Online Referral
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<ul class="er_fld_row"><li class="er_fld_type_date" draggable="false" style="width: 50%;"> <i class="fa fa-calendar"></i><label class="er_fld_label">Date of referral</label><input class="cst_datepicker" name="CST_126" type="text"></li></ul><ul class="er_fld_row"><li class="er_fld_type_content" draggable="false" style="width: 50%;"> <i class="fa fa-info-circle"></i><label>Guidelines\Help Text</label><div class="cst_content er_fld_fontstyle_info">Child's Information</div></li></ul><ul class="er_fld_row"><li class="er_fld_type_text" draggable="false" style="width: 33.3333%;" map_to="CC_FirstName"> <i class="fa fa-font"></i><label class="er_fld_label required">Child's First Name</label><input name="CST_145" type="text" class="er_fld_required"></li><li class="er_fld_type_text" draggable="false" style="width: 33.3333%;" map_to="CC_LastName"> <i class="fa fa-font"></i><label class="er_fld_label required">Child's Last Name</label><input name="CST_127" type="text" class="er_fld_required"></li></ul><ul class="er_fld_row"><li class="er_fld_type_date" draggable="false" style="width: 20%;" map_to="CC_DOB"> <i class="fa fa-calendar"></i><label class="er_fld_label required">Date of Birth</label><input class="cst_datepicker er_fld_required" name="CST_183" type="text"></li><li class="er_fld_type_text" draggable="false" style="width: 20%;" map_to="CC_Birthplace"> <i class="fa fa-font"></i><label class="er_fld_label required">Place of birth:</label><input name="CST_130" type="text" class="er_fld_required"></li><li class="er_fld_type_radio" style="white-space: normal; width: 20%;" draggable="false" map_to="CC_PrimaryLanguage"><i class="fa fa-circle-o"></i><label class="er_fld_label required">Primary Language</label> <label class="er_option"><input class="type_radio er_fld_required" type="radio" name="CST_186" value="English">English</label><label class="er_option"><input class="type_radio er_fld_required" type="radio" name="CST_186" value="Spanish">Spanish</label><label class="er_option er_option_other"><input class="type_radio er_option_other er_fld_required" type="radio" name="CST_186" value="Other:">Other:<input class="cst_Other er_fld_required" name="CST_186_Other" type="text"></label></li><li class="er_fld_type_radio" style="white-space: normal; width: 20%;" draggable="false" map_to="CC_Race"><i class="fa fa-circle-o"></i><label class="er_fld_label required">Ethnicity/Race</label> <label class="er_option"><input class="type_radio" type="radio" name="CST_166" value="American Indian or Alaska Native">American Indian or Alaska Native</label><label class="er_option"><input class="type_radio" type="radio" name="CST_166" value="Asian">Asian</label><label class="er_option"><input class="type_radio" type="radio" name="CST_166" value="Bi-racial">Bi-racial</label><label class="er_option"><input class="type_radio" type="radio" name="CST_166" value="Black or African American">Black or African American</label><label class="er_option"><input class="type_radio" type="radio" name="CST_166" value="Multi-Racial">Multi-Racial</label><label class="er_option"><input class="type_radio" type="radio" name="CST_166" value="Native Hawaiian or Other Pacific Islander">Native Hawaiian or Other Pacific Islander</label><label class="er_option"><input class="type_radio" type="radio" name="CST_166" value="White">White</label><label class="er_option"><input class="type_radio" type="radio" name="CST_166" value="Unknown">Unknown</label><label class="er_option"><input class="type_radio" type="radio" name="CST_166" value="Hispanic or Latinx">Hispanic or Latinx</label><label class="er_option er_option_other"><input class="type_radio er_option_other er_fld_required" type="radio" name="CST_166" value="Other:">Other:<input class="cst_Other er_fld_required" name="CST_166_Other" type="text"></label></li></ul><ul class="er_fld_row"><li class="er_fld_type_radio" style="white-space: normal; width: 16.6667%;" draggable="false" map_to="none"><i class="fa fa-circle-o"></i><label class="er_fld_label required">Biological Gender</label> <label class="er_option"><input class="type_radio er_fld_required" type="radio" name="CST_165" value="Male">Male</label><label class="er_option"><input class="type_radio er_fld_required" type="radio" name="CST_165" value="Female">Female</label><label class="er_option er_option_other er_option_other_off"><input class="type_radio er_option_other er_fld_required" type="radio" name="CST_165" value="Other:">Other:<input class="cst_Other er_fld_required" name="CST_165_Other" type="text"></label></li><li class="er_fld_type_dropdown" draggable="false" style="width: 16.6667%;" map_to="CC_Gender"><i class="fa fa-caret-down"></i><label class="er_fld_label required">Gender Identification:</label><select name="CST_188" class="er_fld_required"><option value="- Not Specified -" selected="">- Not Specified -</option><option value="Male">Male</option><option value="Female">Female</option><option value="Non-Binary">Non-Binary</option><option value="Transgender Female">Transgender Female</option><option value="Transgender Male">Transgender Male</option></select></li><li class="er_fld_type_paragraph er_fld_type_paragraph_small" draggable="false" style="width: 16.6667%;"> <i class="fa fa-paragraph"></i><label class="er_fld_label">Cultural Considerations</label><textarea name="CST_190" style="width:100%;" class=""></textarea></li><li class="er_fld_type_radio" style="white-space: normal; width: 16.6667%;" draggable="false" map_to="CC_Religion"><i class="fa fa-circle-o"></i><label class="er_fld_label required">Religious Preference</label> <label class="er_option"><input class="type_radio" type="radio" name="CST_168" value="- Not Specified -">- Not Specified -</label><label class="er_option"><input class="type_radio" type="radio" name="CST_168" value="Baptist">Baptist</label><label class="er_option"><input class="type_radio" type="radio" name="CST_168" value="Catholic">Catholic</label><label class="er_option"><input class="type_radio" type="radio" name="CST_168" value="Christian (non-denom)">Christian (non-denom)</label><label class="er_option"><input class="type_radio" type="radio" name="CST_168" value="Episcopalian">Episcopalian</label><label class="er_option"><input class="type_radio" type="radio" name="CST_168" value="Jehovah's Witness">Jehovah's Witness</label><label class="er_option"><input class="type_radio" type="radio" name="CST_168" value="Jewish">Jewish</label><label class="er_option"><input class="type_radio" type="radio" name="CST_168" value="LDS">LDS</label><label class="er_option"><input class="type_radio" type="radio" name="CST_168" value="Lutheran">Lutheran</label><label class="er_option"><input class="type_radio" type="radio" name="CST_168" value="Methodist">Methodist</label><label class="er_option"><input class="type_radio" type="radio" name="CST_168" value="Mormon">Mormon</label><label class="er_option"><input class="type_radio" type="radio" name="CST_168" value="Muslim">Muslim</label><label class="er_option"><input class="type_radio" type="radio" name="CST_168" value="Pentacostal">Pentacostal</label><label class="er_option"><input class="type_radio" type="radio" name="CST_168" value="Presbyterian">Presbyterian</label><label class="er_option"><input class="type_radio" type="radio" name="CST_168" value="Protestant">Protestant</label><label class="er_option"><input class="type_radio" type="radio" name="CST_168" value="Reformed">Reformed</label><label class="er_option"><input class="type_radio" type="radio" name="CST_168" value="United Church of Christ">United Church of Christ</label><label class="er_option"><input class="type_radio" type="radio" name="CST_168" value="None">None</label><label class="er_option"><input class="type_radio" type="radio" name="CST_168" value="Declined to provide">Declined to provide</label><label class="er_option er_option_other"><input class="type_radio er_option_other er_fld_required" type="radio" name="CST_168" value="Other:">Other:<input class="cst_Other er_fld_required" name="CST_168_Other" type="text"></label></li></ul><ul class="er_fld_row"><li class="er_fld_type_text" draggable="false" style="width: 20%;"> <i class="fa fa-font"></i><label class="er_fld_label required">TRAILS Client ID</label><input name="CST_142" type="text" class="er_fld_required"></li><li class="er_fld_type_text" draggable="false" style="width: 20%;"> <i class="fa fa-font"></i><label class="er_fld_label required">Medicaid Number</label><input name="CST_140" type="text" class="er_fld_required"></li><li class="er_fld_type_radio" style="white-space: normal; width: 20%;" draggable="false"><i class="fa fa-circle-o"></i><label class="er_fld_label required">Is the child a member of a RAE?