_visible\" ><label class='gfield_label' for='input_157_5' >What coursework have you completed already?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_5' id='input_157_5' class='textarea large'     aria-required=\"true\" aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/div><div id=\"field_157_6\" class=\"gfield gfield_contains_required field_sublabel_below field_description_below gfield_visibility_visible\" ><label class='gfield_label' for='input_157_6' >What is your current GPA?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/label><div class='ginput_container ginput_container_number'><input name='input_6' id='input_157_6' type='number' step='any'   value='' class='large'     aria-required=\"true\" aria-invalid=\"false\"  \/><\/div><\/div><div id=\"field_157_7\" class=\"gfield gfield_contains_required field_sublabel_below field_description_below gfield_visibility_visible\" ><label class='gfield_label' for='input_157_7' >What clinical experiences\/internships have you already completed?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_7' id='input_157_7' class='textarea large'     aria-required=\"true\" aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/div><div id=\"field_157_8\" class=\"gfield gfield_contains_required field_sublabel_below field_description_below gfield_visibility_visible\" ><label class='gfield_label' for='input_157_8' >Why are you interested in an internship at UAB? What goals do you have for yourself if you are selected for this internship?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_8' id='input_157_8' class='textarea large'     aria-required=\"true\" aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/div><div id=\"field_157_9\" class=\"gfield gfield_contains_required field_sublabel_below field_description_below gfield_visibility_visible\" ><label class='gfield_label' for='input_157_9' >What would your previous supervisors say is your greatest strength and weakness?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_9' id='input_157_9' class='textarea large'     aria-required=\"true\" aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/div><div id=\"field_157_10\" class=\"gfield gfield_contains_required field_sublabel_below field_description_below gfield_visibility_visible\" ><label class='gfield_label' for='input_157_10' >What would your best friend say is your greatest strength and weakness?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_10' id='input_157_10' class='textarea large'     aria-required=\"true\" aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/div><div id=\"field_157_12\" class=\"gfield gfield_contains_required field_sublabel_below field_description_below gfield_visibility_visible\" ><label class='gfield_label' for='input_157_12' >What are your top two interests in Speech Pathology?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_12' id='input_157_12' type='text' value='' class='large'     aria-required=\"true\" aria-invalid=\"false\"   \/> <\/div><\/div><div id=\"field_157_13\" class=\"gfield gfield_contains_required field_sublabel_below field_description_below gfield_visibility_visible\" ><label class='gfield_label' for='input_157_13' >What is your learning style?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_13' id='input_157_13' class='textarea large'     aria-required=\"true\" aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/div><div id=\"field_157_14\" class=\"gfield gfield_contains_required field_sublabel_below field_description_below gfield_visibility_visible\" ><label class='gfield_label' for='input_157_14' >How do you take constructive feedback?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_14' id='input_157_14' class='textarea large'     aria-required=\"true\" aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/div><div id=\"field_157_16\" class=\"gfield gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below field_description_below gfield_visibility_visible\" >On a scale of 1-5, with 1 being unfamiliar\/uncomfortable and 5 being comfortable\/independent, how do you feel performing the following skills?<\/div><fieldset id=\"field_157_18\" class=\"gfield gfield--width-half gfield_contains_required field_sublabel_below field_description_below gfield_visibility_visible\" ><legend class='gfield_label'  >Oral Motor Exam<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_157_18'>\n\t\t\t<div class='gchoice gchoice_157_18_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_18' type='radio' value='1'  id='choice_157_18_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_157_18_0' id='label_157_18_0'>1<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_157_18_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_18' type='radio' value='2'  id='choice_157_18_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_157_18_1' id='label_157_18_1'>2<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_157_18_2'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_18' type='radio' value='3'  id='choice_157_18_2' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_157_18_2' id='label_157_18_2'>3<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_157_18_3'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_18' type='radio' value='4'  id='choice_157_18_3' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_157_18_3' id='label_157_18_3'>4<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_157_18_4'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_18' type='radio' value='5'  id='choice_157_18_4' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_157_18_4' id='label_157_18_4'>5<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_157_19\" class=\"gfield gfield--width-half gfield_contains_required field_sublabel_below field_description_below gfield_visibility_visible\" ><legend class='gfield_label'  >Bedside Dysphagia Exam<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_157_19'>\n\t\t\t<div class='gchoice gchoice_157_19_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_19' type='radio' value='1'  id='choice_157_19_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_157_19_0' id='label_157_19_0'>1<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_157_19_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_19' type='radio' value='2'  id='choice_157_19_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_157_19_1' id='label_157_19_1'>2<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_157_19_2'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_19' type='radio' value='3'  id='choice_157_19_2' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_157_19_2' id='label_157_19_2'>3<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_157_19_3'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_19' type='radio' value='4'  id='choice_157_19_3' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_157_19_3' id='label_157_19_3'>4<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_157_19_4'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_19' type='radio' value='5'  