</label> <label class="er_option"><input class="type_radio er_fld_required" type="radio" name="CST_169" value="Yes">Yes</label> <label class="er_option"><input class="type_radio er_fld_required" type="radio" name="CST_169" value="No">No</label> <label class="er_option er_option_other er_option_other_off"><input class="type_radio er_option_other er_fld_required" type="radio" name="CST_169" value="Other:">Other:<input class="cst_Other er_fld_required" name="CST_169_Other" type="text"></label> </li><li class="er_fld_type_radio er_fld_showif" style="white-space: normal; width: 20%;" draggable="false" er_fld_condfld="CST_169" er_fld_condvals="er_fld_showif_values=Yes"><i class="fa fa-circle-o"></i><label class="er_fld_label required">If yes, which one?</label> <label class="er_option"><input class="type_radio er_fld_blank" type="radio" name="CST_170" value="CCHA">CCHA</label><label class="er_option"><input class="type_radio er_fld_blank" type="radio" name="CST_170" value="Colorado Access">Colorado Access</label><label class="er_option"><input class="type_radio er_fld_blank" type="radio" name="CST_170" value="Rocky Mountain Health Plans">Rocky Mountain Health Plans</label><label class="er_option"><input class="type_radio er_fld_blank" type="radio" name="CST_170" value="Carelon (formerly Beacon/United Health Services)">Carelon (formerly Beacon/United Health Services)</label><label class="er_option"><input class="type_radio er_fld_blank" type="radio" name="CST_170" value="CYMHTA">CYMHTA</label><label class="er_option er_option_other"><input class="type_radio er_option_other er_fld_required er_fld_blank" type="radio" name="CST_170" value="Other:">Other:<input class="cst_Other er_fld_required er_fld_blank" name="CST_170_Other" type="text"></label></li></ul><ul class="er_fld_row"><li class="er_fld_type_radio" style="white-space: normal; width: 25%;" draggable="false"><i class="fa fa-circle-o"></i><label class="er_fld_label required">Is there a secondary insurance?</label> <label class="er_option"><input class="type_radio er_fld_required" type="radio" name="CST_171" value="Yes">Yes</label> <label class="er_option"><input class="type_radio er_fld_required" type="radio" name="CST_171" value="No">No</label> <label class="er_option er_option_other er_option_other_off"><input class="type_radio er_option_other er_fld_required" type="radio" name="CST_171" value="Other:">Other:<input class="cst_Other er_fld_required" name="CST_171_Other" type="text"></label> </li><li class="er_fld_type_text er_fld_showif" draggable="false" style="width: 25%;" er_fld_condfld="CST_171"> <i class="fa fa-font"></i><label class="er_fld_label required">If yes, name of carrier</label><input name="CST_134" type="text" class="er_fld_required er_fld_blank"></li><li class="er_fld_type_text er_fld_showif" draggable="false" style="width: 25%;" er_fld_condfld="CST_171" er_fld_condvals="er_fld_showif_values=Yes"> <i class="fa fa-font"></i><label class="er_fld_label required">If yes, what is the plan number</label><input name="CST_136" type="text" class="er_fld_required er_fld_blank"></li></ul><ul class="er_fld_row"><li class="er_fld_type_content" draggable="false" style="width: 50%;"> <i class="fa fa-info-circle"></i><label>Guidelines\Help Text</label><div class="cst_content er_fld_fontstyle_info">Physical Description of Child</div></li></ul><ul class="er_fld_row"><li class="er_fld_type_text" draggable="false" style="width: 20%;"> <i class="fa fa-font"></i><label class="er_fld_label">Height</label><input name="CST_147" type="text" value="" class=""></li><li class="er_fld_type_text" draggable="false" style="width: 20%;"> <i class="fa fa-font"></i><label class="er_fld_label">Weight</label><input name="CST_148" type="text" class=""></li><li class="er_fld_type_radio" style="white-space: normal; width: 20%;" draggable="false"><i class="fa fa-circle-o"></i><label class="er_fld_label">Hair Color</label> <label class="er_option"><input class="type_radio" type="radio" name="CST_172" value="Black">Black</label><label class="er_option"><input class="type_radio" type="radio" name="CST_172" value="Blonde">Blonde</label><label class="er_option"><input class="type_radio" type="radio" name="CST_172" value="Brown">Brown</label><label class="er_option"><input class="type_radio" type="radio" name="CST_172" value="Red">Red</label><label class="er_option er_option_other"><input class="type_radio er_option_other" type="radio" name="CST_172" value="Other:">Other:<input class="cst_Other" name="CST_172_Other" type="text"></label></li><li class="er_fld_type_radio" style="white-space: normal; width: 20%;" draggable="false"><i class="fa fa-circle-o"></i><label class="er_fld_label">Eye Color</label> <label class="er_option"><input class="type_radio" type="radio" name="CST_173" value="Blue">Blue</label><label class="er_option"><input class="type_radio" type="radio" name="CST_173" value="Brown">Brown</label><label class="er_option"><input class="type_radio" type="radio" name="CST_173" value="Green">Green</label><label class="er_option"><input class="type_radio" type="radio" name="CST_173" value="Hazel">Hazel</label><label class="er_option er_option_other"><input class="type_radio er_option_other" type="radio" name="CST_173" value="Other:">Other:<input class="cst_Other" name="CST_173_Other" type="text"></label></li></ul><ul class="er_fld_row"><li class="er_fld_type_text" draggable="false" style="width: 33.3333%;"> <i class="fa fa-font"></i><label class="er_fld_label">Build</label><input name="CST_155" type="text" class=""></li><li class="er_fld_type_text" draggable="false" style="width: 33.3333%;"> <i class="fa fa-font"></i><label class="er_fld_label">Identifying Marks</label><input name="CST_128" type="text" class=""></li></ul><ul class="er_fld_row"><li class="er_fld_type_content" draggable="false" style="width: 50%;"> <i class="fa fa-info-circle"></i><label>Guidelines\Help Text</label><div class="cst_content er_fld_fontstyle_info">Applicant Information:</div></li></ul><ul class="er_fld_row"><li class="er_fld_type_text" draggable="false" style="width: 20%;" map_to="CC_ReferringWorker_Ref"> <i class="fa fa-font"></i><label class="er_fld_label required">Person Submitting Application: Name/Title</label><input name="CST_174" type="text" class="er_fld_required"></li><li class="er_fld_type_text" draggable="false" style="width: 20%;"> <i class="fa fa-font"></i><label class="er_fld_label required">Address:</label><input name="CST_175" type="text" class="er_fld_required"></li><li class="er_fld_type_text" draggable="false" style="width: 20%;" map_to="CC_ReferringPhone_Ref"> <i class="fa fa-font"></i><label class="er_fld_label required">Phone:</label><input name="CST_176" type="text" class="er_fld_required"></li><li class="er_fld_type_text" draggable="false" style="width: 20%;" map_to="CC_ReferringEmail_Ref"> <i class="fa fa-font"></i><label class="er_fld_label required">Email:</label><input name="CST_177" type="text" class="er_fld_required"></li></ul><ul class="er_fld_row"><li class="er_fld_type_text" draggable="false" style="width: 20%;"> <i class="fa fa-font"></i><label class="er_fld_label required">Referring Agency Supervisor:</label><input name="CST_179" type="text" class="er_fld_required"></li><li class="er_fld_type_text" draggable="false" style="width: 20%;"> <i class="fa fa-font"></i><label class="er_fld_label required">Address:</label><input name="CST_178" type="text" class="er_fld_required"></li><li class="er_fld_type_text" draggable="false" style="width: 20%;"> <i class="fa fa-font"></i><label class="er_fld_label required">Phone:</label><input name="CST_180" type="text" class="er_fld_required"></li><li class="er_fld_type_text" draggable="false" style="width: 20%;"> <i class="fa fa-font"></i><label class="er_fld_label required">Email:</label><input name="CST_181" type="text" class="er_fld_required"></li></ul><ul class="er_fld_row"><li class="er_fld_type_content" draggable="false" style="width: 50%;"> <i class="fa fa-info-circle"></i><label>Guidelines\Help Text</label><div class="cst_content er_fld_fontstyle_info">Emergency Contact Information</div></li></ul><ul class="er_fld_row"><li class="er_fld_type_text" draggable="false" style="width: 16.6667%;"> <i class="fa fa-font"></i><label class="er_fld_label required">Name:</label><input name="CST_152" type="text" class="er_fld_required"></li><li class="er_fld_type_text" draggable="false" style="width: 16.6667%;"> <i class="fa fa-font"></i><label class="er_fld_label required">Address:</label><input name="CST_153" type="text" class="er_fld_required"></li><li class="er_fld_type_text" draggable="false" style="width: 16.6667%;"> <i class="fa fa-font"></i><label class="er_fld_label required">Phone:</label><input name="CST_154" type="text" class="er_fld_required"></li><li class="er_fld_type_text" draggable="false" style="width: 16.6667%;"> <i class="fa fa-font"></i><label class="er_fld_label required">After Hours Contact Phone:</label><input name="CST_157" type="text" class="er_fld_required"></li><li class="er_fld_type_text" draggable="false" style="width: 16.6667%;"> <i class="fa fa-font"></i><label class="er_fld_label required">Email:</label><input name="CST_159" type="text" class="er_fld_required"></li></ul><ul class="er_fld_row"><li class="er_fld_type_text" draggable="false" style="width: 16.6667%;"> <i class="fa fa-font"></i><label class="er_fld_label">Name:</label><input name="CST_160" type="text"></li><li class="er_fld_type_text" draggable="false" style="width: 16.6667%;"> <i class="fa fa-font"></i><label class="er_fld_label">Address:</label><input name="CST_161" type="text"></li><li class="er_fld_type_text" draggable="false" style="width: 16.6667%;"> <i class="fa fa-font"></i><label class="er_fld_label">Phone:</label><input name="CST_162" type="text"></li><li class="er_fld_type_text" draggable="false" style="width: 16.6667%;"> <i class="fa fa-font"></i><label class="er_fld_label">After Hours Contact Phone:</label><input name="CST_163" type="text"></li><li class="er_fld_type_text" draggable="false" style="width: 16.6667%;"> <i class="fa fa-font"></i><label class="er_fld_label">Email:</label><input name="CST_164" type="text"></li></ul><ul class="er_fld_row"><li class="er_fld_type_content" draggable="false" style="width: 50%;"> <i class="fa fa-info-circle"></i><label>Guidelines\Help Text</label><div class="cst_content er_fld_fontstyle_info">Parent and/or Guardian Information:</div></li></ul><ul class="er_fld_row"><li class="er_fld_type_text" draggable="false" style="width: 33.3333%;" map_to="none"> <i class="fa fa-font"></i><label class="er_fld_label required">Name of Parent/Custodian (1) of child:</label><input name="CST_1" type="text" class="er_fld_required"></li><li class="er_fld_type_text" draggable="false" style="width: 33.3333%;"> <i class="fa fa-font"></i><label class="er_fld_label required">Address:</label><input name="CST_3" type="text" class="er_fld_required"></li></ul><ul class="er_fld_row"><li class="er_fld_type_text" draggable="false" style="width: 33.3333%;" map_to="CC_ReferringPhone_Ref"> <i class="fa fa-font"></i><label class="er_fld_label required">Phone:</label><input name="CST_5" type="text" class="er_fld_required"></li><li class="er_fld_type_text" draggable="false" style="width: 33.3333%;"> <i class="fa fa-font"></i><label class="er_fld_label required">Email:</label><input name="CST_7" type="text" class="er_fld_required"></li></ul><ul class="er_fld_row"><li class="er_fld_type_text" draggable="false" style="width: 33.3333%;"> <i class="fa fa-font"></i><label class="er_fld_label">Name of Parent/Custodian (2) of child:</label><input name="CST_2" type="text" class=""></li><li class="er_fld_type_text" draggable="false" style="width: 33.3333%;"> <i class="fa fa-font"></i><label class="er_fld_label">Address:</label><input name="CST_4" type="text" class=""></li></ul><ul class="er_fld_row"><li class="er_fld_type_text" draggable="false" style="width: 33.3333%;"> <i class="fa fa-font"></i><label class="er_fld_label">Phone:</label><input name="CST_6" type="text" class=""></li><li class="er_fld_type_text" draggable="false" style="width: 33.3333%;"> <i class="fa fa-font"></i><label class="er_fld_label">Email:</label><input name="CST_8" type="text" class=""></li></ul><ul class="er_fld_row"><li class="er_fld_type_text" draggable="false" style="width: 33.3333%;"> <i class="fa fa-font"></i><label class="er_fld_label required">Name of Foster Parent (1):</label><input name="CST_191" type="text" class="er_fld_required"></li><li class="er_fld_type_text" draggable="false" style="width: 33.3333%;"> <i class="fa fa-font"></i><label class="er_fld_label required">Address:</label><input name="CST_192" type="text" class="er_fld_required"></li></ul><ul class="er_fld_row"><li class="er_fld_type_text" draggable="false" style="width: 33.3333%;"> <i class="fa fa-font"></i><label class="er_fld_label required">Phone:</label><input name="CST_193" type="text" class="er_fld_required"></li><li class="er_fld_type_text" draggable="false" style="width: 33.3333%;"> <i class="fa fa-font"></i><label class="er_fld_label required">Email:</label><input name="CST_194" type="text" class="er_fld_required"></li></ul><ul class="er_fld_row"><li class="er_fld_type_text" draggable="false" style="width: 33.3333%;"> <i class="fa fa-font"></i><label class="er_fld_label">Name of Foster Parent (2):</label><input name="CST_196" type="text" class=""></li><li class="er_fld_type_text" draggable="false" style="width: 33.3333%;"> <i class="fa fa-font"></i><label class="er_fld_label">Address:</label><input name="CST_195" type="text" class=""></li></ul><ul class="er_fld_row"><li class="er_fld_type_text" draggable="false" style="width: 50%;"> <i class="fa fa-font"></i><label class="er_fld_label">Phone</label><input name="CST_197" type="text" class=""></li><li class="er_fld_type_text" draggable="false" style="width: 50%;"> <i class="fa fa-font"></i><label class="er_fld_label">Email:</label><input name="CST_198" type="text" class=""></li></ul><ul class="er_fld_row"><li class="er_fld_type_content" draggable="false" style="width: 50%;"> <i class="fa fa-info-circle"></i><label>Guidelines\Help Text</label><div class="cst_content er_fld_fontstyle_info">Other Agencies Involved (if not applicable mark N/A in the box(es):</div></li></ul><ul class="er_fld_row"><li class="er_fld_type_text" draggable="false" style="width: 20%;"> <i class="fa fa-font"></i><label class="er_fld_label required">Caseworker Name</label><input name="CST_9" type="text" class="er_fld_required"></li><li class="er_fld_type_text" draggable="false" style="width: 20%;"> <i class="fa fa-font"></i><label class="er_fld_label required">Agency:</label><input name="CST_13" type="text" class="er_fld_required"></li><li class="er_fld_type_text" draggable="false" style="width: 20%;"> <i class="fa fa-font"></i><label class="er_fld_label required">Phone: </label><input name="CST_17" type="text" class="er_fld_required"></li><li class="er_fld_type_text" draggable="false" style="width: 20%;"> <i class="fa fa-font"></i><label class="er_fld_label required">Email Address:</label><input name="CST_24" type="text" class="er_fld_required"></li></ul><ul class="er_fld_row"><li class="er_fld_type_text" draggable="false" style="width: 20%;"> <i class="fa fa-font"></i><label class="er_fld_label required">GAL Name</label><input name="CST_10" type="text" class="er_fld_required"></li><li class="er_fld_type_text" draggable="false" style="width: 20%;"> <i class="fa fa-font"></i><label class="er_fld_label required">Agency:</label><input name="CST_14" type="text" class="er_fld_required"></li><li class="er_fld_type_text" draggable="false" style="width: 20%;"> <i class="fa fa-font"></i><label class="er_fld_label required">Phone: </label><input name="CST_18" type="text" class="er_fld_required"></li><li class="er_fld_type_text" draggable="false" style="width: 20%;"> <i class="fa fa-font"></i><label class="er_fld_label required">Email Address:</label><input name="CST_23" type="text" class="er_fld_required"></li></ul><ul class="er_fld_row"><li class="er_fld_type_text" draggable="false" style="width: 20%;"> <i class="fa fa-font"></i><label class="er_fld_label">Attorney Name</label><input name="CST_11" type="text" class=""></li><li class="er_fld_type_text" draggable="false" style="width: 20%;"> <i class="fa fa-font"></i><label class="er_fld_label">Agency:</label><input name="CST_15" type="text" class=""></li><li class="er_fld_type_text" draggable="false" style="width: 20%;"> <i class="fa fa-font"></i><label class="er_fld_label">Phone: </label><input name="CST_19" type="text" class=""></li><li class="er_fld_type_text" draggable="false" style="width: 20%;"> <i class="fa fa-font"></i><label class="er_fld_label">Email Address:</label><input name="CST_22" type="text" class=""></li></ul><ul class="er_fld_row"><li class="er_fld_type_radio" style="white-space: normal; width: 50%;" draggable="false"><i class="fa fa-circle-o"></i><label class="er_fld_label required">Are there other individuals/agencies involved in this case?