id='choice_157_19_4' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_157_19_4' id='label_157_19_4'>5<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_157_21\" class=\"gfield gfield--width-half gfield_contains_required field_sublabel_below field_description_below gfield_visibility_visible\" ><legend class='gfield_label'  >Modified Barium Swallow<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_157_21'>\n\t\t\t<div class='gchoice gchoice_157_21_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_21' type='radio' value='1'  id='choice_157_21_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_157_21_0' id='label_157_21_0'>1<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_157_21_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_21' type='radio' value='2'  id='choice_157_21_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_157_21_1' id='label_157_21_1'>2<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_157_21_2'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_21' type='radio' value='3'  id='choice_157_21_2' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_157_21_2' id='label_157_21_2'>3<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_157_21_3'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_21' type='radio' value='4'  id='choice_157_21_3' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_157_21_3' id='label_157_21_3'>4<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_157_21_4'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_21' type='radio' value='5'  id='choice_157_21_4' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_157_21_4' id='label_157_21_4'>5<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_157_20\" class=\"gfield gfield--width-half gfield_contains_required field_sublabel_below field_description_below gfield_visibility_visible\" ><legend class='gfield_label'  >FEES<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_157_20'>\n\t\t\t<div class='gchoice gchoice_157_20_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_20' type='radio' value='1'  id='choice_157_20_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_157_20_0' id='label_157_20_0'>1<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_157_20_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_20' type='radio' value='2'  id='choice_157_20_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_157_20_1' id='label_157_20_1'>2<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_157_20_2'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_20' type='radio' value='3'  id='choice_157_20_2' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_157_20_2' id='label_157_20_2'>3<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_157_20_3'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_20' type='radio' value='4'  id='choice_157_20_3' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_157_20_3' id='label_157_20_3'>4<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_157_20_4'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_20' type='radio' value='5'  id='choice_157_20_4' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_157_20_4' id='label_157_20_4'>5<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_157_25\" class=\"gfield gfield--width-half gfield_contains_required field_sublabel_below field_description_below gfield_visibility_visible\" ><legend class='gfield_label'  >Speaking Valve Placement<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_157_25'>\n\t\t\t<div class='gchoice gchoice_157_25_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_25' type='radio' value='1'  id='choice_157_25_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_157_25_0' id='label_157_25_0'>1<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_157_25_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_25' type='radio' value='2'  id='choice_157_25_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_157_25_1' id='label_157_25_1'>2<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_157_25_2'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_25' type='radio' value='3'  id='choice_157_25_2' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_157_25_2' id='label_157_25_2'>3<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_157_25_3'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_25' type='radio' value='4'  id='choice_157_25_3' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_157_25_3' id='label_157_25_3'>4<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_157_25_4'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_25' type='radio' value='5'  id='choice_157_25_4' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_157_25_4' id='label_157_25_4'>5<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_157_24\" class=\"gfield gfield--width-half gfield_contains_required field_sublabel_below field_description_below gfield_visibility_visible\" ><legend class='gfield_label'  >Language Evaluation<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_157_24'>\n\t\t\t<div class='gchoice gchoice_157_24_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_24' type='radio' value='1'  id='choice_157_24_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_157_24_0' id='label_157_24_0'>1<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_157_24_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_24' type='radio' value='2'  id='choice_157_24_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_157_24_1' id='label_157_24_1'>2<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_157_24_2'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_24' type='radio' value='3'  id='choice_157_24_2' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_157_24_2' id='label_157_24_2'>3<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_157_24_3'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_24' type='radio' value='4'  id='choice_157_24_3' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_157_24_3' id='label_157_24_3'>4<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_157_24_4'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_24' type='radio' value='5'  id='choice_157_24_4' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_157_24_4' id='label_157_24_4'>5<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_157_23\" class=\"gfield gfield--width-half gfield_contains_required field_sublabel_below field_description_below gfield_visibility_visible\" ><legend class='gfield_label'  >Aphasia Treatment<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_157_23'>\n\t\t\t<div class='gchoice gchoice_157_23_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_23' type='radio' value='1'  id='choice_157_23_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_157_23_0' id='label_157_23_0'>1<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_157_23_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_23' type='radio' value='2'  id='choice_157_23_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_157_23_1' id='label_157_23_1'>2<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_157_23_2'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_23' type='radio' value='3'  