</label> <label class="er_option"><input class="type_radio er_fld_required" type="radio" name="CST_119" value="Yes">Yes</label> <label class="er_option"><input class="type_radio er_fld_required" type="radio" name="CST_119" value="No">No</label> <label class="er_option er_option_other er_option_other_off"><input class="type_radio er_option_other er_fld_required" type="radio" name="CST_119" value="Other:">Other:<input class="cst_Other er_fld_required" name="CST_119_Other" type="text"></label> </li></ul><ul class="er_fld_row"><li class="er_fld_type_text er_fld_showif" draggable="false" style="width: 20%;" er_fld_condfld="CST_119" er_fld_condvals="er_fld_showif_values=Yes"> <i class="fa fa-font"></i><label class="er_fld_label required">Name: </label><input name="CST_12" type="text" class="er_fld_required er_fld_blank"></li><li class="er_fld_type_text er_fld_showif" draggable="false" style="width: 20%;" er_fld_condfld="CST_119" er_fld_condvals="er_fld_showif_values=Yes"> <i class="fa fa-font"></i><label class="er_fld_label required">Relationship to youth/Agency</label><input name="CST_123" type="text" class="er_fld_required er_fld_blank"></li><li class="er_fld_type_text er_fld_showif" draggable="false" style="width: 20%;" er_fld_condfld="CST_119" er_fld_condvals="er_fld_showif_values=Yes"> <i class="fa fa-font"></i><label class="er_fld_label required">Phone: </label><input name="CST_20" type="text" class="er_fld_required er_fld_blank"></li><li class="er_fld_type_text er_fld_showif" draggable="false" style="width: 20%;" er_fld_condfld="CST_119" er_fld_condvals="er_fld_showif_values=Yes"> <i class="fa fa-font"></i><label class="er_fld_label required">Email Address:</label><input name="CST_21" type="text" class="er_fld_required er_fld_blank"></li></ul><ul class="er_fld_row"><li class="er_fld_type_text er_fld_showif" draggable="false" style="width: 20%;" er_fld_condfld="CST_119" er_fld_condvals="er_fld_showif_values=Yes"> <i class="fa fa-font"></i><label class="er_fld_label">Name:</label><input name="CST_120" type="text" class="er_fld_blank"></li><li class="er_fld_type_text er_fld_showif" draggable="false" style="width: 20%;" er_fld_condfld="CST_119" er_fld_condvals="er_fld_showif_values=Yes"> <i class="fa fa-font"></i><label class="er_fld_label">Phone</label><input name="CST_122" type="text" class="er_fld_blank"></li><li class="er_fld_type_text er_fld_showif" draggable="false" style="width: 20%;" er_fld_condfld="CST_119" er_fld_condvals="er_fld_showif_values=Yes"> <i class="fa fa-font"></i><label class="er_fld_label">Agency</label><input name="CST_124" type="text" class="er_fld_blank"></li><li class="er_fld_type_text er_fld_showif" draggable="false" style="width: 20%;" er_fld_condfld="CST_119" er_fld_condvals="er_fld_showif_values=Yes"> <i class="fa fa-font"></i><label class="er_fld_label">Email Address</label><input name="CST_125" type="text" class="er_fld_blank"></li></ul><ul class="er_fld_row"><li class="er_fld_type_content" draggable="false" style="width: 50%;"> <i class="fa fa-info-circle"></i><label>Guidelines\Help Text</label><div class="cst_content er_fld_fontstyle_info">Placement Information:</div></li></ul><ul class="er_fld_row"><li class="er_fld_type_paragraph er_fld_type_paragraph_small" draggable="false" style="width: 50%;"> <i class="fa fa-paragraph"></i><label class="er_fld_label">Where does the child currently reside? What are the barriers to keeping the child in their current placement?</label><textarea name="CST_25" style="width:100%;"></textarea></li></ul><ul class="er_fld_row"><li class="er_fld_type_content" draggable="false" style="width: 50%;"> <i class="fa fa-info-circle"></i><label>Guidelines\Help Text</label><div class="cst_content er_fld_fontstyle_info">Reason for Referral</div></li></ul><ul class="er_fld_row"><li class="er_fld_type_paragraph er_fld_type_paragraph_small" draggable="false" style="width: 50%;" map_to="CC_ReferralReason_Ref"> <i class="fa fa-paragraph"></i><label class="er_fld_label"></label><textarea name="CST_27" style="width:100%;"></textarea></li></ul><ul class="er_fld_row"><li class="er_fld_type_content" draggable="false" style="width: 50%;"> <i class="fa fa-info-circle"></i><label>Guidelines\Help Text</label><div class="cst_content er_fld_fontstyle_info">What is the desired outcome from respite?</div></li></ul><ul class="er_fld_row"><li class="er_fld_type_paragraph er_fld_type_paragraph_small" draggable="false" style="width: 50%;" map_to="CC_Goal_Ref"> <i class="fa fa-paragraph"></i><label class="er_fld_label"></label><textarea name="CST_33" style="width:100%;"></textarea></li></ul><ul class="er_fld_row"><li class="er_fld_type_content" draggable="false" style="width: 50%;"> <i class="fa fa-info-circle"></i><label>Guidelines\Help Text</label><div class="cst_content er_fld_fontstyle_info">Background information</div></li></ul><ul class="er_fld_row"><li class="er_fld_type_paragraph er_fld_type_paragraph_small" draggable="false" style="width: 50%;"> <i class="fa fa-paragraph"></i><label class="er_fld_label">What is the current diagnoses (please attach/send copies of relevant evaluations/assessments).</label><textarea name="CST_28" style="width:100%;" class=""></textarea></li></ul><ul class="er_fld_row"><li class="er_fld_type_paragraph er_fld_type_paragraph_small" draggable="false" style="width: 50%;"> <i class="fa fa-paragraph"></i><label class="er_fld_label">What is the child's IQ or approximate level of functioning?</label><textarea name="CST_29" style="width:100%;" class=""></textarea></li></ul><ul class="er_fld_row"><li class="er_fld_type_text" draggable="false" style="width: 20%;" map_to="CC_School_Name"> <i class="fa fa-font"></i><label class="er_fld_label required">What school does the child attend?</label><input name="CST_37" type="text" class="er_fld_required"></li><li class="er_fld_type_text" draggable="false" style="width: 20%;" map_to="CC_School_District"> <i class="fa fa-font"></i><label class="er_fld_label required">School District</label><input name="CST_38" type="text" class="er_fld_required"></li><li class="er_fld_type_text" draggable="false" style="width: 20%;" map_to="CC_School_Contact"> <i class="fa fa-font"></i><label class="er_fld_label required">Contact name:</label><input name="CST_39" type="text" class="er_fld_required"></li><li class="er_fld_type_text" draggable="false" style="width: 20%;" map_to="CC_School_Phone"> <i class="fa fa-font"></i><label class="er_fld_label required">Contact Phone Number</label><input name="CST_40" type="text" class="er_fld_required"></li></ul><ul class="er_fld_row"><li class="er_fld_type_checkbox er_fld_type_radio_col3" style="white-space: normal; width: 50%;" draggable="false"><i class="fa fa-check-square-o"></i><label class="er_fld_label required">What are the child's strengths?</label> <label class="er_option"><input class="type_checkbox er_fld_required" type="checkbox" name="CST_34" value="Open minded">Open minded</label><label class="er_option"><input class="type_checkbox er_fld_required" type="checkbox" name="CST_34" value="Logical thinker">Logical thinker</label><label class="er_option"><input class="type_checkbox er_fld_required" type="checkbox" name="CST_34" value="Innovator/Creative with craft">Innovator/Creative with craft</label><label class="er_option"><input class="type_checkbox er_fld_required" type="checkbox" name="CST_34" value="Good judgement-knows right and wrong">Good judgement-knows right and wrong</label><label class="er_option"><input class="type_checkbox er_fld_required" type="checkbox" name="CST_34" value="Good decision-making skills">Good decision-making skills</label><label class="er_option"><input class="type_checkbox er_fld_required" type="checkbox" name="CST_34" value="Efficiency/ likes to accomplish task/task oriented">Efficiency/ likes to accomplish task/task oriented</label><label class="er_option"><input class="type_checkbox er_fld_required" type="checkbox" name="CST_34" value="Creative">Creative</label><label class="er_option"><input class="type_checkbox er_fld_required" type="checkbox" name="CST_34" value="Artistic">Artistic</label><label class="er_option"><input class="type_checkbox er_fld_required" type="checkbox" name="CST_34" value="Musically inclined">Musically inclined</label><label class="er_option"><input class="type_checkbox er_fld_required" type="checkbox" name="CST_34" value="Assessing the needs of others">Assessing the needs of others</label><label class="er_option"><input class="type_checkbox er_fld_required" type="checkbox" name="CST_34" value="Storytelling">Storytelling</label><label class="er_option"><input class="type_checkbox er_fld_required" type="checkbox" name="CST_34" value="Creating ideas">Creating ideas</label><label class="er_option"><input class="type_checkbox er_fld_required" type="checkbox" name="CST_34" value="Creating with words">Creating with words</label><label class="er_option"><input class="type_checkbox er_fld_required" type="checkbox" name="CST_34" value="Negotiating with others">Negotiating with others</label><label class="er_option"><input class="type_checkbox er_fld_required" type="checkbox" name="CST_34" value="Verbal communication">Verbal communication</label><label class="er_option"><input class="type_checkbox er_fld_required" type="checkbox" name="CST_34" value="Expressing self in writing ">Expressing self in writing </label><label class="er_option"><input class="type_checkbox er_fld_required" type="checkbox" name="CST_34" value="Persuasive">Persuasive</label><label class="er_option"><input class="type_checkbox er_fld_required" type="checkbox" name="CST_34" value="Singerly Focused ">Singerly Focused </label><label class="er_option"><input class="type_checkbox er_fld_required" type="checkbox" name="CST_34" value="Timeliness">Timeliness</label><label class="er_option"><input class="type_checkbox er_fld_required" type="checkbox" name="CST_34" value="Dedicated to others">Dedicated to others</label><label class="er_option"><input class="type_checkbox er_fld_required" type="checkbox" name="CST_34" value="Detail-oriented">Detail-oriented</label><label class="er_option"><input class="type_checkbox er_fld_required" type="checkbox" name="CST_34" value="Multi-tasking able">Multi-tasking able</label><label class="er_option"><input class="type_checkbox er_fld_required" type="checkbox" name="CST_34" value="Respectful">Respectful</label><label class="er_option"><input class="type_checkbox er_fld_required" type="checkbox" name="CST_34" value="Recover quickly when problems arise">Recover quickly when problems arise</label><label class="er_option"><input class="type_checkbox er_fld_required" type="checkbox" name="CST_34" value="Responsible with siblings">Responsible with siblings</label><label class="er_option"><input class="type_checkbox er_fld_required" type="checkbox" name="CST_34" value="Clever use of time">Clever use of time</label><label class="er_option"><input class="type_checkbox er_fld_required" type="checkbox" name="CST_34" value="Easily uses language, reason">Easily uses language, reason</label><label class="er_option"><input class="type_checkbox er_fld_required" type="checkbox" name="CST_34" value="Strong decision making">Strong decision making</label><label class="er_option"><input class="type_checkbox er_fld_required" type="checkbox" name="CST_34" value="Collaborating with others">Collaborating with others</label><label class="er_option"><input class="type_checkbox er_fld_required" type="checkbox" name="CST_34" value="Understanding others needs">Understanding others needs</label><label class="er_option"><input class="type_checkbox er_fld_required" type="checkbox" name="CST_34" value="Understanding others' ideas">Understanding others' ideas</label><label class="er_option"><input class="type_checkbox er_fld_required" type="checkbox" name="CST_34" value="Manages stress positively">Manages stress positively</label><label class="er_option"><input class="type_checkbox er_fld_required" type="checkbox" name="CST_34" value="Street smart- manages dangerous situations ">Street smart- manages dangerous situations </label><label class="er_option"><input class="type_checkbox er_fld_required" type="checkbox" name="CST_34" value="Motivating others">Motivating others</label><label class="er_option"><input class="type_checkbox er_fld_required" type="checkbox" name="CST_34" value="Mentoring others">Mentoring others</label><label class="er_option"><input class="type_checkbox er_fld_required" type="checkbox" name="CST_34" value="Facilitating with staff led activity ">Facilitating with staff led activity </label><label class="er_option"><input class="type_checkbox er_fld_required" type="checkbox" name="CST_34" value="Give/take constructive criticism">Give/take constructive criticism</label><label class="er_option"><input class="type_checkbox er_fld_required" type="checkbox" name="CST_34" value="Able to determine future options">Able to determine future options</label><label class="er_option"><input class="type_checkbox er_fld_required" type="checkbox" name="CST_34" value="Can resolve conflict when invested in the situation">Can resolve conflict when invested in the situation</label><label class="er_option"><input class="type_checkbox er_fld_required" type="checkbox" name="CST_34" value="• Resilient">• Resilient</label><label class="er_option"><input class="type_checkbox er_fld_required" type="checkbox" name="CST_34" value="• Astute">• Astute</label><label class="er_option"><input class="type_checkbox er_fld_required" type="checkbox" name="CST_34" value="• Calculating-able to understand the cost of an action">• Calculating-able to understand the cost of an action</label><label class="er_option"><input class="type_checkbox er_fld_required" type="checkbox" name="CST_34" value="• Complex">• Complex</label><label class="er_option"><input class="type_checkbox er_fld_required" type="checkbox" name="CST_34" value="• Discerning">• Discerning</label><label class="er_option"><input class="type_checkbox er_fld_required" type="checkbox" name="CST_34" value="• Insightful">• Insightful</label><label class="er_option"><input class="type_checkbox er_fld_required" type="checkbox" name="CST_34" value="• Intelligent">• Intelligent</label><label class="er_option"><input class="type_checkbox er_fld_required" type="checkbox" name="CST_34" value="• Methodical-carries out plans by steps">• Methodical-carries out plans by steps</label><label class="er_option"><input class="type_checkbox er_fld_required" type="checkbox" name="CST_34" value="• Meticulous- notices every detail">• Meticulous- notices every detail</label><label class="er_option"><input class="type_checkbox er_fld_required" type="checkbox" name="CST_34" value="• Objective">• Objective</label><label class="er_option"><input class="type_checkbox er_fld_required" type="checkbox" name="CST_34" value="• Perceptive">• Perceptive</label><label class="er_option"><input class="type_checkbox er_fld_required" type="checkbox" name="CST_34" value="• Practical">• Practical</label><label class="er_option"><input class="type_checkbox er_fld_required" type="checkbox" name="CST_34" value="• Shrewd">• Shrewd</label><label class="er_option"><input class="type_checkbox er_fld_required" type="checkbox" name="CST_34" value="• Strategic">• Strategic</label><label class="er_option"><input class="type_checkbox er_fld_required" type="checkbox" name="CST_34" value="• Thoughtful">• Thoughtful</label><label class="er_option"><input class="type_checkbox er_fld_required" type="checkbox" name="CST_34" value="• Unique">• Unique</label><label class="er_option"><input class="type_checkbox er_fld_required" type="checkbox" name="CST_34" value="• Imaginative">• Imaginative</label><label class="er_option"><input class="type_checkbox er_fld_required" type="checkbox" name="CST_34" value="• Fluent in another language">• Fluent in another language</label><label class="er_option"><input class="type_checkbox er_fld_required" type="checkbox" name="CST_34" value="• Strong mentally">• Strong mentally</label><label class="er_option"><input class="type_checkbox er_fld_required" type="checkbox" name="CST_34" value="• Strong emotionally">• Strong emotionally</label><label class="er_option"><input class="type_checkbox er_fld_required" type="checkbox" name="CST_34" value="• Strong physically">• Strong physically</label><label class="er_option"><input class="type_checkbox er_fld_required" type="checkbox" name="CST_34" value="• Skillful ">• Skillful </label><label class="er_option"><input class="type_checkbox er_fld_required" type="checkbox" name="CST_34" value="• Advanced at self-sufficient actions">• Advanced at self-sufficient actions</label><label class="er_option"><input class="type_checkbox er_fld_required" type="checkbox" name="CST_34" value="• Adept at navigating adult expectations">• Adept at navigating adult expectations</label><label class="er_option"><input class="type_checkbox er_fld_required" type="checkbox" name="CST_34" value="• Valuable-has a positive contribution ">• Valuable-has a positive contribution </label><label class="er_option"><input class="type_checkbox er_fld_required" type="checkbox" name="CST_34" value="• Worthy of effort to support">• Worthy of effort to support</label><label class="er_option er_option_other"><input class="type_checkbox er_option_other er_fld_required" type="checkbox" name="CST_34" value="Other:">Other:<input class="cst_Other er_fld_required" name="CST_34_Other" type="text"></label></li></ul><ul class="er_fld_row"><li class="er_fld_type_checkbox er_fld_type_radio_col3" style="white-space: normal; width: 50%;" draggable="false"><i class="fa fa-check-square-o"></i><label class="er_fld_label required">What are or have been some barriers to treatment/successful placement?