id='choice_157_23_2' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_157_23_2' id='label_157_23_2'>3<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_157_23_3'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_23' type='radio' value='4'  id='choice_157_23_3' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_157_23_3' id='label_157_23_3'>4<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_157_23_4'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_23' type='radio' value='5'  id='choice_157_23_4' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_157_23_4' id='label_157_23_4'>5<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_157_22\" class=\"gfield gfield--width-half gfield_contains_required field_sublabel_below field_description_below gfield_visibility_visible\" ><legend class='gfield_label'  >Apraxia Treatment<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_157_22'>\n\t\t\t<div class='gchoice gchoice_157_22_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_22' type='radio' value='1'  id='choice_157_22_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_157_22_0' id='label_157_22_0'>1<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_157_22_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_22' type='radio' value='2'  id='choice_157_22_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_157_22_1' id='label_157_22_1'>2<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_157_22_2'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_22' type='radio' value='3'  id='choice_157_22_2' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_157_22_2' id='label_157_22_2'>3<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_157_22_3'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_22' type='radio' value='4'  id='choice_157_22_3' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_157_22_3' id='label_157_22_3'>4<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_157_22_4'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_22' type='radio' value='5'  id='choice_157_22_4' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_157_22_4' id='label_157_22_4'>5<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_157_30\" class=\"gfield gfield--width-half gfield_contains_required field_sublabel_below field_description_below gfield_visibility_visible\" ><legend class='gfield_label'  >Cognitive Evaluation<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_157_30'>\n\t\t\t<div class='gchoice gchoice_157_30_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_30' type='radio' value='1'  id='choice_157_30_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_157_30_0' id='label_157_30_0'>1<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_157_30_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_30' type='radio' value='2'  id='choice_157_30_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_157_30_1' id='label_157_30_1'>2<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_157_30_2'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_30' type='radio' value='3'  id='choice_157_30_2' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_157_30_2' id='label_157_30_2'>3<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_157_30_3'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_30' type='radio' value='4'  id='choice_157_30_3' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_157_30_3' id='label_157_30_3'>4<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_157_30_4'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_30' type='radio' value='5'  id='choice_157_30_4' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_157_30_4' id='label_157_30_4'>5<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_157_29\" class=\"gfield gfield--width-half gfield_contains_required field_sublabel_below field_description_below gfield_visibility_visible\" ><legend class='gfield_label'  >Cognitive Treatment<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_157_29'>\n\t\t\t<div class='gchoice gchoice_157_29_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_29' type='radio' value='1'  id='choice_157_29_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_157_29_0' id='label_157_29_0'>1<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_157_29_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_29' type='radio' value='2'  id='choice_157_29_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_157_29_1' id='label_157_29_1'>2<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_157_29_2'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_29' type='radio' value='3'  id='choice_157_29_2' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_157_29_2' id='label_157_29_2'>3<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_157_29_3'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_29' type='radio' value='4'  id='choice_157_29_3' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_157_29_3' id='label_157_29_3'>4<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_157_29_4'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_29' type='radio' value='5'  id='choice_157_29_4' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_157_29_4' id='label_157_29_4'>5<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_157_28\" class=\"gfield gfield--width-full gfield_contains_required field_sublabel_below field_description_below gfield_visibility_visible\" ><legend class='gfield_label'  >Dysphagia Treatment<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_157_28'>\n\t\t\t<div class='gchoice gchoice_157_28_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_28' type='radio' value='1'  id='choice_157_28_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_157_28_0' id='label_157_28_0'>1<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_157_28_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_28' type='radio' value='2'  id='choice_157_28_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_157_28_1' id='label_157_28_1'>2<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_157_28_2'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_28' type='radio' value='3'  id='choice_157_28_2' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_157_28_2' id='label_157_28_2'>3<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_157_28_3'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_28' type='radio' value='4'  id='choice_157_28_3' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_157_28_3' id='label_157_28_3'>4<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_157_28_4'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_28' type='radio' value='5'  id='choice_157_28_4' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_157_28_4' id='label_157_28_4'>5<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><\/div><\/div>\n        <div class='gform_footer top_label'> <input type='submit' id='gform_submit_button_157' class='gform_button button' 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