</label> <label class="er_option"><input class="type_checkbox er_fld_required" type="checkbox" name="CST_35" value="Transitioning challenges">Transitioning challenges</label><label class="er_option"><input class="type_checkbox er_fld_required" type="checkbox" name="CST_35" value="Anticipation stress">Anticipation stress</label><label class="er_option"><input class="type_checkbox er_fld_required" type="checkbox" name="CST_35" value="Non-compliance with expectations">Non-compliance with expectations</label><label class="er_option"><input class="type_checkbox er_fld_required" type="checkbox" name="CST_35" value="Lack of personal awareness ">Lack of personal awareness </label><label class="er_option"><input class="type_checkbox er_fld_required" type="checkbox" name="CST_35" value="Argumentative">Argumentative</label><label class="er_option"><input class="type_checkbox er_fld_required" type="checkbox" name="CST_35" value="Aggressive">Aggressive</label><label class="er_option"><input class="type_checkbox er_fld_required" type="checkbox" name="CST_35" value="Disrespectful">Disrespectful</label><label class="er_option"><input class="type_checkbox er_fld_required" type="checkbox" name="CST_35" value="Disengaged">Disengaged</label><label class="er_option"><input class="type_checkbox er_fld_required" type="checkbox" name="CST_35" value="Denial of need">Denial of need</label><label class="er_option"><input class="type_checkbox er_fld_required" type="checkbox" name="CST_35" value="Disrupted attachments with primary caregivers">Disrupted attachments with primary caregivers</label><label class="er_option"><input class="type_checkbox er_fld_required" type="checkbox" name="CST_35" value="Disrupted family dynamics">Disrupted family dynamics</label><label class="er_option"><input class="type_checkbox er_fld_required" type="checkbox" name="CST_35" value="Angry/Unyielding">Angry/Unyielding</label><label class="er_option"><input class="type_checkbox er_fld_required" type="checkbox" name="CST_35" value="Non empathetic responses">Non empathetic responses</label><label class="er_option"><input class="type_checkbox er_fld_required" type="checkbox" name="CST_35" value="Unable to think rationally">Unable to think rationally</label><label class="er_option"><input class="type_checkbox er_fld_required" type="checkbox" name="CST_35" value="Refusal to engage with therapy process">Refusal to engage with therapy process</label><label class="er_option"><input class="type_checkbox er_fld_required" type="checkbox" name="CST_35" value="Refusal to respond to direct requests for Behavioral compliance">Refusal to respond to direct requests for Behavioral compliance</label><label class="er_option"><input class="type_checkbox er_fld_required" type="checkbox" name="CST_35" value="Refusal to respond to boundaries set and established by primary caregivers">Refusal to respond to boundaries set and established by primary caregivers</label><label class="er_option"><input class="type_checkbox er_fld_required" type="checkbox" name="CST_35" value="Unstable relationships">Unstable relationships</label><label class="er_option"><input class="type_checkbox er_fld_required" type="checkbox" name="CST_35" value="Desire for illegal lifestyle ">Desire for illegal lifestyle </label><label class="er_option"><input class="type_checkbox er_fld_required" type="checkbox" name="CST_35" value="Desire to return to substance use">Desire to return to substance use</label><label class="er_option"><input class="type_checkbox er_fld_required" type="checkbox" name="CST_35" value="Substance use ">Substance use </label><label class="er_option"><input class="type_checkbox er_fld_required" type="checkbox" name="CST_35" value="Psychiatric challenges with thought disorders">Psychiatric challenges with thought disorders</label><label class="er_option"><input class="type_checkbox er_fld_required" type="checkbox" name="CST_35" value="Psychiatric challenges with mood dysregulation">Psychiatric challenges with mood dysregulation</label><label class="er_option"><input class="type_checkbox er_fld_required" type="checkbox" name="CST_35" value="Desire to self-harm">Desire to self-harm</label><label class="er_option"><input class="type_checkbox er_fld_required" type="checkbox" name="CST_35" value="Desire to self-abuse">Desire to self-abuse</label><label class="er_option"><input class="type_checkbox er_fld_required" type="checkbox" name="CST_35" value="Desire to harm other (people or animals)">Desire to harm other (people or animals)</label><label class="er_option"><input class="type_checkbox er_fld_required" type="checkbox" name="CST_35" value="Challenges with understanding healthy relationships ">Challenges with understanding healthy relationships </label><label class="er_option"><input class="type_checkbox er_fld_required" type="checkbox" name="CST_35" value="Challenges with understanding healthy communication">Challenges with understanding healthy communication</label><label class="er_option"><input class="type_checkbox er_fld_required" type="checkbox" name="CST_35" value="Challenges with understanding legal issues">Challenges with understanding legal issues</label><label class="er_option"><input class="type_checkbox er_fld_required" type="checkbox" name="CST_35" value="Challenges with complying with legal consequences">Challenges with complying with legal consequences</label><label class="er_option er_option_other er_option_other_off"><input class="type_checkbox er_option_other er_fld_required" type="checkbox" name="CST_35" value="Other:">Other:<input class="cst_Other er_fld_required" name="CST_35_Other" type="text"></label></li></ul><ul class="er_fld_row"><li class="er_fld_type_paragraph er_fld_type_paragraph_small" draggable="false" style="width: 50%;"> <i class="fa fa-paragraph"></i><label class="er_fld_label required">What are the child's individual needs?</label><textarea name="CST_30" style="width:100%;" class="er_fld_required"></textarea></li></ul><ul class="er_fld_row"><li class="er_fld_type_paragraph er_fld_type_paragraph_small" draggable="false" style="width: 50%;"> <i class="fa fa-paragraph"></i><label class="er_fld_label required">Does the child have a history of trauma? (Please describe)</label><textarea name="CST_31" style="width:100%;" class="er_fld_required"></textarea></li></ul><ul class="er_fld_row"><li class="er_fld_type_paragraph er_fld_type_paragraph_small" draggable="false" style="width: 50%;"> <i class="fa fa-paragraph"></i><label class="er_fld_label required">Describe child's current behavior(s).</label><textarea name="CST_32" style="width:100%;" class="er_fld_required"></textarea></li></ul><ul class="er_fld_row"><li class="er_fld_type_content" draggable="false" style="width: 50%;"> <i class="fa fa-info-circle"></i><label>Guidelines\Help Text</label><div class="cst_content er_fld_fontstyle_info">Mental Health/Medical Information (If not applicable mark box NA)</div></li></ul><ul class="er_fld_row"><li class="er_fld_type_text" draggable="false" style="width: 25%;"> <i class="fa fa-font"></i><label class="er_fld_label">Mental Health Provider: Name</label><input name="CST_42" type="text" value="" class=""></li><li class="er_fld_type_text" draggable="false" style="width: 25%;"> <i class="fa fa-font"></i><label class="er_fld_label">Address</label><input name="CST_43" type="text" value="" class=""></li><li class="er_fld_type_text" draggable="false" style="width: 25%;"> <i class="fa fa-font"></i><label class="er_fld_label">Phone</label><input name="CST_41" type="text" class=""></li></ul><ul class="er_fld_row"><li class="er_fld_type_text" draggable="false" style="width: 25%;"> <i class="fa fa-font"></i><label class="er_fld_label">Psychiatrist: Name</label><input name="CST_44" type="text" value="" class=""></li><li class="er_fld_type_text" draggable="false" style="width: 25%;"> <i class="fa fa-font"></i><label class="er_fld_label">Address</label><input name="CST_48" type="text" class=""></li><li class="er_fld_type_text" draggable="false" style="width: 25%;"> <i class="fa fa-font"></i><label class="er_fld_label">Phone</label><input name="CST_52" type="text" class=""></li></ul><ul class="er_fld_row"><li class="er_fld_type_text" draggable="false" style="width: 25%;"> <i class="fa fa-font"></i><label class="er_fld_label">Medical Provider: Name</label><input name="CST_45" type="text" class=""></li><li class="er_fld_type_text" draggable="false" style="width: 25%;"> <i class="fa fa-font"></i><label class="er_fld_label">Address</label><input name="CST_49" type="text" class=""></li><li class="er_fld_type_text" draggable="false" style="width: 25%;"> <i class="fa fa-font"></i><label class="er_fld_label">Phone</label><input name="CST_53" type="text" class=""></li></ul><ul class="er_fld_row"><li class="er_fld_type_text" draggable="false" style="width: 25%;"> <i class="fa fa-font"></i><label class="er_fld_label">Dental Provider: Name</label><input name="CST_46" type="text" class=""></li><li class="er_fld_type_text" draggable="false" style="width: 25%;"> <i class="fa fa-font"></i><label class="er_fld_label">Address</label><input name="CST_50" type="text" class=""></li><li class="er_fld_type_text" draggable="false" style="width: 25%;"> <i class="fa fa-font"></i><label class="er_fld_label">Phone</label><input name="CST_54" type="text" class=""></li></ul><ul class="er_fld_row"><li class="er_fld_type_text" draggable="false" style="width: 25%;"> <i class="fa fa-font"></i><label class="er_fld_label">Vision Provider: Name</label><input name="CST_47" type="text" class=""></li><li class="er_fld_type_text" draggable="false" style="width: 25%;"> <i class="fa fa-font"></i><label class="er_fld_label">Address</label><input name="CST_51" type="text" class=""></li><li class="er_fld_type_text" draggable="false" style="width: 25%;"> <i class="fa fa-font"></i><label class="er_fld_label">Phone</label><input name="CST_55" type="text" class=""></li></ul><ul class="er_fld_row"><li class="er_fld_type_text" draggable="false" style="width: 33.3333%;"> <i class="fa fa-font"></i><label class="er_fld_label">Other: Specify Name/Discipline</label><input name="CST_56" type="text" class=""></li><li class="er_fld_type_text" draggable="false" style="width: 33.3333%;"> <i class="fa fa-font"></i><label class="er_fld_label">Phone</label><input name="CST_58" type="text" class=""></li><li class="er_fld_type_text" draggable="false" style="width: 33.3333%;"> <i class="fa fa-font"></i><label class="er_fld_label">Address</label><input name="CST_57" type="text" class=""></li></ul><ul class="er_fld_row"><li class="er_fld_type_radio" style="white-space: normal; width: 33.3333%;" draggable="false"><i class="fa fa-circle-o"></i><label class="er_fld_label required">Any injuries/illnesses in the last 3 months?</label> <label class="er_option"><input class="type_radio er_fld_required" type="radio" name="CST_66" value="Yes">Yes</label> <label class="er_option"><input class="type_radio er_fld_required" type="radio" name="CST_66" value="No">No</label> <label class="er_option er_option_other er_option_other_off"><input class="type_radio er_option_other er_fld_required" type="radio" name="CST_66" value="Other:">Other:<input class="cst_Other er_fld_required" name="CST_66_Other" type="text"></label> </li><li class="er_fld_type_paragraph er_fld_type_paragraph_small er_fld_showif" draggable="false" er_fld_condfld="CST_66" er_fld_condvals="er_fld_showif_values=Yes" style="width: 33.3333%;"> <i class="fa fa-paragraph"></i><label class="er_fld_label required">If so, please elaborate</label><textarea name="CST_64" style="width:100%;" class="er_fld_required er_fld_blank"></textarea></li></ul><ul class="er_fld_row"><li class="er_fld_type_radio er_fld_showif" style="white-space: normal; width: 33.3333%;" draggable="false" er_fld_condfld="CST_66" er_fld_condvals="er_fld_showif_values=Yes"><i class="fa fa-circle-o"></i><label class="er_fld_label required">Is the child still receiving treatment for identified illness/injury?</label> <label class="er_option"><input class="type_radio er_fld_required" type="radio" name="CST_67" value="Yes">Yes</label> <label class="er_option"><input class="type_radio er_fld_required" type="radio" name="CST_67" value="No">No</label> <label class="er_option er_option_other er_option_other_off"><input class="type_radio er_option_other er_fld_required" type="radio" name="CST_67" value="Other:">Other:<input class="cst_Other er_fld_required" name="CST_67_Other" type="text"></label> </li><li class="er_fld_type_paragraph er_fld_type_paragraph_small er_fld_showif" draggable="false" style="width: 33.3333%;" er_fld_condfld="CST_67" er_fld_condvals="er_fld_showif_values=Yes"> <i class="fa fa-paragraph"></i><label class="er_fld_label required">If yes, please describe:</label><textarea name="CST_65" style="width:100%;" class="er_fld_required er_fld_blank"></textarea></li></ul><ul class="er_fld_row"><li class="er_fld_type_radio" style="white-space: normal; width: 33.3333%;" draggable="false"><i class="fa fa-circle-o"></i><label class="er_fld_label required">Does the child have any scheduled medical/therapy appointments in the next 14 days?</label> <label class="er_option"><input class="type_radio er_fld_required" type="radio" name="CST_68" value="Yes">Yes</label> <label class="er_option"><input class="type_radio er_fld_required" type="radio" name="CST_68" value="No">No</label> <label class="er_option er_option_other er_option_other_off"><input class="type_radio er_option_other er_fld_required" type="radio" name="CST_68" value="Other:">Other:<input class="cst_Other er_fld_required" name="CST_68_Other" type="text"></label> </li><li class="er_fld_type_paragraph er_fld_type_paragraph_small er_fld_showif" draggable="false" style="width: 33.3333%;" er_fld_condfld="CST_68" er_fld_condvals="er_fld_showif_values=Yes"> <i class="fa fa-paragraph"></i><label class="er_fld_label required">If yes:</label><textarea name="CST_71" style="width:100%;" class="er_fld_blank er_fld_required">Please note the foster family and/or caseworker will be responsible for either rescheduling the appointment or transportation to and from the appointment.</textarea></li></ul><ul class="er_fld_row"><li class="er_fld_type_radio" style="white-space: normal; width: 33.3333%;" draggable="false"><i class="fa fa-circle-o"></i><label class="er_fld_label required">Is there any other specialized medical care to be provided while the child is in placement?</label> <label class="er_option"><input class="type_radio er_fld_required" type="radio" name="CST_96" value="Yes">Yes</label> <label class="er_option"><input class="type_radio er_fld_required" type="radio" name="CST_96" value="No">No</label> <label class="er_option er_option_other er_option_other_off"><input class="type_radio er_option_other er_fld_required" type="radio" name="CST_96" value="Other:">Other:<input class="cst_Other er_fld_required" name="CST_96_Other" type="text"></label> </li><li class="er_fld_type_paragraph er_fld_type_paragraph_small er_fld_showif" draggable="false" style="width: 33.3333%;" er_fld_condfld="CST_96" er_fld_condvals="er_fld_showif_values=Yes"> <i class="fa fa-paragraph"></i><label class="er_fld_label required">If yes, please describe:</label><textarea name="CST_97" style="width:100%;" class="er_fld_blank er_fld_required"></textarea></li></ul><ul class="er_fld_row"><li class="er_fld_type_radio" style="white-space: normal; width: 33.3333%;" draggable="false"><i class="fa fa-circle-o"></i><label class="er_fld_label required">Does the child have any adaptive equipment, including glasses and hearing aides?</label> <label class="er_option"><input class="type_radio er_fld_required" type="radio" name="CST_98" value="Yes">Yes</label> <label class="er_option"><input class="type_radio er_fld_required" type="radio" name="CST_98" value="No">No</label> <label class="er_option er_option_other er_option_other_off"><input class="type_radio er_option_other er_fld_required" type="radio" name="CST_98" value="Other:">Other:<input class="cst_Other er_fld_required" name="CST_98_Other" type="text"></label> </li><li class="er_fld_type_paragraph er_fld_type_paragraph_small er_fld_showif" draggable="false" style="width: 33.3333%;" er_fld_condfld="CST_98"> <i class="fa fa-paragraph"></i><label class="er_fld_label required">If yes, please describe:</label><textarea name="CST_99" style="width:100%;" class="er_fld_blank er_fld_required"></textarea></li></ul><ul class="er_fld_row"><li class="er_fld_type_radio" style="white-space: normal; width: 33.3333%;" draggable="false"><i class="fa fa-circle-o"></i><label class="er_fld_label required">Is the child up-to-date on their immunizations?</label> <label class="er_option"><input class="type_radio er_fld_required" type="radio" name="CST_100" value="Yes">Yes</label> <label class="er_option"><input class="type_radio er_fld_required" type="radio" name="CST_100" value="No">No</label> <label class="er_option er_option_other er_option_other_off"><input class="type_radio er_option_other er_fld_required" type="radio" name="CST_100" value="Other:">Other:<input class="cst_Other er_fld_required" name="CST_100_Other" type="text"></label> </li><li class="er_fld_type_content" draggable="false" style="width: 33.3333%;"> <i class="fa fa-info-circle"></i><label>Guidelines\Help Text</label><div class="cst_content er_fld_fontstyle_info">Please attach/send a copy of the child's immunization record.</div></li></ul><ul class="er_fld_row"><li class="er_fld_type_content" draggable="false" style="width: 50%;"> <i class="fa fa-info-circle"></i><label>Guidelines\Help Text</label><div class="cst_content er_fld_fontstyle_info">What medications is the child currently taking? (Please include all prescriptions, over the counter, supplements and viatmins.)</div></li></ul><ul class="er_fld_row"><li class="er_fld_type_text" draggable="false" style="width: 25%;"> <i class="fa fa-font"></i><label class="er_fld_label">Name of Pharmacy</label><input name="CST_72" type="text" class=""></li><li class="er_fld_type_text" draggable="false" style="width: 25%;"> <i class="fa fa-font"></i><label class="er_fld_label">Address</label><input name="CST_73" type="text"></li><li class="er_fld_type_text" draggable="false" style="width: 25%;"> <i class="fa fa-font"></i><label class="er_fld_label">Phone</label><input name="CST_74" type="text"></li></ul><ul class="er_fld_row"><li class="er_fld_type_text" draggable="false" style="width: 25%;"> <i class="fa fa-font"></i><label class="er_fld_label">Name of Medication</label><input name="CST_75" type="text"></li><li class="er_fld_type_text" draggable="false" style="width: 25%;"> <i class="fa fa-font"></i><label class="er_fld_label">Dosage</label><input name="CST_76" type="text"></li><li class="er_fld_type_text" draggable="false" style="width: 25%;"> <i class="fa fa-font"></i><label class="er_fld_label">How often</label><input name="CST_77" type="text"></li></ul><ul class="er_fld_row"><li class="er_fld_type_text" draggable="false" style="width: 25%;"> <i class="fa fa-font"></i><label class="er_fld_label">Name of Medication</label><input name="CST_78" type="text"></li><li class="er_fld_type_text" draggable="false" style="width: 25%;"> <i class="fa fa-font"></i><label class="er_fld_label">Dosage</label><input name="CST_79" type="text"></li><li class="er_fld_type_text" draggable="false" style="width: 25%;"> <i class="fa fa-font"></i><label class="er_fld_label">How often</label><input name="CST_80" type="text"></li></ul><ul class="er_fld_row"><li class="er_fld_type_text" draggable="false" style="width: 25%;"> <i class="fa fa-font"></i><label class="er_fld_label">Name of Medication</label><input name="CST_81" type="text"></li><li class="er_fld_type_text" draggable="false" style="width: 25%;"> <i class="fa fa-font"></i><label class="er_fld_label">Dosage</label><input name="CST_82" type="text"></li><li class="er_fld_type_text" draggable="false" style="width: 25%;"> <i class="fa fa-font"></i><label class="er_fld_label">How often</label><input name="CST_83" type="text"></li></ul><ul class="er_fld_row"><li class="er_fld_type_text" draggable="false" style="width: 25%;"> <i class="fa fa-font"></i><label class="er_fld_label">Name of Medication</label><input name="CST_85" type="text"></li><li class="er_fld_type_text" draggable="false" style="width: 25%;"> <i class="fa fa-font"></i><label class="er_fld_label">Dosage</label><input name="CST_84" type="text"></li><li class="er_fld_type_text" draggable="false" style="width: 25%;"> <i class="fa fa-font"></i><label class="er_fld_label">How often</label><input name="CST_86" type="text"></li></ul><ul class="er_fld_row"><li class="er_fld_type_text" draggable="false" style="width: 25%;"> <i class="fa fa-font"></i><label class="er_fld_label">Name of Medication</label><input name="CST_88" type="text"></li><li class="er_fld_type_text" draggable="false" style="width: 25%;"> <i class="fa fa-font"></i><label class="er_fld_label">Dosage</label><input name="CST_87" type="text"></li><li class="er_fld_type_text" draggable="false" style="width: 25%;"> <i class="fa fa-font"></i><label class="er_fld_label">How often</label><input name="CST_89" type="text"></li></ul><ul class="er_fld_row"><li class="er_fld_type_text" draggable="false" style="width: 25%;"> <i class="fa fa-font"></i><label class="er_fld_label">Name of Medication</label><input name="CST_90" type="text"></li><li class="er_fld_type_text" draggable="false" style="width: 25%;"> <i class="fa fa-font"></i><label class="er_fld_label">Dosage</label><input name="CST_91" type="text"></li><li class="er_fld_type_text" draggable="false" style="width: 25%;"> <i class="fa fa-font"></i><label class="er_fld_label">How often</label><input name="CST_92" type="text"></li></ul><ul class="er_fld_row"><li class="er_fld_type_text" draggable="false" style="width: 25%;"> <i class="fa fa-font"></i><label class="er_fld_label">Name of Medication</label><input name="CST_94" type="text"></li><li class="er_fld_type_text" draggable="false" style="width: 25%;"> <i class="fa fa-font"></i><label class="er_fld_label">Dosage</label><input name="CST_93" type="text"></li><li class="er_fld_type_text" draggable="false" style="width: 25%;"> <i class="fa fa-font"></i><label class="er_fld_label">How often</label><input name="CST_95" type="text"></li></ul><ul class="er_fld_row"><li class="er_fld_type_content" draggable="false" style="width: 50%;"> <i class="fa fa-info-circle"></i><label>Guidelines\Help Text</label><div class="cst_content er_fld_fontstyle_info">Social, Family, and Community</div></li></ul><ul class="er_fld_row"><li class="er_fld_type_paragraph er_fld_type_paragraph_small" draggable="false" style="width: 50%;"> <i class="fa fa-paragraph"></i><label class="er_fld_label required">How does the child function in social situations?</label><textarea name="CST_102" style="width:100%;" class="er_fld_required"></textarea></li></ul><ul class="er_fld_row"><li class="er_fld_type_content" draggable="false" style="width: 50%;"> <i class="fa fa-info-circle"></i><label>Guidelines\Help Text</label><div class="cst_content">Who are the child's family connections? (e.g. parents, siblings, extended family, friends, community supports, etc.)</div></li></ul><ul class="er_fld_row"><li class="er_fld_type_text" draggable="false" style="width: 33.3333%;"> <i class="fa fa-font"></i><label class="er_fld_label">Name</label><input name="CST_104" type="text"></li><li class="er_fld_type_text" draggable="false" style="width: 33.3333%;"> <i class="fa fa-font"></i><label class="er_fld_label">Relationship</label><input name="CST_105" type="text"></li></ul><ul class="er_fld_row"><li class="er_fld_type_text" draggable="false" style="width: 33.3333%;"> <i class="fa fa-font"></i><label class="er_fld_label">Name</label><input name="CST_106" type="text"></li><li class="er_fld_type_text" draggable="false" style="width: 33.3333%;"> <i class="fa fa-font"></i><label class="er_fld_label">Relationship</label><input name="CST_107" type="text"></li></ul><ul class="er_fld_row"><li class="er_fld_type_text" draggable="false" style="width: 33.3333%;"> <i class="fa fa-font"></i><label class="er_fld_label">Name</label><input name="CST_108" type="text"></li><li class="er_fld_type_text" draggable="false" style="width: 33.3333%;"> <i class="fa fa-font"></i><label class="er_fld_label">Relationship</label><input name="CST_109" type="text"></li></ul><ul class="er_fld_row"><li class="er_fld_type_text" draggable="false" style="width: 33.3333%;"> <i class="fa fa-font"></i><label class="er_fld_label">Name</label><input name="CST_110" type="text"></li><li class="er_fld_type_text" draggable="false" style="width: 33.3333%;"> <i class="fa fa-font"></i><label class="er_fld_label">Relationship</label><input name="CST_111" type="text"></li></ul><ul class="er_fld_row"><li class="er_fld_type_paragraph er_fld_type_paragraph_small" draggable="false" style="width: 50%;"> <i class="fa fa-paragraph"></i><label class="er_fld_label required">What has been the family's involvement in the child's treatment and care?</label><textarea name="CST_112" style="width:100%;" class="er_fld_required"></textarea></li></ul><ul class="er_fld_row"><li class="er_fld_type_radio" style="white-space: normal; width: 33.3333%;" draggable="false"><i class="fa fa-circle-o"></i><label class="er_fld_label required">Are there family visitation arrangements to consider?</label> <label class="er_option"><input class="type_radio er_fld_required" type="radio" name="CST_114" value="Yes">Yes</label> <label class="er_option"><input class="type_radio er_fld_required" type="radio" name="CST_114" value="No">No</label> <label class="er_option er_option_other er_option_other_off"><input class="type_radio er_option_other er_fld_required" type="radio" name="CST_114" value="Other:">Other:<input class="cst_Other er_fld_required" name="CST_114_Other" type="text"></label> </li><li class="er_fld_type_paragraph er_fld_type_paragraph_small er_fld_showif" draggable="false" style="width: 33.3333%;" er_fld_condfld="CST_114" er_fld_condvals="er_fld_showif_values=Yes"> <i class="fa fa-paragraph"></i><label class="er_fld_label required">If yes, please describe:</label><textarea name="CST_113" style="width:100%;" class="er_fld_blank er_fld_required"></textarea></li></ul><ul class="er_fld_row"><li class="er_fld_type_radio" style="white-space: normal; width: 50%;" draggable="false"><i class="fa fa-circle-o"></i><label class="er_fld_label required">Is the biological family involved?</label> <label class="er_option"><input class="type_radio er_fld_required" type="radio" name="CST_199" value="Yes">Yes</label> <label class="er_option"><input class="type_radio er_fld_required" type="radio" name="CST_199" value="No">No</label> <label class="er_option er_option_other er_option_other_off"><input class="type_radio er_option_other er_fld_required" type="radio" name="CST_199" value="Other:">Other:<input class="cst_Other er_fld_required" name="CST_199_Other" type="text"></label> </li><li class="er_fld_type_paragraph er_fld_type_paragraph_small er_fld_selected er_fld_showif" draggable="false" style="width: 50%;" er_fld_condfld="CST_199" er_fld_condvals="er_fld_showif_values=Yes"> <i class="fa fa-paragraph"></i><label class="er_fld_label required">If yes, please describe:</label><textarea name="CST_200" style="width:100%;" class="er_fld_required"></textarea></li></ul>
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